# Presentation: 116801

## Attitudes About and Barriers to Adult Immunization

- Faruque Ahmed, MD, PhD, MPH
- (E-mail: fahmed@cdc.gov)
- Immunization Services Division
- Centers for Disease Control and Prevention

- National Vaccine Advisory Committee
- October, 2007

## Outline of Presentation

**Patient factors**
**Provider factors**
**Systems factors**
**Environmental factors**

## Reasons for Not Getting VaccinatedMedicare Beneficiary Survey

**Influenza**

**Pneumococcal**

**Percent**

- MMWR 48:886-90, 1999

## Reasons Given for Not Receiving Influenza Vaccination

- Healthstyles 2001

## Adults Aged >65 Years Not Receiving Influenza Vaccination

- Singleton J. Am J Prev Med 29:412-20, 2005

|  | White
(%) | Black
(%) | Hispanic
(%) |
| --- | --- | --- | --- |
| Know that flu shot is recommended | 91 | 81 | 79 |
| Provider recommended flu shot since September 2002 (last year) | 24 | 24 | 34 |
| Reasons for not receiving vaccination: |  |  |  |
|     Concerned about side effects | 26 | 26 | 19 |
|     Don’t think I need the vaccine | 22 | 15 | 23 |
|     Don’t think the vaccine works |   5 |   3 |   4 |

## Adults Aged >65 Years Not Receiving Pneumococcal Vaccination

- Singleton J. Am J Prev Med 29:412-20, 2005

|  | White
(%) | Black
(%) | Hispanic
(%) |
| --- | --- | --- | --- |
| Know that pneu. shot is recommended | 56 | 39 | 39 |
| Provider recommended shot since September 2002 (last year) |   8 |   4 | 11 |
| Reasons for not receiving vaccination: |  |  |  |
|     Concerned about side effects |   7 |   8 | 10 |
|     Don’t think I need the vaccine | 33 | 17 | 19 |
|     Don’t think the vaccine works |   2 |   0 |   3 |
|     Don’t know the shot existed | 20 | 40 | 33 |

## Medicare Beneficiaries Reporting Provider Recommendation, READII Survey, 2003

**Influenza ****(last fall)**

**Pneumococcal ****(ever)**

**% of participants**

- Winston C. J Am Geriatr Soc 54:303-10, 2006

## Influenza Vaccination by Attitude and Provider Recommendation (Medicare beneficiaries, READII Survey, 2004)

**Positive**
**attitude**

**Negative **
**attitude**

**No rec**

**Prov rec**

**No rec**

**Prov rec**

- Lindley M. Am J Prev Med 31:281-5, 2006

## When Offered Vaccine, Do Patients Accept (1)

- Vaccinated
- or intend to

- Not vaccinated because afraid, no benefit

- Not vaccinated because not recommended or not strongly enough

**85 (39%)**

**98 (44%)**

**38 (17%)**

- Nicoleau A. J Am Med Dir Assoc 2:56-9, 2001

**221 African American patients in Queens, NY, were asked about influenza vaccination before encounter with provider:**

## When Offered Vaccine, Do Patients Accept (2)

- Vaccinated
- or intend to

- Not vaccinated because afraid, no benefit

- Not vaccinated because not recommended or not strongly enough

**85**

**98**

**38**

- Nicoleau A. J Am Med Dir Assoc 2:56-9, 2001

**Physicians offered influenza vaccine to patients:**

**33/38 (87%) accepted**

**8/85 (9%) accepted**

## Vaccine Acceptance Rates When Systematically Offered

|  | African American |           White |
| --- | --- | --- |
| Detroit – Influenza vaccine*
(Schwartz K, J Gen Intern Med 2006) | 62% | 69% |
| UCSF – Pneumococcal Vaccine†
(Daniels N, J Nat Med Assoc 2006)
 | 81% | 92% |

*** Excluded persons who already received vaccine or stated vaccination as the reason for visit**
**†**** ****Excluded persons who already received vaccine**

## Provider PerspectiveAdult Health Care

- Not prevention-oriented
- Other acute and chronic problems
- Many prevention recommendations          (average 65+: 18 risk factors and 35 rec’s*)
- Complex assessment for influenza
- Refusal
- Cost

- *Medder JD. AJPM 8:150-3, 1992

## Physician Perception of Barriers

| Barrier | Pneumococcal vaccination* | Influenza vaccination* |
| --- | --- | --- |
| Urgent concerns dominate visit | 44 | 43 |
| Not knowing patient immunization history | 36 | 12 |
| Patient concern about vaccine safety | 31 | 58 |
| Inadequate reimbursement | 25 | 26 |
| Identifying eligible patients | 21 | 13 |
| Lack of patient-oriented vaccine information | 20 | 20 |

- *Percent of physicians

- Szilagyi. Prev Med 40:152-61, 2005

## 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)

## Meta-Analysis of Interventions that Increase Use of Adult Immunization 

| Intervention | Odds Ratio* |
| --- | --- |
| Organizational change 
(e.g., standing orders, separate clinics devoted to prevention) | 16.0 |
| Provider reminder |   3.8 |
| Provider education |   3.2 |
| Patient financial incentive |   3.4 |
| Patient reminder |   2.5 |
| Patient education |   1.3 |

- *Compared to usual care or control group, adjusted for all remaining interventions

- Stone E. Ann Intern Med 136:641-51, 2002

## Strategies Used by Physicians to Promote Influenza Vaccinations

- Nichol K. Arch Intern Med 161:2702-8, 2001

## Primary Care Physician Interest in  Strategies to Improve Adult Vaccinations

- Szilagyi P. Prev Med 40:152-61, 2005

## Would an increase in payment  encourage you to adopt new strategies?

- Percent of respondents (N=508)

- Fontanesi J. Physician Reimbursement of Influenza Costs Evaluation (PRICE 1) Study

## Reimbursement for Influenza Vaccine  and Administration in Selected Years

| Year | Administrative Reimbursement | Vaccine Reimbursement |
| --- | --- | --- |
| 2001 |  $4.59 |  $7.12 |
| 2002 |   $3.98 |  $7.12 |
| 2003 | $10.17 |  $7.50 |
| 2005 | $18.00 | $10.40 |
| 2007 | $19.33 | $13.22 |

- All prices approximate national averages.

## Operational Conditions Affecting Vaccination

- Medium and large ambulatory care settings with reminder recall, provider prompting, and standing orders
- 62% of patients aged >50 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 _<_ 1:2, AND
- Provider to staff ratio _>_ 1:4

- Fontanesi J. Am J Prev Med 26:265-70, 2004

## Distribution of Physicians by Practice Size

- Hing E. Advance Data no. 383, NCHS, 2007

## Primary Care Physicians Who Routinely Administer Adult Vaccinations

- Szilagyi P. Prev Med 40:152-61, 2005

## Influenza Vaccine Availability by Subspecialty Practices

- Davis MM. Am J Prev Med 26:307-10, 2004

## Location of Influenza Vaccination

- Singleton J. Am J Infect Control 33:563-70, 2005

## Proportion of Adults With No Regular Personal Health Care Provider

- MMWR 53(40):937-941, 2004

## Influenza Vaccination Among Adults        by Regular Personal Health Care Provider

- MMWR 52(41):987-92, 2003

## Lack of Health Insurance by Race/Ethnicity

- _[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a6.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a6.htm)_

## Lack of Health InsuranceBy Age Group

- http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5415a4.htm

## Influenza Vaccination Among High-Risk Adults Aged 18-64 Years by Health Insurance

- MMWR 54(41):1045-9, 2005

## 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**