Periodic Survey of Fellows #39 - Executive Summary - Immunization practices & referrals, 9/99

Issues in Immunization: Pediatricians' Use of IPV v OPV and DTP v DTaP,
Referrals for Immunizations and Participation in the VFC Program

This report presents findings from Periodic Survey # 39 on pediatricians� practices regarding the polio and diphtheria-tetanus-pertussis vaccine schedules, as well as pediatricians� participation in the Vaccines for Children program, and practices regarding referrals for immunizations. These topics were supported by the Committees on Infectious Disease and Practice and Ambulatory Medicine to provide nationally representative data on pediatricians� immunization practices for educational and policy purposes. The referrals for immunization data compare the current rate of referrals out of physicians� offices to health departments with that documented in the 1992 Periodic Survey # 18. In addition, the data on polio vaccine schedule practices provides baseline data for the Pediatric Research in Office Settings (PROS) network study on the impact of the change in the polio immunization schedule.

The survey was conducted from May to September 1998; after five mailings a total of 1243 completed questionnaires were received for a response rate of 76.4%. Data on use of the polio and pertussis vaccine, as well as participation in the VFC program are based on the 720 post-residency Fellows who provide primary care including immunizations; data on referrals for immunizations are based on the 976 pediatricians (including residents) who provide immunizations.

Seven out of ten pediatricians report they usually recommend the sequential IPV/OPV vaccine for infants in their practice. Sixteen percent of pediatricians recommend the all-OPV and 5% recommend the all-IPV schedule. Nine percent do not recommend a specific schedule.

Pediatricians who participate in bulk purchase programs are more likely to recommend IPV containing schedules than are those who do not participate (76% v. 66%, p<.05).
Male pediatricians are less likely to recommend IPV than females (71% v 80%, p<.01)
Pediatricians in the Midwest (66%) are less likely than those in the Northwest (76%), South (80%), and West (75%) to recommend an IPV schedule (p<.05).

When deciding what polio vaccine to use, about 6 out of 10 pediatricians give primary consideration to the risk to the patient of Vaccine Associated Paralytic Polio (62%) and parents� opinion about which vaccine to use (60%). Nearly one-half (48%) say agency or organization recommendation is a strong influence in their decision.

Most pediatricians (72%) report "almost always" discussing the alternate polio vaccine schedules with parents in addition to providing them with vaccine information materials (VIM) before immunizing their child. Pediatrician indicate that parents rely on them for guidance in making decisions regarding the appropriate polio vaccine schedule: 80% say that parents "often" expect the doctor or nurse to guide them to a decision regarding the appropriate polio vaccine schedule, and 66% say parents "often" expect the doctor to make the decision for them.

These data were presented by Paul M. Darden, MD, at the 1999 Pediatric Academic Societies� (PAS) Annual Meeting.

Eight out of ten pediatricians report they usually recommend the all-acellular pertussis vaccine for infants in their practice. Ten percent of pediatricians recommend the combined DTP and Hib, 7% recommend the DTP/DTaP sequential (DTP at 2, 4, 6 months, DTaP at 12-15 months and 4-6 years), and 3% either do not recommend a specific schedule or recommend some other schedule. There were no variations in pediatricians� adoption of the new form of the pertussis vaccine by measured practice characteristics.

When deciding what pertussis vaccine to use, respondents give primary consideration to:

Risk to the patient of adverse reactions (79%)
Agency or organization recommendation (52%)
Parents� opinion about the vaccine to use (41%).

These findings were presented at the 1999 Association for Health Services Research Annual Meeting by AAP researchers.

Most AAP members who provide immunizations (61%) participate in a bulk purchase program that provides childhood vaccines for free to some or all children. Among those who do not, many cite various administrative reasons.

The majority of participating pediatricians (71%) report they participate in the VFC program, while 26% say they participate in a state bulk purchase program. Fourteen percent are unsure of the source of the bulk purchase program in which they participate.

About 22% of pediatricians do not participate in any bulk purchase program, while 17% do not know if their office participates in such a program. Among respondents who do not participate:

42% say there is too much paperwork involved.
39% say requirements for separate accounting of vaccines are too burdensome.
30% area not sure about the eligible population
16% do not treat the eligible population.

Notably, about one-fourth of nonparticipants (26%) say the decision to participate is not theirs; an additional 16% say their HMO does not participate.

The portion of pediatricians who refer some or all of their patients out for immunizations dropped substantially from 48% in 1992 (findings from PS#18) to 26.0% in 1998 (p<.001). Nearly all referrals are made to health departments. The primary reason stated for referring was the same in both time periods: hardship for patients to pay (about 84% in 1992 and 1998).

Pediatricians practicing in urban, inner-city areas (11%) are much less likely to refer than those in rural (38%), suburban (31%), or urban, on-inner city (26%) areas.
Regional variations in referral rates range from 10% in the Northeast, 27% in the West, 29% in the South and 41% in the Midwest; rates of referrals in all areas dropped from those of 1992.

A majority of pediatricians (54%) say they are referring fewer patients for immunizations since they began participating in VFC and 42% say they are referring about the same number of patients. Two-thirds of pediatricians (66%) say managed care participation has not affected their immunization referral decisions, while 29% say because of managed care participation they are now referring fewer patients for immunizations.

These findings were presented at the 1999 PAS Annual Meeting by AAP researchers.