Few Physicians Stock All Recommended Adult Vaccines

Few physicians stock all adult immunizations, such as those newly recommended for whooping cough and shingles, which may contribute to low vaccination rates among American adults, according to a new study by the University of Michigan. Adult vaccination rates lag way behind those of children. For example, 17 percent of high risk adults under 65 have received the recommended pneumococcal vaccine.

Only 27 percent of family practice and internal medicine physicians stocked all adult recommended vaccines. Doctors who do not stock all or some vaccines, say they do not because vaccines are available elsewhere in their community, inventory is expensive to maintain, and insurers provide low reimbursement or none at all.

The results of this study are now available online in the journal Vaccine.

Many primary care physicians who provide care to adults do not stock all recommended immunizations, says lead author Gary Freed, MD, MPH, chief of the Division of General Pediatrics and director of the University of Michigans Child Health Evaluation and Research (CHEAR) Unit. Efforts to improve adult immunization rates must address this fundamental issue.

The survey of primary care physicians also found 96 percent stocked at least one recommended vaccine. Of those, 2 percent planned to stop and 12 percent planned to increase vaccine purchases; 79 percent planned no changes.

Of the respondents who reported their practice does not stock any vaccines for adults, the most common reasons were that vaccines were available elsewhere in their community (69 percent), the expense of maintaining inventory (61 percent), inadequate reimbursement (56 percent) and inconsistent insurance coverage across plans (53 percent).

At least one-third of all physicians in the study did not stock seven recommended adult vaccines. The vaccine least likely to be stocked by both all was zoster, despite the recent 2006 recommendation for all adults aged 60 and over to receive it to prevent shingles. Further, for internists specifically, the proportion rises to 50 percent not stocking almost all vaccines.

To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, researchers conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians and 997 general internists in the U.S.

The survey asked doctors whether they stocked recommended vaccines for adults aged 1964 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.

Several studies have attempted to examine why adult patients do not receive immunizations in greater numbers. Patients frequently say their doctors do not actively recommend vaccines. Providers say they dont offer vaccines due to patient concerns regarding side effects, patient fear of needles and lack of insurance coverage as reasons for low immunization rates in their practices.

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 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.

Vaccines also 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.

There is not a single dominant or group of factors reported by physicians as reasons why they choose not to stock a particular recommended vaccine, Freed concludes.

Based on that, there is not a single financial action or policy change that will likely have a significant positive impact on the majority of physicians who currently choose not to stock specific vaccines. Yet, efforts to address each of these factors may result in some practices choosing to stock more adult vaccines.

In addition to Freed, authors include: Sarah J. Clark, Anne E. Cowan, of the University of Michigan and Margaret Coleman of the Centers for Disease Control and Prevention.

The work was funded by the Centers for Disease Control and Prevention.