Date

June 2012

Document Type

Thesis

Degree Name

M.P.H.

Department

Dept. Public Health and Preventive Medicine

Institution

Oregon Health & Science University

Abstract

Background: Pregnancy is an immunosuppressed state which develops so that a woman may tolerate a genetically different fetus. This suppressed state poses an increased risk of infections such as influenza among pregnant women. In fact, several established organizations including the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the Advisory Committee of Immunization Practices (ACIP) have proposed that all women who are pregnant during the influenza season should be vaccinated [superscript 1-5]. Despite federal and state recommendations, only 51% of surveyed pregnant women in the US were estimated to have received the influenza vaccine during the 2009-2010 influenza season [superscript 6]. Objective: The main purpose of this study is to determine if a physician’s specialty background and practice location affect routine recommendation (i.e. 91-100% of the time) of flu vaccine to healthy pregnant women. In addition, this study aims to identify physician barriers to offering flu vaccine to pregnant patients. These barriers include beliefs, lack of proper storage facilities, cost, and whether or not offering flu vaccine to pregnant patients is part of routine patient-care activities. Study Design: A cross-sectional survey of Obstetrics and Gynecology (OB/GYN) and Family Medicine (FM) physicians who have active licenses with Oregon’s Board of Medical Examiners (BME) and have provided prenatal care within the last 12 months. Methods: This study uses a mixed-mode design. A self-administered, paper survey was initially sent out to 1,114 physicians with an attached cover letter and a pre-paid return envelope. These physicians were given an option to return the questionnaire through regular mail, on-line internet form, fax, or email. Two weeks after the initial mail-out, reminder postcards were sent out to non-responders. Final reminders were done by telephone communication and occurred four weeks after the initial mail-out. Analysis: Responses to each question were compared by specialties (OB/GYN vs. FM) and location (rural vs. urban) using Yates Corrected χ[superscript 2] or Fishers Exact Test when more than 25% of the cells had expected counts less than 5. All p-values were compared to an alpha significance level of .05. All statistical analysis, tables and figures were done using SAS v9.3 and Stata/IC 11.2. Results: Of the 1,114 providers surveyed, 496 (44.5%) completed the survey. Twenty-nine subjects were either unreachable or inactive and were dropped from the study producing an adjusted response rate of 45.7%. Among the 496 completed surveys, 187 (37.7%) provided prenatal care within the past 12 months and were kept for further analysis. Similar proportions of OB/GYNs and FMs were found to routinely (i.e. 91-100% of the time) recommend flu vaccine to their healthy pregnant patients (89.2% vs.87.6%; p-value = .5638). This did not vary between rural and urban locations. Although ACIP currently recommends flu vaccine at any time during gestation, fewer than 50% of OB/GYNs and FMs indicated they would recommend flu vaccine at ‘any time.’ Among the remaining 50%, more OB/GYNs than FMs indicated they would only recommend flu vaccine at first encounter with their pregnant patient (44.5% vs 27.0%; p-value < .0001), and more FMs than OB/GYNs indicated they would only recommend flu vaccine during 2nd or 3rd trimester (15.4% vs 2.5%; p-value < .0001). Among those that did not routinely recommend flu vaccine, a higher proportion of OB/GYNs than FMs reported the belief that benefits of the flu vaccine outweigh the risk in pregnant women (100.0% vs. 78.0%; p-value < .001). This did not vary between rural and urban locations. Similar proportions of OB/GYNs and FMs indicated they had sufficient storage units to store flu vaccines (89.4% vs. 100.0%; p-value = .056). However, after stratifying by location, few rural than urban OB/GYNs indicated they had the capacity to adequately store flu vaccines (54.5% vs. 100.0%; p-value < .001). A higher proportion of OB/GYNs than FMs reported inadequate reimbursement (19.1% vs 0.0%; p-value = .003) was a barrier to offering flu vaccine. After stratifying by location, more rural than urban OB/GYNs indicated that upfront cost (45.5% vs 0.0%; p-value <.001) and inadequate reimbursement (45.5% vs 11.1%; p-value = .023) were significant barriers. Furthermore, more rural than urban FMs indicated that offering flu vaccine was not part of their routine patient-care activities (22.5% vs 0.0%; p-value = .023). Discussion: Similar proportions of OB/GYNs and FMs, regardless of practice location, were found to routinely recommend flu vaccine to healthy pregnant women. Subsequently, neither a physician’s specialty background nor practice location affects routine recommendation of flu vaccine. The high proportions of physicians who routinely recommend also suggest that routinely recommending flu vaccine is not a significant factor to low vaccine coverage among healthy pregnant women. However, fewer than half of OB/GYN and FMs who provide prenatal care indicated they would recommend flu vaccine any time during pregnancy. Our data suggests that conversations reminding pregnant patients about the benefits and safety of the flu vaccine may be very minimal. While continuous outreaching to OB/GYNs and FMs who provide prenatal care would help to sustain the high proportion of physicians that routinely recommend flu vaccine to pregnant patients, guidelines should recommend that prenatal care providers have reminder conversations with their non-vaccinated pregnant patients at least once every trimester. These conversations should focus on the benefits, safety, and efficacy of the seasonal flu vaccine. These conversations will not only help improve vaccine coverage but will also help reduce the fear of vaccines in general. Among the 11.6% of physicians who did not routinely recommend flu vaccine, the reported barriers varied by specialty. Cost-related and structural–related barriers were more prevalent among OB/GYNs. This includes inadequate reimbursement and upfront cost which was also more prevalent among rural than urban OB/GYNs. Furthermore, more rural than urban OB/GYNs lacked proper vaccine storage units. In contrast, belief and administrative-related barriers were more prevalent among FMs. In fact, 22% of FMs believed there was not enough evidence to assess the benefits and risk of flu vaccine in healthy pregnant women. This belief did not vary by practice location. More rural than urban FM’s reported that offering flu vaccine was not part of their routine patient-care activities. This may be due to the fact that offering flu vaccine increases an already heavy workload, impedes the workflow, and is exacerbated by the delay in arrival of new vaccine after running out of existing supplies. Interventions that address these barriers may improve seasonal flu vaccine coverage among pregnant women. For example, reducing ordering cost and improving financial reimbursement would provide OB/GYNs a better incentive to offer flu vaccines from their practice site. Attempts should also be made to reduce the cost to storing seasonal flu vaccines. This can be achieved through a government subsidized program that reimburses physicians if they purchase a vaccine-quality storage refrigerator. This in turn would increase flu vaccine availability among OB/GYNs, especially in rural areas. An education outreach to prenatal care providers is needed to impart information and awareness regarding the safety, efficacy and benefits of flu vaccine in pregnant women. This can be achieved by providing on-line courses for CME credits and should be made mandatory among FMs that provide prenatal care. Efforts should also focus on improving administrative procedures involved in ordering and administering flu vaccine. For example, improving flu vaccine inventory and patient reminder notification systems may decrease the burden of workload and disruption of workflow associated with offering flu vaccines among FMs. Although interventions targeting OB/GYNs and FMs have been suggested, concomitant intervention strategies targeting pregnant patients is also needed to improve seasonal flu vaccine coverage and to achieve an 80% seasonal flu vaccine coverage among pregnant women, an objective set by Healthy People 2020[superscript 7].

Identifier

doi:10.6083/M4057CXV

School

School of Medicine

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