Laura P. Hurley, MD, MPH; Carolyn B. Bridges, MD; Rafael Harpaz, MD, MPH; Mandy A. Allison, MD, MSPH; Sean T. O’Leary, MD; Lori A. Crane, PhD, MPH; Michaela Brtnikova, PhD; Shannon Stokley, MPH; Brenda L. Beaty, MSPH; Andrea Jimenez-Zambrano, MPH; Faruque Ahmed, PhD; Craig Hales, MD, MPH; Allison Kempe, MD, MPH
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Acknowledgments: The authors thank all general internists and family physicians in the networks for participating in and responding to the survey.
Grant Support: By the Centers for Disease Control and Prevention (SIP–5U48DP001938).
Potential Conflicts of Interests: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2332.
Reproducible Research Statement: Study protocol: Available from Dr. Hurley (Laura.Hurley@dhha.org). Statistical code and data set: Certain portions of the analytic data set are available to approved individuals through written agreements with Dr. Hurley and the Centers for Disease Control and Prevention.
Requests for Single Reprints: Michaela Brtnikova, PhD, Children's Outcomes Research Program, 13199 East Montview Boulevard, Aurora, CO 80045; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Hurley: Wellington Webb Center for Primary Care, 301 West 6th Avenue, MC3251, Denver, CO 80204.
Drs. Bridges, Stokley, and Ahmed: National Center for Immunization and Respiratory Diseases, 1600 Clifton Road, MS A-19, Atlanta, GA 30333.
Drs. Harpaz and Hales: National Center for Immunization and Respiratory Diseases, 1600 Clifton Road, MS A-34, Atlanta, GA 30333.
Drs. Allison, O’Leary, Brtnikova, Beaty, Jimenez-Zambrano, and Kempe: Children's Outcomes Research Program, 13199 East Montview Boulevard, Suite 300, Aurora, CO 80045.
Dr. Crane: Anschutz Medical Campus, 13001 East 17th Place, B119, Building 500, Dean's Suite, Room D, Aurora, CO 80045.
Author Contributions: Conception and design: C.B. Bridges, R. Harpaz, S.T. O’Leary, M. Brtnikova, A. Jimenez-Zambrano, F. Ahmed, A. Kempe.
Analysis and interpretation of the data: C.B. Bridges, R. Harpaz, S.T. O’Leary, M. Brtnikova, B.L. Beaty, C. Hales, A. Kempe.
Drafting of the article: R. Harpaz, S.T. O’Leary, M. Brtnikova, A. Jimenez-Zambrano, A. Kempe.
Critical revision of the article for important intellectual content: C.B. Bridges, R. Harpaz, S.T. O’Leary, M. Brtnikova, B.L. Beaty, F. Ahmed, C. Hales, A. Kempe.
Final approval of the article: C.B. Bridges, R. Harpaz, S.T. O’Leary, M. Brtnikova, B.L. Beaty, A. Jimenez-Zambrano, F. Ahmed, C. Hales, A. Kempe.
Provision of study materials or patients: A. Kempe.
Statistical expertise: S.T. O’Leary, M. Brtnikova, B.L. Beaty, A. Kempe.
Obtaining of funding: A. Kempe.
Administrative, technical, or logistic support: S.T. O’Leary, M. Brtnikova, A. Jimenez-Zambrano, A. Kempe.
Collection and assembly of data: M. Brtnikova, A. Jimenez-Zambrano, A. Kempe.
Hurley LP, Bridges CB, Harpaz R, Allison MA, O’Leary ST, Crane LA, et al. U.S. Physicians’ Perspective of Adult Vaccine Delivery. Ann Intern Med. 2014;160:161-170. doi: 10.7326/M13-2332
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Published: Ann Intern Med. 2014;160(3):161-170.
Adults are at substantial risk for vaccine-preventable disease, but their vaccination rates remain low.
To assess practices for assessing vaccination status and stocking recommended vaccines, barriers to vaccination, characteristics associated with reporting financial barriers to delivering vaccines, and practices regarding vaccination by alternate vaccinators.
Mail and Internet-based survey.
Survey conducted from March to June 2012.
General internists and family physicians throughout the United States.
A financial barriers scale was created. Multivariable linear modeling for each specialty was performed to assess associations between a financial barrier score and physician and practice characteristics.
