Michaela Brtnikova

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.

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.

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 Attitudes toward Adult Vaccines and other Preventive Practices, United States, 2012

Objectives. We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits. Methods. We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians. Results. We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of “Welcome to Medicare” and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month. Conclusions. Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

Adoption of Rotavirus Vaccine by U.S. Physicians Progress and Challenges

BACKGROUND Pentavalent rotavirus vaccine (RV5) was recommended for routine use in 2006 followed by monovalent rotavirus vaccine (RV1) in 2008. PURPOSE To describe, among a U.S. sample of pediatricians (n=289 respondents) and family medicine physicians (n=243 respondents), (1) current practices regarding rotavirus vaccine (RV) and barriers to use with comparison to a 2007 survey and (2) knowledge of recent safety concerns regarding RV1 and their impact on its use. METHODS A mail and Internet survey was conducted with the physicians, from November 2010 to January 2011; analyses were conducted March-September 2011. RESULTS Response rates were 70% (289/410) for pediatricians and 61% (243/401) for family medicine physicians; routine administration of RV was reported by 95% of pediatricians and 65% of family medicine physicians (2007: 85% and 45%). Almost all barriers to use of RV had decreased compared to 2007. For pediatricians and family medicine physicians, respectively, 94% and 70% were aware of the temporary suspension of RV1 due to presence of porcine circovirus; 49% and 45%, respectively, were aware of the addition to RV1 labeling regarding a possible increased risk of intussusception. Among physicians aware of the safety issues, <5% reported stopping giving RV as a result. After reading information about porcine circovirus, 35% of pediatricians and 59% of family medicine physicians reported it had increased their own concerns about the safety of RV; and 31% and 60%, respectively, reported this regarding intussusception. CONCLUSIONS The acceptance of RV has increased, and barriers to use have decreased. Among physicians, recent safety questions about RV1 have not affected use of RV, although they have raised safety concerns.

Use of Immunization Information Systems in Primary Care

INTRODUCTION Immunization information systems (IISs) are highly effective for increasing vaccination rates but information about how primary care physicians use them is limited. METHODS Pediatricians, family physicians (FPs), and general internists (GIMs) were surveyed by e-mail and mail from January 2015 to April 2015 from all states with an existing IIS. Providers were recruited to be representative of national provider organization memberships. Multivariable log binomial regression examined factors associated with IIS use (October 2015-April 2016). RESULTS Response rates among pediatricians, FPs, and GIMs, respectively, were 75% (325/435), 68% (310/459), and 63% (272/431). A proportion of pediatricians (5%), FPs (14%), and GIMs (48%) did not know there was a state/local IIS; 81%, 72%, and 27% reported using an IIS (p<0.0001). Among those who used IISs, 64% of pediatricians, 61% of FPs, and 22% of GIMs thought the IIS could tell them a patients immunization needs; 22%, 29%, and 51% did not know. The most frequently reported major barriers to use included the IIS not updating the electronic medical record (29%, 28%, 35%) and lack of ability to submit data electronically (22%, 27%, 31%). Factors associated with lower IIS use included FP (adjusted risk ratio=0.85; 95% CI=0.75, 0.97) or GIM (adjusted risk ratio=0.33; 95% CI=0.25, 0.42) versus pediatric specialty and older versus younger provider age (adjusted risk ratio=0.96; 95 CI%=0.94, 0.98). CONCLUSIONS There are substantial gaps in knowledge of IIS capabilities, especially among GIMs; barriers to interoperability between IISs and electronic medical records affect all specialties. Closing these gaps may increase use of proven IIS functions including decision support and reminder/recall.

