1. Racial differences in topics discussed and time spent in provider-patient encounters in the delivery of immunization services
Karen Wooten, MA, Alan Janssen, MPH
Philip Smith, PhD, Larry Pickering, MD
National Immunization Program
Good Morning, Today I’d like to share with you the findings of a study conducted by the Gallup Organization for the National Immunization Program. This presentation examines practice characteristics of the health care delivery system where immunization service is received and examines factors such as topics discussed in patient-physician encounters, time spent providing immunization education and total time spent in patient-physician encounters and examines whether these factors vary by practice characteristics and patients’ race ethnicity.

2. Background Immunization rates among children are high
Under-immunization exist:
Associated with patient characteristics:
Minority racial status
Low socioeconomic status
Urban settings
Provider practice characteristics:
Practice size
Time allocated for patient-provider encounters
Time allocated for vaccine education
Studies show that vaccination coverage among U.S. children are higher today than ever before. Although we have seen notable progress over the years, there are continuing disparities by members of certain racial and ethnic groups compared with the U.S. population as a whole, specifically coverage levels among black and Hispanic children continue to fall behind those of white children. While most of the documented disparities in vaccination coverage pertain to differences across racial/ethnic groups, other factors such as socioeconomic status and living in urban settings have also been found associated with lower vaccination coverage. Factors associated with the immunization practice itself such as practice size, time allocated for patient provider encounters and time allocated for vaccine education may also impact vaccination rates.

3. Research Questions
Does time spent in patient-provider encounters differ by practice characteristics?
Does amount of time spent in patient-provider encounters differ by race/ethnicity?
Which immunization topics are provider more likely to discussed with patients?
Does number of topics discussed in a typical encounter differ by race/ethnicity of the patient?
The research questions that drove this investigation are: Does time spent in patient-provider encounters differ by practice size, by the mix of payers such as percent of the patient population that are Medicaid recipients, and the racial distribution of the patient population? Does mean time spent in patient physician encounters differ by race-ethnicity of the patient? Which immunization topics are physicians more likely to discuss with patients and does the number of topics discussed in a typical immunization encounter differ by race/ethnicity of the patient?

4. Methods: Data Used
2003 National Primary Care Physician Immunization Survey
Purpose: study of vaccination attitudes and practices of physicians and the patients they serve
Sample frame: American Medical Association list
Pediatricians and family practitioners who regularly vaccinate children under two years of age
Randomly selected sample contacted via mail and followed up by telephone where necessary
Selected physicians who agreed to participate in physician-patient encounters study during a randomly selected week
We used data collected for the 2003 National Primary Care Physician Immunization Survey conducted by the Gallup Organization and sponsored by the Office of Communications of the National Immunization Program. The survey was conducted between June and August of 2003.
The purpose of the survey was to obtain nationally representative data on vaccination attitudes and practices of pediatricians and family physicians, and their patients. Pediatricians and family practitioners were selected from the American Medical Association master list and screened to identify those who regularly provide vaccinations to at least 9 children under two years of age per week. A random sample of physicians who met this criteria was selected and members contacted to participate in the study. A subsample of physicians were asked to participate in a survey of patient-physician encounters during a randomly selected week. Only encounters in which immunizations were administered were included in the study.

5. Sample distribution by physicians and patient-physician encounters by practice size
Study results are based on 757 patient-physician encounters conducted among 80 pediatric and family practices. In this slide, I’ve presented the distribution of physicians in the study and the patient encounters by practice size. About 45% of the physicians in the study were in practices where they were the only practicing physician and these practices represent 40% of the encounters. 30% of physicians in the study were in large practices representing 37% of the encounters.

6. Methods: Outcome Measures
Distribution of care (Access to Care):
Mean time spent with patients
Encounters < 15 minutes or >15 minutes
Distribution of Immunization Education:
Topics discussed
Mean number of topics discussed
Mean time spent on immunization education
Encounters <10 minutes, 10+ minutes
Two main outcome measures were examined, the distribution of care and the distribution of immunization education. The distribution of care is measured as mean time spent in patient-physician encounters. In addition to mean Time spent, a dichotomized time measure was used to compare encounters conducted greater than 15 minutes in length to those conducted in less time. The distribution of immunization education is measured as mean number of topics discussed during patient encounters, mean time spent on immunization education and similarly a dichotomized time measure for time spent on immunization education.

