Physician practices and attitudes regarding adult immunizations
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.
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