Laura P. Hurley

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.

U.S. Physicians’ Perspective of Adult Vaccine Delivery

Context Vaccination rates in adults are low, even though more than 95% of Americans who die of vaccine-preventable disease each year are adults. General internists and family medicine physicians were surveyed about vaccine perceptions and practices. Contribution Barriers related to vaccine delivery included lack of regular assessment of vaccine status, insufficient stocking of some vaccines, and financial disincentives for vaccination in the primary care setting. Use of electronic tools to record and prompt vaccination was low. Most physicians surveyed accepted vaccination outside of the medical home but believed communication between themselves and alternate vaccinators was suboptimal. Implication System changes are necessary to improve adult vaccination in the United States. The Editors Vaccination remains underutilized in adults. An annual average of more than 30 000 Americans die of vaccine-preventable diseases, mostly influenza, and more than 95% of these persons are adults (1). The Advisory Committee on Immunization Practices recommends 12 vaccines for adults, including vaccines recommended universally, vaccines for persons who did not receive them in childhood (catch up), and vaccines for those in high-risk groups (2). According to recent estimates (3, 4), only 62% and 65% of adults aged 65 years or older received a pneumococcal or influenza vaccine, respectively; only 20% of high-risk adults aged 19 to 64 years received a pneumococcal vaccine; and only 16% of adults aged 60 years or older received a herpes zoster vaccine. All of these percentages are well short of Healthy People 2020 goals (5). None of the studies that examined reasons for low rates of adult vaccination (612) comprehensively examined adult vaccination. Furthermore, the context of adult vaccination has changed in recent years: There are newly recommended adult vaccines, some vaccines are now covered by Medicare Part D (a pharmaceutical benefit), and the site of vaccine delivery has shifted away from primary care settings. Almost half of adult seasonal influenza vaccinations in the 20102011 season occurred in health departments, pharmacies, work places, or other nonmedical locations (13), but physician perceptions regarding collaboration with alternate vaccinators have only been documented limitedly (14). Given the increase in the number of vaccines recommended for adults and the increasing importance of alternative sites for vaccine delivery, we sought to describe the following among U.S. primary care physicians: practices regarding assessing vaccination status and stocking of recommended adult vaccines; barriers to stocking and administering vaccines; characteristics of physicians who report greater financial barriers to delivering vaccines; and practices, experiences, and attitudes regarding vaccination outside of the medical home. Methods Study Setting From March to June 2012, we administered a survey to a network of primary care physicians (Supplement). The Human Subjects Review Board at the University of Colorado Denver approved this study as exempt research that did not require written informed consent. Supplement. Survey on Adult Immunization and Preventive Care Study Sample The Vaccine Policy Collaborative Initiative conducted this study (15). The Initiative was designed collaboratively with the Centers for Disease Control and Prevention (CDC) to perform rapid-turnaround surveys to assess physician attitudes about vaccine issues. We developed a network of primary care physicians for this program by recruiting general internists (GIMs) and family medicine physicians (FMs) from the memberships of the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP). We conducted quota sampling (16) to ensure that network physicians were similar to the ACP and AAFP memberships with respect to region, urban versus rural location, and practice setting (GIMs only). We previously demonstrated that survey responses from network physicians compared with those of physicians randomly sampled from American Medical Association physician databases (which reflect all practicing physicians and not just members of the American Medical Association) had similar demographic characteristics, practice attributes, and attitudes about a range of vaccination issues (16). Survey Design We developed a survey appraising physician practices regarding assessment of vaccination status for and stocking of the 11 adult vaccines routinely recommended in 2012 (17), as well as referral practices to alternate vaccinators when vaccines were not stocked. We used 4-point Likert scales for questions assessing attitudes about the role of different adult vaccine providers (strongly agree to strongly disagree) and barriers to stocking and administering vaccines in the practice (major barrier to not a barrier) (18). For brevity, certain questions were asked in a generic manner and were not related to specific vaccines. After an advisory panel