Elsevier

Preventive Medicine

Volume 40, Issue 2, February 2005, Pages 152-161
Preventive Medicine

Physician practices and attitudes regarding adult immunizations

https://doi.org/10.1016/j.ypmed.2004.05.010Get rights and content

Abstract

Objectives. To assess immunization practices and attitudes of U.S. primary care physicians regarding adult influenza and pneumococcal immunizations.

Methods. Mailed survey of primary care internists and family physicians across the United States; four follow-up contacts by mail and telephone. Bivariate and multivariate analyses assessed immunization practices and attitudes and differences by physician characteristics.

Results. Three hundred and sixteen of 668 eligible physicians responded (50 refused, response rate of 266 = 40%); 220 provided adult vaccinations. More than 64% indicated they routinely vaccinated patients ≥65 years and those <65 years with chronic disease indications with both influenza and pneumococcal vaccine. Reported barriers for influenza vaccination included vaccine safety concerns by patients (58%), urgent concerns dominating visits (43%), and inadequate reimbursement (26%). Reported barriers for pneumococcal vaccination included urgent concerns during office visits (44%), no patient immunization history (36%), patient concerns about vaccine safety (31%), and inadequate reimbursement (25%). Many physicians indicated willingness to try tracking systems (72%), chart reminders (55%), patient reminders (53%), standing orders (36%), external lists of unimmunized patients for pneumococcal vaccination (74%), external patient reminders (70%), and office training of physicians (36%) or staff (46%).

Conclusions. While most physicians favored adult vaccinations, practical barriers to vaccination exist. Most physicians would adopt evidence-based strategies to improve immunization delivery.

Introduction

Influenza contributes to more than 36,000 deaths annually in the United States [1] while pneumococcal disease contributes to between 10,000 and 40,000 deaths annually [2], [3], [4]. Most deaths are among the elderly or adults with underlying chronic conditions [1], [2], [5], and many are preventable by effective influenza [6], [7], [8] and pneumococcal vaccines [8], [9]. Despite increasing attention to adult vaccination [10], [11], [12], coverage rates among adults ≥65 years have reached a plateau for both influenza vaccine (1999 and 2001 rates of 66% [13] and 63% [14]) and for pneumococcal vaccine (1999 and 2001 rates of 54% [9] and 52% [15]). Further, large disparities in adult immunization rates persist, with Black and Hispanic adults having lower immunization levels than white adults [16], [17], [18]. A Healthy People 2000 goal [19] was to achieve greater than 60% coverage for both influenza and pneumococcal vaccines for adults ≥65 years; this goal was not met for pneumococcal vaccine. The new Healthy People 2010 goal of ≥90% coverage for persons ≥65 years for both influenza and pneumococcal vaccines [20] will be difficult to achieve unless barriers to vaccination are understood and overcome.

The reasons for our failure to achieve higher adult immunization rates and to match the high levels of childhood vaccination rates [21] are not entirely clear. Commonly cited barriers to adult immunization include system problems such as vaccine supply, [22], [23] inadequate access to health services among some adults [24], costs of vaccinations [25], provider or practice barriers such as the focus on acute or chronic problems and the inability to track, remind, or recall patients needing vaccinations [26], patient barriers such as lack of knowledge about the benefits of vaccination [27], [28], [29], and concerns about vaccine safety [30]. A recent survey of influenza vaccination rates among elderly patients noted that those who received influenza vaccination were more likely to report that their health provider had recommended the vaccination [31], suggesting that provider barriers are critical.