Adoption of Serogroup B Meningococcal Vaccine Recommendations

We examined how primary care physicians are adopting the MenB vaccine after it received a category B recommendation by the ACIP in 2015. BrightcoveDefaultPlayer10.1542/6138648371001PEDS-VA_2018-0344 Video Abstract BACKGROUND AND OBJECTIVES: In 2015, the Advisory Committee on Immunization Practices recommended that 16- to 23-year-olds may be vaccinated with the serogroup B meningococcal (MenB) vaccine on the basis of individual clinical decision-making (Category B). We assessed the following among US pediatricians and family physicians (FPs): (1) practices regarding MenB vaccine delivery, (2) factors influencing a decision to recommend the MenB vaccine, and (3) factors associated with discussing the MenB vaccine. METHODS: We surveyed a nationally representative sample of pediatricians and FPs via e-mail and Internet from October 2016 to December 2016. RESULTS: The response rate was 72% (660 of 916). During routine visits, 51% of pediatricians and 31% of FPs reported always or often discussing MenB vaccine. Among those who discussed often or always, 91% recommended vaccination; among those who never or rarely discussed, 11% recommended. We found that 73% of pediatricians and 41% of FPs currently administered the MenB vaccine. Although many providers reported not knowing about factors influencing recommendation decisions, MenB disease outbreaks (89%), disease incidence (62%), and effectiveness (52%), safety (48%), and duration of protection of MenB vaccine (39%) increased the likelihood of recommendation, whereas the Category B recommendation (45%) decreased likelihood. Those somewhat or not at all aware of the MenB vaccine (risk ratio 0.32 [95% confidence interval 0.25–0.41]) and those practicing in a health maintenance organization (0.39 [0.18–0.87]) were less likely, whereas those aware of disease outbreaks in their state (1.25 [1.08–1.45]) were more likely to discuss MenB vaccine. CONCLUSIONS: Primary care physicians have significant gaps in knowledge about MenB disease and the MenB vaccine, and this appears to be a major driver of the decision not to discuss the vaccines.

Immunization Practices of U.S. Obstetrician/Gynecologists for Pregnant Patients

INTRODUCTION U.S. obstetrician/gynecologists play a critical role as vaccinators of pregnant women. However, little is known about their current immunization practices. Thus, study objectives were to determine (1) practices related to assessment of vaccination status and vaccine delivery for pregnant patients; (2) barriers to stocking and administering vaccines; and (3) factors associated with administering both influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. METHODS An e-mail and mail survey among a national sample of obstetrician/gynecologists conducted July-October 2015 (analysis August 2016-August 2017). RESULTS The response rate was 73.2% (353/482). Among obstetrician/gynecologists caring for pregnant women (n=324), vaccination status was most commonly assessed for influenza (97%), Tdap (92%), and measles, mumps, and rubella vaccines (88%). Vaccines most commonly administered included influenza (85%) and Tdap (76%). Few respondents reported administering other vaccines to pregnant patients. More physicians reported using standing orders for influenza (66%) than Tdap (39%). Other evidence-based strategies for increasing vaccine uptake were less frequently used (electronic decision support, 42%; immunization information system to record [13%] or assess vaccination status [11%]; reminder/recall, 7%). Barriers most commonly reported were provider financial barriers, yet provider attitudinal barriers were rare. Providers who administered both influenza and Tdap vaccines were more likely to be female, perceive fewer financial and practice barriers, less likely to be in private practice, and perceive more patient barriers. CONCLUSIONS Although most obstetrician/gynecologists administer some vaccines to pregnant women, the focus remains on influenza and Tdap. Financial barriers and infrequent use of evidence-based strategies for increasing vaccination uptake may be hindering delivery of a broader complement of adult vaccines in obstetrician/gynecologist offices.

Vaccine Financing and Billing in Practices Serving Adult Patients: A Follow-Up Survey

BACKGROUND Financial concerns are often cited by physicians as a barrier to administering routinely recommended vaccines to adults. The purpose of this study was to assess perceived payments and profit from administering recommended adult vaccines and vaccine purchasing practices among general internal medicine (GIM) and family medicine (FM) practices in the United States. METHODS We conducted an interviewer-administered survey from January-June 2014 of practices stratified by specialty (FM or GIM), affiliation (standalone or ≥ 2 practice sites), and level of financial decision-making (independent or larger system level) in FM and GIM practices that responded to a previous survey on adult vaccine financing and provided contact information for follow-up. Practice personnel identified as knowledgeable about vaccine financing and billing responded to questions about payments relative to vaccine purchase price and payment for vaccine administration, perceived profit on vaccination, claim denial, and utilization of various purchasing strategies for private vaccine stocks. Survey items on payment and perceived profit were assessed for various public and private payer types. Descriptive statistics were calculated and responses compared by physician specialty, practice affiliation, and level of financial decision-making. RESULTS Of 242 practices approached, 43% (n = 104) completed the survey. Reported payment levels and perceived profit varied by payer type. Only for preferred provider organizations did a plurality of respondents report profiting on adult vaccination services. Over half of respondents reported losing money vaccinating adult Medicaid beneficiaries. One-quarter to one-third of respondents reported not knowing about Medicare Part D payment levels for vaccine purchase and vaccine administration, respectively. Few respondents reported negotiating with manufacturers or insurance plans on vaccine purchase prices or payments for vaccination. CONCLUSIONS Practices vaccinating adults may benefit from education and technical assistance related to vaccine financing and billing and greater use of purchasing strategies to decrease upfront vaccine cost.