This national survey demonstrates that virtually all general internists reported recommending PPV to their high-risk patients, but were more likely to recommend it strongly to the elderly than to the non-elderly with chronic conditions. This could be explained by the greater difficulty of identifying vaccine candidates based on diagnoses rather than age. Although internists reported the intention of vaccinating high-risk patients, they had little capacity at the practice level to systematically accomplish this. Few reported using methods that have been shown to increase immunization rates in children, such as immunization registries or computerized reminder/recall13
. The most frequently cited barriers to PPV included competing demands in primary care, difficulty determining patients’ vaccination status, not remembering to vaccinate, and patient and physician concerns regarding re-imbursement or insurance coverage of the vaccine. Although there has been some controversy in the literature about the strength of the efficacy data supporting the use of PPV vaccine14,15
, only 14% of internists surveyed reported concerns about efficacy as a barrier to their use of the vaccine.
The vast majority of respondents reported that they would be willing to vaccinate all adults ≥50 years, if such a recommendation were made. There are a number of reasons why such a change has been proposed. It is estimated that half of individuals 50–64 years of age already fall into a high-risk group either because of chronic medical conditions or risk factors for invasive pneumococcal disease, such as being of African-American, Native American, or Alaskan Native race or because they are smokers7,16
. Cost-effectiveness assessments have demonstrated that for individuals 50–64 with high-risk conditions, vaccination saves costs and improves health9
. In addition, for vaccination in the 50–64 year age group, the cost per added year of healthy life would be below that of well-established preventive measures such as colon cancer screening9
. Finally, lowering the age of universal immunization would harmonize the influenza and pneumococcal schedules, mitigating one of the major barriers cited by the National Vaccine Advisory Committee17
. Universal vaccination beginning at age 50 years would decrease the need to identify chronic conditions and could enhance the use of standing orders for PPV delivery18,19
There are important limitations of our data. Despite the demonstrated similarity of our survey network to random samples from the AMA, respondents may not express similar views as those who chose not to join the network or did not respond. Our study sample slightly over-represented those working in managed care settings and underrepresented those in private settings. In addition, all data were based on self-report of current or future practices rather than measurement of actual practice.
This study demonstrates some barriers to optimal implementation of PPV recommendations despite support for the vaccine by most general internists. Some are not easily remedied, such as multiple competing demands in primary care or inadequate vaccine reimbursement. Changing to age-based criteria for PPV would eliminate the need to identify high-risk patients among those >50 years, potentially decreasing the time required for screening and enhancing the practicality of using standing orders in vaccine delivery. Harmonization of the influenza and PPV immunization criteria at age 50 would have obvious benefits in simplifying the screening demands and saving time. However, some respondents believed that the vaccine is less effective in healthy 50–64 year olds. The subgroup who identified acute problems taking precedence over preventive care as a barrier to vaccination were less likely to institute such a change and, if the decreased need to screen did not lead to greater efficiencies in vaccination delivery, this group might not be as willing to comply with an expansion of recommendations. Finally, the reimbursement barriers identified by our respondents might be additionally complicated by expansion, as vaccines would not automatically be covered by Medicare in patients 50–64 years. Despite these potential drawbacks, our data indicate that the majority of general internists would be willing to routinely vaccinate 50–64 year olds if changes were made to national recommendations, and almost a third report they are currently recommending the vaccine in this age group.