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.

Effectiveness of primary care-public health collaborations in the delivery of influenza vaccine: a cluster-randomized pragmatic trial.

OBJECTIVE: To assess effectiveness and feasibility of public-private collaboration in delivering influenza immunization to children. METHODS: Four pediatric and four family medicine (FM) practices in Colorado with a common public health department (PHD) were randomized at the beginning of baseline year (10/2009) to Intervention (joint community clinics and PHD nurses aiding in delivery at practices); or control involving usual care without PHD. Generalized estimating equations compared changes in rates over baseline between intervention and control practices at end of 2nd intervention year (Y2=5/2011). Barriers to collaboration were examined using qualitative methods. RESULTS: Overall, rates increased from baseline to Y2 by 9.2% in intervention and 3.2% in control (p<.0001), with significant increases in both pediatric and FM practices. The largest increases were seen among school-aged and adolescent children (p<.0001 for both), with differences for 6-month-old to 5-year-old children and for children with high-risk conditions not reaching significance. Barriers to collaboration included uncertainty regarding the delivery of vaccine supplies, concerns about using up all purchased vaccine by practices, and concerns about documentation of vaccination if collaboration occurred. CONCLUSIONS: In spite of barriers, public-private collaboration resulted in significantly higher influenza immunization rates, particularly for older, healthy children who visit providers less frequently.

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.

HPV vaccination of boys in primary care practices.

OBJECTIVE: In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended the quadrivalent human papillomavirus vaccine (HPV4) for the routine immunization schedule for 11- to 12-year-old boys. Before October 2011, HPV4 was permissively recommended for boys. We conducted a study in 2010 to provide data that could guide efforts to implement routine HPV4 immunization in boys. Our objectives were to describe primary care physicians': 1) knowledge and attitudes about human papillomavirus (HPV)-related disease and HPV4, 2) recommendation and administration practices regarding HPV vaccine in boys compared to girls, 3) perceived barriers to HPV4 administration in boys, and 4) personal and practice characteristics associated with recommending HPV4 to boys. METHODS: We conducted a mail and Internet survey in a nationally representative sample of pediatricians and family medicine physicians from July 2010 to September 2010. RESULTS: The response rate was 72% (609 of 842). Most physicians thought that the routine use of HPV4 in boys was justified. Although it was permissively recommended, 33% recommended HPV4 to 11- to 12-year-old boys and recommended it more strongly to older male adolescents. The most common barriers to HPV4 administration were related to vaccine financing. Physicians who reported recommending HPV4 for 11- to 12-year-old boys were more likely to be from urban locations, perceive that HPV4 is efficacious, perceive that HPV-related disease is severe, and routinely discuss sexual health with 11- to 12-year-olds. CONCLUSIONS: Although most physicians support HPV4 for boys, physician education and evidence-based tools are needed to improve implementation of a vaccination program for males in primary care settings.

Things are not as bad as they seem: physicians' ability to predict their clinical practice when a new vaccine becomes available.

Survey results regarding primary care physicians' likelihood of recommending a new vaccine were compared before and after the vaccine was licensed by the Food and Drug Administration for three new vaccines: herpes zoster (HZ), human papillomavirus (HPV) and rotavirus (RV), using physician networks representative of United States physicians. The main purpose of this study was to determine (a) how accurately physicians predict their eventual vaccine recommendations and the barriers they will experience in delivering the new vaccine and (b) whether physicians shift towards more or less strongly recommending a new vaccine from pre- to post-licensure. Responses from 284, 152 and 184 physicians were analyzed for the three vaccines, respectively. For all vaccines, there was a significant association between physicians' pre- and post-licensure recommendations (p<0.05). When responses changed from pre- to post-licensure, physicians tended to recommend a given vaccine more strongly than they had anticipated pre-licensure. Before vaccine availability, physicians tended to predict greater barriers to vaccine delivery than they eventually experienced. Surveys are useful for predicting physician practices, but may provide a slightly pessimistic view of physician adoption of new vaccines. Such data can be helpful in devising strategies to encourage vaccine delivery by physicians.

Influenza vaccination in the 2009-2010 pandemic season: the experience of primary care physicians.

