For immunization SR write-up
Zimmerman 2004 – Elderly only
- PRECEDE-PROCEED factors (Table 3)
- Agreement with and increased perception of importance associated with better
vaccination rates.
- Limitations of increasing physician awareness – negative association is weird, suggests
that higher yield may be obtained by focusing elsewhere. (Multivariable analysis, table 4).
- VA institutions performed the best …
- Competing demands – physicians spending lots of time on acute issues had lower
vaccination rates.
- References pieces suggesting that physician recommendation is an important, if not the
most important, determinant of vaccination. Patient education can only do so much – but
there will always be a central role for the physician. This is also supported by evidence on
lower vaccination rates if physicians out-refer patients for vaccination, and on lower
vaccination rates in regions with lower primary care physician density.
- Prevalence of practice QI. Practice QI appears to make a difference.
o Flu shot clinic prevalence = 45%
o Provider prompts for PPV prevalence = 33%
o Influenza rates calculated = 36% (not sure in 20%).
- Financial factors – physician concerns with Medicare reimbursement levels associated
with fewer vaccinations.
O’Malley 2006 – Elderly only
- Residual racial disparity (See adjusted ORs and decomposition analyses).
- Primary care physician density associated with improved vaccinations.
- Patient level factors – education, age, income, attitudes, supplementary insurance.
- Physician factors – accessible practice, information-giving, generalist training. Continuity
of care, enrollment in an HMO.
Santibanez 2004 – Elderly only
- PRECEDE-PROCEED factors (Table)
- No associations with predisposing or reinforcing factors.
- Practice QI appears to make a difference. Prevalence of practice QI:
o Influenza vax promoted through patient education efforts – 45%.
o Flu shot clinics in 38%
o Patient reminders for influenza vaccination in 16%
o Office PPV prompts in 33%
o Immunization clinics or other specific programs in 45% (Same as Zimmerman)
- Financial factors – physician concerns with Medicare reimbursement levels associated
with fewer vaccinations. Results generally similar to Zimmerman 2004.
- Discussion: Awareness-to-adherence model factors do not appear to make a difference.
Most physicians report routinely providing PPV, so it appears they are aware, and have
already adopted and adhered. Examine environmental factors, especially reimbursement
(since lots of practices have internal QI as well).
Zimmerman 2005 – Age >50
- PPV patters did not differ by race
- Age, number of physician visits, last complete physical examination (planned care)
(bivariable). Education was not multivariate significant. Income and employment not
factored into multivariable model. Effects of age and physician visit frequency
disappeared in a model with 2 Triandis factors (attitudes and social influences,
pneumonia risk and vaccine efficacy). Room for patient education, importance of planned
care that cannot be explained away by patient education.
- Reason for non-vaccination – most common did not know they needed it (50% /
physician did not recommend. Prevalence of this higher for aged 50-64 vs 65+. All other
reasons relatively infrequent by comparison.
- Attitudes and social influences – not just knowledge. OR = 8.24! May include provider
recommendations as a key social influence.
Weingarten 1995
- Kaiser Permanente physician and patient survey, with MRR. Focus was on guidelines
generally.
- Physician perception of specific guideline importance significantly associated with receipt
of pneumococcal and influenza vaccine on patient survey.
Szilagyi 2005
- National physician survey, focus on practice-level barriers. 316 of 688 eligible physicians
responded.
- Physician practices (do you routinely vaccinate for …) generally good but lower for <65.
- High prevalence of walk-in immunization service, patient education materials, preventive
services flow sheets in patient charts, and policies to assess vax status at each visit
(>45%). Low prevalence of other techniques, especially registries. Resistance to standing
orders and audit and feedback, although many physicians would try these.
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Sub-optimal adult immunization rates not due to lack of interest among primary care
physicians. Importance rated fairly high. Interest in developing new strategies for
improving vaccinations.
- Note the apparent price elasticity of vaccination coverage. Authors suggest that
responses to hypothetical scenarios support payment reform.
Straits-Troster 2006
- VA SHEPS complex patient survey, 117614 patients >= 50 years old.
- Racial differences maintained in fully adjusted model (OR 0.67 for black, 0.91 for
Hispanic/Latino, etc..), adjusting for age, gender, marital status, education level,
employment, having a PCP, level confidence/trust in PCP, and overall health status.
However, no consistent measurement of knowledge/attitude constructs.
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Other significant predictors: Married, higher income, retiried/home-maker/unable to
work, having a VA PCP, having complete trust, and non-“good” self-reported health
status.
- Very high vaccination rates in the VA. Use of automated evidence-based practices,
perhaps.
Singleton 2005
- National Adult Immunization Survey (NAIS) 2003 – complex survey of elderly >= 65, 1891
adults interviewed (Tables 1 and 2 are mislabeled in the paper).
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-
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58% of respondents receiving 2002-03 influenza vaccination received one from a doctor’s
office. Racial disparity appears specific to the stratum with less than a high school
education.
PPV – racial disparities larger than that for influenza, specific to the less than high school
education category.
