Issuance of Patient Reminders for Influenza Vaccination by US-Based Primary Care Physicians During the First Year of Universal Influenza Vaccination Recommendations

Abstract

To estimate the number of physician-reported influenza vaccination reminders during the 2010–2011 influenza season, the first influenza season after universal vaccination recommendations for influenza were introduced, we interviewed 493 members of the Physicians Consulting Network. Patient vaccination reminders are a highly effective means of increasing influenza vaccination; nonetheless, only one quarter of the primary care physicians interviewed issued influenza vaccination reminders during the first year of universal vaccination recommendations, highlighting the need to improve office-based promotion of influenza vaccination.

Provider-issued reminders are highly effective in increasing influenza vaccine uptake and are well accepted by patients.^1,2 The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and other professional societies, such as the American Academy of Family Physicians and the American Academy of Pediatrics, have long recommended the issuance of patient reminders to increase influenza vaccination.³

We present estimates of physician-reported issuance of influenza vaccination reminders during the 2010–2011 influenza season, the first in which the Advisory Committee on Immunization Practices recommended influenza vaccination to all people aged 6 months and older.⁴ Universal vaccination recommendation eliminated the need to target influenza vaccination on the basis of complex combinations of risk factors and age. We also compared the issuance of reminders for influenza vaccination with that for check-ups and well-care visits to assess the priority placed on promoting influenza vaccination relative to that for other forms of health promotion.

METHODS

The data came from a pilot study assessing the utility of Internet panels for analyzing office-based influenza vaccination practices.⁵ We collected cross-sectional self-reported data from a stratified, quota sample of 493 US-based primary care physicians—124 family or general practitioners, 122 internists, 122 obstetricians and gynecologists, and 125 pediatricians—between October 3 and October 8, 2010. All participants were members of the Physicians Consulting Network, an Internet-based survey research panel of health care workers recruited from the American Medical Association Master File and other types of targeted mailing and membership lists. The universe of Physicians Consulting Network panelists from the aforementioned specialties served as our sampling frame.⁶ Before enrollment, the network verifies the identity of physicians using the American Medical Association database. The Physicians Consulting Network also pays financial incentives for survey participation, which typically range from $5 to $175 depending on the specialty and interview duration.

Table 1 summarizes selected characteristics of respondents and their practice settings. Respondents were on average 51 years old and predominantly male and non-Hispanic White, and represented both metropolitan and nonmetropolitan areas. About 70% worked in group practices.

TABLE 1—

Sample Characteristics of the RAND Influenza Vaccination Physician Survey Data: United States, October 2010

Characteristic	All Specialties (n = 493)	Family or General Practice (n = 124)	Internal Medicine (n = 122)	Obstetrics–Gynecology (n = 122)	Pediatrics (n = 125)
Age, y, mean	51	52	51	51	50
Sex, no.
Female	131	31	18	41	41
Male	361	93	104	81	83
Missing	1	0	0	0	1
Race/ethnicity, no.
Hispanic	19	3	6	4	6
Non-Hispanic Black	21	6	4	7	4
Non-Hispanic White	293	79	61	82	71
Other non-Hispanic and mixed race	160	36	51	29	44
Region, no.
Northeast	125	26	33	31	35
Midwest	99	33	22	24	20
South	178	43	49	45	41
West	90	22	18	22	28
Missing	1	0	0	0	1
Metropolitan statistical area status, no.
Metropolitan	420	94	108	103	115
Nonmetropolitan	72	29	14	19	10
Missing	1	1	0	0	0
Health care setting, no.
Group practice	344	82	88	89	85
Solo practice	104	33	25	28	18
Hospital or academic medical center	26	2	4	4	16
Integrated delivery systema	6	1	1	1	3
Otherb	10	5	3	0	2
Missing	3	1	1	0	1

Note. Data collection based on members of the Physician Consulting Network Internet panel. The sample size was n = 493.

^aIncludes providers such as the Veterans Administration and Kaiser Permanente.

^bIncludes, for example, community health clinics and long-term care facilities.

The survey asked physicians whether the location at which they see most of their patients issues reminders to patients to be vaccinated for influenza and to schedule check-ups and well-care visits. We estimated the proportion of physicians reporting that their main work location issues (1) influenza vaccination reminders, (2) check-up and well-care visit reminders, and (3) influenza vaccination reminders conditional on reporting issuance of reminders to schedule check-ups and well-care visits. We assessed the statistical significance of differences in the proportion of physicians reporting issuance of different types of reminders overall and by specialty using the Wald test. For each of the aforementioned proportions, we also assessed the statistical significance of differences by specialty using the χ² test. We performed all computations using STATA 12.1 SE (StataCorp, College Station, TX).

RESULTS

Of all interviewed physicians, 24.3% reported that their work locations issued reminders for influenza vaccination compared with 55.2% of respondents who reported the issuance of reminders for check-ups or well-care visits (P < .001; Table 2). We observed differences of similar magnitude and significance within each primary care specialty. Moreover, only 39.9% of physicians reporting the issuance of check-up or well-care visit reminders also reported the use of influenza vaccination reminders in their practices.

