Physician survey regarding updated PCV13 vaccine recommendations for adults ≥65 years

Abstract

Background:

In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM).

Objectives:

We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years.

Design:

This was done by mail and internet-based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs).

Results:

The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% “Strongly,” 39% “Somewhat”) that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% “Strongly,” 42% “Somewhat”) that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change.

Conclusions:

Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted.

INTRODUCTION

In 2018, infections due to Streptococcus pneumoniae caused approximately 31,400 cases of invasive pneumococcal disease and 3480 deaths in the United States.¹ Annually, more than 150,000 hospitalizations from pneumonia caused by S. pneumoniae occur in this country.² Individuals aged ≥65 years are disproportionately affected by serious pneumococcal disease.^1,3

Two pneumococcal vaccines, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13), are available and have been recommended by the Advisory Committee on Immunization Practices (ACIP) for people at increased risk for pneumococcal disease including adults aged ≥65 years. For adults in this age range, ACIP has routinely recommended PPSV23 since 1984, and PCV13 be given in series with PPSV23 beginning in 2014.^4,5 Both vaccines have been recommended for two primary reasons. Both provide protection against invasive pneumococcal disease; in addition, PCV13 offers protection against pneumococcal pneumonia,⁶ whereas the effectiveness of PPSV23 against pneumococcal pneumonia has been inconsistent.⁷ PPSV23 has still been recommended because a large portion of invasive pneumococcal disease in the United States results from serotypes unique to PPSV23.⁸ When the 2014 recommendation for PCV13 was made, it was recognized that this recommendation would need to be re-evaluated, as it was anticipated that continued PCV13 use in children would reduce PCV13 serotype disease in adults through reduced carriage and transmission of vaccine serotypes from children to adults.

In June 2019, the ACIP recommended discontinuing the 2014 recommendation for routine use of PCV13 among adults ≥65, as this recommendation had had only minimal impact on PCV13-type disease at the population level in this age group and additional data demonstrated continued reductions in PCV13-type disease due to indirect effects of PCV13 use among children.⁹ Current recommendations are that PCV13 can be used for adults aged ≥65 years based on shared clinical decision making (SCDM), defined as recommendations that are based on and informed by a decision process between the healthcare provider and the patient.¹⁰ Formal publication of these recommendations in November 2019 included talking points to consider when having a SCDM conversation with a patient about the vaccine, including that PCV13-type disease is much lower than it was before routine pediatric vaccination with PCV13 was implemented and that the remaining risk of each individual is a function of exposure to PCV13 serotypes and underlying medical conditions that put individuals at increased risk.⁹ The published recommendations also provided examples of individuals who providers may consider regularly offering PCV13 (e.g., persons residing in nursing homes), as well as of those in whom PCV13 may be considered based on underlying medical conditions (e.g., chronic heart lung and liver disease). ACIP continues to recommend that all adults aged ≥65 years receive one dose of PPSV23.⁹

Given the essential role primary care physicians play in administering vaccines to patients and the recency of this recommendation change, the objectives of this study were to assess among U.S. primary care physicians (1) knowledge and attitudes regarding the recent SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years.

METHODS

From October 2019 to January 2020, we surveyed US physicians specializing in general internal medicine (GIM) and family medicine (FP) who spent ≥50% of their time providing primary care. The survey was administered by email or mail, according to physician preference, to national networks of physicians representative of American College of Physician and American Academy of Family Physician memberships with respect to region, practice location, and setting. No incentives were provided. Detailed methods and validation have been published previously.^11–13 The survey tool, which included a variety of vaccine-related topics, was developed jointly between the investigators and CDC and pilot-tested and revised prior to implementation. Survey implementation began 4 months after the ACIP vote and 1 month prior to the publication of the recommendation for SCDM for PCV13 for adults aged ≥65 years. A descriptive summary of responses using SAS 9.4 (Cary, NC) was prepared with comparisons between specialties conducted using chi-square analyses. The Colorado Multi-institutional Review Board approved this study as exempt research.

