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Gaps found in adult vaccination referrals, administrations
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Implementation of the Standards for Adult Immunization Practice varied substantially by vaccine and provider type, according to findings recently published in the American Journal of Preventive Medicine.
“Although previous studies have reported on assessment, recommendation and administration practices for adult vaccination among primary care physicians, the present study also included OB-GYNs, subspecialists and pharmacists, and assessed multiple vaccine types,” Chelsea S. Lutz, MPH, of the Immunization Services Division at the CDC and colleagues wrote.
Researchers analyzed survey responses from 261 pharmacists and 1,714 clinicians regarding their or their support staff’s vaccine administration or referral for eight different vaccines. Of the clinicians, 30.7% were family physicians, 25.5% were internal medicine practitioners, 23.6% OB-GYN, and 20.2% subspecialists.
Lutz and colleagues found that more than 80% of providers assessed for and recommended the influenza vaccine, but 48.9% of subspecialists and 24.3% of the OB-GYNs did not stock influenza vaccine for administration. In addition, although more than 89% of PCPs recommended the herpes zoster vaccine, less than 58% stocked the vaccine. However, 91.6% of pharmacists stocked herpes zoster vaccine.
Other differences between implementation and provider type included 91.2% of OB-GYNs recommended the HPV vaccine vs. 68.6% of internal medicine respondents; more family medicine respondents than OB-GYN respondents indicated they recommended hepatitis B (78.9% vs. 31.6%) and tetanus and diphtheria toxoids (73.6% vs. 23.4%) vaccines. Also, 80.7% family physicians kept 13-valent pneumococcal conjugate in stock vs. 88.8% of pharmacists, with the numbers for these professionals stocking the 23-valent pneumococcal polysaccharide at 79.2% vs. 88.8% and tetanus-diphtheria-acellular pertussis vaccines at 88.8% vs. 78.2%.
“This analysis highlights ... the need to ensure communication among providers regarding vaccinations provided and vaccination needs of their adult patients. It also highlights the need to maintain the capacity of health departments and pharmacies to provide vaccinations for adult patients whose medical provider does not stock one or more recommended vaccines. Improvements to vaccination coverage among adults may be achieved by increasing provider implementation of the [Standards for Adult Immunization Practice],” Lutz and colleagues concluded. – by Janel Miller
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Gregory Poland, MD
These findings by Lutz et al are not surprising and are predictable based on the incentives and disincentives that practicing physicians and pharmacists experience. Think about it: OB-GYNs stock vaccines against diseases more common to the subgroup of patients that they see, such as HPV. For the same reason, it’s why pharmacists often don’t stock tetanus-diphtheria vaccine, since that is something more typically administered in an ER or by an internist to older patients. On the other hand, the pharmacist will keep a plentiful supply of the zoster vaccine on hand because it is covered by Medicare Part D, and many of these patients go to their pharmacist to get this vaccine.
My research over the past 30 years has shown we have a hobbled and cobbled together system for providing vaccines to adults. The government has organized and assembled various committees that have examined all the data to make expert recommendations on who should get what vaccines and for what reason. These are evidence-based. The problem is in the next step of the process, which is the disconnect between policy and payment. With vaccines, there is a limited shelf life and if physicians cannot give them to enough of their patients, why would you stock them? That is a question many physicians struggle with every day. They have to consider the vaccine’s availability, whether or not many of their patients will accept the vaccine, and then whether they — the physician — will be reimbursed for all that work. Depending upon where you practice and under what conditions, not all those scenarios are favorable to physicians trying to deliver vaccines according to expert recommendations.
There are other burdens in delivering vaccines to the population. I wrote the first Adult Immunization Standards, which have subsequently been revised. We have many physicians who don’t think about vaccines and who don’t routinely recommend and provide them to their patients. I have written many papers regarding vaccines and who to distribute them to , and the effect of anti-vaccine misinformation. We need a compelling easy to understand meta-narrative for adult immunization that demonstrates the clear-cut, definable and quantifiable benefits to our health.
We also have a culture that is increasingly uninformed about vaccines, and this undermines the credibility of vaccines. It is incomprehensible to me that there are celebrities who have no training in the science of vaccinology who are given a pulpit to proclaim their views, which are often inaccurate, and that much of the public bases their medical decisions on what that celebrity says. So we are left with a system that wants to give life-saving and health-preserving vaccines, a population often reluctant to receive vaccines, a piecemeal delivery system, and a payment system that makes it difficult to reimburse vaccines, and many in the medical community often feel like giving up.
Vaccines, along with diet and exercise, are among the simplest ways to avoid disease, and as medical professionals, we cannot give up — we need to educate our patients about the importance of vaccines.
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