OBJECTIVES: Determine among a representative sample of pediatricians (Peds), family medicine (FM), and general internal medicine (GIM) physicians in the 2009-2010 influenza season physicians': 1) practices and experiences with delivery of seasonal and pH1N1 influenza vaccines; and 2) anticipated and experienced barriers. METHODS: Two US national surveys administered 7/2009-10/2009 (before pH1N1 distribution) and 3/2010-6/2010 (after pH1N1 distribution) to 416 Peds, 424 FM and 432 GIM. RESULTS: Of respondents who received both surveys, 62% (776/1253) completed both. Overall, 98% reported administering seasonal influenza vaccine and 86% pH1N1, with 70% reporting that working with public health in delivery of pH1N1 was a positive experience. Due to limited supplies of pH1N1, 63% of providers reported prioritizing who received vaccine even within high risk groups. Pre-distribution, 71% perceived that patient/parental safety concerns about pH1N1 would be a barrier, and post-distribution 72% perceived it had been a barrier. Physician concern about safety decreased, with 44% reporting safety a barrier pre-distribution and 12% post-distribution (p<0.001). CONCLUSIONS: In the setting of a pandemic most primary care physicians collaborated with public health in delivery of pH1N1. Physicians faced challenges with patient/parent safety concerns about pH1N1 and supply issues with pH1N1 that required physicians to prioritize who received vaccine.

Pediatricians' attitudes about collaborations with other community vaccinators in the delivery of seasonal influenza vaccine.

OBJECTIVE: Achieving universal influenza vaccination among children may necessitate collaborative delivery involving both practices and community vaccinators. We assessed among pediatricians nationally their preferences regarding location of influenza vaccination for patient subgroups and their attitudes about collaborative delivery methods. METHODS: The design/setting was a national survey conducted from July 2009 to October 2009. Participants included a representative sample of pediatricians from the American Academy of Pediatrics. RESULTS: The response rate was 79% (330 of 416). Physicians felt strongly that vaccination should occur in their practice for children with chronic conditions (52%) and healthy 6-24-month-old infants (48%), but few felt strongly about healthy 5-18-year-olds (17%). Most (78%) thought having multiple delivery sites increased vaccination rates, and 86% thought that influenza vaccine should be available at school. Physicians reported being very/somewhat willing to hold joint community clinics with public health entities (76%) and to suggest to patient subgroups that they receive vaccine at community sites, including public clinics or pharmacies (76%). The most frequently reported barriers to collaborative delivery with community sites or school-located delivery included concerns about the following: estimating the amount of vaccine to order if children are vaccinated elsewhere (community 56%; school 80%); transfer of vaccine records (community 57%; school 78%); and reluctance of families to go outside of the office (community 45%; school 74%). CONCLUSIONS: Most physicians are in favor of school-located or collaborative influenza vaccine delivery with community vaccinators, especially for healthy school-aged children. Collaborative approaches will require planning to ensure transfer of records, effective targeting of subgroups, and provisions to protect providers from being left with extra influenza supply.

Adherence to expanded influenza immunization recommendations among primary care providers.

OBJECTIVE: To assess practices regarding the expanded Advisory Committee on Immunization Practices (ACIP) recommendations for influenza vaccination in children among US pediatricians and family medicine physicians (FMs) and strategies to promote vaccination. STUDY DESIGN: We administered a survey between July and October 2009 to 416 pediatricians and 424 FMs from nationally representative networks. RESULTS: The response rate was 75% (79% pediatricians, 70% FMs). FMs were less likely than pediatricians to report adherence to ACIP recommendations (35% vs 65%; adjusted risk ratio [RR], 0.60; 95% CI, 0.50-0.72). Most physicians (89% pediatricians and 89% FMs) reported using posters or pamphlets to encourage influenza vaccination, and 57% pediatricians and 41% FMs reported offering after hours dedicated influenza vaccination clinics. Only 23% pediatricians and 14% FMs reported providing written, telephone, or e-mail reminders to all children. Having dedicated influenza vaccination clinics after hours or weekends was associated with routine vaccination of all children (adjusted RR, 1.33; 95% CI, 1.15-1.57). CONCLUSION: In the first year of the expanded ACIP recommendations to immunize all eligible children against influenza, two-thirds of pediatricians and one-half of FMs reported adherence, although less than one-quarter were actively engaging in reminder/recall efforts. Practices that adhered to the ACIP recommendations were more likely to put a substantial effort into promoting vaccination opportunities.

