Study highlights barriers, solutions for keeping up on adult vaccines

Research and recommendations on vaccines is always evolving, and this can make it difficult for clinicians to keep up.

A new study, published in The Journal of the American Board of Family Medicine, surveyed clinicians to uncover what they know about recommendations on pneumococcal vaccination, and what barriers they have in complying with this guidance.

While most clinicians are clear on the current recommendations, Hurley said several knowledge gaps were identified in this study. Some of the top issues with implementing the Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices’ (ACIP) recommendations involved financial barriers and difficulty in determining a patient’s vaccine history.

While more than 95 percent of clinicians surveyed for the study reported routinely assessing adult vaccination status and recommending both vaccines, and 88 percent reported that the recommendations were “very” to “somewhat” clear, 20 percent of clinicians struggled with the cost of vaccines or lack of reimbursement.

“In terms of financial barriers, it is important to think of various type of insurance coverage for the vaccines,” Hurley said. “Both pneumococcal vaccines are covered by Medicare Part B for Medicare beneficiaries. There were some initial disparities between Medicare policy and the recommendations which might have led to physicians experiencing that the vaccines were not covered by Medicare Part B.  Those issues have been resolved.”

There have been numerous changes to pneumococcal vaccine recommendations since the original guidance was published in 1984, said lead author Laura P. Hurley, MD, MPH, a primary care physician at Denver Health. 

Recently, ACIP recommended the 13-valent pneumococcal conjugate vaccine (PCV13) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) back in 2012 for high-risk adults over age 19. In 2014, that recommendation was expanded to all adults over age 65. 

Hurley also points out that while the Affordable Care Act mandates that all ACIP recommended vaccines be covered by private insurance, 23 percent of employer-based insurances are “grandfathered” and do not have to adhere to this mandate. 

“Some physicians might have experienced private insurance not covering these vaccines,” Hurley said. “Also, not all state Medicaid programs pay for all recommended adult vaccines, so physicians also might have encountered pneumococcal vaccines not being covered for their patients with Medicaid.”

Finally, Hurley said physician practices have to pay for these vaccines up-front without a guarantee of being reimbursed. Some physicians found this to be a barrier in administering the two vaccines in series, she said.

As for determining patient history, Hurley said adult patients tend to receive vaccines in a number of settings-the outpatient clinic, hospitals, pharmacies-and this can cause confusion.

“Physicians do not want to given unnecessary vaccines and also do not want to give vaccines without the appropriate time interval between them as this could have implications for vaccine effectiveness and also for reimbursement for vaccine delivery,” she said.

To overcome these barriers, Hurley said the study identified several interventions.

“The first step to overcome the financial barriers is for physicians and their patients to understand the insurance coverage for pneumococcal vaccines which can be difficult to ascertain especially given the variety of private insurance plans available and the variability of state Medicaid coverage of these vaccines,” Hurley said. 

Clinicians should also familiarize themselves with vaccine eligibility and tracking systems.

“There are three distinct populations: 65-plus, a population aged 19 to 64 that is ‘very high risk’, and 19 to 64 ‘high risk.’ The recommendations differ depending on which population your patient falls into,” Hurley said. 

Hurley said physicians and patients should be also educated about immunization information systems (IIS), or confidential, population-based, computerized databases that consolidate all immunization administered by participating providers to persons residing within a given geopolitical area, she said. 

“The Standards for Adult Immunization published in 2014 call for adult vaccine providers to record vaccine administration in an IIS,” Hurley said. “More widespread use of these systems might address the barrier of difficulty determining a patient’s vaccination history.”

Hurley said she was surprised in the course of her research to see how many clinicians were unclear on ACIP’s recommendations.

“Hands down, the pneumococcal recommendations are what my physician colleagues find the most confusing of the adult vaccine recommendations,” she said. “My hope is that acknowledgement of the complexity of the recommendations opens a conversation about how best to implement them.  I would like more efforts to be made to have electronic health records facilitate the vaccine delivery process.”

Additionally, Hurley suggested that clinical decision support systems (CDSSs) could be built to accurately prompt physicians to apply the ACIP recommendations.  

“Several providers across the nation are now using the same electronic health systems so creating such tools could have broad applicability,” she said. “A minority of physicians reported having such CDSSs in place for pneumococcal vaccine delivery.”