A Shot in the Arm for Adult Vaccination

Each year, millions of American adults become sick from illnesses that could have been prevented by vaccination, and thousands die as a result. The vaccine-preventable diseases that strike Americans most frequently are influenza, shingles, the human papillomavirus (HPV), hepatitis A and B, invasive pneumococcal disease, and pertussis. In addition to causing needless illness and death, vaccine-preventable diseases impose a costly burden on the U.S. economy. The health and productivity costs of influenza alone may reach $90 billion a year, depending on the severity of the influenza season. Despite this toll, adult vaccination rates remain relatively low. For example, in 2009, less than 70 percent of adults at the highest risk of influenza and influenza complications were vaccinated, and only 10 percent of adults were vaccinated for shingles.

Recent changes in the policy and practice environment surrounding adult vaccination have created an opportunity to improve vaccination rates for adults. Health care reform legislation promotes preventive care and financial access to adult vaccination. Moreover, the growing availability of vaccinations outside of provider offices — in workplaces, pharmacies, and retail medical clinics — makes obtaining vaccinations easier than ever.

To help leverage these opportunities, a RAND team identified barriers to improving the delivery of adult vaccination and recommended strategies to address these barriers. The team's approach included reviewing the published literature on adult vaccination, convening a stakeholder workshop in January 2011, and conducting follow-up interviews with meeting participants and additional experts, as well as a survey of 1,278 adults to learn about the relationship between influenza vaccination and beliefs about the safety of influenza vaccine.

Provider Offices Are a Promising Setting for Boosting Adult Vaccination Rates

Most vaccinations are delivered in health care providers' offices. Recent survey data show that more than twice as many influenza vaccinations were administered in physician offices and medical clinics than in any other setting. In addition, national surveys suggest that almost half of adults not intending to be vaccinated for influenza indicated a willingness to be vaccinated if given a strong recommendation from a health care provider (see figure). In contrast, little is known about the ability of other vaccinators to persuade hesitant individuals to be vaccinated.

Vaccination Status of U.S. Adults Recommended for Influenza Vaccination, March 2009

SOURCE: Harris KM, Maurer J, and Lurie N, "Do People Who Intend to Get a Flu Shot Actually Get One?" Journal of General Internal Medicine, Vol. 24, No. 12, December 2009, pp. 1311–1313. NOTE: Recommendations made by Advisory Committee on Immunization Practices.

Boosting adult vaccination rates in provider settings requires addressing two critical barriers:

(1) Office-based health care providers are not doing enough to promote and administer adult vaccination. Surveys conducted between 2007 and 2010 suggest that only 27 percent of physicians stock all recommended adult vaccines beyond influenza. Furthermore, patients report that they seldom discuss vaccination with health care providers, suggesting that providers are not making the most of opportunities to recommend vaccination.

(2) Adult practices may lack a strong business case to offer vaccination or refer patients for vaccination. Currently, providers who want to deliver vaccinations in office settings must make a substantial up-front investment. This investment can only be recouped if demand is strong and predictable, as it often is in pediatric practices. In adult practices, however, payment rates for adult vaccination are typically low, the volume of patients recommended for vaccination may be highly variable, and incentives to discuss vaccinations with hesitant patients are currently lacking. For these reasons, providers may focus on other concerns and skip efforts to promote vaccination. Moreover, many providers who do not vaccinate also do not refer patients elsewhere for vaccination.

Recommendations: Strengthen Guidance and Financial Incentives for Providers

To make adult vaccination in office-based settings more routine, stakeholders need to collaborate to integrate advice about vaccination and other efforts to incorporate vaccination into routine office-based care. The RAND team recommended specific actions that vaccination stakeholders and substantive experts should undertake to accomplish these goals:

• Help physicians assess the need for adult vaccination. To facilitate implementation of government-issued recommendations, provider offices would benefit from guidance and tools that allow them to assess patients' vaccination status more easily and more quickly, particularly in the absence of a patient's vaccination history.
• Develop counseling protocols to help physicians communicate more effectively with patients. Many patients are concerned about the safety of vaccination or skeptical about its effectiveness. Thus, providers would benefit from prompts and protocols that help them persuade skeptical patients who would benefit from vaccination to accept it.
• Help providers make financial calculations about the advantages of vaccinating on site. One approach would be to develop a decision tool to help office-based providers determine whether they have adequate patient volume, case mix, and practice characteristics for vaccinating on site or should refer patients to outside sources.
• Formalize a process for referring patients for vaccination to outside provider offices. Stakeholders should work at the local level to develop referral systems that give patients specific information about recommended vaccinations and the locations and hours of operation of community vaccinators. These systems should ensure that documentation of vaccinations gets returned to referring providers.
• Facilitate performance-based payments to providers. Pay-for-vaccination programs that are designed to encourage providers to vaccinate adults or refer them to other vaccinators would benefit from mechanisms that credit office-based providers who refer patients for vaccination in other settings. Without such mechanisms, nonvaccinating providers have little incentive to promote vaccination.

Topics

• Influenza
• Medical Professionals
• United States
• Vaccination