Adherence to New Pediatric Recommendations for Influenza Vaccination Among Pediatric and Family Medicine Physicians Allison Kempe, MD, MPH

Disclosures No relevant financial relationships with any commercial interests are present No reference will be made to the use of medications in manners not licensed by the Food and Drug Administration

Vaccine Policy Collaborative Initiative Allison Kempe, MD, MPH (PI) Lon McQuillan, MD Matthew F. Daley, MD Lori A. Crane, PhD, MPH L. Miriam Dickinson, PhD Jennifer Barrow, MSPH Christine Babbel, MSPH Brenda L. Beaty, MSPH CDC Collaborators Pascale M. Wortley, MD, MPH Shannon Stokley, MPH

Influenza Morbidity and Mortality Each year, influenza causes on average: 36,000 deaths 226,000 hospitalizations Children <2 years old at increased risk of death and hospitalization compared to healthy older children and adults Children 24-59 months old at increased risk of clinic and ED visits Thompson WW, JAMA, 2003 Thompson WW, JAMA, 2004 Poehling KA, N Engl J Med, 2006

Influenza Vaccination Recommendations 6-23 month old children “Encouraged”: 2002-2003 and 2003-2004 seasons Universally recommended since 2004-2005 24-59 month old children: universally recommended since 2006-2007 season Hot off the Press! ACIP votes to expand universal influenza vaccination up to 18 years of age CDC, MMWR, 2007

Study Objectives To determine, in a national survey of family medicine (FM) and pediatric (Peds) physicians: Current influenza vaccination practices for children 6-23 and 24-59 months old Barriers to implementation of recommendations for 24-59 month olds Factors associated with adherence to recommendations for universal vaccination of 24-59 month olds

Study Setting and Population Conducted in 2 sentinel physician networks developed for Vaccine Policy Collaborative Initiative Networks recruited from random samples from: American Academy of Family Physicians American Academy of Pediatrics In prior work, sentinel networks shown to be comparable to physicians surveyed from American Medical Association with respect to: Practice characteristics Physician demographics Key vaccine-related attitudes Crane LA, Eval Health Prof, 2008

Survey Design and Administration Pilot-tested in community advisory panels consisting of family physicians and pediatricians from across US Survey focused on reported practices and perceived barriers to vaccination during 2006-2007 influenza season Physicians surveyed by internet or mail depending on preference Survey period: March – June 2007

Results: Survey Response Response rates FM: 76% (N=318) Peds: 75% (N=321) For FM and Peds, respondents (R) did not differ significantly from non-respondents (NR) by type of practice, region of country, urbanicity Peds R differed from NR with respect to: Females and older physicians less likely to respond

Respondent Characteristics FM (n=318) Peds (n=321) Practice Setting, % Private Hospital or clinic HMO/other 78 20 2 87 11 Region, % West South Northeast Midwest 25 30 16 29 17 33 21 Location of practice, % Urban, inner-city Suburban / Urban, non-inner city Rural 26 46 28 45 42 13

Current Influenza Vaccination Practices, 6-23 Month Old Children Distributions between Peds and FM are different at p=<.0001

Current Influenza Vaccination Practices, 24-59 Month Old Children Distributions between Peds and FM are different at p=<.0001

PEDS: Comparison of Vaccination Practices, 6-23 vs PEDS: Comparison of Vaccination Practices, 6-23 vs. 24-59 Month Old Children Distributions between 6-23 mo and 24-59 mo are different at p=<.0001

FM: Comparison of Vaccination Practices, 6-23 vs FM: Comparison of Vaccination Practices, 6-23 vs. 24-59 Month Old Children Distributions between 6-23 mo and 24-59 mo are different at p=<.0001