7. Methods: Practice Level Measures
Practice Size:
Number of physicians per practice (1, 2, >2)
Practice Distribution by:
Insurance status
<20%, 20-50%, >50% Medicaid patients
Race/Ethnicity
<20%, 20-50%, >50% White patients
The main practice level variables used in the analysis were number of physicians per practice, and practice distribution based on insurance status of patient population in which, practices were categorized as having <20%, 20-50% and >50% Medicaid population. The final practice level measure used was the racial distribution of the patient population categorized as having <20%, 20-50% and >50% white patient population.

8. Methods: Patient Level Explanatory Measures
Race/Ethnicity
Non-Hispanic White, Non-Hispanic Black, Hispanics, Other
Vaccines given at recommended age
Payment Source: Immunization paid by
Fee-for service insurance
HMO
VFC
The primary patient level measure used was race/ethnicity of the child in the encounter. Secondary measures examined were whether the child had received previously administered vaccines at the recommended age and payment source of vaccines administered whether fee for service insurance, HMO or VFC.

9. Methods: Analysis Strategy
Analysis conducted using SUDAAN Software Package
Survey analysis tool for complex sample survey data
Chi Square Test for Statistical Significance
Multivariate Logistic Regression:
Wald Chi Square Tests of Significance
Odds Ratios (Adjusted)
SUDAAN software for complex sample survey data were used for the analysis. Bivariate associations were evaluated using Chi square tests of independence and Adjusted Odds ratios were estimated through multivariate logistic regression methods.

10. Mean time spent in patient-provider encounters by race/ethnicity of child
Although there are observed differences in mean time spent in encounters with black and Hispanic patients compared to mean time spent in encounters with white patients, access to care, measured as mean time spent in patient-physician encounters did not differ statistically by child’s race/ethnicity.

11. Time spent in patient-physician encounters by race/ethnicity of the child
A decision was made to recode time spent in patient-physician encounters to create a dichotomized variable of encounters of 15 minutes or less to more than 15 minutes to examine if race differences exist in lengthy encounters. Although there are observed racial differences in encounters of more than 15 minutes in length, where white and other race patients were more often engaged in lengthy encounters with physicians than black or Hispanic patients, the differences were not statistically significant.

12. Mean time spent on immunization education by race/ethnicity of child
Concerning time spent in patient-provider encounters on immunization education, the mean time spent on immunization education with black patients was statistically different from that of white patients. Physicians on average spent more time on immunization education in encounters with Black patients than in encounters with white patients.

13. Time spent in patient-provider encounters on immunization education by race/ethnicity
Time spent in patient-provider encounters on immunization education was recoded to create a dichotomized variable of education encounters of less than 10 minutes to 10 minutes or more to examine if race differences exist in lengthy education encounters. Physicians were more likely to spend 10 or more minutes on immunization education with black patients and least likely to spend this amount of time on immunization education with white patients. The difference was statistically significant.

14. Childhood Vaccination: All vaccines given at recommended age by child’s race/ethnicity
To recap, mean time spent in encounters with blacks and Hispanics were lower although not significantly so compared to whites, but mean time spent on immunization education in encounters with black patients was significantly higher than mean time spent in encounters with white patients. Since access to care in terms of mean time spent in encounters did not appear to be a barrier in this study, we examined whether racial disparities in vaccination coverage existed. Physicians were asked to review the child’s record and report whether the child had received all past vaccines at the recommended age. Although physicians reported white patients to have received their vaccines at the recommended age more often in this study, there were no statistical differences in vaccination coverage by child’s race/ethnicity. This led to further analysis of the role of practice size in the likelihood of vaccines being given at the recommended age.

15. Childhood vaccination: All vaccines given at recommended age by child’s race/ethnicity and practice size
Patients in encounters conducted in small practices were equally likely to have received all vaccines at the recommended age regardless of patients’ race/ethnicity. But vaccination coverage for patients in encounters in large practices differed by patients’ race/ethnicity. White patients in large practices were more likely to have received all vaccines at the recommended age than patients of other race groups. The difference was statistically significant.

16. Mean time spent in patient-physician encounters by practice size
We hypothesized that mean time spent in patient-physician encounters in large practices would be lower than mean time spent in encounters in smaller practices. In this chart, we see that mean time spent in encounters in large practices was lower than the mean time spent in encounters in small practices, but the difference was not statistically significant.

