Research article
Physician Practices Regarding Adult Hepatitis B Vaccination: A National Survey

https://doi.org/10.1016/j.amepre.2009.01.037Get rights and content

Background

Less than 50% of adults with risk factors for hepatitis B infection have been vaccinated. Although primary care settings typically serve an important role in immunization delivery, little is known about adult hepatitis B vaccination practices in primary care, including the use of strategies such as standing orders to improve immunization rates. The objectives of this study were to assess, among family physicians and general internists, current approaches to assessing adult patients for hepatitis B risk factors, reported hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination.

Methods

From September to November 2006, a national sample of 433 family physicians and 420 general internists were surveyed. Results were analyzed in 2007 and 2008.

Results

Response rates were 65% for family physicians and 79% for general internists. Thirty-one percent of physicians reported assessing most or all adult patients for hepatitis B risk factors and vaccinating patients identified as high risk. Perceived barriers to hepatitis B vaccination included patients not disclosing high-risk behaviors, lack of adequate reimbursement for vaccination, and feeling too pressed for time to assess risk factors. Most surveyed physicians were very (47%) or somewhat (38%) supportive of using standing orders for hepatitis B vaccination in their practices. However, staff time constraints and patient unwillingness to disclose sensitive information to staff were perceived as barriers to using standing orders by a majority of respondents.

Conclusions

In a national survey, less than one third of primary care physicians reported routinely assessing for and vaccinating adults with hepatitis B risk factors. This finding suggests that new strategies for adult hepatitis B vaccination in primary care settings are needed. Most physicians supported using standing orders for vaccination, but barriers were anticipated.

Introduction

Approximately 1.25 million people in the U.S. are chronically infected with hepatitis B virus, with an estimated 46,000 new infections and 2000–4000 deaths attributable to hepatitis B occurring each year.1, 2 Hepatitis B vaccination is the most effective means of preventing hepatitis B infection and its serious consequences.3, 4 The current U.S. strategy for hepatitis B prevention involves universal hepatitis B vaccination of children and adolescents,5 and a risk-based approach in adults, with vaccination recommended for adults at increased risk of acquiring hepatitis B.3 Although there are a number of identified risk factors for hepatitis B infection,6 the majority of acute hepatitis B cases in adults occur in individuals reporting either high-risk sexual activity or injection drug use.1, 3

For a risk-based vaccination strategy to succeed, adults at increased risk of infection need to seek care and be appropriately assessed for risk factors. In the 2000 National Health Interview Survey (NHIS),7 81% of adults with risk factors for hepatitis B infection reported visiting a clinician in the prior year, including 65% who had visited an internist or family physician. However, in the 2004 NHIS, only 45% of high-risk adults reported receiving one or more doses of hepatitis B vaccine, with immunization rates slightly higher among adults with health insurance and those reporting a usual source of health care.8 These data indicate that missed vaccination opportunities7, 9 may represent a greater barrier to hepatitis B vaccination than limited healthcare access. Are vaccination opportunities being missed because physicians are not routinely assessing their patients for hepatitis B risk factors? The answer to this question is unclear, because the hepatitis B vaccination practices of U.S. physicians have not been closely examined.

In recently revised guidelines for adult hepatitis B vaccination, the Advisory Committee on Immunization Practices (ACIP) recommended the routine use of standing orders in primary care clinics and other settings to identify and vaccinate high-risk adults against hepatitis B.3 Standing orders would give nurses and other healthcare personnel the authority to identify and vaccinate high-risk adults by protocol, thereby taking the task of assessing for hepatitis B risk factors out of physicians' hands.10 However, physician attitudes about standing orders, particularly the use of standing orders in outpatient settings for risk-based vaccination, are largely unknown. The objectives of the current investigation were to evaluate, among a national sample of family physicians and general internists, current approaches to assessing patients for hepatitis B risk factors, reported adult hepatitis B vaccination practices, and attitudes about standing orders for hepatitis B vaccination.

Section snippets

Study Setting

From September to November 2006, a survey was administered to a national research network of primary care physicians. The human subjects review board at the University of Colorado Denver approved this study, and written informed consent was not required.

Population

This study was conducted by the Vaccine Policy Collaborative Initiative, a program designed collaboratively with the CDC to perform rapid assessments of physician attitudes about pressing vaccine-related issues. A national network of primary

Survey Response

Survey response rates were 65% (282 of 433) for family physicians and 79% (332 of 420) for general internists. Survey respondents were similar to nonrespondents with respect to age, gender, region of the country, location of practice, and practice type. Among respondents, 81% of family physicians and 76% of general internists worked in private practice settings; for both specialties, fewer than 4% worked in managed care organizations. Sixteen respondents (six family physicians, ten general

Discussion

This study, to our knowledge, is the first national survey of adult hepatitis B vaccination practices in primary care settings. Despite long-standing vaccination recommendations,3 only 31% of family physicians and general internists reported routinely assessing for and vaccinating their patients against hepatitis B. Few surveyed physicians regarded identifying and vaccinating high-risk adults as a high priority, few reported a systematic approach to assessing for high-risk sexual behaviors or

Conclusion

Based on this national survey of general internists and family physicians, the process of identifying and vaccinating high-risk adults against hepatitis B does not appear to be systematically or consistently occurring in most primary care practices. Standing orders have the potential to improve immunization delivery processes; however, competing staff priorities and the process of risk assessment may remain obstacles to hepatitis B vaccination. Although eventually universal childhood hepatitis

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