Timing of adolescent meningococcal conjugate vaccination attitudes and practices of pediatricians and family medicine physicians.

BACKGROUND: The meningococcal conjugate vaccine (MCV4) was recommended for those aged 11-18 years in 2005. Initial supply issues led to an emphasis on immunizing older adolescents. When supply improved in 2007, routine immunization was recommended for those aged 11-12 years. PURPOSE: Among a U.S. sample of pediatricians and family medicine physicians, describe (1) recommendation and administration practices for MCV4; (2) preferences regarding MCV4 administration; and (3) attitudes and characteristics associated with recommendation for those aged >12 years. METHODS: A mail and Internet survey in a nationally representative sample of physicians was conducted between December 2009 and March 2010. Analysis was conducted between March 2010 and October 2010, including a multivariable analysis to examine factors associated with deferring MCV4 to ages >12 years. RESULTS: Response rates were 88% (pediatricians 367/419) and 63% (family medicine physicians 268/423). In all, 95% of pediatricians and 73% of family medicine physicians reported administering MCV4 routinely to those aged 11-18 years (p<0.0001); 83% (pediatricians) and 45% (family medicine physicians) reported strongly recommending MCV4 for those aged 11-12 years (p<0.0001); 27% (pediatricians) and 40% (family medicine physicians) preferred to administer MCV4 to those aged >12 years (p<0.0001). Compared with those who strongly recommend for those aged 11-12 years, physicians who do not regularly stock MCV4, family medicine physicians, and physicians concerned about waning immunity were more likely to defer their recommendation, whereas physicians practicing in the Northeast and those with more Latino patients were less likely to defer. CONCLUSIONS: Most pediatricians and family medicine physicians administer MCV4, but many, especially family medicine physicians and those concerned about waning immunity, defer their recommendation for MCV4 to patients aged >12 years.

Seasonal influenza vaccination in adults: practice and attitudes about collaborative delivery with community vaccinators.

BACKGROUND: Less than half of adults for whom seasonal influenza vaccine is recommended receive the vaccine. Little is known about physician willingness to collaborate with community vaccinators to improve delivery of vaccine. OBJECTIVES: To assess among general internists and family medicine physicians: (1) seasonal influenza vaccination practices, (2) willingness to collaborate with community vaccinators, (3) barriers to collaboration, and (4) characteristics associated with unwillingness to refer patients to community sites for vaccination. DESIGN: Mail and Internet-based survey. SETTING: National survey conducted during July-October 2009. PARTICIPANTS: General internists and family medicine physicians. MEASUREMENTS: Survey responses on vaccination practices, willingness to collaborate to deliver vaccine and barriers to collaboration. RESULTS: Response rates were 78% (337/432 general internists) and 70% (298/424 family medicine physicians). Ninety-eight percent of physicians reported giving influenza vaccine in their practice during the 2008-2009 season. Most physicians reported willingness to refer certain patients to other community vaccinators such as public clinics or pharmacies (79%); to collaborate with public health entities in holding community vaccination clinics (76%); and set up vaccination clinics with other practices (69%). The most frequently reported barriers to collaboration included concerns about record transfer (24%) and the time and effort collaboration would take (21%). Reporting loss of income (RR 1.40, 95% CI 1.03-1.89) and losing opportunities to provide important medical services to patients with chronic medical conditions (RR 1.77, 95% CI 1.25-2.78) were associated with unwillingness to refer patients outside of the practice for vaccination. LIMITATIONS: Surveyed physicians may not be representative of all physicians. CONCLUSIONS: The majority of physicians report willingness to collaborate with other community vaccinators to increase influenza vaccination rates although some will need assurance that collaboration will be financially feasible and will not compromise care. Successful collaboration will require reliable record transfer and must not be time consuming.

Influenza vaccine delivery delays from the perspective of primary care physicians.

