touchMEETING HIGHLIGHTS FMX 2023 – Boosting adult immunizations: Practical solutions for optimization

Introduction
The burden of vaccine-preventable diseases and importance of adult immunization

Despite the availability of effective vaccines, diseases such as influenza, pertussis, herpes zoster and pneumococcal disease still exert a substantial patient and healthcare burden in the US, with the problem predicted to worsen over time as the population both increases and ages.¹  Indeed, recent survey and population-based modeling studies have shown that over the next 30 years, the average life expectancy is projected to increase beyond 80 years for both men and women,² with cumulative societal costs for these four vaccine-preventable diseases expected to reach $1.3 trillion and cause over 1-million deaths.¹

Key to preventing this impact is ensuring patients are receiving recommended vaccines, especially those adults who have weaker immune systems and are therefore more at risk from viruses such as influenza and pneumococcal disease.³  However, data from the National Health Interview Survey from 2019–2021 show that of the vaccine-preventable diseases that have target vaccination coverage rates, as defined by the Healthy People goals from the US Office of Disease Prevention and Health Promotion (e.g., 70% for influenza by  2030; 30% for herpes zoster by 2020 [in people ≥60 years]; 90% for pneumococcal disease by 2020 [in people ≥65 years]),^4,5 only herpes zoster currently meets these targets.^6,7 This highlights a clear opportunity to improve adult immunization rates.

Here we present a summary of an Expert Panel Discussion on the optimization of adult immunizations, held at the American Academy of Family Physicians – Family Medicine Experience (AAFP-FMX) conference, 2023.  In this meeting, leading Family Medicine specialists Dr Jeremy Szeto (Szeto Medical, Texas) and Dr Kristen Robillard (Lakeshore Primary Care Associates, New York) discuss their personal experiences with adult immunizations and the practical approaches they use to improve adult immunization.

This article is intended as a summary of the key messages from the meeting, as explained by the experts here on this page in the above video player.

Expert Panel Discussion
Vaccine promotion, stocking, and financial barriers 

Question 1: Firstly, what type of patients do you see in your practice, and in general how receptive are they to immunization?

Dr Szeto: Overall, I would say my patients are on the younger side, mostly 25–55 years of age, well educated, upper-middle class, with commercial or private insurance (no Medicare or Medicaid).

Dr Robillard: As part of a large practice, which includes a dedicated pediatrician, we cover a wide variety of ages, including families. Around three-quarters of our patients have private insurance (70–75%), with the remainder Medicare or Medicaid. I would say that overall our patients are pretty receptive to immunization, especially since everyone in the office primes the patients to receive vaccines from the minute they walk in the door so that they get used to the idea.

Question 2: I also understand that you stock vaccines in your offices – what drove that decision and what benefits does this provide?

Dr Robillard: In my experience not having them in the office is a huge barrier to vaccination, as a patient is much more likely to take a vaccine if it is there on hand when you are discussing it, instead of having to make a separate visit to the pharmacy. Also, you don’t need to overstock. They only take a few days to be delivered so you only need to buy around 10 at a time.

Dr Szeto: I agree, keeping vaccines in the office is important as it aids adherence (to immunization recommendations) and definitely improves vaccination rates. In terms of stocking them, with the fast delivery times I’m also able to order them in small quantities, and if you are part of a larger buying group there are often discounts. The important thing is to make sure there is adequate inventory management to keep the vaccines on hand, and then you can provide a great service for the patient.

Question 3: What approaches have you implemented in your practice to help recommend vaccines to your patients?

Dr Szeto: There are several things we do to improve our vaccination rates, including scheduling their next appointment before they leave the office (for vaccines that require several doses), and simplifying the dosing regimens so they are easier for the patient to follow and remember. For example, asking the patient to come back for their second shingles vaccine dose in 3 months, instead of asking them to come back in 2–6 months, thereby streamlining the decision.

Dr Robillard: I agree, we also set up the next appointment while they’re in the office and it’s extremely helpful, as everybody then knows the date of the next vaccination and we can follow-up with them if they miss the appointment. We also have electronic health records that include disease management and health maintenance tools. These allow us to see whether a patient is due for a vaccination as soon as they walk into the office, which makes it easier for us to encourage vaccinations at every routine visit (provided the patient is due for them).

Question 4: How do you deal with any potential financial barriers to implementing vaccinations?

Dr Robillard: There are a lot of financial barriers, as you can’t always get reimbursed for every vaccine you administer in the office. As mentioned before, it’s good to start small, stocking a few vaccines in the office for a single disease, such as flu. Then you can evaluate the barriers, set up a system such as joining a buying group to mitigate costs, and then build from there to stock vaccines for more diseases.

Dr Szeto: I think it is probably easier in my practice, because with commercial insurance we are likely to be reimbursed for each vaccine, so the main barrier to administering vaccines is adequate inventory management.

