Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19–64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue.
Although the provision of immunizations has become a routine part of preventive care for children, the same is not true for adults. For example, only 17% of non-elderly (<65 years) high-risk adults have received the recommended pneumococcal vaccine .
Several studies have attempted to examine why adult patients do not receive immunizations in greater numbers. Patients frequently have reported their physician does not actively recommend vaccines and have identified mistaken assumptions regarding their own need for immunization . Providers often identify different issues than those raised by patients, including patient concerns regarding side effects, patient fear of needles and lack of insurance coverage as reasons for low immunization rates in their practices . Others studies have found a variety of factors contributing to low adult immunization rates such as the lack of a regular primary care provider , potentially confusing lifestyle or conditionbased indications for some vaccines , and lack of prioritization from professional societies of physicians who provide care for adults .
Routine methods of informing physicians who provide preventive care for adults of the immunization schedule also have been lacking. Although a combined childhood immunization schedule has been published annually in the journal Pediatrics for at least the past decade, it was not until late 2007 that the Annals of Internal Medicine first promulgated the national adult schedule and will now do so annually in its pages . Such efforts are greatly needed as many physicians do not make recommendations to their patients because they are not aware of current adult immunization recommendations .
Over the past several years, there have been several new vaccines recommended for adults. Provision of these vaccines in private practice settings would require physicians to stock these vaccines in their practices. In contrast to many other pharmaceuticals or biologics prescribed by physicians, vaccines must be purchased directly by practices in advance of patient demand. This requires a financial outlay on the part of the practice to purchase vaccines that the practice may, or may, not be able to resell. The greater the number of types of vaccine products and numbers of doses purchased, the greater the up-front expenditure required without a certainty of resale. Additionally, vaccines require sensitive cold-chain storage and this, in turn, requires an investment in special refrigerators and temperature alarms.
Although pediatricians have long been accustomed to stocking many different vaccines, little is known regarding the immunization purchase and stocking practices of physicians who provide primary care to adults. Such practices are an essential part of creating an environment of vaccine availability to adult patients. We sought to determine the proportion of internal medicine and family physicians who routinely stock specific adult vaccines and their rationale for those decisions.
We drew a national random sample of 1000 family physicians (FPs) and 1000 general internists (IMs) from the American Medical Association (AMA) Physician Masterfile through a contracted vendor. The AMA Physician Masterfile is the most comprehensive database of physicians licensed to practice in the United States, and includes both AMA members and non-members. Our sampling frame included all allopathic (MD) and osteopathic (DO) physicians self-described as a family physician or general internist in office-based, direct patient care. Excluded were physicians with any subspecialty board certification, age ≥70 years, currently in residency training, or employed at federally owned medical facilities (e.g., Veterans Affairs). After review of the 2000 records in the AMA Masterfile sample, we excluded 7 FPs and 3 IMs that were found to not meet our inclusion criteria.
2.2. Survey design
The 4-page, 15-item survey instrument addressed whether the respondent’s practice currently stocks any vaccines for adults aged 19–64 years and, if not, reasons for not stocking any vaccines for this group. Then for each of 10 vaccines relevant for adults aged 19–64 years, the survey asked whether the practice currently stocks that vaccine for adults aged 19–64 years and, if not, reasons for not stocking that vaccine for this group. The 10 vaccines were:
hepatitis A; hepatitis B; human papillomavirus vaccine (HPV); combined measles, mumps, and rubella (MMR); meningococcal conjugate vaccine (MCV4); pneumococcal polysaccharide (PPSV23); tetanus diphtheria (Td); combined tetanus, diphtheria, and pertussis (Tdap); varicella; and zoster.
Other questions addressed respondent attitudes regarding reimbursement for the cost and administration of vaccines for adults aged 19–64 years; the practice’s plans in the next year for stocking vaccines for adults aged 19–64 years (stop, increase/decrease/same number of different vaccines); whether the practice participates with a purchasing cooperative or buying group for adult vaccine; and practice characteristics.
An additional question targeted respondent decision-making involvement in the practice with respect to vaccine purchase, asking “To what extent are you involved in decisions about vaccine purchase for your practice?” Respondents who reported that they are “directly involved in vaccine purchase decisions” were defined as decision-makers (DMs). Those who said they were “indirectly involved” or “not involved at all” were classified as non-decisionmakers (nDMs).
The Institutional Review Board of the University of Michigan Medical School approved this study.
2.3. Survey administration
The initial survey mailing was sent at the end of April 2009 to 1990 physicians (993 FPs, 997 IMs) and included a personalized cover letter, the survey instrument, and a $5 cash incentive. Two additional mailings to non-respondents occurred at approximately 4-week intervals.