Christine Babbel

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P < .001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P < .001; family physicians: 50% and 86%, respectively; P < .001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07–1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66–2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Barriers to the Use of Herpes Zoster Vaccine

BACKGROUND The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally. OBJECTIVE To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. DESIGN Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. SETTING National survey conducted from July to September 2008. PARTICIPANTS General internists and family medicine physicians. MEASUREMENTS Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. RESULTS Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues. LIMITATIONS Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. CONCLUSION Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.

Sentinel Physician Networks as a Technique for Rapid Immunization Policy Surveys

This study compared the use of mail and Internet surveys of sentinel networks of physicians with traditional random sample mail surveys for three national vaccine policy surveys. Three nationally representative sentinel networks of physicians were established (pediatricians, n = 427; general internists, n = 438; and family physicians, n = 433). Surveys of the sentinel networks were compared with simultaneous surveys conducted with random samples of the American Medical Association (AMA) Physician Masterfile. Response rates were 74% to 78% for sentinel surveys and 29% to 43% for traditional random sample surveys. Respondents to the two methods were generally comparable in demographic characteristics. While there were some differences in responses to survey topic questions, none of the differences were likely to affect policy decisions. Sentinel networks represent the opinions and experiences of physicians in a manner equivalent to traditional mail surveys and may provide a more efficient approach to conducting physician surveys.

Adoption of Rotavirus Vaccination by Pediatricians and Family Medicine Physicians in the United States

OBJECTIVES: The goals were to assess, among pediatricians and family medicine physicians, (1) rates of offering the vaccine in their office; (2) knowledge of Advisory Committee on Immunization Practices recommendations; (3) barriers to use; and (4) factors associated with offering the vaccine. METHODS: Surveys of pediatricians and family medicine physicians were conducted in August to October 2007. RESULTS: Response rates were 84% for pediatricians and 79% for family medicine physicians (N = 623). Proportions routinely offering the vaccine were 85% of pediatricians and 45% of family medicine physicians (P < .0001); 70% of pediatricians and 22% of family medicine strongly recommended the vaccine (P < .0001). Sixty-two percent of pediatricians and 32% of family medicine physicians (P < .0001) knew the age by which all 3 doses should be completed. Definite barriers to vaccine use included reported lack of coverage by insurance companies (family medicine physicians: 22%; pediatricians: 19%; not significant), costs of purchasing vaccine (family medicine physicians: 22%; pediatricians: 17%; not significant), lack of adequate reimbursement (family medicine physicians: 18%; pediatricians: 15%; not significant), concerns about safety (family medicine physicians: 25%; pediatricians: 9%; P < .0001), and concerns about adding another vaccine to the schedule (family medicine physicians: 22%; pediatricians: 5%; P < .0001). CONCLUSIONS: Rates of offering the new rotavirus vaccine are high among pediatricians but <50% among family medicine physicians. Both specialties identified financial barriers to use of the vaccine, but family medicine physicians had significantly more concerns about safety and about adding another vaccine to the vaccination schedule.

Will Pediatricians Adopt the New Rotavirus Vaccine

OBJECTIVES. Our objective was to determine the following among US pediatricians: (1) perceptions regarding burden of rotavirus disease and need for a vaccine; (2) intentions for recommending a newly licensed rotavirus vaccine; (3) perceived barriers to implementation; and (4) factors associated with plans for vaccine adoption. PATIENTS AND METHODS. A network of 431 pediatricians was recruited from a random sample of American Academy of Pediatrics’ members. The network was designed to be representative of the American Academy of Pediatrics with respect to region of the country, practice type, and practice setting. During January and February 2006, physicians were surveyed by Internet or mail. The survey contained a paragraph summarizing results of the new rotavirus vaccine trial. Respondents were asked about intentions to use the vaccine and anticipated barriers. RESULTS. The survey response rate was 71%. Of the respondents, 52% strongly agreed and 37% somewhat agreed with the need for a rotavirus vaccine. If recommended for routine use, 50% would strongly recommend and 34% would recommend but not strongly; 52% would begin to use within 6 months and 27% from 6 months to 1 year. The top 3 “definite” barriers to implementation included concerns about uniform coverage of vaccine by insurers, lack of adequate reimbursement, and parental reluctance because of withdrawal of previous rotavirus vaccine. In multivariate analysis, factors associated with very likely adoption of the vaccine included perception of a high burden of rotavirus disease and a high level of confidence in prelicensure studies of vaccine safety. The presence of physician concerns about safety of the new vaccine and the perception of parental concerns about vaccine safety in general were negatively associated with adoption. CONCLUSIONS. The majority of pediatricians reported willingness to implement the new rotavirus vaccine, most within 6 months. Major barriers to optimal implementation included provider concerns about reimbursement issues and parental acceptance of the vaccine.

Pediatricians’ Attitudes About Collaborations With Other Community Vaccinators in the Delivery of Seasonal Influenza Vaccine

OBJECTIVE Achieving universal influenza vaccination among children may necessitate collaborative delivery involving both practices and community vaccinators. We assessed among pediatricians nationally their preferences regarding location of influenza vaccination for patient subgroups and their attitudes about collaborative delivery methods. METHODS The design/setting was a national survey conducted from July 2009 to October 2009. Participants included a representative sample of pediatricians from the American Academy of Pediatrics. RESULTS The response rate was 79% (330 of 416). Physicians felt strongly that vaccination should occur in their practice for children with chronic conditions (52%) and healthy 6-24-month-old infants (48%), but few felt strongly about healthy 5-18-year-olds (17%). Most (78%) thought having multiple delivery sites increased vaccination rates, and 86% thought that influenza vaccine should be available at school. Physicians reported being very/somewhat willing to hold joint community clinics with public health entities (76%) and to suggest to patient subgroups that they receive vaccine at community sites, including public clinics or pharmacies (76%). The most frequently reported barriers to collaborative delivery with community sites or school-located delivery included concerns about the following: estimating the amount of vaccine to order if children are vaccinated elsewhere (community 56%; school 80%); transfer of vaccine records (community 57%; school 78%); and reluctance of families to go outside of the office (community 45%; school 74%). CONCLUSIONS Most physicians are in favor of school-located or collaborative influenza vaccine delivery with community vaccinators, especially for healthy school-aged children. Collaborative approaches will require planning to ensure transfer of records, effective targeting of subgroups, and provisions to protect providers from being left with extra influenza supply.