of GIMs (n= 6) and FMs (n= 7) pretested the survey, we modified it on the basis of their feedback. The survey was then piloted by 86 primary care physicians (63 GIMs and 23 FMs) and further modified according to this feedback. Survey Administration According to physician preference, we sent the survey either over the Internet (Verint; Melville, New York) or through the U.S. Postal Service. We sent the Internet group an initial e-mail with up to 8 e-mail reminders, and we sent the mail group an initial mailing and up to 2 additional reminders. Nonrespondents in the Internet group were also sent a mail survey in case of problems with e-mail correspondence. We patterned the mail protocol on Dillmans tailored design method (19). Statistical Analysis We pooled Internet and mail surveys together for analyses because other studies have found that physician attitudes are similar when obtained by either method (2022). We compared respondents with nonrespondents on all available characteristics using Wilcoxon and chi-square analyses. Characteristics of nonrespondents were obtained from the recruitment survey for the sentinel networks. We found financial barriers to be commonly reported and therefore assessed whether certain characteristics of primary care physicians were associated with perceiving more financial barriers because this information could lead to actionable policymaking. To assess associations with perception of financial barriers and to avoid issues associated with multiple comparisons, we created a financial barriers scale composed of 8 financial barrier survey questions (Table 1). We combined the scores of these 8 variables (not a barrier= 0; minor barrier= 1; moderate barrier= 2; major barrier= 3) and divided that sum by the number of questions answered. We excluded respondents who had answered fewer than 5 of the 8 questions on financial barriers. A Cronbach was calculated to determine the internal consistency of the financial barriers scale. We used this scale as the outcome measure to evaluate associations between financial barriers and demographic and practice characteristics (sex, age, region, practice location, practice setting, number of providers in the practice, and proportion of patients with Medicare Part D and Medicaid) in a multivariable linear regression model for each specialty. Analyses were done by using SAS, version 9.2 (SAS Institute, Cary, North Carolina). Table 1. Perceived Barriers to Stocking and Administering Vaccines for Adult Patients in Respondents Practice Role of the Funding Source Investigators at the CDC were involved with the survey design, analysis, and the decision to submit the manuscript for publication. Results Survey Response Rates and Respondent Characteristics Response rates were 79% for GIMs (352 of 443) and 62% for FMs (255 of 409). All questions had fewer than 8% missing items, with most having fewer than 5% missing. The number of missing items did not differ between GIMs and FMs or between physicians who responded by Internet and those who responded by mail. No GIMs and only 2 FMs were from the same practice site. Respondents and nonrespondents did not differ significantly by sex, age, region, practice location, practice setting, or number of providers in the practice. Table 2 displays characteristics of respondents and their practices and patient populations. Table 2. Comparison of Respondents and Nonrespondents and Additional Characteristics of Respondents Practices Current Practices Regarding Assessing Need for and Stocking of Routinely Recommended Adult Vaccines Almost all physicians reported assessing patients vaccination status at annual visits (GIMs and FMs, 97%) or initial visits (GIMs, 94%; FMs, 89%), whereas fewer physicians (GIMs, 29%; FMs, 32%) reported doing so at every visit. The most commonly reported method for assessing immunization status was to check the medical record (GIMs, 95%; FMs, 96%). Although most physicians reported asking patients about vaccination status verbally (GIMs, 89%; FMs, 90%), by questionnaire (GIMs, 57%; FMs, 52%), or by having a staff member ask (GIMs, 57%; FMs, 66%), very few (GIMs, 1%; FMs, 2%) relied exclusively on patient-supplied information. A minority used immunization information systems (IISs) (GIMs, 8%; FMs, 36%). Forty-six percent of GIMs and 48% of FMs reported that it was moderately/very difficult to determine an adult patients vaccination status for vaccines other than seasonal influenza. Almost all physicians reported assessing the vaccination status for seasonal influenza; pneumococcal; tetanus and diphtheria (Td); tetanus, diphtheria, and acellular pertussis (Tdap); and zoster vaccines. Fewer reported assessing the status for the remainder of the recommended vaccines (Figure 1). Family physicians were more likely than GIMs to assess the need for hepatitis A; hepatitis B; measles, mumps, and rubella (MMR); human papillomavirus; meningococcal; and varicella vaccines. Figure 1. Percentage of physicians w

Physician response to parental requests to spread out the recommended vaccine schedule.