Optimizing adult immunization rates

Question 1: How to you approach the subject of vaccinations in patients who may be vaccine-hesitant?

Dr Szeto: While in my practice there are not many of these patients, we would try and discuss disease prevention as a natural part of their visit, alongside ways of maintaining a healthy lifestyle, such as regular exercise or vitamins. I think if you give patients a bit of time and try and educate them early, they will accept vaccinations and make them part of their yearly routine.

Dr Robillard: We try not to push the patients into taking vaccines, but we do try to educate them on the immune system, how it fights infection, how the vaccines are far safer than getting the diseases, and that even if you do get infected the outcomes will be far worse if you haven’t had the vaccine. We make sure to prime the patient on what to expect afterwards, such as feeling bad for a couple of days, or local reactions, and we also use anecdotes from personal experience to reassure patients. For example, describing my experiences during COVID, or explaining that I have 25 years of medical experience and that I feel they [the vaccines] are good enough to use on myself and my family.

Dr Szeto: We take care of entire families, so I also prime parents on the concept and importance of vaccines when they bring their children in for their mandatory vaccinations. I explain that we are vaccinating the children not just so they can go to school, but because it is important for their health and wellbeing as well. In this way, the parents are more aware of the need for vaccinations when they come into the office as patients themselves – if it’s good for their children, it’s good for them.

Question 2: How do you manage medical exemptions in your practice?

Dr Szeto: As a general rule we don’t really permit medical exemptions in our (private) practice, and I’m proud to say this has resulted in an almost 100% vaccine coverage rate in both children and adults.

Dr Robillard: We don’t usually accept exemptions in children, and if the family is there we try and educate them as best we can, but in the end it is their decision. With adult patients we strongly encourage things such as the flu vaccine. It’s difficult to find the time to educate and convince vaccine-hesitant patients of the benefits, but it’s worth it as vaccines certainly save lives, prevent comorbidities, and reduce healthcare costs.

Patient education and communication

Question 1: From seeing patients to managing your practice there must be a lot of constraints on your time, so how do you approach patient-doctor conversations about vaccination?

Dr Robillard: The first thing I usually do when I sit down with a patient is bring up their health records on the computer, and then go through everything that they need to do before discussing what the patient wants me to do. The checklist serves as a reminder on what’s important to discuss, what needs to be scheduled, and what we will follow-up on.

Dr Szeto: We too have prompts on the health records, but we also try and include vaccination conversations in every visit as a natural part of discussions about patients’ concerns. For example, with older patients the main things we will discuss at each visit will be heart disease, cancer, and vaccines and prevention.

Question 2: How do you discuss more complex vaccination guidance, such as the ACIP shared clinical decision-making recommendations,⁸ with your patients?

Dr Robillard: We would usually try and generalize the discussions a little, for example saying that RSV [respiratory syncytial virus] is something you would be at risk of because of your age, as it mainly affects people over 60 and under 6, and then relate it to causes of illness they would be familiar with, such as flu and COVID. I would also make sure to personalize the discussion by saying that if it were me, I would consider getting the vaccine, and then take the time to have a good conversation about their own risk based on their current health. This holds true for other vaccine-preventable diseases with shared clinical decision-making recommendations, such as hepatitis B, HPV [human papilloma virus], pneumococcal disease, and meningitis.

Dr Szeto: It’s the same for me in my practice as well. My patients are generally well-educated so they tend to come in and ask about, for example, the RSV vaccine, and then we’ll have a conversation about the disease and their personal risk.

Question 3: If there was one piece of practical advice you could give to your peers about vaccines and implementing them into their practice, what would it be?

Dr Szeto: I would say the strongest message you could give to a patient is to tell them that you have done it yourself, whether it be taking vitamins, seeing a cardiologist, or getting you and your loved ones vaccinated. It’s a simple as that.

Dr Robillard: I agree, and would add that stocking vaccines in your office is very useful, as is using anecdotes to personalize discussions around vaccination – anything that can improve the primary care relationship, as that’s extremely valuable and important.

Summary

The expert discussion between Dr Jeremy Szeto and Dr Kristen Robillard provided some key insights into steps that can be taken to improve vaccination coverage, highlighting the importance of having vaccines stocked at the clinic, doctor-patient interaction, and patient education on the importance and health benefits of vaccination. In particular, clear, consistent (at each clinic visit) and relatable communication, electronic health records, vaccine inventory management, and streamlining of the decision-making process, such as by simplifying dosing schedules and ensuring follow-up appointments are booked at each visit, were highlighted as key approaches that can optimize immunization in adults.

Further information on the importance of immunization, best practices, immunization recommendations, and guidance can be found at the AAFP website (https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines.html).