BACKGROUND: The effects of delayed influenza vaccine delivery on primary practices are currently unknown. PURPOSE: To describe, among primary care physicians nationally regarding the 2006-2007 influenza season: (1) how physicians defined influenza vaccine delay; (2) the extent of reported vaccine delays; and (3) the perceived effects of vaccine delays. METHODS: Between March and June 2007, a total of 1268 primary care physicians nationally were surveyed. RESULTS: Survey response was 74% (n=940). The majority of physicians (79%) defined "influenza vaccine delay" as not receiving vaccine by November 1. Fifty-three percent reported a vaccine delay. Providers reported the following as effects of delays: reduced satisfaction of patients or parents in the practice (72%); decreased percentage in their practice who received the vaccination (65%); disruption of scheduling influenza clinics (55%); increased referral of patients elsewhere for vaccination (55%); and negative financial impact caused by unused vaccine (46%). Those who reported experiencing delays more often reported not meeting demand for vaccine (adjusted risk ratio [ARR]=1.83, 95% CI=1.64, 2.07); that grocery stores, retail outlets, or pharmacies had vaccine before their practices did (ARR=1.82, 95% CI=1.53, 2.26); not receiving all vaccine that was ordered (ARR=1.19, 95% CI=1.06, 1.36); and having leftover vaccine (ARR=1.17, 95% CI=1.04, 1.32). CONCLUSIONS: During the 2006-2007 influenza season, a non-shortage season, the majority of respondents reported experiencing an influenza vaccine delivery delay. Experiencing a delay was thought to decrease vaccination use, increase referrals elsewhere, and have a negative financial impact on practices. Delayed delivery of influenza vaccine is disruptive for primary care practices, and it consequently may affect vaccination coverage.

Prevalence of parental concerns about childhood vaccines: the experience of primary care physicians.

BACKGROUND: Little is known about the effects of increased parental vaccine safety concerns on physicians' vaccine communication attitudes and practices. PURPOSE: To assess among pediatricians and family medicine (FM) physicians: (1) prevalence of parental requests to deviate from recommended vaccine schedules; (2) responses to such requests; and (3) attitudes about the burden and success of vaccine communications with parents. METHODS: Survey of nationally representative samples of pediatricians and FM physicians (N=696) conducted during February to May 2009 with analysis in 2010. RESULTS: Response rates were 88% for pediatricians and 78% for FM physicians. Overall, 8% of physicians reported that ≥10% of parents refused a vaccine and 20% reported that ≥10% of parents requested to spread out vaccines in a typical month. More pediatricians than FM physicians reported always/often requiring parents to sign a form if they refused vaccination (53% vs 31%, p<0.0001); 64% of all physicians would agree to spread out vaccines in the primary series at least sometimes. When talking with parents with substantial concerns, 53% of physicians reported spending 10-19 minutes and 8% spending ≥20 minutes. Pediatricians were more likely than FM physicians to report their job less satisfying because of parental vaccine concerns (46% vs 21%, p<0.0001). Messages most commonly reported as "very effective" were personal statements such as what they would do for their own children. CONCLUSIONS: The burden of communicating with parents about vaccines is high, especially among pediatricians. Physicians report the greatest success convincing skeptical parents using messages that rely on their personal choices and experiences.

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P<.001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P<.001; family physicians: 50% and 86%, respectively; P<.001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07-1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66-2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

Late-season influenza vaccination: a national survey of physician practice and barriers.

BACKGROUND: Although late-season influenza vaccination has been recently promoted, existing data suggest it occurs infrequently. PURPOSE: This study aims to describe among primary care physicians: (1) late-season vaccination practices; (2) perceived barriers; and (3) factors associated with late-season influenza vaccination in a year when vaccine supplies are inadequate or delayed. METHODS: A survey administered March 2007-June 2007 to 1268 primary care providers in a national survey network. Data analysis was completed in 2009. RESULTS: Overall response rate was 74% (n=940). Seventy-one percent of respondents reported vaccinating until February/March when there were adequate vaccine supplies and 84% reported vaccinating until February/March when vaccine supplies were inadequate or delayed. Perceived barriers to late-season vaccination included difficulty administering a second dose in children if the first was given late in the season (91% of respondents); providers/patients forgetting about vaccination (77%); and concern about having unused vaccine left at the end of a season (74%). Physicians who reported vaccinating into February/March when vaccine supplies were inadequate or delayed more often reported believing late-season vaccination is clinically beneficial, experiencing difficulty persuading patients to accept late-season vaccination, forgetting about the need for vaccination, not being able to meet demand for influenza vaccine and experiencing high patient volumes during winter months. CONCLUSIONS: Most physicians appear willing to perform late-season vaccination despite existing data demonstrating that it occurs infrequently. Efforts to increase late-season vaccination should address vaccine supply issues, late-season influenza vaccine reminders, and patient and provider education on its clinical benefits.