OBJECTIVES: To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests. METHODS: An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012. RESULTS: The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective. CONCLUSIONS: Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice.

Prediction of Cardiovascular Death in Racial/Ethnic Minorities Using Framingham Risk Factors

Background—Risk factors for cardiovascular disease (CVD) derived from the Framingham study are widely used to guide preventive efforts. It remains unclear whether these risk factors predict CVD death in racial/ethnic minorities as well as they do in the predominately white Framingham cohorts. Methods and Results—Using linked data from the National Health and Nutrition Examination Survey III (1988 to 1994) and the National Death Index, we developed Cox proportional hazard models that predicted time to cardiovascular death separately for non-Hispanic white (NHW), non-Hispanic black (NHB), and Mexican American (MA) participants ages 40 to 80 years with no previous CVD. We compared calibration and discrimination for the 3 racial/ethnic models. We also plotted predicted 10-year CVD mortality by age for the three racial/ethnic groups while holding other risk factors constant (3437 NHW, 1854 NHB, and 1834 MA subjects met inclusion criteria). Goodness-of-fit &khgr;2 tests demonstrated adequate calibration for the 3 models (NHW, P=0.49; NHB, P=0.47; MA; P=0.55), and areas under the receiver operating characteristic curves demonstrated similar discrimination (c-statistics: NHW, 0.8126; NHB, 0.7679; and MA, 0.7854). Older age was more strongly associated with CVD mortality in NHWs (hazard ratio, 3.37; 95% CI, 2.80 to 4.05) than NHBs (hazard ratio, 2.29; 95% CI, 1.91 to 2.75) and was intermediate in MAs (hazard ratio, 2.46; 95% CI, 1.95 to 3.11). Predicted 10-year mortality rate was highest for NHBs across all age ranges and was higher for MAs than NHWs until late in the seventh decade. Conclusions—Framingham risk factors predict CVD mortality equally well in NHWs, NHBs, and MAs, but the strength of the association between individual risk factors and CVD mortality differs by race and ethnicity. When other risk factors are held constant, minority individuals are at higher risk of CVD mortality at younger ages than NHWs.

Primary Care Physicians' Perspectives About HPV Vaccine.

BACKGROUND AND OBJECTIVES: Because physicians’ practices could be modified to reduce missed opportunities for human papillomavirus (HPV) vaccination, our goal was to: (1) describe self-reported practices regarding recommending the HPV vaccine; (2) estimate the frequency of parental deferral of HPV vaccination; and (3)identify characteristics associated with not discussing it. METHODS: A national survey among pediatricians and family physicians (FP) was conducted between October 2013 and January 2014. Using multivariable analysis, characteristics associated with not discussing HPV vaccination were examined. RESULTS: Response rates were 82% for pediatricians (364 of 442) and 56% for FP (218 of 387). For 11-12 year-old girls, 60% of pediatricians and 59% of FP strongly recommend HPV vaccine; for boys,52% and 41% ostrongly recommen. More than one-half reported ≥25% of parents deferred HPV vaccination. At the 11-12 year well visit, 84% of pediatricians and 75% of FP frequently/always discuss HPV vaccination. Compared with physicians who frequently/always discuss , those who occasionally/rarely discuss(18%) were more likely to be FP (adjusted odds ratio [aOR]: 2.0 [95% confidence interval (CI): 1.1–3.5), be male (aOR: 1.8 [95% CI: 1.1–3.1]), disagree that parents will accept HPV vaccine if discussed with other vaccines (aOR: 2.3 [95% CI: 1.3–4.2]), report that 25% to 49% (aOR: 2.8 [95% CI: 1.1–6.8]) or ≥50% (aOR: 7.8 [95% CI: 3.4–17.6]) of parents defer, and express concern about waning immunity (aOR: 3.4 [95% CI: 1.8–6.4]). CONCLUSIONS: Addressing physicians’ perceptions about parental acceptance of HPV vaccine, the possible advantages of discussing HPV vaccination with other recommended vaccines, and concerns about waning immunity could lead to increased vaccination rates.

