Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

BACKGROUND: Rotavirus vaccine (RV) coverage levels for US infants are <80%. METHODS: We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age. RESULTS: Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age. CONCLUSIONS: US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.

Primary care physicians' perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adults.

BACKGROUND: Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine. METHODS: We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs. RESULTS: The response rate was 67% (620/930). Forty-nine percent of respondents (n = 303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n = 317), 73% and 57% responded that in patients ≥ 50 years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%). CONCLUSIONS: Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.

Knowledge and Attitudes Regarding Category B ACIP Recommendations Among Primary Care Providers for Children.

OBJECTIVE: In 2015, the Advisory Committee on Immunization Practices (ACIP) made a category B recommendation for use of serogroup B meningococcal (MenB) vaccines, meaning individual clinical decision-making should guide recommendations. This was the first use of a category B recommendation pertaining to a large population and the first such recommendation for adolescents. As part of a survey regarding MenB vaccine, our objectives were to assess among pediatricians (Peds) and family physicians (FPs) nationally: 1) knowledge of the meaning of category A versus B recommendations and insurance coverage implications, and 2) attitudes about category A and B recommendations. METHODS: We surveyed a nationally representative sample of Peds and FPs via e-mail and mail from October to December 2016. RESULTS: The response rate was 72% (660 of 916). Although >80% correctly identified the definition of a category A recommendation, only 24% were correct about the definition for category B. Fifty-five percent did not know that private insurance would pay for vaccines recommended as category B, and 51% did not know that category B-recommended vaccines would be covered by the Vaccines for Children program. Fifty-nine percent found it difficult to explain category B recommendations to patients; 22% thought ACIP should not make category B recommendations; and 39% were in favor of category B recommendations because they provide leeway in decision-making. CONCLUSIONS: For category B recommendations to be useful in guiding practice, primary care clinicians will need to have a better understanding of their meaning, their implications for insurance payment, and guidance on how to discuss them with parents and patients.

Vaccine financing and billing in practices serving adult patients: A follow-up survey.

BACKGROUND: Financial concerns are often cited by physicians as a barrier to administering routinely recommended vaccines to adults. The purpose of this study was to assess perceived payments and profit from administering recommended adult vaccines and vaccine purchasing practices among general internal medicine (GIM) and family medicine (FM) practices in the United States. METHODS: We conducted an interviewer-administered survey from January-June 2014 of practices stratified by specialty (FM or GIM), affiliation (standalone or ≥ 2 practice sites), and level of financial decision-making (independent or larger system level) in FM and GIM practices that responded to a previous survey on adult vaccine financing and provided contact information for follow-up. Practice personnel identified as knowledgeable about vaccine financing and billing responded to questions about payments relative to vaccine purchase price and payment for vaccine administration, perceived profit on vaccination, claim denial, and utilization of various purchasing strategies for private vaccine stocks. Survey items on payment and perceived profit were assessed for various public and private payer types. Descriptive statistics were calculated and responses compared by physician specialty, practice affiliation, and level of financial decision-making. RESULTS: Of 242 practices approached, 43% (n = 104) completed the survey. Reported payment levels and perceived profit varied by payer type. Only for preferred provider organizations did a plurality of respondents report profiting on adult vaccination services. Over half of respondents reported losing money vaccinating adult Medicaid beneficiaries. One-quarter to one-third of respondents reported not knowing about Medicare Part D payment levels for vaccine purchase and vaccine administration, respectively. Few respondents reported negotiating with manufacturers or insurance plans on vaccine purchase prices or payments for vaccination. CONCLUSIONS: Practices vaccinating adults may benefit from education and technical assistance related to vaccine financing and billing and greater use of purchasing strategies to decrease upfront vaccine cost.

Immunization Practices of U.S. Obstetrician/Gynecologists for Pregnant Patients.

INTRODUCTION: U.S. obstetrician/gynecologists play a critical role as vaccinators of pregnant women. However, little is known about their current immunization practices. Thus, study objectives were to determine (1) practices related to assessment of vaccination status and vaccine delivery for pregnant patients; (2) barriers to stocking and administering vaccines; and (3) factors associated with administering both influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. METHODS: An e-mail and mail survey among a national sample of obstetrician/gynecologists conducted July-October 2015 (analysis August 2016-August 2017). RESULTS: The response rate was 73.2% (353/482). Among obstetrician/gynecologists caring for pregnant women (n=324), vaccination status was most commonly assessed for influenza (97%), Tdap (92%), and measles, mumps, and rubella vaccines (88%). Vaccines most commonly administered included influenza (85%) and Tdap (76%). Few respondents reported administering other vaccines to pregnant patients. More physicians reported using standing orders for influenza (66%) than Tdap (39%). Other evidence-based strategies for increasing vaccine uptake were less frequently used (electronic decision support, 42%; immunization information system to record [13%] or assess vaccination status [11%]; reminder/recall, 7%). Barriers most commonly reported were provider financial barriers, yet provider attitudinal barriers were rare. Providers who administered both influenza and Tdap vaccines were more likely to be female, perceive fewer financial and practice barriers, less likely to be in private practice, and perceive more patient barriers. CONCLUSIONS: Although most obstetrician/gynecologists administer some vaccines to pregnant women, the focus remains on influenza and Tdap. Financial barriers and infrequent use of evidence-based strategies for increasing vaccination uptake may be hindering delivery of a broader complement of adult vaccines in obstetrician/gynecologist offices.

