Influenza Vaccine Delay From the Primary Care Physician’s Perspective Lon McQuillan, MD

Disclosures I have no financial disclosures to make

Study Team Vaccine Policy Collaborative Initiative Univ. of CO Denver Allison Kempe, MD, MPH (PI) Matthew Daley, MD Lori Crane, PhD, MPH Miriam Dickinson, PhD Jennifer Barrow, MSPH Christine Babbel, MSPH Brenda Beaty, MSPH Sandra Black, DVM John Steiner, MD MPH Steve Berman, MD CDC Shannon Stokley, MPH Pascale Wortley, MD, MPH

Background Influenza Most common vaccine-preventable disease in US 36,000 annual deaths 226,000 annual hospitalizations Influenza Vaccination Yearly vaccination recommended in high-risk groups: Children 6-59 months

Background Influenza Most common vaccine-preventable disease in US 36,000 annual deaths 226,000 annual hospitalizations Influenza Vaccination Yearly vaccination recommended in high-risk groups: Children 6-59 months

Background Influenza Most common vaccine-preventable disease in US 36,000 annual deaths 226,000 annual hospitalizations Influenza Vaccination Yearly vaccination recommended in high-risk groups: Children 6 months to 18 years and adults ≥50 years Pregnant women Any age with certain chronic medical conditions Caregivers of children in high-risk groups

Background Vaccine Supply Problems Influenza vaccine supply problems over past several seasons Shortages: 2003-04, 2004-05 Manufacturing delays: 2000-01, 2001-02, 2005-06

Background Gaps in the Literature Analyses of flu vaccine supply problems have focused on shortage seasons (e.g. 2004-05) Little is known about: Extent of delays and their impact on practice during a non-shortage season Provider expectations regarding the timing of influenza vaccine arrival and what constitutes a vaccine delay

Study Objectives To describe among primary care physicians nationally in 2006-07, a non-shortage season: 1: Perceptions regarding what constitutes vaccine delay 2: The extent of vaccine delays by physician report 3: The impacts of vaccine delays on practice

Methods Study Setting National survey of pediatricians, family physicians, and general internal medicine physicians Conducted in 3 sentinel physician networks Developed as part of the Vaccine Policy Collaborative Initiative Designed to be representative of the memberships of: American Academy of Pediatrics American Academy of Family Physicians American College of Physicians

Methods Prior study showed AMA random sample and networks similar in: Practice characteristics Provider demographics Attitudes regarding flu vaccine shortages

Methods Pretested in three national community advisory panels Pilot tested survey in national sample of primary care physicians

Methods Survey Administration Conducted from March – June 2007 Email: Respondents sent an email with link to survey E-mail reminders sent every 3 days for 7 attempts and then once a week for 2 additional attempts Mail: Dillman’s Tailored Design method

Results

Results Response rates Overall: 74% (940/1,268) Pediatricians: 75% (321/430) Family physicians: 76% (318/421) Internists: 72% (301/417)

Results Excluded providers not administering flu vaccine 1% Pediatricians 3% Family practitioners 4% Internists Excluded providers not practicing at least 50% primary care

Results Respondents vs. Non-Respondents Pediatricians No differences in practice setting, practice location, or region Respondents were 45% female while non-respondents were 62% female (p=0.004) Respondent mean birth year 1957 while non-respondent mean birth year 1960 (p=0.006) Family physicians and Internists No differences in practice setting, practice location, region, gender, or birth year

Obj. 1: Perceptions regarding what constitutes vaccine delay

Obj. 1: Perceptions regarding what constitutes vaccine delay

Obj. 1: Perceptions regarding what constitutes vaccine delay

Obj. 1: Perceptions regarding what constitutes vaccine delay

Obj. 2: The extent of vaccine delays by physician report 53% reported vaccine delays 67% of these were dissatisfied with supplier communication regarding the delay

Factors associated with vaccine delay % Reporting Delay p-value Specialty Pediatrics 67 <0.0001 Family Medicine 45 General Internal Medicine 48 Practice Setting Private Practice 57 HMO/MCO University/Hospital/CHC VFC Participation Yes 60 0.03 No 50

Factors associated with vaccine delay % Reporting Delay p-value Region Midwest 46 0.02 Northeast 55 South 59 West 50 Did retailers in your area receive vaccine before your practice? Yes 63 <0.0001 No 23

Factors associated with vaccine delay Vaccine Delayed Vaccine Not Delayed p-value Number of providers in practice, median 5 6 0.0005

Obj. 3: The impacts of vaccine delays on practice Approached this in two ways: Bivariate analyses looking for association between reporting a vaccine delay and potential impacts We asked a series of Likert questions regarding the impacts of influenza vaccine delays

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% No 41% What percentage of patients were referred elsewhere for vaccination? 0-9% ≥10% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% No 41% What percentage of patients were referred elsewhere for vaccination? 0-9% ≥10% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% ≥10% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% ≥10% 68% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% ≥10% 68% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% 80% ≥10% 68% 20% How much of your vaccine went unused?

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% 80% ≥10% 68% 20% How much of your vaccine went unused? 67% 33%

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% 80% ≥10% 68% 20% How much of your vaccine went unused? 67% 33%

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you meet demand for vaccine in your practice? Yes 59% 94% <0.0001 No 41% 6% What percentage of patients were referred elsewhere for vaccination? 0-9% 32% 80% ≥10% 68% 20% How much of your vaccine went unused? 67% 76% 0.007 33% 24%

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you receive all of the influenza vaccine you ordered? Yes 73% No 27%

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you receive all of the influenza vaccine you ordered? Yes 73% No 27%

Obj. 3: The impacts of vaccine delays on practice Factor Vaccine Delayed Vaccine not Delayed p-value Did you receive all of the influenza vaccine you ordered? Yes 73% 97% <0.0001 No 27% 3%

Obj. 3: Perceived effects of delays on practice

Limitations Data based on self-report Are reports of delays, vaccine arrival, etc. accurate? Sentinel network is a select group who volunteered to participate in these sentinel surveys- Response bias? Published study showing little difference in responses between sentinel network and AMA master-file sample for each specialty Recall bias? Likely not large based on timing of survey

Conclusions There is a great deal of variation in when providers consider vaccine to be delayed Majority of providers reported experiencing influenza vaccine delay in a non-shortage season Providers were dissatisfied with the communication they received regarding the delay Experiencing a vaccine delay may increase the risk of having unused, unreturnable vaccine Providers may need to adjust expectations and practice as supply problems are likely to recur

Acknowledgments Funded by the Centers for Disease Control and Prevention Administered through the Rocky Mountain Prevention Research Center, University of Colorado at Denver Rocky Mountain Prevention Research Center