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Author beliefs
Next Steps: Overcoming Barriers
Further study of disparities needed
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Scott L Johnston, Wright, Wyoming Family physician
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Although pneumococcal vaccine does reduce the risk of invasive pneumococcal disease it does not appear to affect overall morbidity or mortality . The article has addressed the ways one can attempt to change/improve vaccination rates. The fact that the vaccine decreases pneumococcal pneumonia rates answers the wrong question. The question should have been; does the vaccine make patients live longer or be hospitalized less. The answer to that question is still no. The only evidence that the vaccine improves life span or decreases hospitalizations comes from data from the 1940’s . Studies since that time all agree that this vaccine is no more effective than placebo in decreasing hospitalizations for pneumonia and/or death from pneumonia . Asking the wrong question yields an invalid answer. This letter is heavily plagiarized from Bandolier (evidenced based thinking about health care). BG Hutchison et al. Clinical effectiveness of pneumococcal vaccine: meta-analysis. Canadian Family Physician 1999 45: 2392-93. Kaufmann P. Studies in old age pneumonia. II. Prophylactic effects of pneumococcus polysaccharide against pneumonia. Archives of Internal Medicine 1941 67: 304-19. Kaufmann P. Pneumonia in old age: active immunization against pneumonia with pneumococcus polysaccharide; results of a six-year study. Archives of Internal Medicine 1947 79: 518-31. MacLoed CM et al. Prevention of pneumococcal pneumonia by immunization with specific capsular polysaccharides. Journal of Experimental Medicine 1949 82: 445-65 Austrian R. Surveillance of pneumoccal infection for field trials of polyvalent pneumococcal vaccines. National Institute of Health Publication DAB-VDP-12-84. Contract No 1A13257. Bethesda MD. 1980, pp 1-59. Gaillat J, Zmirou D, Mallaret MR, Rouhan D, Bru JP, Stahl, JP et al. Essai clinique du vaccin antipneumococcique ches des personnages agées vivant en institution. Rev Epidem Santé Publ 1985;33:437-444. Klatersky J, Mommen P, Canteraine F, Safary A. Placebo controlled pneumococcal immunization in patients with bronchogenic carcinoma. Eur J Cancer Clin Oncol 1986;22:807-813. Simberkoff MS, Cross AP, Al-Ibrahim, M, Baltch AL, Geiseler PJ, Nadler J et al. Efficacy of pneumococcal vaccine in high-risk patients. N Eng J Med 1986;315:1318-1327. Davis AL, Aranda CP, Schiffman G, Christianson, LC. Pneumococcal infection and immunologic response to pneumococcal vaccine in chronic obstructive pulmonary disease. Chest 1987;92:202-212. Leech JA, Gervais A, Ruben FL. Efficacy of pneumococcal vaccine in severe chronic obstructive pulmonary disease. Can Med Assoc J 1987 136: 361-365. Koivula I, Stén M, Leinonen M, Mäkelä PH. Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population -based study. Am J Med 1997;103:281-290. Örtqvist A, Hedlund J Burman L-A Elbel E, Höfer M, Leinonen M et al. randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet 1998;351:399-403. Gilks CF, French N, Nakiyingi, Carpenter L, Lugadda E, Watera C et al. Lack of efficvacy of 23-valent pneumococcal polysaccharide vaccine in HIV- 1 infected Ugandan adults. Proceedings of the Pneumococcal Vaccines for the World 1998 Conference. October 12-14, 1998. Washington DC, USA. Riley ID, Tarr PI, Andrews M, Pfeiffer M, Howard R, Challands P et al. Immunisation with a polyvalent pneumococcal vaccine. Lancet 1977;I:1338- 1341. Austrian R, Douglas RM, Schiffman G, Coetzee AM, Koornman HJ, Hayden-Smith S, Reid RD. Prevention of pneumococcal pneumonia by vaccination. Trans Assoc Am Physician 1976;89:184-194. Smit P, Oberholzer D, Hayden-Smith S, Koornhof HJ, Hillman MR. Protective efficacy of pneumococcal polysaccharide vaccines. JAMA 1977;238:2613-2616. http://www.jr2.ox.ac.uk/bandolier/band113/b113-5.html and http://www.jr2.ox.ac.uk/bandolier/band72/b72-4.html Competing interests: None declared |
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Kenneth S Fink, Rockville, MD Physician
