Physician practices and attitudes regarding adult immunizations
Introduction
Influenza contributes to more than 36,000 deaths annually in the United States [1] while pneumococcal disease contributes to between 10,000 and 40,000 deaths annually [2], [3], [4]. Most deaths are among the elderly or adults with underlying chronic conditions [1], [2], [5], and many are preventable by effective influenza [6], [7], [8] and pneumococcal vaccines [8], [9]. Despite increasing attention to adult vaccination [10], [11], [12], coverage rates among adults ≥65 years have reached a plateau for both influenza vaccine (1999 and 2001 rates of 66% [13] and 63% [14]) and for pneumococcal vaccine (1999 and 2001 rates of 54% [9] and 52% [15]). Further, large disparities in adult immunization rates persist, with Black and Hispanic adults having lower immunization levels than white adults [16], [17], [18]. A Healthy People 2000 goal [19] was to achieve greater than 60% coverage for both influenza and pneumococcal vaccines for adults ≥65 years; this goal was not met for pneumococcal vaccine. The new Healthy People 2010 goal of ≥90% coverage for persons ≥65 years for both influenza and pneumococcal vaccines [20] will be difficult to achieve unless barriers to vaccination are understood and overcome.
The reasons for our failure to achieve higher adult immunization rates and to match the high levels of childhood vaccination rates [21] are not entirely clear. Commonly cited barriers to adult immunization include system problems such as vaccine supply, [22], [23] inadequate access to health services among some adults [24], costs of vaccinations [25], provider or practice barriers such as the focus on acute or chronic problems and the inability to track, remind, or recall patients needing vaccinations [26], patient barriers such as lack of knowledge about the benefits of vaccination [27], [28], [29], and concerns about vaccine safety [30]. A recent survey of influenza vaccination rates among elderly patients noted that those who received influenza vaccination were more likely to report that their health provider had recommended the vaccination [31], suggesting that provider barriers are critical.
Most published studies of provider barriers for adult immunizations have involved either local community investigations [32], [33], [34], [35], [36] or reviews [17], [37], [38], [39], [40]. Little is known about provider barriers to adult immunizations on a national scale. In addition, evidence-based expert recommendations for improving adult immunization rates [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51] include use of standing orders, patient reminder or recall systems, provider prompts, and audit feedback techniques to measure immunization rates at a practice level. However, little is known about the degree to which primary care practitioners have incorporated these methods on a national level into their regular practice [52] or would be willing to try them. Knowledge about incorporation of these strategies on a national level, and about barriers to their use, may help experts in designing educational interventions and means to overcome practice-level barriers. A recent national survey of knowledge, attitudes, and immunization practices of physicians noted that a sizeable proportion did not strongly recommend influenza or pneumococcal vaccinations to elderly or high-risk individuals and were not utilizing recommended strategies for enhancing vaccination rates [53]. Another national survey of internists and family physicians about timing of influenza vaccinations and use of patient reminders found that most physicians do routinely administer influenza vaccine but lack patient reminder systems [54]. The current study, conducted at about the same time as these two surveys, was distinct in that it focused on practice-level barriers for both influenza and pneumococcal vaccination, strategies beyond patient reminders, and the willingness of physicians to try new strategies.
The objectives of this study were to assess, on a national level, practices and attitudes of primary care physicians regarding adult influenza and pneumococcal immunizations: (a) general immunization practices, (b) specific barriers to adult immunizations, and (c) use of and willingness to try evidence-based strategies to improve immunization rates.
Section snippets
Methods
The Research Subjects Review Board of the University of Rochester approved this study.
Population (Table 1)
Of the 668 eligible physicians surveyed, 316 responded (47%) and 50 (7%) refused to participate, for a response rate of 40% (266/668 physicians). In addition, 46 (7%) were ineligible (42 physicians were no longer practicing primary care). Data were analyzed for the final sample of 220 physicians (only 33% of the original sample) whose demographic characteristics are shown in Table 1. Physicians who responded to the first two survey mailings did not differ in key demographic characteristics from
Discussion
Consistent with guidelines, the vast majority of primary care internists and family physicians state that they encourage influenza and pneumococcal vaccines to both target populations—the elderly, and patients of any age who have chronic disease indications. Influenza vaccination is encouraged more aggressively than pneumococcal vaccination. While there were no differences by physician specialty, rural physicians appeared to encourage pneumococcal vaccinations somewhat less aggressively than
Acknowledgements
We acknowledge the contributions of Marc LaForce, MD, in this work.
