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The American Journal of Managed Care November 2019
Population Health Screenings for the Prevention of Chronic Disease Progression
Maren S. Fragala, PhD; Dov Shiffman, PhD; and Charles E. Birse, PhD
Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs
Leticia R. Moczygemba, PhD, PharmD; Ahmed M. Alshehri, PhD; L. David Harlow III, PharmD; Kenneth A. Lawson, PhD; Debra A. Antoon, BSPharm; Shanna M. McDaniel, MA; and Gary R. Matzke, PharmD
One Size Does Not Always Fit All in Value Assessment
Anirban Basu, PhD; Richard Grieve, PhD; Daryl Pritchard, PhD; and Warren Stevens, PhD
Value Assessment and Heterogeneity: Another Side to the Story
Steven D. Pearson, MD, MSc
From the Editorial Board: Joshua J. Ofman, MD, MSHS
Joshua J. Ofman, MD, MSHS
Multimodality Cancer Care and Implications for Episode-Based Payments in Cancer
Suhas Gondi, BA; Alexi A. Wright, MD, MPH; Mary Beth Landrum, PhD; Jose Zubizarreta, PhD; Michael E. Chernew, PhD; and Nancy L. Keating, MD, MPH
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Emily A. Gadbois, PhD; Shayla Durfey, BS; David J. Meyers, MPH; Joan F. Brazier, MS; Brendan O’Connor, BA; Ellen McCreedy, PhD; Terrie Fox Wetle, PhD; and Kali S. Thomas, PhD
Cost Analysis of COPD Exacerbations and Cardiovascular Events in SUMMIT
Richard H. Stanford, PharmD, MS; Anna D. Coutinho, PhD; Michael Eaddy, PharmD, PhD; Binglin Yue, MS; and Michael Bogart, PharmD
CKD Quality Improvement Intervention With PCMH Integration: Health Plan Results
Joseph A. Vassalotti, MD; Rachel DeVinney, MPH, CHES; Stacey Lukasik, BA; Sandra McNaney, BS; Elizabeth Montgomery, BS; Cindy Voss, MA; and Daniel Winn, MD
Currently Reading
Importance of Reasons for Stocking Adult Vaccines
David W. Hutton, PhD; Angela Rose, MPH; Dianne C. Singer, MPH; Carolyn B. Bridges, MD; David Kim, MD; Jamison Pike, PhD; and Lisa A. Prosser, PhD
Multipayer Primary Care Transformation: Impact for Medicaid Managed Care Beneficiaries
Shaohui Zhai, PhD; Rebecca A. Malouin, PhD, MPH, MS; Jean M. Malouin, MD, MPH; Kathy Stiffler, MA; and Clare L. Tanner, PhD

Importance of Reasons for Stocking Adult Vaccines

David W. Hutton, PhD; Angela Rose, MPH; Dianne C. Singer, MPH; Carolyn B. Bridges, MD; David Kim, MD; Jamison Pike, PhD; and Lisa A. Prosser, PhD
Economic factors associated with the purchase and maintenance of vaccine inventory and inadequate reimbursement for vaccination services were the most important to pharmacy and doctors’ office decision makers when considering whether to stock adult vaccines.
ABSTRACT

Objectives: To identify the most important reasons underlying decisions to stock or not stock adult vaccines.

Study Design: US physicians, nurses, pharmacists, and administrators of internal medicine, family medicine, obstetrics/gynecology, and multispecialty practices who were involved in vaccine stocking decisions (N = 125) completed a best–worst scaling survey online between February and April 2018.

Methods: Sixteen potential factors influencing stocking decisions were developed based on key informant interviews and focus groups. Respondents selected factors that were most and least important in vaccine stocking decisions. Relative importance scores for the best–worst scaling factors were calculated. Survey respondents described which vaccines their practice stocks and reasons for not stocking specific vaccines. Subgroup analyses were performed based on the respondent’s involvement in vaccine decision making, role in the organization, specialty, and affiliation status, as well as practice characteristics such as practice size, insurance mix, and patient age mix.

Results: Relative importance scores for stocking vaccines were highest for “cost of purchasing vaccine stock,” “expense of maintaining vaccine inventory,” and “lack of adequate reimbursement for vaccine acquisition and administration.” Most respondents (97%) stocked influenza vaccines, but stocking rates of other vaccines varied from 39% (meningococcal B) to 83% (tetanus-diphtheria-pertussis). Best–worst scaling results were consistent across respondent subgroups, although the range of vaccine types stocked differed by practice type.