Perceived Barriers to Vaccination of 24-59 Month Old Children Definite / Somewhat of a Barrier FM % Peds Concerns about having enough vaccine supply 47 48 Parental doubts about necessity of vaccination in this age 45* 35* Concerns about insurance coverage 34 27 Ability of practice to handle increased time and resources 25 24 Need to educate parents regarding new recommendations 39* 19* Not seeing 24-59 month old children frequently enough 32* 13* *p<0.01 for comparison between FM and Peds

Peds: Factors Significantly Associated with Routine Vaccination of 24-59 Month Children Bivariate OR (95% CI) Multivariate OR (95%CI) Concern about not having enough vaccine - “a definite barrier “ 0.3 (0.2-0.5) 0.3 (0.1-0.5) Age group not seen often – “a definite barrier” 0.2 (0.1-0.9) 0.2 (0.0-0.9) Concern about insurance coverage -“a definite barrier” 0.4 (0.2-0.9) NS Vaccine shipment delayed 1.4 (0.8-2.6) 2.1 (1.1-3.9) The following factors NOT significant in final model after adjustment for other significant factors: gender, practice type, # of providers, region, urbanicity, computerized method for identifying patients needing immunizations, VFC, and all other reported barriers

FM: Factors Significantly Associated with Routine Vaccination of 24-59 Month Children Bivariate OR (95% CI) Multivariate OR (95%CI) Concern about not having enough vaccine – “a definite barrier” 0.4 (0.2-0.8) 0.4 (0.2-0.9) Age group not seen often enough – “a definite barrier” 0.4 (0.2-1.0) NS Educating parents that vaccination is recommended – “a definite barrier” 0.3 (0.1-0.7) 0.3 (0.1-0.9) The following factors NOT significant in final model after adjustment for other significant factors: gender, practice type, # of providers, region, urbanicity, computerized method for identifying patients needing immunizations, VFC, and all other reported barriers

Study Limitations Possible response bias in those who chose to respond to survey Survey measured reported practices rather than observing actual vaccination practices

Summary of Findings Three years out from ACIP's recommendations for 6-23 month olds Reported adherence almost universal among Peds 72% of FM routinely vaccinating A year after expanded recommendations for 24-59 month olds Reported adherence 80% among Peds < half of FM routinely vaccinating

Summary of Findings Reported barriers to adherence to 24-59 month recommendations in both specialties Major = Concerns about vaccine supply Others = parents doubting necessity of vaccine, concerns about insurance coverage, ability of practice to handle increased volume FM also reported concerns regarding Need to educate parents about new recommendations Not seeing children in this age group frequently enough 20

Conclusions Despite reported barriers, adoption of expanded influenza recommendations has been rapid and high among Peds Adoption among FM physicians slower and less uniform, suggesting the need to more actively address the barriers they perceive Optimal adoption of recently expanded recommendations to all children up to 18 years will necessitate better solutions to problems with vaccine supply and distribution 21

Acknowledgments This investigation was funded by the Centers for Disease Control and Prevention, through the Rocky Mountain Prevention Research Center, Denver, CO

Additional Slides

Creation of Sentinel Networks (1) Subjects recruited from random sample of: 3000 American Academy of Family Physicians (AAFP) members 2500 American Academy of Pediatrics (AAP) members Respondents practicing < 50% primary care excluded

Creation of Sentinel Site Network (2) Respondents stratified by: Region of country (NE, S, MW, W) Location (urban, suburban, rural) AAP respondents also stratified by setting (private, managed care, community/hosp.); setting unavailable for AAFP members All possible combinations of respondent characteristics determined (36 “cells” for AAP; 12 for AAFP) Each cell with an expected frequency based on membership files; quota sampling used to fill cells

Final Sentinel Network Family physicians X physicians X of y cells (xx%) with expected number of physicians Pediatricians In prior work, sentinel physicians compared to family physicians and pediatricians surveyed from a random sampling from American Medical Association (AMA) masterfile; generally comparable with respect to: Practice characteristics Physician demographics Key vaccine-related attitudes Crane LA, Eval Health Prof, 2008