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Vaccinations in Adults: Missed Opportunities

RICHARD K. ZIMMERMAN, M.D., M.P.H., and
JUDITH A. BALL, M.S.

University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania

Mortality and morbidity from vaccine-preventable diseases remain high in adults, despite the development and dissemination of vaccine recommendations for this age group. It is estimated that each year, vaccination could prevent 8,260 deaths related to influenza and 19,200 deaths related to pneumococcal infection.¹ In 1995, only 58 percent and 36 percent of persons 65 years of age or older reported receiving influenza and pneumococcal vaccines, respectively,² despite national recommendations that they and younger persons with high-risk medical conditions be vaccinated. Vaccination rates were even lower among blacks, adults younger than 65 years of age with high-risk medical conditions, and persons below the poverty level. Why, when so many deaths could be prevented by compliance with vaccination recommendations, does the rate of vaccination remain so low?

Missed opportunities to vaccinate adults seen at acute care visits, chronic care visits and hospital discharge are one reason for low immunization rates. For instance, one retrospective study³ of patients discharged with a diagnosis of pneumonia showed that 61 to 62 percent had been hospitalized within the four preceding years and that 87 percent of these patients had one or more high-risk conditions recognized during the previous admissions that indicated the need for pneumococcal vaccine. Some medical practices may not stock certain vaccines for adult immunizations, particularly the more expensive vaccines. The cumulative effect is missed opportunities with the result that many high-risk adults who access medical care are not immunized.

Many patients who are aware of the need for vaccinations are hesitant to be vaccinated because of concerns about adverse events, although, for example, most adverse events after influenza vaccination are mild, local reactions at the injection site⁴ and, occasionally, fever. Media attention to adverse events increases public awareness and may even further decrease receptivity to vaccination.

Reimbursement issues related to underimmunization in adults include cost and the lack of insurance coverage for adult immunizations. Medicare now covers the cost of influenza and pneumococcal vaccines, thereby reducing the financial barriers to vaccination for elderly persons. However, many younger adults do not have insurance coverage for needed vaccines, and some vaccines (e.g., hepatitis B) are expensive.

With the goal of improving adult vaccination practices in the United States, there are steps that health care professionals can take to make an impact. We recommend proactive office systems, such as patient-oriented reminder and recall systems, provider-oriented prompts and standing orders for nurses, which have been proved to increase the use of preventive services, including immunizations.⁵ In addition, we recommend the establishment of systems for vaccination at hospital discharge, and target-based incentive programs that have physicians set a goal for influenza vaccination rates and regularly monitor progress.⁶

The classic meta-analysis on immunization delivery methods was conducted by Gyorkos and colleagues.⁵ They found that standing orders to administer vaccine increased pooled influenza vaccination rates by 39 percent and pneumococcal rates by 45 percent. They also found that provider-oriented strategies, primarily chart reminders, increased pooled influenza vaccination rates by 18 percent and pneumococcal vaccination rates by 7.5 percent. In addition, patient-oriented strategies, such as reminder letters or telephone calls, or educational pamphlets, increased pooled influenza vaccination rates by 12 percent.

The use of multiple strategies has been found to be beneficial. The multimodal Medicare Influenza Vaccine Demonstration Project increased rates from 26 percent in 1989-90 to 48 percent in 1991-92.⁷ A multimodal program in a Veterans Affairs institution including standing orders, a "walk-in" influenza vaccination clinic, patient mailings and clinician reminders achieved a 78 percent vaccination rate for elderly persons.⁸

Clinicians who are unaware of current guidelines may obtain them through the AAFP's Web site (http://www.aafp.org/clinical/) or the Centers for Disease Control and Prevention Web site (http://www.cdc.gov/nip/). To increase vaccination rates, guidelines must be both adopted in practice and actually followed.⁹

The opportunity to reduce thousands of deaths through adult vaccination makes implementation worthwhile.

Dr. Zimmerman is assistant professor in the Department of Family Medicine and Clinical Epidemiology at the University of Pittsburgh School of Medicine and is a member of the AAFP Commission on Clinical Policies and Research. He is the AAFP Liaison to the Advisory Committee on Immunization Practices. Ms. Ball is project administrator, Immunizations Research Group, Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh.

