Research article
Influenza Vaccination of High-Risk Children: What the Providers Say

https://doi.org/10.1016/j.amepre.2005.10.016Get rights and content

Background

Despite a longstanding national recommendation to administer influenza vaccine to children at high risk for disease complications, physicians’ adherence remains low. This study evaluated physicians’ perspectives on previously documented and persistent under-utilization of influenza vaccine for high-risk children.

Methods

A cross-sectional survey mailed in 2001–2002 to a nationally representative sample of 1460 U.S. physicians in four key medical specialties. The primary outcome was whether the physician provided annual influenza vaccine to children with asthma or other cardiopulmonary diseases. The hypothesis was that factors predicting reported use would fall into four categories: (1) physician knowledge, (2) physician endorsement of recommendation, (3) perceived barriers, and (4) practice patterns.

Results

The overall response rate was 55% (n=600), but differed by specialty. Most physicians were knowledgeable about the recommendation, but collectively tended to overestimate their own achievements in immunizing high-risk children. Adherence varied by physician specialty, endorsement of recommendation, perceived barriers (including difficulty identifying subpopulations of high-risk children and confusion about who should vaccinate those receiving care from multiple providers), and under-utilization of strategies known to improve vaccination rates.

Conclusions

Better communication strategies are needed to resolve confusion about providing influenza vaccine to high-risk children in subspecialty settings. Because of the difficulties in selectively identifying high-risk patient subgroups, research is needed to assist in putting support strategies into practice. Findings from research in promising areas of practice-based quality improvement may be particularly applicable.

Introduction

For almost 40 years, annual influenza vaccination has been recommended for persons aged ≥6 months with underlying health conditions that place them at high risk for complications of influenza.1 According to recent estimates, influenza vaccination rates for children with asthma—the most prevalent condition conferring risk—range from 3% to 10% in primary care practices.2 Although higher rates have been reported in other settings (79% in a pulmonary practice affiliated with a cystic fibrosis center,3 25% to 40% in allergy clinics,2, 4 and 30% to 42% in primary care practices equipped with computerized reminder systems5, 6, 7), <1% of asthmatic children visit subspecialty clinics during the vaccination season,2, 8 and the percentage of primary care practices equipped with computerized reminder systems is not known.

In 2002, the Advisory Committee on Immunization Practices (ACIP) encouraged universal influenza vaccination of children aged 6 to 23 months9; in 2004, the encouragement became a formal recommendation.10 Preliminary reports on adoption of the recommendation are mixed: National Immunization Survey (NIS) estimates for the 2003–2004 season (4.4% to 7.4%)11 were lower than Behavioral Risk Factor Surveillance System (BRFSS) estimates for the 2004–2005 season (34.8% to 48.4%).12 A study of influenza vaccination rates among 6–59 month-old patients was conducted in a large pediatric clinic in the winters before and after the 2002 ACIP “encouragement.”13 Rates for healthy 6–23 month olds increased from 1% to 17%, and accounted for most of the total increase observed in the study. Rates for asthmatic members of the study group increased from 13% to 37%. However, NIS data require physician verification while BRFSS data are based solely on self-report, making comparison of the respective findings difficult. Although this study and others14 found physician recommendation to be the strongest predictor of vaccination, 65% of parents of asthmatic children in this study did not recall receiving such a recommendation.

To better understand factors that influence physicians’ use of the influenza vaccine for high-risk children, a nationally representative survey was conducted of physicians in four medical specialties. Reported vaccine use was studied as a function of provider characteristics and four hypothesized determinants of vaccine use: (1) physician knowledge, (2) physician endorsement of the recommendation, (3) perceived barriers, and (4) practice patterns.

Section snippets

Survey Sample

In November 2001, a 41-item questionnaire that was field tested and approved by the Institutional Review Board of the Centers for Disease Control and Prevention was mailed to 1460 licensed physicians practicing in office or hospital settings in the United States. This sample size provided 99% power to detect a 5% difference among the specialists and to achieve national representation, assuming a response rate of 45%. Demographic, practice, and contact information for participants was obtained

Response Rate

Of the 1460 surveys, 797 were returned. Of these, 600 were complete, 197 were ineligible (physician no longer practicing or not practicing in targeted specialties); 663 were not returned. Using Council of American Survey Research Organization16 standards to apply the ineligibility rate for returned surveys (25%) to those not returned, the total response rate was calculated as follows: 600/(600+[663×0.75])=55% Returned completed response rates were highest for PDPs (70%); intermediate for

Discussion

Self-reported use of the influenza vaccine in high-risk children varies by specialty, and appears to be mediated by endorsement of national guidelines, perceived barriers, and use of strategies known to improve risk-based vaccine delivery.

Findings from this survey are consistent with others2, 3, 4 that have found influenza vaccination rates higher in subspecialty than in primary care practices. This likely reflects the higher proportion of high-risk children in subspecialists’ practices.

Conclusions

Findings from this study suggest the need for intervention in several areas. First, better communication among primary care physicians, specialty physicians, and parents is needed to resolve issues concerning responsibility for providing influenza vaccine. Second, because evidence-based strategies to improve vaccination coverage exist but are infrequently used, efforts are needed to ensure translation of these strategies into practice. Third, research is needed in the use of practical quality

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