RESULTS

The overall response rate was 64% (617/968); 71% (336/474) for FP and 57% (281/494) for GIM. Characteristics of the respondents and nonrespondents are shown in Table 1. Respondents and nonrespondents did not differ by census location (urban, suburban, or rural), region, or whether decisions regarding purchasing and handling of vaccines by the practice were made independently or at a larger system level. Male and older physicians as well as physicians from private and smaller practices were less likely to respond. Item non-response was less than 10% for each question.

TABLE 1.

Demographic and practice characteristics of survey respondents, United States, 2019 (n = 968)

Characteristic	Respondents (N = 617)	Nonrespondents (N = 351)	p Value
Mean (SD) provider age in years	54.8 (9.4)	56.7 (9.1)	0.002a
Female, %	50	38	<0.001
Specialty
Family physician, %	54	39	<0.001
General internist, %	46	61
Region
Midwest	24	26	0.08
Northeast	19	21
South	33	36
West	24	17
Location of practice
Urban,%	27	23	0.19
Suburban, %	67	68
Rural, %	6	9
Practice setting b
Private practice, %	66	78	<0.001
Hospital or clinic, %	25	17
HMO, %	9	5
Median (IQR) number of providers in practice	6 (3–12)	5 (2–10)	0.002c
Decisions are made about purchasing or handling vaccines
Independent	53	57	0.28
At a larger system level	47	43
≥25% of patients aged ≥65 years, %	69	—	N/A
≥25% of patients uninsured, %	4	—	N/A
≥25% of patients with Medicare, %	56	—	N/A
≥25% of patients with Medicaid, %	16	—	N/A
≥25% of patients with private insurance, %	76	—	N/A

Abbreviations: SD, standard deviation; HMO, health maintenance organization; IQR, interquartile range.

^at-Test used.

^bNumber may not add to 100% owing to rounding.

^cWilcoxon test used.

Physician knowledge and attitudes regarding SCDM recommendation for PCV13 vaccination

We first asked physicians whether they were aware of the SCDM PCV13 recommendations and then provided those recommendations to them. Forty-one percent (n = 246) of respondents were aware of the SCDM PCV13 vaccination recommendation for adults aged ≥65 years. Physician attitudes regarding this recommendation are presented in Figure 1. The majority of respondents agreed that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23) (76%, n = 455), that they were unsure of what points to emphasize when having a SCDM conversation with patients about receiving PCV13 (60%, n = 356), and that increased advertising for adults in this age range to receive PCV13 would make having a SCDM conversation about it difficult (59%, n = 351).

FIGURE 1.

Physician attitudes regarding updated PCV13 vaccine recommendations for adults aged ≥65 years, United States, 2019–2020 (n = 617). *p < 0.05 for comparison between family physicians and general internists (Chi-square test) with general internists being more likely to agree. Some percentages do not add up to 100% due to rounding

Anticipated effect of ACIP recommendation on physician recommendation for PCV13 vaccination in adults ≥65 years

After reading a statement describing the new SCDM recommendation, 52% (n = 316) of respondents reported that they would be less likely to recommend PCV13 for adults ≥65 years as a result of the new recommendation, and 42% (n = 250) reported that their recommendation for PCV13 would not change (Figure 2). Thirty-seven percent (n = 222) of respondents reported that their practice had received materials from the PCV13 manufacturer promoting or encouraging PCV13 use in adults aged ≥65 years; 37% (n = 222) had not received materials, and 25% (n = 150) did not know if materials had been received.

FIGURE 2.

How will these new ACIP recommendations affect the way you recommend PCV13 to adults age ≥65 years? (n = 617). ACIP, Advisory Committee on Immunization Practices

DISCUSSION

As the first study to evaluate the physician perspective on the updated PCV13 recommendation for adults aged ≥65 years, we found that the majority of physicians were unaware of this change, were uncertain about what to emphasize in having a SCDM conversation about the vaccination, had concerns that patients would find this change confusing, and that advertising for the vaccine would make having a SCDM conversation more difficult. A large minority (42%) of physicians reported that the new ACIP recommendation would not change how they recommend PCV13 to adults in this age range, suggesting they would continue to recommend this vaccination routinely in their patients aged ≥65 years.

