While almost all internists and family physicians feel a responsibility to ask about patients’ immunization status at least annually, most refer them to another source for all but basic seasonal vaccines.
A national survey determined that less than a third of these primary care providers stocked all 11 of the recommended adult vaccines. Financial issues were the biggest barrier to keeping all of the vaccines on hand and administering them, Dr. Laura Hurley and her colleagues wrote in the February issue of Annals of Internal Medicine (Ann. Int. Med. 2014;160:161-70).
"Although primary care physicians appear motivated to ensure that patients are up to date on vaccinations, many barriers exist. Implementation of system changes, including adopting practices that improve communication between primary care physicians and alternate vaccinators, more widespread use of effective tools ... and removing policy-related barriers, could improve adult vaccination in the United States," wrote Dr. Hurley of the Wellington E. Webb Center for Primary Care, Denver, and her coauthors.
Conducted by the Vaccine Policy Collaborative Initiative (VPCI), the survey assessed how responsible primary care physicians feel about adult vaccination, how often they assess and provide it, and what the barriers are to how vaccination is handled. The survey was mailed to 443 general internists and 409 family physicians, of whom 352 and 255 physicians, respectively, responded.
Ninety-seven percent of both groups said they assessed vaccination status at annual visits, but only about a third reported doing so at each visit.
Automated systems were fairly low down on the list of assessment techniques, although more family doctors than internists reported using them (36% vs. 8%). About half of all the respondents said it was moderately to very difficult to get up-to-date information on anything but the seasonal influenza vaccine.
In addition to the flu vaccine, most physicians checked on the status of pneumococcal; tetanus, diphtheria, and pertussis (Td and Tdap); and shingles vaccines. Family doctors were more likely to check on hepatitis A and B; MMR; and varicella vaccines.
Most physicians reported stocking influenza, pneumococcal, Td, and Tdap vaccines. Family physicians were more likely to stock both hepatitis vaccines, as well as those for human papillomavirus, varicella, meningitis, and shingles. Thirty-one percent of family physicians and 20% of internists said they routinely stocked all 11 of the recommended adult vaccines.
Money issues were the biggest barriers to stocking and administering vaccines, the respondents said. Commonly cited problems were lack of reimbursement for purchasing and administering; lack of insurance coverage for vaccines; and the up-front cost of buying the vaccine. Some providers worried the vaccine would expire before it could all be used, and others said patients simply refused them because they couldn’t pay.
Physicians in private and small group practices reported the biggest financial barriers, as did those who served a large number of Medicare Part D patients.
But even if they couldn’t provide the service themselves, respondents were sending patients to places that could – mostly pharmacies and public health departments. Still, financial issues were the biggest reasons for referrals; lack of insurance coverage or low insurance reimbursement figured prominently.
That can be a tricky proposition, however, said Dr. Jonathan Temte, chair of the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices.
Section 317 of the Public Health Service Act provides federally purchased vaccine for free immunizations for qualifying patients, including uninsured adults. But underinsured adults or those who have very high insurance deductibles can’t get free immunizations with 317-purchased vaccines.
"Changes in the federal 317 rules prohibit adult patients who are insured from receiving vaccines without charge through public health agencies," Dr. Temte said in an interview. "Accordingly, the practice of ‘referring adults to public health’ for immunization doesn’t work too well."
When they did send patients to another source, most respondents were able to follow up on vaccination status. The most common way was to communicate with the vaccination provider. About a third of the two groups used an immunization information system. The information was usually recorded in the patient’s electronic health record or in a written chart or vaccine record.
"Of note," the authors said, "almost all physicians agreed that it was the primary care physician’s responsibility to see that patients receive recommended vaccines, even if they did so elsewhere."
The CDC sponsored the survey; none of the authors had any financial disclosures.