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Santibanez et al. conducted a study looking for associations between physician factors and rate of reported pneumococcal polysaccharide vaccination (PPV) among their elderly patients. (1) The investigators followed the PRECEDE-PROCEED framework and used a questionnaire and an interview to obtain information from physicians about predisposing, reinforcing, enabling, and environmental factors related to PPV. They found that certain enabling and environmental factors were significantly associated with vaccination rate, but predisposing and reinforcing factors were not. Higher rates of vaccination were associated with office use of patient reminders, physician reminders, and immunization clinics or other specific programs. The physician was the unit of analysis and although the physician may be the one in the examination room with the patient, office- based systems can contribute to improving vaccination rates. The entire office staff can participate, and health information technology can have an increasingly useful role. Translating research into practice continues to be challenging. PPV is recommended for all adults 65 years and older who do not have contraindications. (2) However, as reported in the article national vaccination rates are about 55%. The patients in this study reported a vaccination rate of 67% even though 95% of study physicians reported that PPV was important for asymptomatic elderly patients. This suggests that factors other than physician knowledge create barriers. In this study, economic factors such as reimbursement were indirectly assessed by evaluating physicians’ likelihood to refer patients to the health department for PPV, and increased referral was associated with lower vaccination rates. However, the manner in which responses were dichotomized for analysis (i.e. very unlikely versus somewhat unlikely to very likely) somewhat complicates interpreting the results. Nevertheless, environmental factors appear to be associated with vaccination rates. This study is one more example of an evidence-based intervention with a low delivery rate. Identifying barriers to higher delivery rates is the first step for developing interventions to address them. Translational research utilizing office-based (and even health system-based) strategies is needed to develop effective interventions to improve the quality of healthcare. 1. Santibanez TA, Zimmerman RK, Nowalk MP, Jewell IK, Bardella IJ. Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status. Ann Fam Med 2004;2:41-18. 2. Update on Adult Immunization Recommendations of the Immunization Practices Advisory Committee (ACIP). (http://www.cdc.gov/mmwr/preview/mmwrhtml/00025228.htm) Competing interests: None declared |
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Anthony J. Costa, Orlando, FL USA Orlando Campus Dean, Florida State University College of Medicine
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The study by Santibanez, et al., in this issue of the Annals of Family Medicine, describes physician attitudes that influence the pneumococcal immunization status of their patients and makes a valuable contribution to a literature which has previously explored patient characteristics predictive of immunization status. (1) The immunization rate in this study was 67%, which compares favorably to other published studies in largely white patient populations. Immunization rates for blacks and Hispanics are about half this rate, however. Immunization rates for whites have gone from ~20% in 1989 to ~60% in 2001, while those for blacks and Hispanics have gone from ~10% to ~30% over the same period of time. (2) Thus, the disparity has actually increased over the past decade. Dr. Santibanez’s patient population in this study, reported in a previous publication, was 95% white. (3) Whether similar factors are at play in black and Hispanic populations is an important question and deserves further study. 1. CDC. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations – United States, 1996. MMWR 1999; 48(39):556-561. 2. CDC. Racial/ethnic disparities in influenza and pneumococcal vaccination levels among persons aged > 65 – United States, 1989-2001. MMWR 2003; 52(40): 958-962. 3. Zimmerman RK, Santibanez TA, Janosky JE, et al. What influences older patients’ influenza vaccination behavior? An analysis from inner-city, suburban, rural, and veterans affairs practices. Am J Med. 2003; 114:31- 38. Anthony J. Costa, M.D. Florida State University College of Medicine Competing interests: None declared |
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