Response rates were 79% (352 of 443) for general internists and 62% (255 of 409) for family physicians. Twenty-nine percent of general internists and 32% of family physicians reported assessing vaccination status at every visit. A minority used immunization information systems (8% and 36%, respectively). Almost all respondents reported assessing need for and stocking seasonal influenza; pneumococcal; tetanus and diphtheria; and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines. The most commonly reported barriers were financial. Characteristics significantly associated with reporting greater financial barriers included private practice setting, fewer than 5 providers in the practice, and, for general internists only, having more patients with Medicare Part D. The most commonly reported reasons for referring patients elsewhere included lack of insurance coverage for the vaccine (55% for general internists and 62% for family physicians) or inadequate reimbursement (36% and 41%, respectively). Patients were most often referred to pharmacies/retail stores and public health departments.
Surveyed physicians may not be representative of all physicians.
Improving adult vaccination delivery will require increased use of evidence-based methods for vaccination delivery and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D.
Centers for Disease Control and Prevention.
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.
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.
System changes are necessary to improve adult vaccination in the United States.
Table 1. Perceived Barriers to Stocking and Administering Vaccines for Adult Patients in Respondents’ Practice
Table 2. Comparison of Respondents and Nonrespondents and Additional Characteristics of Respondents’ Practices
Percentage of physicians who reported assessing vaccination status of patients and stocking vaccines.
FM = family physician; GIM = general internists; HPV = human papillomavirus; MMR = measles, mumps, and rubella; PPSV23 = pneumococcal polysaccharide; Td = tetanus and diphtheria; Tdap = tetanus, diphtheria, and acellular pertussis.
Table 3. Characteristics Associated With Perception of Financial Barriers to Stocking and Administering Vaccines in Practice*
Physicians’ attitudes and beliefs regarding the role of different adult vaccine providers.*
FM = family physician; GIM = general internist.
* Number of FMs = 255; number of GIMs = 352.
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Gordon Dickinson, MD, Lujan Soler, MD
University of Miami
July 24, 2014
We read with interest the report, “U.S. Physicians’ Perspective of Adult Vaccine Delivery by Dr. Hurley and her colleagues in the February 4, 2014 issue of Annals of Internal Medicine. We have been working to address the failure of many adult Hispanic-Americans in our community to receive the ACIP (Advisory Committee on Immunization Practices) recommended vaccinations. While the levels of adult vaccinations among adult Hispanic-Americans lag those of the general populations, all lag from the goals set by Healthy People 2020. Our observations within Miami-Dade County are consistent with the findings of Hurley et al. What especially resonated with our impression is the implication noted by the editors: "system changes are necessary to improve adult vaccination in the United States." Among the potential solutions that we find most attractive is the expanded role of pharmacies as a provider of vaccines. Thousands of people visit pharmacies every day and this is a great opportunity to not only offer vaccines but also educate and reinforce the community about the importance of vaccination for the prevention of infectious diseases.With the affordable care act mandating financing of ACIP recommended vaccines, cost should no longer be a factor. And with the local pharmacy providing vaccinations, access should be much improved. There will still be a key role for physicians as providers, but the logistics of the cold chain and the documentation indicate that outside of large clinical operations, the financial aspects of giving adult vaccines in small clinics is not attractive. Physicians will always remain a key source of information and teaching for our patients. An important as yet unresolved (in our community) is the linkage of documentation of vaccination in a pharmacy with the patient's permanent record. And for many persons, there is no permanent record. With this caveat aside, we think the system change needed to raise the level of adult vaccination in the United States is for the pharmacist to become the vaccinator.We know that the American College of Physicians leadership concurs with the importance of life-long vaccinations. We are hoping that you will consider writing an editorial supporting vaccination by pharmacies across the United States. Thank you,Gordon Dickinson, MDLujan Soler, MDUniversity of Miami Miller School of Medicine andFIDEC (Fighting Infections in Developing Countries_Potential Conflicts of Interest: None DisclosedReferencesHurley LP, Bridges CB, Harpaz R, et al. U.S., Physicians’ Perspective of adult vaccine delivery. Ann Intern Med. 2014;160:161-170.U.S.Department of Health and Human Services. Healthy People 2020. Immunization and infectious diseases. 2012. http//healthypeople.gov/2020/topicsobjectives2020.
Infectious Disease, Prevention/Screening, Vaccines/Immunization.
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