Attitudes About and Barriers to Adult Immunization

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Attitudes About and Barriers to Adult Immunization
National Vaccine Advisory Committee October, 2007

• Faruque Ahmed, MD, PhD, MPH
• (E-mail fahmed_at_cdc.gov)
• Immunization Services Division
• Centers for Disease Control and Prevention

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Outline of Presentation

• Patient factors
• Provider factors
• Systems factors
• Environmental factors

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Reasons for Not Getting VaccinatedMedicare
Beneficiary Survey
Influenza
Pneumococcal
Percent
MMWR 48886-90, 1999
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Reasons Given for Not Receiving Influenza
Vaccination
Healthstyles 2001
5
Adults Aged gt65 Years Not Receiving Influenza
Vaccination
Singleton J. Am J Prev Med 29412-20, 2005
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Adults Aged gt65 Years Not Receiving Pneumococcal
Vaccination
Singleton J. Am J Prev Med 29412-20, 2005
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Medicare Beneficiaries Reporting Provider
Recommendation, READII Survey, 2003
of participants
Influenza (last fall)
Pneumococcal (ever)
Winston C. J Am Geriatr Soc 54303-10, 2006
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Influenza Vaccination by Attitude and Provider
Recommendation (Medicare beneficiaries, READII
Survey, 2004)
No rec
Prov rec
No rec
Prov rec
Positive attitude
Negative attitude
Lindley M. Am J Prev Med 31281-5, 2006
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When Offered Vaccine, Do Patients Accept (1)
221 African American patients in Queens, NY, were
asked about influenza vaccination before
encounter with provider
Vaccinated or intend to
Not vaccinated because not recommended or not
strongly enough
38 (17)
98 (44)
85 (39)
Not vaccinated because afraid, no benefit
Nicoleau A. J Am Med Dir Assoc 256-9, 2001
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When Offered Vaccine, Do Patients Accept (2)
Physicians offered influenza vaccine to patients
33/38 (87) accepted
Vaccinated or intend to
Not vaccinated because not recommended or not
strongly enough
38
98
85
Not vaccinated because afraid, no benefit
8/85 (9) accepted
Nicoleau A. J Am Med Dir Assoc 256-9, 2001
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Vaccine Acceptance Rates When Systematically
Offered
Excluded persons who already received vaccine
or stated vaccination as the reason for visit
Excluded persons who already received vaccine
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Provider PerspectiveAdult Health Care

• Not prevention-oriented
• Other acute and chronic problems
• Many prevention recommendations (average
  65 18 risk factors and 35 recs)
• Complex assessment for influenza
• Refusal
• Cost

Medder JD. AJPM 8150-3, 1992
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Physician Perception of Barriers
Percent of physicians
Szilagyi. Prev Med 40152-61, 2005
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Evidence-Based Interventions

• Provider or system-based interventions
• Provider reminder/recall
• Feedback to providers
• Standing orders for adults
• Increasing community demand
• Client reminder/recall
• Multicomponent education
• Enhancing access
• Reducing out-of-pocket costs
• Multicomponent expanding access (drop-in clinic,
  emergency dept, inpatient, sub-specialty clinics)

Guide to Community Preventive Services
(www.thecommunityguide.org)
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Meta-Analysis of Interventions that Increase Use
of Adult Immunization
Compared to usual care or control group,
adjusted for all remaining interventions
Stone E. Ann Intern Med 136641-51, 2002
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Strategies Used by Physicians to Promote
Influenza Vaccinations
Nichol K. Arch Intern Med 1612702-8, 2001
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Primary Care Physician Interest in Strategies to
Improve Adult Vaccinations
Szilagyi P. Prev Med 40152-61, 2005
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Would an increase in payment encourage you to
adopt new strategies?
Percent of respondents (N508)
Fontanesi J. Physician Reimbursement of Influenza
Costs Evaluation (PRICE 1) Study
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Reimbursement for Influenza Vaccine and
Administration in Selected Years
All prices approximate national averages.
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Operational Conditions Affecting Vaccination

• Medium and large ambulatory care settings with
  reminder recall, provider prompting, and standing
  orders
• 62 of patients aged gt50 years with scheduled
  visits received influenza vaccinations
• Best pathway to immunization
• Pt. asked about vaccinations by staff prior to
  exam, AND
• Pt. asked about vac by provider in exam room, AND
• Time with provider to total time in clinic, ratio
  lt 12, AND
• Provider to staff ratio gt 14

Fontanesi J. Am J Prev Med 26265-70, 2004
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Distribution of Physicians by Practice Size
Hing E. Advance Data no. 383, NCHS, 2007
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Primary Care Physicians Who Routinely Administer
Adult Vaccinations
Szilagyi P. Prev Med 40152-61, 2005
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Influenza Vaccine Availability by Subspecialty
Practices
Davis MM. Am J Prev Med 26307-10, 2004
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Location of Influenza Vaccination
Singleton J. Am J Infect Control 33563-70, 2005
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Proportion of Adults With No Regular Personal
Health Care Provider
MMWR 53(40)937-941, 2004
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Influenza Vaccination Among Adults by
Regular Personal Health Care Provider
MMWR 52(41)987-92, 2003
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Lack of Health Insurance by Race/Ethnicity
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a6.
htm
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Lack of Health InsuranceBy Age Group
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5415a4.
htm
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Influenza Vaccination Among High-Risk Adults Aged
18-64 Years by Health Insurance
MMWR 54(41)1045-9, 2005
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Summary

• Patient factors
• Concerns, misconceptions
• Lack of awareness
• Mistrust
• Cultural / ethnic issues
• Provider factors
• Competing demands
• Missed opportunities
• Systems factors
• Practices may have limited resources available
• Availability of vaccine in physician practices
• Environmental factors
• Inconvenient access
• No regular health care provider
• Lack of health insurance