Reasons for non-receipt of influenza – side effect concerns primary, except in Hispanics,
who did not think they needed it. Reasons for non-receipt of PPV – Not thinking it was
needed or knowing that it existed. Regarding not thinking it was needed – mostly
because patients did not think they would get
pneumonia, althought thight with not having a
health professional recommendation.
Missed opportunities estimated by patients with
recent doctor visit but did not receive flu shot or
recommendation – 26.9% for Blacks, 16.2% for
non-Hispanic whites (denominator = all respondents).
- Great breakdown of location of vaccination for both influenza AND PPV!!!!!
Nichol 1996
- VAMC in Minneapolis – standing nurse orders, walk-in clinics from mid-October to midDecember, standardized forms, annual mailings, for both influenza and PPV.
- Cross-sectional survey on 700 patients. >95% white, so
no race questions.
- Awareness – Almost ¾ respondents aware of PPV,
>87% aware of influenza. High vaccination rates.
- Patient knowledge and attitudes: Influenza serious,
vaccine safe effective, flu shots good idea +ive related
to vax. Also those whose doctor or nurse
recommended the shot, and those willing to comply
(Bivariate, table 2).
- PPV – similar relations with pt knowledge and
attitudes (Bivariate, table 3).
- See importance of “positive attitudes”, where these
are defined as a postive response to believing that
pneumonia / influenza is a serious disease in the
elderly, that vaccination prevents disease, that people
do not often get sick from vaccine, and that
vaccination is a good idea.
- Importance of physicians’ recommendations support
emphasis on srategies directed towards clinical
practices of health care providers.
Nichol 2001
- National physician survey, 1874 respondents of 5858
eligible.
- Generalists more likely to consider vaccination
important.
- Generalists more likely to use QI interventions – frequency of standing orders, patient
reminders, etc., measured. Mean number of major strategies 1.18 +/ 1.09 vs 0.70 +/0.94, and 0.79 +/- 0.94 vs 0.51 +/- 0.82 for influenza and PPV (p < 0.001).
- Certain physician knowledge and attitudes associated with providing very strong
recommendations (Table 4). Self-reported practices / intent to make a recommendation
important because of the impact of physician recommendation, but also because it is an
important part of actually doing it, as predicted by the TPB.
- Authors note: Concerning proportions of physicians do not strongly recommend
vaccination. (Proportions 30% max, though). Authors suggest that physician education
should work, because of the associations with KAB. However, prevalence of negative
attitudes actually quite low (Table 2).
- Very important factors in decision to recommend (self-reported, Table 4) – these
highlight barriers and facillitators of vaccinations
o Reimbursement/cost issues actually low on in frequency, relatively speaking.
o Patient risk and VE high. Also, ease of targeting high-risk patients, remembering
to offer vaccine, and recommendations from expert groups high. Having
sufficient time and personnel more frequent than cost/reimbursement.
Davis 2002
- National physician survey of 969/1606 physicians.
- Survey focused on when and how physician practices delivered vaccine, and focused on
capacity for reminders. No questions re: standing order strategies. Multiple regression
employed to confirm bivariate relations between certain variables and reminder system
use.
- Over 90% of physicians relied on office visits to target high-risk patients. List generating
ability was thought to exist for half and 75% (chronic illness and elderly patients). Low use
of patient reminders and recal, no sig. differences by physician specialty. Physician
network settings more likely to use reminders.
- Nearly half of physicians reluctant to administer vaccine after influenza season begins.
Family physicians more likely than internists to adminster influenza vaccine and to
continue vaccinating past the typical January peak.
- Data suggests that 18% and 24% of of FPs and Gen. Internists have not adopted
recommendations (do not routinely administer vaccination).
Poel
- Quoted in Davis 2002 – In 1998-1999, about one half of all influenza vaccine doses
overall, and nearly two thirds of doses for elderly, are administered in physician offices.
About 2-% of doses overall are administered at workplaces. The remainder is composed
of community centers, local public health clinics, and health departments.
Hebert 2005
- MCBS and Medicare Claims for 1995 to 1996.
- MCBS analysis classified patients as resistant if they did not receive vaccination and
answered attitude questions negatively. Access to care from claims.
- Hebert sought evidence for provider discrimination. He used a reverse argument,
wherein he excluded other explanations. Encounters among black and white patients
were compared, matched on usual provider and week (removes disparities due to
different providers, access to care). Special attention was given to removing the influence
of patient-initiated vaccination encounters. White patients more likely to get
vaccinations, but also more likely to initiatve visits for vaccinations. No difference by race
if these visit-sets are excluded. Minority patients may visit providers who give fewer
adjunct vaccinations – but no evidence of individual provider discrimination was
detected.
- Reasons for non-vaccination given. Resistant attitudes and beliefs. Most common was
lack of knowledge (21.9%), response more frequent in Hispanics. Prevalence reported by
race.
- Missed opportunities: 36.0% non-vaccinated. Of these, 54.72% had a medical encounter.
24.8% had both a medical encounter and non-resistant attitudes. Missed opportunities
differed between races.
- See Hebert 2005’s discussion of attitudes and beliefs. Data on similar adjunct vaccination
rates among blacks and whites used to suggest that resistant attitudes among AfricanAmericans do not affect vaccination uptake. (However, this may depend on having
received a provider recommendation.)