APNA 2019 National Conference
Ms Jean Kittson
Excellent, now, this is on the vexatious question of vaccinations, I’m not talking about the dingbats who won’t vaccinate their children. We have that, you know, we’ve had three measles warnings in New South Wales this year already, but I’m talking about closing the gap on adult vaccination. Allow me to introduce our esteemed speaker Dr John Litt, is a recipient of the RACGP – I should have asked you how to pronounce that – but he’s a recipient of the RACGP Lifetime Achievement Award, a Lung Foundation Ambassador for Cancer South Australia, and the 2016 RACGP Rose Hunt Award Winner.
He is an academic general practitioner and a public health physician, until recently he was an Associate Professor for General Practice and Teaching Coordinator in the Flinders University Doctor of Medicine Program. His major clinical and research interests are in prevention, and its implementation. He has published over a hundred referred publications. He has a special interest in vaccination in adults and older persons. He is one of the inaugural directors of the influenza specialist group and remains on the Scientific Advisory Board of the Immunisation Coalition. He has a lifetime interest in vaccination. Please welcome to the stage, give a very warm welcome to Dr John
Assoc Prof John Litt:
Thanks Jean. Thanks very much for inviting me to attend and to present to this very large group, and congratulations on your success for the largest numbers attending the practice nurse conference. It’s perhaps not surprising it’s happening in Adelaide, but that’s terrific. For those that came to the workshop that Angela and I ran yesterday, the first couple of slides might appear to be fairly similar, but it gets interesting after that, so you can snooze through the first few, but you’ll need to be sort of waking up for later.
So, I am going to try and give you an overview of immunisation and some of this you will know, so I’ll be fairly quick in the first part of that, and I’ll be looking mainly at vaccination in older adults. So, we are looking at influenza, herpes, zoster, and pneumococcal infection, particularly communityacquired pneumonia. I’m going to talk about the challenges we have with that, because of coverage is nowhere like what we get with children, so elder adults often become – it’s not second class citizens – but we don’t pay the same degree of attention to that. We reminded people in the workshop yesterday that the last national survey on vaccination older people was done in 2009, so it’s long overdue to do another one. I’m going to talk about some of the issues and paradoxes, so we could spend a whole session on defining a paradox, but it really means something that’s not as it appears to be. On the surface, it looks like something is fairly straightforward, but there’s more to the story, and so the focus is going to be particularly on implementation.
Implementation is the sort of poor cousin that when we have health care interventions, we spend a lot of time getting there in terms of the science and running the trials, and we pay very little attention and time to the things that actually make a difference, to make sure that the people get those very effective interventions and vaccines so we get health outcomes, and so I’m going to talk about some of the reasons behind that. Some of them may be somewhat provocative, which should be good. But we’ll give you kind of a journey where my life has been in the last 30 years or so. I’m going to use the College of GPs Green book. So that’s the preventing - implementation of prevention in the practice setting. It was based on my PhD thesis, and there are only four unfortunate people have had to read my thesis, because it was 976 pages. Now you could do that, because you could have a second volume, which was much longer with all the appendices, and I said, “No one’s ever going to read this.” So the Green book is a summary. Watching ‘Yes Minister’, the Green book should have been two pages, but we managed to get it down to about one hundred.
So just to remind you about flu. Flu happens every year, we’ve got it happening quite significantly with a summer outbreak. In a typical season, we will have something like, five percent of the population, so one in 20 Australians, will develop influenza over the flu season. In 2009 when we had the pandemic, we have serological evidence that one in four Australians developed pandemic influenza, and the impact, the burden, of that disease falls particularly on older people, and so 90 precent of the hospital admissions are people over the age of 65. If a person over 65 gets the flu, they’ve got about a 1% chance, as an upper limit, of ending up in hospital, and a small number of those will end up in ICU. So we really need to ensure that that group of people get the flu vaccine every year.
