KANSAS CITY, MO. — Physicians support using risk-based standing orders for adult hepatitis B vaccinations, but see clear barriers to their implementation, results of a national survey show.
Prior studies show that age- and risk-based standing orders that authorize health care personnel to vaccinate by protocol without physician involvement have increased adult pneumococcal and influenza vaccination rates by 16%–97%, when done as part of a multicomponent strategy.
But unlike assessing adults for pneumococcal disease or influenza, using standing orders to assess for hepatitis B virus (HBV) risk factors requires obtaining potentially sensitive information, Dr. Allison Kempe and her associates reported in a poster at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention. Like HIV, HBV can be transmitted through unprotected sex with an infected person or through shared needles.
“This is a debate because some people think that risk-based criteria are far less effective than age-based criteria, and the CDC has decided to go with risk based,” Dr. Kempe, of the Children's Hospital in Denver, said in an interview.
In December 2006, the CDC's Advisory Committee on Immunization Practices recommended, as part of its new comprehensive HBV strategy, that practitioners in primary care settings implement standing orders to identify and vaccinate adults with HBV risk factors.
In September and October 2006, Dr. Kempe and her associates used a mail- or Internet-based questionnaire to survey family medicine and general internal medicine physicians on the feasibility of implementing HBV risk-based standing orders. Surveys were completed by 65% (282 of 433) of family physicians and 79% (332 of 420) general internists. Responses generally did not differ by specialty, so data were combined.
Overall, 47% of respondents reported being “very supportive” and 37% “somewhat supportive” of implementing hepatitis B vaccination of at-risk adults using risk-based standing orders.
“However, physicians reported significant barriers to risk-based approaches, suggesting that alternative strategies might be needed for hepatitis B vaccination to be successfully implemented,” the authors wrote.
Factors identified as “definite barriers” or “somewhat of a barrier” to standing orders included patients not disclosing sensitive information (definite 36%, somewhat 38%); nurses and medical assistants being too pressed for time to assess patients' risk (30%, 37%); risk screening negatively impacting patient flow (20%, 27%); risk screening requiring a higher level of knowledge than nurses or medical assistants have (16%, 30%); and the fact that because of the complexity of the standing orders, nurses and medical assistants would still have questions about who should be immunized (15%, 31%).
The investigators did not perform a head-to-head comparison between risk- and age-based criteria, but feasibility was thought to be higher for age-based criteria, Dr. Kempe said.
Just 25% of family physicians and 27% of internists thought risk-based criteria would be “very feasible” for nurses and medical assistants to implement, compared with 38% and 37% for age-based criteria.
In a second analysis of the same data, most of the family and internal medicine physicians reported that hepatitis B vaccination was a “moderate priority” (42% of the family medicine physicians, 45% of the internists) or a “low priority” (39%, 28%) in their practices, Dr. Matthew Daley and his associates reported in a separate poster at the meeting.
A minority (37%) of respondents routinely use written questionnaires at an initial inpatient visit to assess sexual behavior or drug use, reported Dr. Daley, also of the Children's Hospital.