This work was funded by Wyeth Laboratories (Grant # 5-24192), the Centers for Disease Control and Prevention, Cooperative Agreement # [U38/CCU217969], and Health Research, Inc. (The New York State Emerging Infections Program) [#815-3478A]. None of these organizations have reviewed this manuscript. This entire project was conceived, conducted, and analyzed by the investigators alone.
References (89)
The best and worst of times: use of adult immunizations
Am. J. Prev. Med
(2000 (Oct.))- et al.
Influenza vaccination among minority populations in the United States
Prev. Med
(2002 (Feb.)) - et al.
What affects influenza vaccination rates among older patients? An analysis from inner-city, suburban, rural, and veteran affairs practices
Am. J. Med
(2003 (Jan.)) - et al.
Barriers to immunization—an examination of factors that influence the application of pneumococcal vaccine by house staff
Vaccine
(1994 (Oct.)) - et al.
Pneumococcal vaccination: perceptions of primary care physicians
Prev. Med
(1998) - et al.
Adult pneumococcal vaccination: a review of physician and patient barriers
Vaccine
(2002 (Jan. 31)) The best and worst of times: use of adult immunizations
Am. J. Prev. Med
(2000 (Oct.))- et al.
Adult immunizations: recommendations for practice
Mayo Clin. Proc
(1999 (Apr.)) - et al.
Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program
Am. J. Med
(1990 (Aug)) - et al.
Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The task force on community preventive services
Am. J. Prev. Med
(2000 (Jan.))
“McFlu” the Monroe county, New York, Medicare vaccine demonstration
Am. J. Prev. Med
Performance-based physician reimbursement and influenza immunization rates in the elderly. The primary-care physicians of Monroe county. Randomized controlled trial
Am. J. Prev. Med
Direct observation of rates of preventive service delivery in community family practice
Prev. Med
The delivery of preventive services for patient symptoms
Am. J. Prev. Med
Cost utility of public clinics to increase pneumococcal vaccines in the elderly
Am. J. Prev. Med
Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing
Am. J. Prev. Med
Effect of state vaccine-financing strategy on hepatitis B immunization in hospital nurseries
Ambul. Pediatr
The vaccines for children program. Policies, satisfaction, and vaccine delivery
Am. J. Prev. Med
State-level perspectives on immunization policies, practices, and program financing in the 1990s
Am. J. Prev. Med
A clinical trial of tailored office systems for preventive service delivery. The study to enhance prevention by understanding practice (STEP-UP)
Am. J. Prev. Med
Response rates to mailed surveys published in medical journals
J. Clin. Epidemiol
Mortality associated with influenza and respiratory syncytial virus in the United States
JAMA
Prevention of pneumococcal disease: recommendations of the advisory committee on immunization practices (ACIP)
Morb. Mortal. Wkly. Rep. Recomm. Rep
Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years—United States, 1995
Morb. Mortal. Wkly. Rep
Pneumococcal vaccination in the United States and 20 other developing countries 1981–1996
Clin. Infect. Dis
Influenza, pneumococcal, and tetanus toxoid vaccination of adults–United States, 1993–7
Morb. Mortal. Wkly. Rep. CDC Surveill. Summ
The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community
N. Engl. J. Med
The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature
Ann. Intern. Med
The effectiveness of vaccination against influenza in healthy, working adults
N. Engl. J. Med
Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)
Morb. Mortal. Wkly. Rep
Adult immunizations
Ann. Intern. Med
Recommended adult immunization schedule—United States, 2002–2003
Morb. Mortal. Wkly. Rep
Vaccination levels among Hispanic and non-Hispanic whites aged ≥65 years—Los Angeles County, California, 1996
Morb. Mortal. Wkly. Rep
Influenza and pneumococcal vaccination levels among persons aged ≥65 years—United States, 1999
Morb. Mortal. Wkly. Rep
Ten great public health achievements—United States, 1900–1999
Morb. Mortal. Wkly. Rep
Delayed influenza vaccine availability for 2001–02 season and supplemental recommendations of the advisory committee on immunization practices
Morb. Mortal. Wkly. Rep
Immunization policies and vaccine coverage among adults: the risk for missed opportunities
Ann. Intern. Med
Evaluation of a simple office-based strategy for increasing influenza vaccine administration and the effect of differing reimbursement plans on the patient acceptance rate
J. Gen. Intern. Med
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