Barriers to the use of herpes zoster vaccine.

BACKGROUND: The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally. OBJECTIVE: To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. DESIGN: Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. SETTING: National survey conducted from July to September 2008. PARTICIPANTS: General internists and family medicine physicians. MEASUREMENTS: Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. RESULTS: Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues. LIMITATIONS: Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. CONCLUSION: Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

Knowledge of interim recommendations and use of Hib vaccine during vaccine shortages.

OBJECTIVES: The goals were to determine among pediatricians and family physicians (1) knowledge of interim recommendations regarding Haemophilus influenzae type b (Hib) vaccine administration, (2) current practices, and (3) factors associated with nonadherence. METHODS: An Internet-based survey was conducted in April 2008 among national samples. RESULTS: Response rates were 68% (220 of 325 physicians) among pediatricians and 51% (153 of 302 physicians) among family physicians. Seventy-three percent of pediatricians and 45% of family medicine physicians reported insufficient Hib vaccine supplies, and 22% to 24% reported having to defer doses for infants 2 to 6 months of age > or =10% of the time. Ninety-eight percent of pediatricians and 81% of family physicians were aware of the interim recommendations (P < or = .0001), and virtually all knew that the booster dose should be deferred; however, 22% of pediatricians and 33% of family medicine physicians reported not deferring this dose. Physicians in both specialties were less likely to adhere to recommendations to defer in this age group if they thought that their practice had sufficient vaccine supplies (pediatricians, odds ratio: 0.01 [95% confidence interval: 0.003-0.03]; family medicine physicians, odds ratio: 0.10 [95% confidence interval: 0.03-0.33]). Family medicine physicians were less likely to adhere to recommendations if they had not heard about the interim recommendations (odds ratio: 0.04 [95% confidence interval: 0.01-0.21]). CONCLUSIONS: Most primary care physicians experienced Hib vaccine shortages, and many have had to defer doses for 2- to 6-month-old children. Most are knowledgeable regarding interim recommendations, but one-fifth to one-third reported nonadherence.

Adoption of rotavirus vaccination by pediatricians and family medicine physicians in the United States.

OBJECTIVES: The goals were to assess, among pediatricians and family medicine physicians, (1) rates of offering the vaccine in their office; (2) knowledge of Advisory Committee on Immunization Practices recommendations; (3) barriers to use; and (4) factors associated with offering the vaccine. METHODS: Surveys of pediatricians and family medicine physicians were conducted in August to October 2007. RESULTS: Response rates were 84% for pediatricians and 79% for family medicine physicians (N = 623). Proportions routinely offering the vaccine were 85% of pediatricians and 45% of family medicine physicians (P < .0001); 70% of pediatricians and 22% of family medicine strongly recommended the vaccine (P < .0001). Sixty-two percent of pediatricians and 32% of family medicine physicians (P < .0001) knew the age by which all 3 doses should be completed. Definite barriers to vaccine use included reported lack of coverage by insurance companies (family medicine physicians: 22%; pediatricians: 19%; not significant), costs of purchasing vaccine (family medicine physicians: 22%; pediatricians: 17%; not significant), lack of adequate reimbursement (family medicine physicians: 18%; pediatricians: 15%; not significant), concerns about safety (family medicine physicians: 25%; pediatricians: 9%; P < .0001), and concerns about adding another vaccine to the schedule (family medicine physicians: 22%; pediatricians: 5%; P < .0001). CONCLUSIONS: Rates of offering the new rotavirus vaccine are high among pediatricians but <50% among family medicine physicians. Both specialties identified financial barriers to use of the vaccine, but family medicine physicians had significantly more concerns about safety and about adding another vaccine to the vaccination schedule.

Physician practices regarding adult hepatitis B vaccination: a national survey.

