Primary Care Docs Unsure on Pneumococcal Vaccine Guidelines

Veronica Hackethal, MD

January 29, 2018

Primary care physicians (PCPs) are unclear on certain aspects of the pneumococcal vaccination guidelines even though they enthusiastically endorse them, a nationwide survey finds.

The results, published in the January-February issue of the Journal of the American Board of Family Medicine, suggest that incorporating prompts in electronic medical records might improve pneumococcal vaccination rates.

"The confusion identified here suggests that having an active clinical decision support system...to identify adult patients who need pneumococcal vaccines at a visit, and not relying on physician knowledge, could help implement pneumococcal vaccine recommendations," write first author Laura Hurley, MD, MPH, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, and colleagues.

Pneumococcal pneumonia can cause serious illness. The infection is responsible for an estimated 445,000 hospitalizations annually and killed 3350 Americans in 2015. Despite longstanding recommendations for vaccination, only 64% of adults aged 65 years and older and only 23% of high-risk adults aged 19 to 64 years were vaccinated in 2015, the authors note.

These low rates may be in part a result of confusion about who to vaccinate, perhaps related to recent guideline revisions. In 2012, the Advisory Committee on Immunization Practices recommended that at-risk adults aged 19 years and older who have not yet been vaccinated should first receive the 13-valent pneumococcal conjugate vaccine (PCV13), followed 8 weeks later by the 23-valent pneumococcal polysaccharide vaccine.

In 2014, the Advisory Committee on Immunization Practices expanded these recommendations to include vaccine-naive adults aged 65 years and older. These patients should receive the PCV13 vaccine first, followed 6 to 12 months later by 23-valent pneumococcal polysaccharide vaccine. And in 2015, the Advisory Committee on Immunization Practices revised these recommended intervals to 1 year.

To explore how providers think about and use these recommendations, Dr Hurley and colleagues conducted an email and postal survey of primary care physicians in the United States between December 2015 and January 2016.

The survey had a response rate of 66%, and the analysis included responses from 602 physicians. More than 95% of respondents reported routine assessment of patients' vaccination status, as well as recommending both vaccines.

Overall, 50% of respondents said the current recommendations are "very clear," and 38% said they were "somewhat clear." Most also reported that the recommendations are easy to implement (48% said it was "very easy," and 34% said it was "somewhat easy").

Even with this reported enthusiasm, providers showed variable knowledge about the recommendations. They were most knowledgeable about the fact that the PCV13 vaccine should be given first to vaccine-naive adults aged 65 years and older (83% answered correctly). However, just 21% knew the correct recommended interval between PCV13 and 23-valent pneumococcal polysaccharide vaccine in high-risk individuals younger than 65 years.

"Despite being given the option to say they would need to look the answer up, approximately a third or more of physicians answered half of the questions incorrectly," the authors write.

Top barriers to administering the vaccines in series included financial concerns, especially regarding insurance reimbursement, and problems obtaining the patients' pneumococcal vaccination history. Respondents reported that prompts in the electronic medical record could help clarify recommendations, although the majority said they did not have them.

The authors note that although the survey was designed to represent members of the American College of Physicians and the American Academy of Family Physicians, the opinions of this sample may not fully represent primary care physicians in the United States.

The study was supported by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.

J Am Board Fam Med. 2018;31:94-104. Abstract

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