If we look at pneumococcal disease, we have a very effective children’s program with the Prevnar 13-valent conjugate vaccine. We don’t at the moment have a current recommendation, it’s about to be renewed by the PBAC and ATAGI for the Pneumococcal vaccine. I’m speaking of the 23-valent polysaccharide vaccine, which is given to people over the age of 65. There are about 90 serotypes for pneumococcus, 23 of them are bad guys, and there are 23 serotypes in the pneumococcal vaccine. Invasive disease is an issue. The pneumococcus accounts for probably about 14 percent of a community acquired pneumonia, and that has dropped. It is essentially halved since we’ve had the conjugate pneumococcal program in children, but it is still a significant illness, because people end up in hospital, and a number of them develop what we call catastrophic disability, which makes it hard for them to go back to being ambulatory and independent, and very costly to the Community Service, if they actually go into residential care.
Herpes zoster is also an issue. People still have misperception about zoster, believing they can catch it. 95% of us, by the age of 35, have actually had varicella. Now that we have a children’s program, we’re actually preventing that, and so hopefully you won’t see as much zoster in that group than we will in our current cohort. But once you’ve had varicella, that little virus sits in your dorsal root ganglion for a lifetime. The herpes virus has evolved over 2 million years, it’s very good at availing the immune system, and when your immune system is challenged or compromised in some way, and the biggest predictor of that is actually to be older, or if you have some immunity in a compromising condition, then you’re going to get a bout of zoster. You get a ganglionitis, that damages the dorsal root ganglion, the virus travels down the nerve, you get the typical rash of stars for weeks, and a small proportion, but much more in older people, because of the damage done to the ganglion and to the peripheral nerves, get a postherpetic neuralgia, which is really difficult to treat. We have antivirals to treat acute zoster, but they do not reduce the incidence of postherpetic neuralgia. The only way to boost a persons immunity, to give them protection against zoster, is to offer them the zoster vaccine and we have a live attenuated vaccine and a program for people aged 70 to 79. The incidence of zoster rises from the age of 60, I had my zoster shot at 60, and I’d recommend other people to do much the same. Zoster has a much bigger impact other than just pain. It commonly leads to a loss of function, it has an impact on ADLs and on people’s mental health. It’s not an uncommon story that someone whose had a bout of zoster, again, from being initially independent and now, actually having chronic pain and relying on others to provide care and support for that person after a bout of zoster.
If we actually look at the coverage here, this is data, a composite data. First thing, just to correct, if you have a look at the axis that says childrens, actually adults, that was in the original publication of the CDC. If we look, we can look at influenza, and we can see, that you’ve actually got a plateau, so we’re amongst the top five countries in the world in the over 65s with flu coverage, so we could give us a pat on the back to a certain extent, although that has not improved, and so there are still 1 in 4 Australians in the age group at risk, who would benefit from having an influenza vaccine.
Pneumococcal is another story, so the recommendation for the Pneumovax has been to have one dose, in someone whose not got other risk conditions, at the age of 65. That was first funded in 2005, even though it had been a recommendation by the NHMRC for a number of years ahead of time. In 2011, because of the increased incidence of adverse effects with this booster dose of Pneumovax, the decision was made to actually stop that second dose. Now a number of countries around the world are continuing to do that. If you’re in Germany, you get it every five years, and so it is a sort of possible interaction, or adverse event, but what’s happened is its actually led to a decline in the rate of zoster, so we’re down around 45%.
Zostervax, you guys ought to give yourselves a pat on the back. So in 2016, from a standing start where we had nobody having a dose of Zostervax, in the last two and a half years we now have coverage rates indirectly of around 60 to 65%, and that is an amazing sort of story. So that’s in three years, we’ve gone from nought to 60 to 65%. In America, whose had the Zostervax for over 10 years, they’re not even above 50. We’ve still got to beat the Poms, the Poms in three years are up to 70 percent, so we shouldn’t rest on our laurels, but it’s going to be much harder to do the latter part to get it above that.