Seasonal influenza vaccination in adults: Practice and attitudes about collaborative delivery with community vaccinators

BACKGROUND Less than half of adults for whom seasonal influenza vaccine is recommended receive the vaccine. Little is known about physician willingness to collaborate with community vaccinators to improve delivery of vaccine. OBJECTIVES To assess among general internists and family medicine physicians: (1) seasonal influenza vaccination practices, (2) willingness to collaborate with community vaccinators, (3) barriers to collaboration, and (4) characteristics associated with unwillingness to refer patients to community sites for vaccination. DESIGN Mail and Internet-based survey. SETTING National survey conducted during July-October 2009. PARTICIPANTS General internists and family medicine physicians. MEASUREMENTS Survey responses on vaccination practices, willingness to collaborate to deliver vaccine and barriers to collaboration. RESULTS Response rates were 78% (337/432 general internists) and 70% (298/424 family medicine physicians). Ninety-eight percent of physicians reported giving influenza vaccine in their practice during the 2008-2009 season. Most physicians reported willingness to refer certain patients to other community vaccinators such as public clinics or pharmacies (79%); to collaborate with public health entities in holding community vaccination clinics (76%); and set up vaccination clinics with other practices (69%). The most frequently reported barriers to collaboration included concerns about record transfer (24%) and the time and effort collaboration would take (21%). Reporting loss of income (RR 1.40, 95% CI 1.03-1.89) and losing opportunities to provide important medical services to patients with chronic medical conditions (RR 1.77, 95% CI 1.25-2.78) were associated with unwillingness to refer patients outside of the practice for vaccination. LIMITATIONS Surveyed physicians may not be representative of all physicians. CONCLUSIONS The majority of physicians report willingness to collaborate with other community vaccinators to increase influenza vaccination rates although some will need assurance that collaboration will be financially feasible and will not compromise care. Successful collaboration will require reliable record transfer and must not be time consuming.

Vaccine Financing From the Perspective of Primary Care Physicians

OBJECTIVES: Because of high purchase costs of newer vaccines, financial risk to private vaccination providers has increased. We assessed among pediatricians and family physicians satisfaction with insurance payment for vaccine purchase and administration by payer type, the proportion who have considered discontinuing provision of all childhood vaccines for financial reasons, and strategies used for handling uncertainty about insurance coverage when new vaccines first become available. METHODS: A national survey among private pediatricians and family physicians April to September 2011. RESULTS: Response rates were 69% (190/277) for pediatricians and 70% (181/260) for family physicians. Level of dissatisfaction varied significantly by payer type for payment for vaccine administration (Medicaid, 63%; Children’s Health Insurance Program, 56%; managed care organizations, 48%; preferred provider organizations, 38%; fee for service, 37%; P < .001), but not for payment for vaccine purchase (health maintenance organization or managed care organization, 52%; Child Health Insurance Program, 47%; preferred provider organization, 45%; fee for service, 41%; P = .11). Ten percent of physicians had seriously considered discontinuing providing all childhood vaccines to privately insured patients because of cost issues. The most commonly used strategy for handling uncertainty about insurance coverage for new vaccines was to inform parents that they may be billed for the vaccine; 67% of physicians reported using 3 or more strategies to handle this uncertainty. CONCLUSIONS: Many primary care physicians are dissatisfied with payment for vaccine purchase and administration from third-party payers, particularly public insurance for vaccine administration. Physicians report a variety of strategies for dealing with the uncertainty of insurance coverage for new vaccines.

Physician practices regarding adult hepatitis B vaccination: a national survey.

BACKGROUND Less than 50% of adults with risk factors for hepatitis B infection have been vaccinated. Although primary care settings typically serve an important role in immunization delivery, little is known about adult hepatitis B vaccination practices in primary care, including the use of strategies such as standing orders to improve immunization rates. The objectives of this study were to assess, among family physicians and general internists, current approaches to assessing adult patients for hepatitis B risk factors, reported hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination. METHODS From September to November 2006, a national sample of 433 family physicians and 420 general internists were surveyed. Results were analyzed in 2007 and 2008. RESULTS Response rates were 65% for family physicians and 79% for general internists. Thirty-one percent of physicians reported assessing most or all adult patients for hepatitis B risk factors and vaccinating patients identified as high risk. Perceived barriers to hepatitis B vaccination included patients not disclosing high-risk behaviors, lack of adequate reimbursement for vaccination, and feeling too pressed for time to assess risk factors. Most surveyed physicians were very (47%) or somewhat (38%) supportive of using standing orders for hepatitis B vaccination in their practices. However, staff time constraints and patient unwillingness to disclose sensitive information to staff were perceived as barriers to using standing orders by a majority of respondents. CONCLUSIONS In a national survey, less than one third of primary care physicians reported routinely assessing for and vaccinating adults with hepatitis B risk factors. This finding suggests that new strategies for adult hepatitis B vaccination in primary care settings are needed. Most physicians supported using standing orders for vaccination, but barriers were anticipated.