17. Mean time spent in patient-provider encounters by race/ethnicity of child and practice size
Next we examined the role of practice size on time spent in encounters by patients’ race/ethnicity. Physicians in small practices, that is, 1 physician per practice spent on average 17 minutes in encounters with Hispanic patients compared to an average of 22 minutes in encounters with other patients. The difference was statistically significant. Physician encounters in large practices, that is , more than 2 physicians per practice in encounters with white and other race patients averaged 19 minutes compared to 14 minute encounters with black and Hispanic patients. The differences were statistically significant. These data suggest that physicians in small practices are likely to spend less time in encounters with Hispanic patients compared to other patients, and physicians in large practices are also likely to spend less time in encounters with Hispanic as well as Black patients.

18. Mean time spent in patient-physician encounters on immunization education by practice size
Next we examined time spent on immunization education by practice size. The average amount of time time spent in patient-physician encounters on immunization education did not differ statistically by practice size. These data suggest that physicians as a whole, are likely to spend the same amount of time on immunization education regardless of practice size.

19. Mean time spent on Immunization Education by Race/Ethnicity of Child and Practice Size
When time spent on immunization education was examined by practice size and patients’ race/ethnicity, we found no significant differences. Although no differences were found, the data suggest the possibility that physicians in large practices may spend slightly more time on immunization education with minority patients than white patients.

20. Topics Discussed #injections given 77.2% (74.2-79.9)
Short-term side effects
69.5 ( )
If child experience pain
69.3 ( )
Safety of vaccines
62.2 ( )
Necessity of vaccines
50.1 ( )
#vaccines
46.9 ( )
If child had previous side effects
44.1 ( )
Long-term side effects
43.2 ( )
Whether vaccines work
37.7 ( )
Contraindications
36.8 ( )
Cost of vaccines
4.4 ( )
Next we examined the topics discussed during these encounters. Topics highlighted in yellow are the five most frequently reported topics discussed. The total number of injections to be given during the encounter was the most frequently discussed topics, followed by potential short term side effects, what to do if the child experienced pain, the safety of the vaccines administered, and the necessity of the vaccines.

21. Mean number of topics discussed during encounters by race/ethnicity of child
Mean number of topics discussed in patient-provider encounters did not differ statistically by race/ethnicity of the child, although on average physicians discussed fewer topics with white and black patients compared to patients of other race groups.

22. Topics discussed in >50% of Patient-Physician Encounters
Whites
Blacks
Hispanics
Other
Short term side effects ●
#injections
Vaccine safety
If child had pain
Previous side effects
Long-term side effects
# vaccines
Necessity of vaccines
Whether they work
Contraindications
This table shows the most frequently cited topics discussed in encounters by race/ethnicity of the child. The first 4 topics were discussed in 50% or more of all encounters regardless of race/ethnicity of the child, although at varying degrees. Previous side effects was an additional topic discussed in at least half of the encounters with black patients. Long term side effects and number of vaccines were two additional topics discussed with patients of other race, and all topics except the cost of vaccines which is not included here were discussed in more than 50% of the encounters with Hispanic patients. The first four topics were discussed in more than 70% of the encounters with Hispanic and other race patients. Providers discussed short time side effects in over 70% of the encounters with white, Hispanic and other race patients but discussed in it in 50 and 60% of the encounters with black patients.

23. Mean number of topics discussed during provider-patient encounters by practice size
This slide displays the mean number of topics discussed in encounters by practice size. Physicians in large practices on average discussed fewer topics than physicians in smaller practices. The difference was statistically significant.

24. Mean number of topics discussed during provider-patient encounters by race/ethnicity and practice size
We also examined mean number of topics discussed in encounters by practice size and race/ethnicity of the child. Physicians in small practices discussed more immunization topics with Hispanics and patients of other race than with white and black patients.

25. Mean number of topics discussed by Race/ethnicity of child and time spent in patient-physician encounters
The mean number of topics discussed ranged from 5 in encounters with black patients to 8 in encounters with Hispanic patients. When we looked at encounters of 15 minutes or less, physicians discussed more topics in less time with minority race patients than they did in encounters with white patients. The difference was statistically significant. When we looked at encounters of more than 15 minutes in length, physicians discussed more topics in encounters with Hispanic patients than any other race group. In the same lengthy encounters, physicians discussed fewer topics with black and white patients. The difference in the number of topics discussed was only significant between Hispanic and white patients.