So if we look at some paradoxes, and I’m going to take a bit of license here, it’s really useful to think about what you are currently doing, and so one of the kind of themes of my talk is that we are taking a quality improvement approach at the College, and essentially, that means you need to measure something to see what you are doing currently and what your need is, you need to intervene, and then you need to re-measure to see, did you have an effect. What I would suggest is when you actually measure it, have a think about where your performance is starting, and if we look at the three vaccines here, they’re kind of different stories. So when we started with Zostervax, we had nobody who'd had the Zoster – the Zoster vaccine, nobody knew about it, there as a lot of preparatory work to get people up to speed about what it was, what the risks were, what the concerns were, how effective it was, and that’s both the healthcare professionals and for the community. So that kind of initial, overcoming the inertia and getting started, applies to a lot of other programs. If you’ve got things like cardiovascular disease, we did a trial on waist circumference, we found that most GPs are doing only about five to ten percent of patients, and so when you’ve got a performance below 33%, you’ve got to really think hard in the practice, are you geared up with the capacity and the capability to do that. Have you got all of the things lined up, that this is actually going to be achievable.
Then you’ve got the mid-zone, which is where we have Pneumovax at whoops today where we have Pneumovax at the time oops can we go back if we have a look with Pneumovax – well, we are pushing the wrong way, if you look at Pneumovax, you can see that we plateau and to a similar extent with influenza. But influenza would plateau at a much higher level, Pneumovax we’ve actually plateaued and declining, and so we need to think a lot of the simple intervention strategies that sort of level of coverage will likely lead to some sort of great improvement
When we look at the flu vaccine, we’ve done a lot of things, and we’re up to 75%, so we need to really think outside the square, how do we get that last 25%. Now all of you can recognise how hard it is to get the last 25%. It is a principle called the Pareto Principle, that was invented by an Italian economist, and if I translate it for clinicians, because economic ones a little bit fuzzy. 10% of your patients sort of govern 90 percent of your work. Chasing that last sort of 10%, think about when the GPII program was in and the Commonwealth kept raising the bar, it was much harder to get the last ten precent, than it was the first ten percent, when you’re down with your performance around 50 percent. So looking at the performance, think about where you are on the curve, because it’s going to require different sorts of interventions, if you are to become more effective.
So, the next paradox is that we often think that doing more is better. Think about the number of people that take a vitamin tablet, if they take another one it will be better. It’s like me in the garden, if I put twice as much fertilizer on my tomato, you will be much higher. The reality is, and if we have a look here, this is what we think. If we take our time as an effective intervention, and we spend twice as long with patients, we’re going to get twice the health benefit. This is data taken from smoking cessation, looks at the time that healthcare practitioners, nurses or GPs spend on smoking cessation, and if you notice that after you get to about five minutes, the curves depart. So the blue dashed line is what the evidence suggests, the red dashed line is what we think we’re doing, and so the reality is if you spent 30 minutes with a patient and giving them smoking cessation advice, you will get about 1 in 3 people quitting. If you spend about five minutes, you could probably get in 1 in 15, but if you look on the return on effort, which is what a lot of practitioners think about, then for the 30 minutes spent by doing it more, for a shorter time, with fewer numbers of people, whether so a larger number of people than just the one patient for 30 minutes, your impact is bigger. So trying to have some sort of effect in an area, it’s really important to look at the reach, and make sure that various people are covered, and offered the intervention, rather than spending a lot of time with everybody.
This data underlines the sort of the third principle. Again, you’ve got to be strategic in the combination of things you put together to be effective. Jeremy Grimshaw in this publication 15 years ago, did a systematic review of all of the implementation strategies that were kind of delivering improvements in care, and both chronic disease and in prevention, and what do you notice from the curve? If you have a look there, that after you have done more than two things, so like a reminder system, notices in the waiting room, some education, whatever you’re deciding to do, very depressingly, you’ve got no further improvement in your outcome, and so it’s not just your time. Just by taking a number of interventions, and I’m thinking I’m doing lots, I’m going to get an outcome, the reality is you’ve got to think about how those bits fit together, because just doing more on its own won’t lead to some sort of improvement. You actually need to target specific issues, specific barriers, other things that you know are problematic, if you actually want to get a gain, an improvement.
The last one might come sort a bit more home to roost is just knowing that there’s a need or making an effort doesn’t translate into things. So it’s kind of depressing when you look at the literature, most of the time, when we kind of estimate our performance of doing something and use some other objective measure to kind of corroborate that - a patient survey or case note order. The reality is we generally overestimate our performance, and not uncommonly by a factor of about two, and so what does that mean? They’re saying, you’re saying, I’ve got everybody in my practice having their hba1c in the last three years, I’ve got all my patients with flu know, who at risk from flu having a flu vaccine, and so if you believe that you don’t see that there’s actually a need when you go and measure it, the actual reality is the level of coverage is actually a lot less than that, and so you can’t just use your own estimate of that. You actually have to use some other objective means to come and have a look at what’s actually happening.