Most published studies of provider barriers for adult immunizations have involved either local community investigations [32], [33], [34], [35], [36] or reviews [17], [37], [38], [39], [40]. Little is known about provider barriers to adult immunizations on a national scale. In addition, evidence-based expert recommendations for improving adult immunization rates [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51] include use of standing orders, patient reminder or recall systems, provider prompts, and audit feedback techniques to measure immunization rates at a practice level. However, little is known about the degree to which primary care practitioners have incorporated these methods on a national level into their regular practice [52] or would be willing to try them. Knowledge about incorporation of these strategies on a national level, and about barriers to their use, may help experts in designing educational interventions and means to overcome practice-level barriers. A recent national survey of knowledge, attitudes, and immunization practices of physicians noted that a sizeable proportion did not strongly recommend influenza or pneumococcal vaccinations to elderly or high-risk individuals and were not utilizing recommended strategies for enhancing vaccination rates [53]. Another national survey of internists and family physicians about timing of influenza vaccinations and use of patient reminders found that most physicians do routinely administer influenza vaccine but lack patient reminder systems [54]. The current study, conducted at about the same time as these two surveys, was distinct in that it focused on practice-level barriers for both influenza and pneumococcal vaccination, strategies beyond patient reminders, and the willingness of physicians to try new strategies.

The objectives of this study were to assess, on a national level, practices and attitudes of primary care physicians regarding adult influenza and pneumococcal immunizations: (a) general immunization practices, (b) specific barriers to adult immunizations, and (c) use of and willingness to try evidence-based strategies to improve immunization rates.

Section snippets

Methods

The Research Subjects Review Board of the University of Rochester approved this study.

Population (Table 1)

Of the 668 eligible physicians surveyed, 316 responded (47%) and 50 (7%) refused to participate, for a response rate of 40% (266/668 physicians). In addition, 46 (7%) were ineligible (42 physicians were no longer practicing primary care). Data were analyzed for the final sample of 220 physicians (only 33% of the original sample) whose demographic characteristics are shown in Table 1. Physicians who responded to the first two survey mailings did not differ in key demographic characteristics from

Discussion

Consistent with guidelines, the vast majority of primary care internists and family physicians state that they encourage influenza and pneumococcal vaccines to both target populations—the elderly, and patients of any age who have chronic disease indications. Influenza vaccination is encouraged more aggressively than pneumococcal vaccination. While there were no differences by physician specialty, rural physicians appeared to encourage pneumococcal vaccinations somewhat less aggressively than

Acknowledgements

We acknowledge the contributions of Marc LaForce, MD, in this work.

This work was funded by Wyeth Laboratories (Grant # 5-24192), the Centers for Disease Control and Prevention, Cooperative Agreement # [U38/CCU217969], and Health Research, Inc. (The New York State Emerging Infections Program) [#815-3478A]. None of these organizations have reviewed this manuscript. This entire project was conceived, conducted, and analyzed by the investigators alone.

References (89)

  • W.H. Barker et al.

    “McFlu” the Monroe county, New York, Medicare vaccine demonstration

    Am. J. Prev. Med

    (1999 (Apr.))
  • R.W. Kouides et al.

    Performance-based physician reimbursement and influenza immunization rates in the elderly. The primary-care physicians of Monroe county. Randomized controlled trial

    Am. J. Prev. Med

    (1998 (Feb.))
  • K.C. Stange et al.

    Direct observation of rates of preventive service delivery in community family practice

    Prev. Med

    (2000 (Aug.))
  • G.S. Cooper et al.

    The delivery of preventive services for patient symptoms

    Am. J. Prev. Med

    (2001 (Oct.))
  • D.B. Mukamel et al.

    Cost utility of public clinics to increase pneumococcal vaccines in the elderly

    Am. J. Prev. Med

    (2001 (Jul.))
  • P.G. Szilagyi et al.

    Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing

    Am. J. Prev. Med

    (2000 (May))
  • M.D. Cabana et al.

    Effect of state vaccine-financing strategy on hepatitis B immunization in hospital nurseries

    Ambul. Pediatr

    (2002 (Sep.–Oct.))
  • R.K. Zimmerman et al.

    The vaccines for children program. Policies, satisfaction, and vaccine delivery

    Am. J. Prev. Med

    (2001 (Nov.))
  • G.L. Freed et al.