Incident chronic kidney disease and the rate of kidney function decline in individuals with hypertension

Background. Little is known about the decline of kidney function in patients with normal kidney function at baseline. Our objectives were to (i) identify predictors of incident chronic kidney disease (CKD) and (ii) to estimate rate of decline in kidney function. Methods. The study used a retrospective cohort of adult patients in a hypertension registry in an inner-city health care delivery system in Denver, Colorado. The primary outcome was development of incident CKD, and the secondary outcome was rate of change of estimated glomerular filtration rate (eGFR) over time. Results. After a mean follow-up of 45 months, 429 (4.1%) of 10 420 patients with hypertension developed CKD. In multivariate models, factors that independently predicted incident CKD were baseline age [odds ratio (OR) 1.13 per 10 years, 95% confidence interval (CI), 1.03–1.24], baseline eGFR (OR 0.69 per 10 units, 95% CI 0.65–0.73), diabetes (OR 3.66, 95% CI 2.97–4.51) and vascular disease (OR 1.67, 95% CI 1.32–2.10). We found no independent association between age, gender or race/ethnicity and eGFR slope. In patients who did not have diabetes or vascular disease, eGFR declined at 1.5 mL/min/1.73 m2 per year. Diabetes at baseline was associated with an additional decline of 1.38 mL/min/1.73 m2. Conclusions. Diabetes was the strongest predictor of both incident CKD as well as eGFR slope. Rates of incident CKD or in decline of kidney function did not differ by race or ethnicity in this cohort.

Care of Undocumented Individuals With ESRD: A National Survey of US Nephrologists

BACKGROUND Although Medicare covers most dialysis therapy for US citizens with end-stage renal disease (ESRD), no national standards for dialysis provision exist for undocumented (ie, immigrant) patients with ESRD. STUDY DESIGN Cross-sectional survey. SETTING & PARTICIPANTS Mail and internet survey from October 2006 to February 2007 of American Society of Nephrology member nephrologists. PREDICTORS Region of the country, practicing in a state with a high undocumented population, inpatient and outpatient practice setting, and practice location. OUTCOMES Characteristics of nephrologists who report caring for undocumented patients with ESRD and those who perceive that such patients have access to maintenance dialysis therapy. RESULTS Response rate was 57% (990 of 1,723). Of nephrologists surveyed, 65%, representing 44 states, reported providing care to undocumented patients with ESRD and 61% reported increasing prevalence. Being from a state with a high undocumented population (OR, 1.67; 95% CI, 1.21 to 2.30) was associated with undocumented ESRD patient care; being from the Northeastern United States (OR, 0.55; 95% CI, 0.34 to 0.88) or a small town/rural area (OR, 0.27; 95% CI, 0.18 to 0.40) were negatively associated. Of the respondents, 91% reported that undocumented patients had access to emergent dialysis, but only 51% reported access to maintenance dialysis therapy. The characteristic associated with reporting access to maintenance dialysis was practicing in a state with a high undocumented population (OR, 1.91; 95% CI, 1.37 to 2.66), whereas practicing in the Southern United States was negatively associated (OR, 0.37; 95% CI, 0.24 to 0.57). Emergent-only dialysis for undocumented patients was reported by 28%. Of respondents knowledgeable about reimbursement, most reported inadequate compensation and 35% reported that outpatient dialysis units provide uncompensated dialysis care to undocumented patients with ESRD. LIMITATIONS Selection and information biases inherent to survey methods. CONCLUSIONS Dialysis for undocumented patients with ESRD is an increasing problem involving the majority of US nephrologists. Inadequately compensated or uncompensated care may limit the availability of long-term maintenance dialysis therapy for undocumented patients with ESRD. Regional variations argue for more rational and uniform national policy regarding this issue.

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.