BACKGROUND: Less than 50% of adults with risk factors for hepatitis B infection have been vaccinated. Although primary care settings typically serve an important role in immunization delivery, little is known about adult hepatitis B vaccination practices in primary care, including the use of strategies such as standing orders to improve immunization rates. The objectives of this study were to assess, among family physicians and general internists, current approaches to assessing adult patients for hepatitis B risk factors, reported hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination. METHODS: From September to November 2006, a national sample of 433 family physicians and 420 general internists were surveyed. Results were analyzed in 2007 and 2008. RESULTS: Response rates were 65% for family physicians and 79% for general internists. Thirty-one percent of physicians reported assessing most or all adult patients for hepatitis B risk factors and vaccinating patients identified as high risk. Perceived barriers to hepatitis B vaccination included patients not disclosing high-risk behaviors, lack of adequate reimbursement for vaccination, and feeling too pressed for time to assess risk factors. Most surveyed physicians were very (47%) or somewhat (38%) supportive of using standing orders for hepatitis B vaccination in their practices. However, staff time constraints and patient unwillingness to disclose sensitive information to staff were perceived as barriers to using standing orders by a majority of respondents. CONCLUSIONS: In a national survey, less than one third of primary care physicians reported routinely assessing for and vaccinating adults with hepatitis B risk factors. This finding suggests that new strategies for adult hepatitis B vaccination in primary care settings are needed. Most physicians supported using standing orders for vaccination, but barriers were anticipated.

Impact of the 2004-2005 influenza vaccine shortage on pediatric practice: a national survey.

BACKGROUND: A severe influenza vaccine shortage occurred during the 2004-2005 influenza season because of the loss of all vaccine made by Chiron (Emeryville, CA) for US distribution. OBJECTIVES: The objectives of this study were to assess among pediatricians nationally: (1) influenza vaccine-delivery strategies; (2) reported vaccine shortages and factors associated with experiencing shortages; and (3) the impact of shortages on vaccine redistribution, patient referral, and clinical practice, including patient prioritization. METHODS: A survey was administered in March 2005 through June 2005 to 427 pediatricians who participated in a national network representative of the American Academy of Pediatrics membership. RESULTS. Our response rate was 82%. Thirty-nine percent of the pediatricians had a computerized method for identifying patients at high risk needing vaccination. Ninety-four percent and 79% reported giving high-priority to children >/=24 months old with high-risk conditions and children 6 to 23 months old, respectively, whereas 41% gave high-priority to household contacts and caregivers of children <6 months old. Forty-three percent reported experiencing shortages of vaccine for patients at high risk, whereas only 14% ordered Chiron vaccine. In multivariate analyses, ordering vaccine from Chiron and ordering Aventis Pasteur (Lyon, France) vaccine solely from a vaccine distributor were associated with experiencing a shortage. Forty-eight percent of respondents obtained additional vaccine from another source, most frequently the public health sector, whereas 37% reported selling or giving away vaccine. In addition, 47% referred patients at high risk elsewhere for vaccination, primarily to public health clinics. Forty-nine percent reported having unused vaccine remaining at the end of the season. CONCLUSIONS: Although few pediatricians ordered Chiron vaccine, substantial influenza vaccine shortages were reported, highlighting the tenuousness of injectable influenza vaccine supplies for children. The extensive redistribution of vaccine suggests that cooperative efforts between the private and public sectors were widespread. Efforts to vaccinate patients at high risk during shortages would be aided by better systems to identify and recall these patients.

Pneumococcal vaccination in general internal medicine practice: current practice and future possibilities.

BACKGROUND: Pneumococcal vaccine (PPV) is recommended for adults >or=65 years and those with chronic illness, but there are potential advantages of universal vaccination of adults age 50-64 years. OBJECTIVE: To assess reported (1) recommendations and administration practices of general internists for PPV, (2) barriers to vaccination, and (3) willingness to expand vaccination to all adults >or=50 years. METHODS: National survey of general internists representative of the American College of Physicians. RESULTS: Response rate was 74% (N = 326). Although 99% reported giving PPV, less than 20% used a computerized database to identify eligible patients by age or diagnoses and only 6% recalled patients. Major barriers included acute problems taking precedence over preventive care (39%), difficulty determining vaccination history (30%), not thinking of it/not a priority (20%), and inadequate reimbursement for vaccine (19%). If ACIP expanded recommendations, 60% would definitely and 37% would probably institute this change. CONCLUSIONS: Most general internists reported giving PPV, but delivery was hindered by competing demands, lack of systems to identify patients needing vaccination, and reimbursement issues. Barriers might be decreased by a policy of universal vaccination of adults >or=50 years, and the majority of physicians reported they would follow such a recommendation if it were made.