GSA Guides Providers, Older Patients to Vaccine Consensus

In “Vaccines for Older Adults: Overcoming the Challenges of Shared Clinical Decision Making,” a new white paper from The Gerontological Society of America (GSA) National Adult Vaccination Program, a team of experts outlines a set of recommendations to encourage better definition and increased understanding of how health professionals talk with their older patients about the need for certain vaccines.

Shared clinical decision making, a recently added category of recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), involves an informed discussion between the patient and health professional and a collaborative decision on whether to use the vaccine in that patient. This is a new approach for vaccines that have previously been universally recommended based on age or risk factor, and for health professionals who have previously been encouraged to use a presumptive recommendation to encourage vaccination.

Currently four vaccines have been added to the shared clinical decision making category — meningococcal B, human papillomavirus, hepatitis B, and one of the two pneumococcal vaccines licensed for use in adults — and this has led to questions in practice about when to initiate a conversation about vaccination and with whom. Decades of research on shared decision making for palliative medicine and oncology offers some help, recognizing the technique was created for situations where there is not a “right” decision.

In developing the white paper, GSA assembled feedback from a group of thought leaders on vaccines, communicating with older adults, and shared decision making — to identify gaps in knowledge and specific tactics for health professionals to use in successfully implementing shared clinical decision making as recommended by ACIP for vaccines for older adults, with a focus on pneumococcal vaccines recommended for adults aged 65 years or older.

“We recognized that past goals to increase vaccination rates may not align with shared clinical decision making,” said Sherry Greenberg, PhD, RN, GNP-BC, FGSA, FAANP, FAAN, one of the stakeholders who provided input. “The new goal is to ensure that older adults have access to information and a conversation about options including whether or not a vaccine is right for them.”

The thought leaders identified several recommendations to better support health professionals who are tasked with shared clinical decision making, including:

• Recognize patients with whom a conversation about pneumococcal vaccines should be initiated.
• Create unambiguous specifications of shared clinical decision making for prompts in electronic health record systems and clinical decision support systems.
• At the health-system level, include time during encounters with older adult patients, such as the Welcome to Medicare preventive visit and other wellness conversations, to recommend vaccines — and use appropriate codes to ensure payment for the additional time.
• Explain the logic behind the Advisory Committee on Immunization Practices recommendations in order to build trust with health professionals.

Shared decision making has emerged in medicine as a model for focusing on patient-centered health care, and vaccines have been proven to play a vital role in reducing morbidity and mortality in people of all ages. In older adulthood, age-related decline of the immune system creates greater susceptibility to pathogens. Vaccines provide important boosts for the immune system in order to avoid infectious diseases and their complications. While vaccination may not be the ultimate outcome in the process of shared clinical decision making, sharing information, discussing risks and benefits, and making decisions together serve as the foundation for patient-centered care.

“While this model is new to vaccinations, it is not new for health professionals who work with older adults,” said Aisha Langford, PhD, MPH, who also contributed to the white paper. “Despite potential challenges to implementation, especially during initial rollout, using this model can ultimately contribute to increased confidence in the vaccination decision.”

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The Gerontological Society of America (GSA) is the nation's oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society.