Barriers to Adult Vaccination Identified

Fran Lowry

February 03, 2014

A survey of 607 general internists and family physicians in the United States has revealed numerous barriers to achieving the recommended vaccination schedule for adults.

Led by Laura P. Hurley, MD, MPH, from Denver Health in Colorado, researchers found inconsistent assessment of patients' vaccination status among the physicians surveyed and insufficient stocking of certain recommended vaccines, in many instances because of the expense of the vaccines.

The survey results were published in the February 4 issue of the Annals of Internal Medicine.

"Vaccination remains underutilized in adults," Dr. Hurley and colleagues write. "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."

The Advisory Committee on Immunization Practices recommends that adults receive 12 vaccines, including vaccines for people who did not receive them as children (so called catch-up vaccination) and for people who are considered to be high-risk.

Recent estimates show that only 62% of adults aged 65 years or older received a pneumococcal vaccine, and just 65% received an influenza vaccine. Only 16% of adults aged 60 years or older received a herpes zoster vaccine, and just 20% of high-risk adults aged 19 to 64 years received a pneumococcal vaccine.

"All of these percentages are well short of Healthy People 2020 goals," the researchers write.

Therefore, Dr. Hurley and colleagues sought to determine the way US primary care physicians assess their patients' vaccination status; their stocking of recommended adult vaccines; barriers to stocking and administering vaccines, including financial barriers; and experiences and attitudes regarding vaccination outside of the medical home.

The survey was administered between March and June 2012. Response rates were 79% (352/443) for general internists and 62% (255/409) for family physicians.

Just 29% of general internists and 32% of family physicians reported that they assessed their patients' vaccination status at every visit. A few (8% of general internists and 36% of family physicians) said they used immunization information systems.

Almost all physicians said they assessed the need for and stocked seasonal influenza, pneumococcal, tetanus and diphtheria, and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines, such as hepatitis vaccines, catch-up vaccines (human papillomavirus; measles, mumps, and rubella; varicella; and meningococcal), and zoster vaccine.

Family physicians were more likely to report stocking hepatitis B and catch-up vaccines than general internists, but large proportions of both groups said they did not stock zoster vaccine.

Only 31% of family physicians and 20% of general internists reported stocking all 11 adult vaccines that were recommended for routine use in 2012.

The most important barrier to stocking and administering vaccines was financial for both family physicians and internists.

Physicians in private practice, those with fewer than 5 members in a practice, physicians from the South, West (for family physicians only), and Midwest, and those who had a higher proportion of patients with Medicare part D (internists only) reported the most financial barriers.

Most physicians reported that they refer patients to get the vaccines they did not stock, most often to a pharmacy or public health department. The reasons most often cited 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% for general internists and 41% for family physicians).

Almost all physicians agreed it was the primary care physicians' responsibility to make sure patients received recommended vaccinations, even if the patients received the vaccines elsewhere; the physicians also thought the pharmacist played an important role in vaccinating adults.

A possible limitation of their study is that the surveyed physicians may not be representative of all physicians.

The authors conclude that improving the delivery of recommended vaccines to adults will require increased use of evidence-based methods "and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D."

According to Carolyn B. Bridges, MD, associate director for science of the Centers for Disease Control and Prevention's (CDC's) Immunization Services Division, Atlanta, Georgia, and one of the authors of this study, a healthcare professional's recommendation is one of the most important factors in whether a person chooses to get recommended vaccines.

"The CDC encourages all healthcare providers to incorporate routine assessment of their patients' vaccine needs into their clinical practice, recommend needed vaccines, and either vaccinate or refer them to a vaccinating provider if they don't stock needed vaccines," Dr. Bridges told Medscape Medical News.

"Although providers often recommend vaccination during well visits, vaccines are usually not discussed during other visits, and these represent missed opportunities," she said.

Dr. Bridges said healthcare providers should also stress vaccines such as the influenza; tetanus, diphtheria, and acellular pertussis; and shingles vaccines to protect against diseases that affect many people in the United States.

"They should also check to be sure their adult patients are up to date on vaccines they might have missed as an adolescent, such as [the human papillomavirus] vaccine. Many of the illnesses that vaccines prevent are very common. For example, CDC estimates that about 1 million adults in the US get shingles each year. Healthcare providers armed with such statistics can make a very persuasive case for adult immunizations," she concluded.

This study was funded by the CDC. Dr. Hurley reports receiving grants from the CDC during the conduct of the study. The other authors have disclosed no relevant financial relationships.

Ann Intern Med. 2014;160:161-170.

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