If you look at the second point, and again, it’s a function of our healthcare systems, managers and bureaucrats and public health people like myself, will look at the total population. You as clinicians will actually look at the person in front of you. You are very much focused on making a difference with the person with you, and if you do a good job with every single one of those, therefore, you’ll have a good outcome. Well, let’s just take the flu for example - in a typical flu season, if you rely on an opportunistic strategy, and we know that 90% or so of people over 65, they’re going to come and see you, or come to the practice in the pre-flu season, that if you offered it opportunistically, you get a 90 percent coverage. But think about it, you’ve got Mrs Smith, whose got diabetes, Alzheimers, and as a carer the flu vaccine is the last thing that you tackle, because you’ve got to deal with the urgent things that are there, then you’ve got the people that are actually concerned about the flu vaccine or will never have it, and you have to spent more time with them, and so, when you look at the various interventions, by just kind of being opportunistic, or to think about ways of actually doing it, you’re not going to get an improvement, unless you look at all the steps in the process, and we talked about that as the quality cascade, and I’ll give you an example of that shortly.
The final element is that we tend to go to education sessions that were already good at, and so the things that we need to improve on are the things that we often don’t turn up to, and the ways that we learn about things in terms of, you know, try to get better, often involve systems change, so reading journals, doing to a dinner in the evening and having a speaker, is a great mental health exercise for us, but it has very little impact on improving our performance. Having a performance coach within the practice, so having a Director of Quality, just like we do that when we accredit the practice, will a big difference. Having a systematic look at the thing, knowing the denominator, measuring what you’re doing, all of those sound very boring and managerial, but are the kind of things that will actually make you more effective, based on what we know in the current evidence. So here’s an example of the quality cascade, and this is talking about pneumococcal vaccination, so you can actually have a look. When you look at all your steps, even if you’re aware of the guidelines, you actually believe them, you do have a commitment to apply them, and actually offer them to your patients. You get a leakage at each point along the curve, and so you might think, I can get everybody, but various steps along the process, the performance to clients, and when you get down to the patient, you’re only offering a splitting fraction of that. Not all of those accept it, and then in a recent GP survey that I did on 600 people in December – 600 clinicians – a lot of GPs don’t even bother with the second dose of the pneumococcal vaccine. They don’t believe it’s needed, and so all of that filters down, so is it not surprising that this level of coverage here which is what we have reported on is around 40%, that each of the steps in the process has an impact on that. So this is probably the busiest slide of my talk, and is kind of the take home messages, and I’m going to elaborate on each of these points one at a time.
So what we have done in the new College Green book is to look at the quality improvement process and we have dressed it up with what we’ve found in the evidence as being effective in terms of actually having an impact, and so there’ll be some recurrent themes here.
So we need to think about the total population. If you don’t know who they are, then you can’t measure performance. Quality requires two numbers - it needs to know, you need to know the numerator and you need to know the denominator, and until you have both, you’re not going to actually do any better, and it’s more than just having a net plan result, it’s actually using that figure for your own purposes. To say I’ve been doing such and such, I’ve got 60 percent coverage - how am I going to get to the last 40 percent?
Planning, culture, collaboration, being realistic, looking at the return on evidence, being evidencebased and thinking about the complexity. I’m going to tackle each of these in turn.
So when we do a needs assessment, this probably doesn’t happen very often in church, but you will do it in your practice setting to see, well, what we are currently doing in pneumococcal, do we know how many people have actually had the pneumococcal vaccine, or who’s actually been offered the zoster, and who’s actually not appropriate to have that. There are people that have died that we don’t want to be prompting or sending a reminder to, so that’s the first step of actually measuring that.
