Pneumococcal vaccine recommendations can be unclear

Rates of pneumococcal vaccination in U.S. adults are less than optimal, and the intricacies of the current recommendations from the CDC's Advisory Committee on Immunization Practices (ACIP) may be partly to blame, a recent study suggests.

From December 2015 to January 2016, researchers surveyed primary care physicians from across the U.S. and asked about their knowledge, attitudes, and beliefs about pneumococcal vaccines and how they use them. Six hundred seventeen of 935 physicians responded, for a response rate of 66%. Of these, more than 95% said they routinely assessed their adult patients' vaccination status and recommended both the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23).

Most of the physicians surveyed also said that they found the current ACIP recommendations to be very clear or somewhat clear. But when their knowledge was tested with questions about the recommendations and several case scenarios, many of the survey respondents answered incorrectly, especially when discussing patients younger than age 65. Physicians also often answered knowledge questions incorrectly even when they were offered the option of responding “I would need to look this up,” instead. The study was published in the January-February Journal of the American Board of Family Medicine.

Part of the trouble with the pneumococcal vaccination recommendations is that they are complicated and have changed frequently, with separate updates issued in 2010, 2012, 2014, and 2015, said Laura P. Hurley, MD, MPH, FACP, the study's lead author and an associate professor of general internal medicine at the University of Colorado Anschutz Medical Campus in Denver. The recommendations also differ by age, chronic conditions, and vaccination history. Dr. Hurley recently spoke to ACP Internist about why pneumococcal vaccinations can be particularly challenging to administer and how internists can improve rates in their practices.

Q: Why did you decide to focus on pneumococcal vaccination specifically?

A: It had to do with some interest from the Pneumococcal Working Group with the Advisory Committee on Immunization Practices, and then from my personal experience as a general internist trying to implement these quite complicated vaccine recommendations, so it was twofold. [It was] the CDC and ACIP wanting some feedback about the recommendations and then me trying to get at some of the challenges I've faced and whether other primary care physicians like myself are facing those challenges.

Q: Physicians in the survey said that they supported the recommendations and administered vaccines as scheduled, but their knowledge about the content of the recommendations when asked was often unclear. Do you think this indicates that their vaccination rates could be better in their day-to-day clinical practice?

A: I do, actually. We're always a little reserved about asking knowledge questions of physicians on our surveys, but we really thought about this, and with the case scenario format we thought it would be a little more acceptable. We're not trying to say physicians are not trying to do the right thing …. [W]hat I'm trying to convey is that these recommendations are confusing and physicians think they understand them but they actually don't.

Q: Do you think that confusion is the main reason respondents may have thought their knowledge was better than it actually was?

A: I do. I think physicians think they're simple recommendations. I don't think that vaccines are always on the forefront of internal medicine doctors' or family physicians' minds because we have so much we're addressing in a primary care visit. It's kind of an easy box to check, to say, “Oh yeah, let's give that vaccine,” without really understanding the nitty-gritty of the recommendations.

Q: When you offered physicians different case scenarios, they were more likely to choose appropriate options for older patients than for younger patients, correct?

A: Yes, and that's been kind of a study interest of mine for the past decade. Risk-based recommendations for vaccines are so much more difficult to implement [than age-based recommendations], and I think that speaks to it with the response that we were seeing.

Q: What are some of the difficulties?

A: For pneumococcal recommendations in particular, there's terminology used like “cardiovascular disease,” that is, vaccinate those with cardiovascular disease. Well, for an internist, there are a lot of things that constitute cardiovascular disease. When I first started working on this several years ago, I asked adult vaccination experts at the CDC, “What exactly do you mean by that? Does every person with hypertension need to get a pneumococcal vaccine?” They came back to me and said, “Oh, no, we didn't intend people just with hypertension to get the vaccine.” [There are] real scenarios that are occurring in practice where we need more specificity [about the vaccine recommendations] without getting too overburdened.

Q: Physicians in your study also identified barriers to vaccination, such as lack of reimbursement. How much of the issue is due to lack of knowledge and how much is due to economic barriers?

A: I don't think we can tell from this research. I've always been of the impression that the low rates for adult vaccinations that we see in this country are multifactorial. But certainly for this particular vaccine, pneumococcal vaccine, I think some of the low rates are due to lack of understanding of the specific recommendations. If we were going to compare it to flu, now there's a universal recommendation for flu, so it's certainly more complicated than the flu recommendations. The [herpes] zoster recommendations have been an age-based recommendation, so that's a little bit simpler. We often are dealing with hepatitis virus vaccinations, which are risk-based and are also complicated but still I don't think top the complications of pneumococcal vaccine recommendations.

Q: Regarding potential solutions, would EHR-based fixes or education be more helpful?

A: It's always easy to say education, but when the rubber hits the road and your internist is seeing somebody who has three chronic medical conditions and some social issues that are interfering with them being optimally cared for, making it easy for the physician to do the right thing is what we should do. I just don't think that can be overemphasized. I have colleagues that really want to be great immunizers, but very often our electronic health record is not working perfectly. I get asked questions at least on a weekly basis if not a daily basis about whether they should give this person a PPSV23 or a PCV13. That takes time out of their visit to ask me that question when they could be addressing other things. So given that over 90% of the physicians who were surveyed are using electronic health records and a minority have what they consider to be a computerized way to identify somebody who needs the conjugate vaccine at an age less than 65, it seems like an area where we might be able to come up with an electronic solution to help physicians do the right thing.

Q: Was there anything specific about your findings that surprised you?

A: I thought it was surprising how clear physicians thought the recommendations were and how easy they were to implement. I think there's some social desirability bias factoring in there—they want to tell us that they're easy and they're easy to implement—but I thought those numbers were a little higher than I would have expected.

Q: For internists who want to improve pneumococcal vaccination rates in their practices, where would you recommend that they start?

A: Some things are clarified in our paper, and I actually think the paper is a good starting point. People should always be referred to the ACIP recommendations on the CDC website and [advised to] work with their EHR vendor to help create clinical decision support systems to support these efforts. That's a difficult process in and of itself. ACIP is working to provide more guidance in terms of coding that could be used for an electronic health record to identify patients. We all should be trying to encourage our EHR vendors to help us deliver preventive care and within that include vaccinations. Anecdotally, I can tell you a lot of people have decided that what their EHR is telling them about these vaccinations is not valid, so they don't even look at it. That's kind of a missed opportunity to use your electronic capability to the best of your ability.