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

2. 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

3. 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

4. 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 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

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

6. 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 months old
Barriers to implementation of recommendations for month olds
Factors associated with adherence to recommendations for universal vaccination of month olds

7. 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

8. 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 influenza season
Physicians surveyed by internet or mail depending on preference
Survey period: March – June 2007

9. 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

10. 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

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

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

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

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

15. 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 month old children frequently enough
32*
13*
*p<0.01 for comparison between FM and Peds

16. 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 ( )
0.3 ( )
Age group not seen often – “a definite barrier”
0.2 ( )
0.2 ( )
Concern about insurance coverage -“a definite barrier”
0.4 ( ) NS
Vaccine shipment delayed
1.4 ( )
2.1 ( )
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

17. 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 ( )
0.4 ( )
Age group not seen often enough – “a definite barrier”
0.4 ( ) NS
Educating parents that vaccination is recommended – “a definite barrier”
0.3 ( )
0.3 ( )
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

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

19. 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 month olds
Reported adherence 80% among Peds
< half of FM routinely vaccinating

20. Summary of Findings
Reported barriers to adherence to 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

21. 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

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

23. Additional Slides

24. 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

25. 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

26. 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