The planning process is always critical. Show of hands, anybody in this room when they’re involved in accreditation who do not have a coordinator to tackle it? Is there a practice where you kind of do it in an ad hoc fashion or would everybody agree that you have somebody there who’s delegated to pull all the bits together? The latter? Some nods. I would say the same with delivering quality, is you actually need to have someone to coordinate it and so that’s quite an involved process, and there are a number of things within the office environment, that’s going to make it more friendly. There’s kind of the planning process, so that you can avoid some of the mistakes. You can learn from things that other people have done and sort of not repeat their mistakes. If you do a more timely review, you don’t have, you can just have tadpoles rather than frogs. So actually getting on with it and then looking quickly to see that you’ve got some sort of return on effort, to see whether you’re wasting your time is really important.
So the culture is important. Think about the pilots, how many times have you heard on a flight to
Melbourne, we’re travelling at 35,000 feet, we’re doing 700 kilometres an hour, we touch down in Melbourne in 20 minutes, and you have a 95% chance of arrival. Now, if you translate that, and you have to laugh, because my wife and I published a paper in quality care about 15 years ago, because she was working on iatrogenic events in hospital. If you go into a major teaching hospital, and not just as a visitor, but as a patient, you have a 5% chance of having a iatrogenic event, that would be unacceptable in the airline industry. As clinicians, we need to have a focus on quality and safety, first and foremost, to actually make sure that our patients are not harmed by the process. So, we have a look and here’s another example from the smoking. We don’t have to do it all ourselves. So if we actually look at smoking cessation, the Quit Line counsellors - if a person has a call back program, three or four calls in the first three months from someone in the corp from the Quit Line centre, the quit rates about 30%. You would need to spend 180 minutes to get the same results as they would, to do that, and so whatever you do within the practice, are there people outside of you who can work with you, who can do it more efficiently and more effectively. The Quit Line do it in all languages, except Urdu, and they’re open most hours, and so we don’t often have analogies and things like vaccinations, it often settles down with the practice. But I would suggest you, the person, we actually need to collaborate within the practice setting is the patient. In this age group in older people, the biggest influence on the patient’s decision about their vaccination, is what you recommend to them. So, having a look at the realism things there, again, we’re repeating this to just remind people, this is the waiting room and the nurses area, and the reception and this is the GP setting here, so that we can recognise that the nurses are really busy. Quite often the GPs have offloaded some of that work on the nurses, far more effectively to share that, because then everybody’s happy, particularly if they’re paid the appropriate amount, and you can actually do what you are good at, so you get a much better result done.
Things have got to be targeted, and so if you’re going to aim for things if you’ve got a 30% coverage with pneumococcal, you would love to get to 90%, but it’s like a journey to Sydney or to Melbourne, but I’m going to Sydney or to Melbourne, I’ve got to go through Murray Bridge first. So if you think about your performance, and you’re sitting at 30%, be realistic, because if you can achieve something, and it’s incremental, it gives you energy and momentum and motivation to go to the next step. If you aim for a hundred percent and fail, then you’re going to be disappointed, and it’s unrealistic to expect you’re going from 30 percent to hundred percent in a very short period of time. So the interventions you need to choose, the evidence-base and we are always good at doing that. Think about the return on effort, how much work is it going to be, and can we sustain this, can we build it into the routine within the practice environment.
So here’s an example around reminder systems, and some of this work comes from my PhD. We know from the evidence base that we can get about a 10 to 15 percent absolute improvement by sending out a reminder to the patient. The problem is, if we mail it out, it’s expensive, it’s a stamp and the postage and the staff time. If we use an SMS, something like Hot Docs or Smartvax, we can actually do it far more efficiently. We have a much greater reach, and we can still have the impact. But remember we send out, if we send out, write reminders routinely to people, people get habituated. When you stop the reminder, the patient thinks, I no longer need the vaccine, and it’s also a lot of work, because there’s a lot of areas that actually need a reminder, that if you do it with too many conditions, you’re just going to feel overwhelmed.