26. Multivariate Analysis: Likelihood of spending > 15 minutes in Patient-Physician Encounters
Adjusted
Region:
%Medicaid Pats.
Northeast
1.0
<20%
1.1
Midwest
2.2
20-50%
Ref
South
>50%
1.9
West
Practice Size 1
2.6 2
2.3
>2
Using the dichotomized measure of time spent in encounters to identify practice characteristics that increase the likelihood of physicians spending more than 15 minutes in encounters with patients, a multivariate analysis shows region of the country to be a predictor, physicians in the mid west had an increased likelihood of spending more than 15 minutes in encounters compared to physicians in other regions of the country. Practice size is also a predictor of time spent in encounters with patients. Physicians in 1 or 2 physician practices were 2 or more times likely to spend more than 15 minutes in encounters with patients than physicians in larger practices. Physicians in practices where greater than 50% of the patient population is Medicaid were nearly two times likely to spend more than 15 minutes in encounters with patients. Other factors included in the model were race/ethnicity of the child, % white population and patient payment source. These factors were not predictors of physicians spending more than 15 minutes in encounters with patients.

27. Multivariate Analysis: Likelihood of > 10 minute encounters on Education Immunization
Odds Ratio
Region:
%Medicaid: <20
2.6
Northeast
3.0
20-50%
Ref
Midwest
0.6
>50%
2.2
South
%White: <20%
0.8
West
0.5
Practice Size
0.4
1 Physician
1.3
Pay type: HMO
0.2 2
2.4
Insured
>2
VFC
0.9
In a multivariate analysis of time spent on immunization education, physicians more likely to spend 10 or more minutes or more on immunization education were those in the Northeast region of the country, those in 2 physician practices, and physicians in practices where greater than 50% of its patient population are Medicaid recipients. Physicians in practices where more than 50% of the patient population is white were least likely to spend this amount of time on immunization education. Physicians in encounters with patients whose immunization services were paid through an HMO were least likely to spend 10 or more minutes on immunization education.

28. Summary of Findings
Vaccination at recommended age differed by practice size and child’s race/ethnicity.
Physicians in large practices spent the least amount of time in encounters with black and Hispanic patients and those in small practices spent the least amount of time with Hispanic patients.
Time spent on immunization education with black patients was greater than time spent with white patients.
In summary, 1. vaccination coverage at the recommended age differed by practice size and race/ethnicity. White children in encounters with physicians in large practices were more likely to have received all vaccines at the recommended age than children of other race groups in the same sized practice.
Physicians in large practices spent less time in encounters with patients particularly black and Hispanic patients. Physicians in smaller practices more often spent less time with Hispanic patients than other race patients.
However, physicians spent more time on immunization education in encounters with black patients than in encounters with white patients. Practice size did not play a role in time spent on immunization education.

29. Summary of Findings (con’t)
Physicians discussed fewer topics in encounters with black and white patients than they did in encounters with other patients.
Physicians in large practices discussed fewer topics than physicians in small practices.
Most time spent in- Midwest practices, smaller practices
Most time on education in- Northeast practices, high SES practice or Low SES practice.
Concerning the frequency of topics discussed in encounters, physicians discussed fewer topics in encounters with black and white patients compared to encounters with Hispanic and other race patients. Physicians discussed more topics in encounters with Hispanic patients in less time compared to encounters with other race patients. Physicians in large practices discussed fewer immunization topics their patients than physicians in smaller practices.
And finally, physicians who are likely to spend the most time in encounters with patients are those who practice in the Midwest region of the country, have smaller practices and have a patient population of more than 50% Medicaid recipients. Providers who are likely to spend the most time on immunization education are those in the Northeast region of the country, and have a patient population of <20% or >50% Medicaid recipients.

30. Limitations
Sample size may be too small to detect statistical significance
The possibility that the busiest physicians were less likely to participate in the survey
Time spent does not exclude time spent to review the medical record to discern patient’s need
Time spent is not a measure of quality of care received
Time spent with patient may be a factor of number of vaccines administered
There are several limitations to the study. First, the sample size may have been too small to detect some of the associations we investigated. We do not know much about physicians who refused to participate in the survey. Most of the physicians in the survey were in small practices, so it is possible that those who refused to participate were the busiest physicians. It is unknown if time spent in encounters consistently excluded time spent reviewing medical records.
In this analysis time spent was used as a measure of the distribution of care, and not a measure of quality of care received, And it is possible, that an increase in time spent may be a factor of the number of vaccines administered.

31. Conclusions
Large practices may allow less time for immunization visits and less time to discuss patients’ immunization concerns
Efforts to improve equity in the delivery of immunization services might focus on ensuring that parents get the time they need in patient-physician encounters regardless of practice size.
In conclusion, large practices may allow less time for immunization visits and less time to discuss patients’ immunization concerns. Efforts to improve equity in the delivery of immunization services might focus on ensuring that parents get the time they need in patient-physician encounters regardless of practice size.