REFERENCES

1. Adult immunization: a report by the National Vaccine Advisory Committee. Atlanta: U.S. Department of Health and Human Services, 1994.
2. Pneumococcal and influenza vaccination levels among adults aged > or=65 years--United States, 1995 [published erratum appears in MMWR Morb Mortal Wkly Rep 1997;46:974]. MMWR Morb Mortal Wkly Rep 1997;46:913-9.
3. Fedson DS, Harward MP, Reid RA, Kaiser DL. Hospital-based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA 1990;264:1117-22.
4. Margolis KL, Nichol KL, Poland GA, Pluhar RE. Frequency of adverse reactions to influenza vaccine in the elderly. A randomized, placebo-controlled trial [published erratum appears in JAMA 1991; 265:2810]. JAMA 1990;264:1139-41.
5. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, Bedard L, Carsley J, Franco ED, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health 1994;85(Suppl 1):S14-30.
6. Buffington J, Bell KM, LaForce FM. A target-based model for increasing influenza immunizations in private practice. Genesee Hospital Medical Staff. J Gen Intern Med 1991;6:204-9.
7. Final report: Medicare influenza vaccine demonstration--selected states, 1988-1992. MMWR Morb Mortal Wkly Rep 1993;42:601-4.
8. Nichol KL. Improving influenza vaccination rates for high-risk inpatients. Am J Med 1991;91:584-8.
9. Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance. Med Care 1996;34:873-89.

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Impact of Family Physicians on Mammography Screening

JEANNE PARR LEMKAU, PH.D.

Wright State University School of Medicine,
Dayton, Ohio

KATHLEEN E. GRADY, PH.D.

Massachusetts Institute of Behavioral Medicine,
Springfield, Massachusetts

We may debate about when an asymptomatic woman should receive her first mammogram or begin annual mammography screening, how long the interval should be between mammograms for women or about what situations warrant cessation of screening, but on this we agree: early detection through annual mammography and clinical breast examination decreases mortality from breast cancer in older women. The evidence is solid and irrefutable. Annual screening of all women over 50 years of age would result in a decrease of 25 to 40 percent in deaths from breast cancer.¹

Unfortunately, although utilization of mammography screening has increased in recent years, underutilization remains the norm. In 1993, only 47 percent of women 50 to 64 years of age and 39 percent of women age 70 or older reported having received a recent mammogram.² Screening rates have been especially low among black women and women with low incomes. These women have higher rates of breast cancer mortality. Family practitioners play a crucial role in addressing the persistent problem of underutilization of mammography screening.

Physician recommendation is the most powerful predictor of whether a woman will or will not have mammography screening. Numerous studies have demonstrated that women who receive physician encouragement are four to 12 times more likely to have mammograms than those who do not receive encouragement.^3,4 Differences in physician referral rates were found to account for 60 to 75 percent of racial differences in mammography use in two North Carolina counties,⁵ suggesting that greater involvement of physicians in referring white women partially accounts for the recently documented decline in mortality from breast cancer in white but not black women.⁶

Although many factors contribute to physician nonreferral, an important obstacle to overcome is physician underestimation of the impact that they have on their patients. Our recent three-year longitudinal study,⁷ sponsored by the National Cancer Institute (NCI), strongly refutes the notion that physician referral does not make much difference in patient compliance. This study was conducted among community practices of family practitioners and general internists in two major cities and examined the impact of physician referral on mammography completion and compliance of women 50 years of age and older. Referral and mammography compliance data were gathered by audits of over 11,000 patient charts of 95 physicians.

Physician referral and patient compliance were found to be strongly related in our study⁷; of patients referred for mammography by their physician, 70 percent had a mammogram within the year, whereas only 18 percent completed one on their own initiative.

Why are physician referrals so powerful? The NCI's Breast Cancer Consortium studies found that women who never had a mammogram said that they just never thought of it or that they did not think there was a problem that warranted mammography (40 percent); that their physician never recommended it (28 percent); or that they had never heard of it (10 percent).³ With brief office counseling, a physician can efficiently address these three most common reasons women cite for not having been screened. No wonder that when a physician recommends mammography, it makes a difference!

The problem is that physicians make too few referrals. In our study,⁷ physicians averaged a referral rate of only 20 percent at baseline, based on audits of medical charts for the three months preceding the study. Only 38 percent of patients at baseline had received mammograms in the previous 14 months. Referral rates and patient compliance rates were comparable for family physicians and general internists.