It is understandable that physicians may be unclear about how to approach a SCDM conversation about PCV13. Although SCDM, or the conversation between a patient and clinician to reach a healthcare choice, is ubiquitous in clinical practice,^14,15 applying this concept to adult vaccination recommendations by ACIP is relatively new. The only other examples of this concept being applied to adult vaccinations include the 2018 hepatitis B vaccination recommendation for adults aged ≥60 with diabetes¹⁶ and the 2019 HPV vaccination recommendation for adults aged 27–45 years.¹⁷ A study among pediatricians and family physicians showed that approximately 60% found it hard to explain the category B recommendation (a prior recommendation type equivalent to SCDM) for serogroup B meningococcal disease vaccination to adolescent patients and their parents.¹⁸ These SCDM recommendations are also likely to impact pharmacists, considering many adults receive vaccinations at pharmacies.¹⁹ Interestingly, a recent editorial by the leadership of the American Pharmaceutical Association expressed no concerns about pharmacists implementing SCDM for vaccinations,²⁰ but additional research may be needed to solicit perspectives of all vaccinators as SCDM recommendations become more common.

Another reason for the lack of enthusiasm about SCDM for PCV13 is that physicians are accustomed to formally applying SCDM to decisions that are associated with more risk than receiving a vaccination, like whether a patient should be screened for lung cancer²¹ or have a joint replaced.²² PCV13 is a safe vaccine with minimal side effects that are mostly related to local reactions.^6,9 Spending a significant amount of time in a time-limited visit discussing a vaccine that comes with less than a full recommendation may not be tenable to many clinicians. Another potential risk is financial; however, most patients ≥65 years will have Medicare,²³ and Medicare Part B covers PCV13 even if it is recommended through SCDM. Nonetheless, from a societal perspective, cost considerations did factor significantly in the ACIP recommendation to shift from a routine to SCDM recommendation, as modeling studies indicate that continued use of PCV13 in series with PPSV23 for adults aged ≥65 is less cost effective compared with PPSV23 alone.^9,24,25

Physicians who need further guidance about implementing the new PCV13 recommendations for adults aged ≥65 years should look to the published recommendation,⁹ which includes “considerations for shared clinical decision-making” regarding the use of PCV13 in this age group. Risk of PCV13-type disease in adults aged ≥65 years is a function of exposure to PCV13-type disease and underlying risk conditions. In terms of exposure, the recommendations state that providers “may consider regularly offering” PCV13 to adults in nursing homes or long-term care facilities or traveling to settings with no pediatric PCV13 program or to settings with low pediatric PCV13 uptake, these latter two groups perhaps being difficult to identify. In terms of underlying risk conditions, the recommendation states providers “may consider offering” PCV13 to persons with chronic heart, lung, or liver disease, diabetes, or alcoholism, and those who smoke cigarettes or who have more than one chronic medical condition, which may comprise a large portion of the geriatric population. In other words, even though there is no longer a routine recommendation for adults aged ≥65 to receive PCV13, it seems that a substantial proportion of patients could still be encouraged to receive the vaccine under the new recommendations. A decision aid, which has been suggested to facilitate SCDM,¹⁴ could prove useful in relaying this information.

This survey includes nationally representative samples of US primary care physicians and the response rate was high. However, the findings are subject to several limitations. The generalizability of the findings may be limited because males, older physicians, and physicians from smaller private practices were less likely to respond. We were unable to assess why many physicians reported not intending to change their recommendations. Also, based on the timing of the survey, some of the physicians completed the survey before the new ACIP recommendation was published, so their perception of SCDM may have changed since then.

The majority of adults aged ≥65 years remain unvaccinated against PCV13 according to most recent estimates.²⁶ The results of this study demonstrate the need to (1) inform physicians seeing older adult patients about this new recommendation, (2) develop tools to help implement it, and (3) study why physicians feel their recommendations for PCV13 will not change despite the new recommendation. Encouraging adults aged ≥65 years at higher risk of pneumococcal disease to receive PCV13 has the potential to prevent pneumococcal disease and associated healthcare utilization.

Key Points.

• Many physicians were unaware of the new PCV13 vaccine recommendation for older adults.

• Most physicians were uncertain how to implement the change.

Why Does this Paper Matter?

To protect older adults from pneumococcal disease, physicians need to be informed about this new recommendation and may need tools to implement it.