Financing of Vaccine Delivery in Primary Care Practices.

OBJECTIVE: Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances. METHODS: A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices. RESULTS: The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51-4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded 'yes,' and 24% of Ped and 26% of FM practices responded 'no, but have seriously considered.' CONCLUSIONS: Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

Primary care physicians' perspective on financial issues and adult immunization in the Era of the Affordable Care Act.

BACKGROUND: Financial barriers to adult vaccination are poorly understood. Our objectives were to assess among general internists (GIM) and family physicians (FP) shortly after Affordable Care Act (ACA) implementation: (1) proportion of adult patients deferring or refusing vaccines because of cost and frequency of physicians not recommending vaccines for financial reasons; (2) satisfaction with reimbursement for vaccine purchase and administration by payer type; (3) knowledge of Medicare coverage of vaccines; and (4) awareness of vaccine-specific provisions of the ACA. METHODS: We administered an Internet and mail survey from June to October 2013 to national networks of 438 GIMs and 401 FPs. RESULTS: Response rates were 72% (317/438) for GIM and 59% (236/401) for FP. Among physicians who routinely recommended vaccines, up to 24% of GIM and 30% of FP reported adult patients defer or refuse certain vaccines for financial reasons most of the time. Physicians reported not recommending vaccines because they thought the patient's insurance would not cover it (35%) or the patient could be vaccinated more affordably elsewhere (38%). Among physicians who saw patients with this insurance, dissatisfaction ('very dissatisfied') was highest for payments received from Medicaid (16% vaccine purchase, 14% vaccine administration) and Medicare Part B (11% vaccine purchase, 11% vaccine administration). Depending on the vaccine, 36-71% reported not knowing how Medicare covered the vaccine. Thirty-seven percent were 'not at all aware' and 19% were 'a little aware' of vaccine-specific provisions of the ACA. CONCLUSIONS: Patients are refusing and physicians are not recommending adult vaccinations for financial reasons. Increased knowledge of private and public insurance coverage for adult vaccinations might position physicians to be more likely to recommend vaccines and better enable them to refer patients to other vaccine providers when a particular vaccine or vaccines are not offered in the practice.

Physician Attitudes Toward Adult Vaccines and Other Preventive Practices, United States, 2012.

OBJECTIVES: We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits. METHODS: We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians. RESULTS: We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month. CONCLUSIONS: Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

U.S. physicians' perspective of adult vaccine delivery.

BACKGROUND: Adults are at substantial risk for vaccine-preventable disease, but their vaccination rates remain low. OBJECTIVE: To assess practices for assessing vaccination status and stocking recommended vaccines, barriers to vaccination, characteristics associated with reporting financial barriers to delivering vaccines, and practices regarding vaccination by alternate vaccinators. DESIGN: Mail and Internet-based survey. SETTING: Survey conducted from March to June 2012. PARTICIPANTS: General internists and family physicians throughout the United States. MEASUREMENTS: A financial barriers scale was created. Multivariable linear modeling for each specialty was performed to assess associations between a financial barrier score and physician and practice characteristics. RESULTS: Response rates were 79% (352 of 443) for general internists and 62% (255 of 409) for family physicians. Twenty-nine percent of general internists and 32% of family physicians reported assessing vaccination status at every visit. A minority used immunization information systems (8% and 36%, respectively). Almost all respondents reported assessing need for and stocking seasonal influenza; pneumococcal; tetanus and diphtheria; and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines. The most commonly reported barriers were financial. Characteristics significantly associated with reporting greater financial barriers included private practice setting, fewer than 5 providers in the practice, and, for general internists only, having more patients with Medicare Part D. The most commonly reported reasons 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% and 41%, respectively). Patients were most often referred to pharmacies/retail stores and public health departments. LIMITATIONS: Surveyed physicians may not be representative of all physicians. CONCLUSION: Improving adult vaccination delivery will require increased use of evidence-based methods for vaccination delivery and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Vaccine financing from the perspective of primary care physicians.

OBJECTIVES: Because of high purchase costs of newer vaccines, financial risk to private vaccination providers has increased. We assessed among pediatricians and family physicians satisfaction with insurance payment for vaccine purchase and administration by payer type, the proportion who have considered discontinuing provision of all childhood vaccines for financial reasons, and strategies used for handling uncertainty about insurance coverage when new vaccines first become available. METHODS: A national survey among private pediatricians and family physicians April to September 2011. RESULTS: Response rates were 69% (190/277) for pediatricians and 70% (181/260) for family physicians. Level of dissatisfaction varied significantly by payer type for payment for vaccine administration (Medicaid, 63%; Children's Health Insurance Program, 56%; managed care organizations, 48%; preferred provider organizations, 38%; fee for service, 37%; P < .001), but not for payment for vaccine purchase (health maintenance organization or managed care organization, 52%; Child Health Insurance Program, 47%; preferred provider organization, 45%; fee for service, 41%; P = .11). Ten percent of physicians had seriously considered discontinuing providing all childhood vaccines to privately insured patients because of cost issues. The most commonly used strategy for handling uncertainty about insurance coverage for new vaccines was to inform parents that they may be billed for the vaccine; 67% of physicians reported using 3 or more strategies to handle this uncertainty. CONCLUSIONS: Many primary care physicians are dissatisfied with payment for vaccine purchase and administration from third-party payers, particularly public insurance for vaccine administration. Physicians report a variety of strategies for dealing with the uncertainty of insurance coverage for new vaccines.