TABLE 2—

Self-Reported Issuance of Patient Reminders for Influenza Vaccination and Check-Ups and Well-Care Visits Among US Primary Care Physicians’ Work Locations: October 2010

Reminder Status	All Primary Care Specialties, No. or % (95% CI)	Family or General Practice, No. or % (95% CI)	Internal Medicine, No. or % (95% CI)	Obstetrics–Gynecology, No. or % (95% CI)	Pediatrics, No. or % (95% CI)	P for Test of Equal Proportions Across Specialties
Issuance of patient reminders for influenza vaccination						.002
Issued reminder	24.3 (20.5, 28.1)	19 (12, 26)	30 (22, 39)	15 (8, 21)	33 (24, 41)
Did not issue reminder	69.6 (65.5, 73.6)	77 (69, 84)	66 (58, 75)	76 (69, 84)	59 (50, 68)
Don’t know	4.1 (2.3, 5.8)	1 (0, 2)	2 (0, 5)	6 (2, 9)	7 (3, 12)
Refuse	2.0 (0.7, 3.3)	3 (0, 6)	1 (0, 2)	3 (0, 6)	1 (0, 2)
Total no.	493	124	122	122	125
Issuance of patient reminders for check-ups and well-care visits						.013
Issued reminder	55.2* (50.8, 59.6)	47* (38, 56)	52* (43, 61)	62* (54, 71)	60* (51, 69)
Did not issue reminder	39.8 (35.4, 44.1)	48 (39, 57)	43 (35, 52)	32 (24, 40)	35 (27, 44)
Don’t know	3.7 (2.0, 5.3)	1 (0, 2)	5 (1, 8)	5 (1, 9)	4 (1, 7)
Refuse	1.4 (0.4, 2.5)	4 (1, 8)	…	1 (0, 2)	1 (0, 2)
Total no.	493	124	122	122	125
Issuance of patient reminders for influenza vaccination among physicians issuing patient reminders for check-ups and well-care visits						.012
Issued reminder	39.3 (33.5, 45.2)	36 (23, 49)	54 (41, 67)	22 (13, 32)	47 (35, 58)
Did not issue reminder	56.3 (50.3, 62.2)	60 (47, 73)	44 (32, 57)	70 (59, 80)	49 (38, 61)
Don’t know	2.6 (0.7, 4.5)	2 (0, 5)	…	4 (0, 8)	4 (0, 8)
Refuse	1.8 (0.2, 3.4)	2 (0, 5)	2 (0, 5)	4 (0, 8)	…
Total no.	272	58	63	76	75

Note. CI = confidence interval. The sample size was n = 493.

*P < .001; statistically significant differences from physician-reported proportion issuing patient reminders for influenza vaccination.

Physician-reported issuance of influenza vaccination reminders also differed by primary care specialty (P = .002), and these differences remained significant when considering only physicians who reported issuance of reminders for check-ups or well-care visits (P = .012). Internists and pediatricians more frequently reported the issuance of both types of reminders than did obstetricians and gynecologists, and family or general practitioners. Physician-reported issuance of reminders for check-ups and well-care visits also differed by primary care specialty (P = .013), with family or general practitioners and internists reporting the lowest frequency of reminder issuance and obstetricians and gynecologists reporting the highest.

DISCUSSION

Only about 1 in 4 of interviewed US-based primary care physicians reported issuing patient reminders for influenza vaccination during the 2010–2011 vaccination season, despite their well-documented effectiveness in increasing vaccination, high levels of patient acceptance, long-standing recommendations from professional societies, and increased ease of implementation. The significantly higher issuance of patient reminders for check-ups and well-care visits further suggests that suitable systems for sending patient reminders often already exist and may be ready to use, especially because the current universal vaccination recommendations for influenza do not call for special targeting on the basis of patient characteristics. Yet, compared with published estimates from previous influenza seasons, issuance of vaccination reminders does not appear to have increased after the Centers for Disease Control and Prevention’s universal vaccination recommendation.^7,8

Our study has several limitations. First, although our approach based on a stratified quota sample of physicians achieved the goal of interviewing about 500 family or general practitioners, internists, obstetricians and gynecologists, and pediatricians from a wide range of practice settings and geographical regions, our data may not be representative of all practicing physicians from the 4 targeted primary care specialties in the United States. Moreover, our data rely on survey self-reports, whose accuracy is unknown and may be subject to upward bias because of social desirability or downward bias because of some physicians’ potential lack of knowledge regarding the issuance of patient reminders at their work location.

Despite these shortcomings, our data are—to our knowledge—the only source of reasonably generalizable provider-level data on the issuance of patient reminders for influenza vaccination obtained during the first year of universal influenza vaccination recommendations. As such, it provides a unique benchmark for assessing improvement in vaccination-related provider behavior going forward. Increasing the issuance of patient reminders for influenza vaccination could significantly increase influenza vaccination and should therefore be a focus of future improvement efforts.