So this is work from Alan Leeb, just to remind you we all know that nurses are triathletes, they can multitask, so they’re on the phone making an appointment, talking to a patient, the doctors whispering in their ear, and they’re probably tapping with their foot, doing something else. If we have a look at the data here, this is from Alan’s work on Smartvax in different practices, that were signed up to the Smartvax and sending out for pneumococcal reminders. The average performance was a 15% improvement, but have a look up here - some doctors got 63%. Now, my suspicion is that that doctor didn’t believe in vaccination and suddenly woke up and said, ‘I’m at the bottom of the pile, I’m around ten percent and I have to do something to get a whole lot better’, but there’s a lot of variation in that, but you can expect quite a reasonable increase in performance for a pretty reasonable return on effort.
So let’s now have a look at some further data about your effectiveness and the intervention of what you can do. If we actually have a look at the sort of recommendation of a healthcare professional. Twenty years ago, I did the first National Influenza and Pneumococcal Survey. We surveyed four and a half thousand people across 200 practices around Australia, and after adjusting for all the other factors that were influencing the person’s likelihood of getting the vaccine, the recommendation of a practice nurse or a GP was the most potent factor on influencing the person to get the vaccine. So for influenza, it was – whoops - it was eight fold for pneumococcal because people knew much less about that. There wasn’t much information around, people confused a pneumococcal vaccine with the influenza vaccine. It’s actually only given every five years and over 65 percent are given once so there is a lot of confusion about pneumococcal, so if you’re recommending it, then the patient says, ‘Well, they’ve obviously checked my records, they think it’s important, I’ll actually get it.’
Ten years later, I did the Australian zoster study, so we did that in two divisions in Adelaide, and we had a random sample of 1,300 people that we interviewed and asked them about their views prior to the implementation of the zoster program. Again, when we adjusted for all of the other factors that would influence zoster, the key influence was the recommendation, and they’re all about the same, and so that’s a very efficient way of actually getting some gain, and so if we think about when I showed you that curve from Jeremy Grimshaw, that adding in the interventions doesn’t need to be important. What I would suggest is think about the categories that are important, that are actually going to make sure that if you do more, you do get a better return on effort, and so incremental is a sort of common theme. Going to Murray Bridge before you go to Sydney, you’ve got to get there in the first tip, put it up on the notice board and as the kind of message to say this is what we are doing. I had a colleague in New South Wales, he put smoking rates on the noticeboard and it actually attracted a lot of people to come and talk about smoking. He felt very embarrassed when they relapse, but when he actually asked them they said, ‘No leave it up there’, he said ‘We relapse, it wasn’t you, you gave us the sort of impetus to get there, it’s actually nice to know what you’re doing.’ It’s kind of a measure of the quality of what you’re doing, and sort of a statement of what you believe in. You’ve got to address the barriers and we’ve talked about the number of those, it needs to be tailored to your setting, multi-component, with a fair degree of thought and the return on effort is absolutely critical. So if you want a kind of snapshot of that, this is another public health area, look at what we’ve had to do in motor vehicles over 30 years to actually get the level improvement we have. So it’s not going to happen in a hurry, and even that has plateaued, as you can see in the blue bars, so thinking about the reality pyramid, start at the bottom. What you can do in practice, think about your one minute strategies, you’re going to spend more time with people that have got issues or whatever to actually lead to an improvement. All of this is outlined in the Green book.
Here are some of the reasons why people don’t get the vaccines and it commonly centres around concern about adverse effects, perceiving to be healthy, or actually believing natural immunity is better. A recommendation from you normally offsets most of those things.
So in summary, vaccine preventable disease and older people are really important. You have an very important role, you are the engine room. I think someone described the other day that the nurse is the neck, I think an engine room is a far more effective sort of strategy. You guys are much more focused on the process, and getting good outcomes, and implementation is really important as part of your core activity.
Quality improvement will help you. Here’s the PRACTICE framework. The Green book is here, I have ten copies, there is a little slip with an online survey that you can get. I’ve got a few copies, the rest I’m on the secure stand if you complete it, the first ten people to complete it until May get a book today. The next 10 get a copy mailed to them, but the College is offering it at no cost, so you’re only paying the postage which is about five to eight dollars, and the PRACTICE framework, all of those kinds of key issues, they will bring all of those things together. So you can actually do a better job than what you’re currently doing. So in a number of ways, you’ve done really well, but I think we can have an expectation that things will actually continue to go onwards and upwards. Thank you.