Why don't physicians order more mammograms? Sixty percent of physicians in our study⁷ reported that, at least some of the time, they did not discuss mammography because they assumed that the patient saw a gynecologist who would make the referral. However, visits to gynecologists decrease with age and are lowest among the very women who are at most risk for not being referred--older women, nonwhite women, and women insured by Medicaid or Medicare. In contrast, older women typically see a primary care physician three or more times a year, and the frequency of visits increases with age. Given these realities, it is reasonable to assume that the primary care physician is the person on whom older women most rely for advice on breast cancer screening.

Other reasons given by physicians in our study⁷ for not referring women were comorbidity and advanced age. At what point is a woman too sick or too old to benefit from early detection of breast cancer? Although there are no official guidelines for weighing these factors, family physicians can help patients balance considerations of longevity, comorbidity and the quality of life as these relate to preventive screening. Physicians can empower patients by explaining the assumptions that underlie clinical judgments and inviting patients to participate in decision-making.

Many physicians in our study⁷ reported that they rely on appointments with patients for full physical examinations or annual Papanicolaou tests and pelvic examinations to discuss cancer screening. This practice has the unfortunate result of missing the opportunities for referral available to women who only see their physician for acute care. These women are less likely to be missed if every office visit is seen as an opportunity to mention screening mammography.

An office reminder system can alert the physician to a woman's mammography screening status, whatever the reason for an office visit. In our study,⁷ rates of patient compliance with screening were significantly higher in the practices randomly assigned to use a chart sticker system. Numerous options to streamline office practice with cueing and tracking systems have been described.^8-10 The development of an efficient system for ensuring the delivery of preventive care should be a high priority for physicians who are setting up their office practices.

Family physicians can have a direct impact on mortality from breast cancer by becoming strong advocates of screening mammography for asymptomatic women 50 years of age and older. Physician recommendation and referral are powerful predictors of who gets screened. Because older women are less likely to see gynecologists than younger women, their contacts with primary care physicians are especially important. Any office visit for routine or acute care can be an opportunity for mentioning screening mammography and addressing patient concerns.

Family physicians are in the ideal position to help reach the goal of Healthy People 2000: a screening mammogram and a clinical breast examination for 60 percent of women over age 50 by the year 2000.¹¹

Dr. Lemkau is professor and vice-chair for research in the Department of Family Medicine, Wright State University School of Medicine, Dayton, Ohio. She is a clinical psychologist. Dr. Grady is president of the Massachusetts Institute of Behavioral Medicine, Inc., Springfield, Mass. She is a social psychologist with extensive experience in behavioral health research. Together Drs. Grady and Lemkau recently completed a study, Mammography Referral in Primary Care, supported by a grant from the National Cancer Institute.

REFERENCES

1. Harris JR, Lippman ME, Veronesi U, Willett W. Breast cancer: first of three parts. N Engl J Med 1992;327:319-28.
2. Office of Women's Health, Centers for Disease Control and Prevention. Breast and cervical cancer [report posted on the World Wide Web]. CDC, Atlanta, Ga. Retrieved August 27, 1997, from the World Wide Web: http://www.cdc.gov/od/owh/whbc.htm.
3. Screening mammography: a missed clinical opportunity? Results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey Studies. JAMA 1990;264:54-8.
4. Grady KE, Lemkau JP, McVay JM, Reisine ST. The importance of physician encouragement in breast cancer screening of older women. Prev Med 1992;21:766-80.
5. O'Malley MS, Earp JA, Harris RP. Race and mammography use in two North Carolina counties. Am J Public Health 1997;87:782-6.
6. Chevarley F, White E. Recent trends in breast cancer mortality among white and black U.S. women. Am J Public Health 1997;87:775-81.
7. Grady KE, Lemkau JP, Lee NR, Caddell C. Enhancing mammography referral in primary care. Prev Med 1997;26:791-800.
8. Gaston MH, Moody LE. Improving utilization of breast and cervical cancer screening in your office practice. J Natl Med Assoc 1995;87:700-4.
9. Pommerenke FA, Dietrich A. Improving and maintaining preventive services, part 1: Applying the patient path model [published erratum appears in J Fam Pract 1992;34:398]. J Fam Pract 1992;34:86-91.
10. Pommerenke FA, Dietrich A. Improving and maintaining preventive services, part 2: Practical principles for primary care. J Fam Pract 1992;34:92-7.
11. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: national health promotion and disease prevention objectives: full report, with commentary. DHHS No. (PHS) 91-50212, Washington, D.C.

Copyright © 1998 by the American Academy of Family Physicians.
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