    State-level perspectives on immunization policies, practices, and program financing in the 1990s

    Am. J. Prev. Med

    (2000 (Oct.))
  • M.A. Goodwin et al.

    A clinical trial of tailored office systems for preventive service delivery. The study to enhance prevention by understanding practice (STEP-UP)

    Am. J. Prev. Med

    (2001 (Jul.))
  • D.A. Asch et al.

    Response rates to mailed surveys published in medical journals

    J. Clin. Epidemiol

    (1997)
  • W.W. Thompson et al.

    Mortality associated with influenza and respiratory syncytial virus in the United States

    JAMA

    (2003 (Jan. 8))
  • Centers for Disease Control and Prevention

    Prevention of pneumococcal disease: recommendations of the advisory committee on immunization practices (ACIP)

    Morb. Mortal. Wkly. Rep. Recomm. Rep

    (1997)
  • Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years—United States, 1995

    Morb. Mortal. Wkly. Rep

    (1997 (Oct. 3))
  • D.M. Fedson

    Pneumococcal vaccination in the United States and 20 other developing countries 1981–1996

    Clin. Infect. Dis

    (1998)
  • J.A. Singleton et al.

    Influenza, pneumococcal, and tetanus toxoid vaccination of adults–United States, 1993–7

    Morb. Mortal. Wkly. Rep. CDC Surveill. Summ

    (2000 (Sep. 22))
  • K.L. Nichol et al.

    The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community

    N. Engl. J. Med

    (1994 (Sept. 22))
  • P.A. Gross et al.

    The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature

    Ann. Intern. Med

    (1995 (Oct. 1))
  • K.L. Nichol et al.

    The effectiveness of vaccination against influenza in healthy, working adults

    N. Engl. J. Med

    (1995 (Oct. 5))
  • Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)

    Morb. Mortal. Wkly. Rep

    (1997)
  • P. Gardner et al.

    Adult immunizations

    Ann. Intern. Med

    (1996 (Jan. 1))
  • Centers for Disease Control and Prevention

    Recommended adult immunization schedule—United States, 2002–2003

    Morb. Mortal. Wkly. Rep

    (2002)
  • Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory...
  • Early Release of Selected Estimates from the National Health Interview Surveys: Influenza Vaccination. Source: National...
  • Early release of selected estimates from the national health interview surveys: pneumococcal vaccination. Source:...
  • Centers for Disease Control and Prevention

    Vaccination levels among Hispanic and non-Hispanic whites aged ≥65 years—Los Angeles County, California, 1996

    Morb. Mortal. Wkly. Rep

    (1997)
  • Centers for Disease Control and Prevention

    Influenza and pneumococcal vaccination levels among persons aged ≥65 years—United States, 1999

    Morb. Mortal. Wkly. Rep

    (2001 (June 29))
  • Public Health Service. Healthy People 2000: national health promotion and disease prevention objectives—Healthy People...
  • US Department of Health and Human Services. Healthy People 2010 (conference ed., 2 vols). Washington, DC: US Department...
  • Centers for Disease Control and Prevention

    Ten great public health achievements—United States, 1900–1999

    Morb. Mortal. Wkly. Rep

    (1999 (Apr. 2))
  • Centers for Disease Control and Prevention

    Delayed influenza vaccine availability for 2001–02 season and supplemental recommendations of the advisory committee on immunization practices

    Morb. Mortal. Wkly. Rep

    (2001 (Jul. 13))
  • US DHHS and the National Vaccine Program Office. A report of the National Vaccine Advisory Committee: strengthening the...
  • W.W. Williams et al.

    Immunization policies and vaccine coverage among adults: the risk for missed opportunities

    Ann. Intern. Med

    (1988 (Apr.))
  • P.A. Merkel et al.

    Evaluation of a simple office-based strategy for increasing influenza vaccine administration and the effect of differing reimbursement plans on the patient acceptance rate

    J. Gen. Intern. Med

    (1994 (Dec.))
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