Conclusions: Economic factors associated with the purchase and maintenance of vaccine inventory and inadequate reimbursement for vaccination services were the most important to decision makers when considering whether to stock or not stock vaccines for adults.

Am J Manag Care. 2019;25(11):e334-e341
Takeaway Points
  • Prior research has shown that many providers do not stock adult vaccines and this can be a barrier to patients receiving recommended vaccinations.
  • We surveyed US physicians, nurses, pharmacists, and administrators involved in vaccine stocking decisions to understand barriers to stocking vaccines for adults.
  • We used novel best–worst scaling methods (from marketing) to quantify how decision makers rank the relative importance of different barriers.
  • Relative importance scores for stocking vaccines overall were highest for “cost of purchasing vaccine stock,” “expense of maintaining vaccine inventory,” and “lack of adequate reimbursement for vaccine acquisition and administration.”
Although vaccination rates for childhood vaccines are high in the United States, rates are lower for adult vaccines.1 The United States has achieved the Healthy People 2020 (HP2020) target of 30% for the shingles vaccine but not the adult influenza or pneumococcal immunization targets.1,2 The HP2020 target is for 70% of noninstitutionalized adults to be vaccinated for influenza,2 but just 43.3% of adults were immunized at the end of the 2016-2017 season.3 The HP2020 targets for pneumococcal vaccination are 60% for high-risk adults aged 18 to 64 years and 90% for noninstitutionalized adults 65 years or older,2 yet coverage rates are stagnant at 24% and 67%, respectively.4 Estimates from Medicare claims data show even lower pneumococcal vaccine coverage for adults 65 years or older, at 59% for any pneumococcal vaccine and just 24% for both the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13).5

Provider recommendations are a key predictor of adult vaccination; however, providers are less likely to recommend vaccines they do not stock.6,7 A survey conducted in 2009 of family practice and internal medicine physicians found that many do not stock all adult vaccines and that reimbursement was a barrier to stocking adult vaccines.8 A survey conducted in 2012 of primary care providers found that financial barriers were important to decisions about recommending and stocking vaccines for adults.9 More recent surveys of providers have reported dissatisfaction with reimbursement levels in relation to their costs and profitability varying widely between payers.10,11 A survey conducted in 2015 of obstetricians and gynecologists found that many adult vaccines were not stocked and that financial barriers were most important to stocking decisions.12 Most of these studies have focused on general internal medicine and family medicine providers, and several have asked about how these barriers affect both recommending and stocking vaccines. The majority of these studies also relied on a Likert scale to understand how providers feel about the barriers. In the time since those studies were published, there have been changes in insurance reimbursement for vaccines with the Affordable Care Act, vaccination has expanded in pharmacies, and pharmacists are able to administer vaccines in all 50 states.13

In this current study, we seek to identify the most important reasons underlying decisions to stock adult vaccines. We focus on provider stocking decisions and expand the pool of providers beyond those studied in the past to include pharmacists. We also expand beyond general internal medicine and family medicine physicians to survey physicians specializing in obstetrics and gynecology (OB/GYN) and multispecialty practices. This study uses an innovative best–worst scaling methodology from the field of marketing to quantify the ranking of importance of these barriers.14

METHODS

Best–worst scaling is a survey approach used to identify the relative values associated with objects.14 It does so by repeatedly asking respondents to identify the most important and least important objects from different lists of objects. Best–worst scaling has been shown to be more reliable than Likert rating scales15 and can be used to avoid scale biases.16,17 In this analysis, the objects that we are interested in ranking are the factors that may influence vaccine stocking decisions.

Survey Development, Design, and Administration

We used qualitative data from 3 focus groups (n = 12 total participants) and key informant interviews (n = 9 key informants) along with relevant literature6-12 to identify 16 factors potentially influencing vaccine stocking decisions (Table 1). The focus groups and key informant interviews involved vaccine stocking decision makers in medical practices and pharmacies and were conducted from January to October 2017 using a standardized interview guide to identify potential factors influencing these decisions.

Based on the results from the focus groups and key informant interviews, we developed a survey to assess the importance of factors in stocking vaccines. The survey included an introduction to the factors and their definitions, as shown in Table 1. Each respondent was asked to assess 4 sets of 6 factors selected from the overall 16 that were developed using a balanced incomplete block design methodology to ensure even representation of factors across survey versions (Figure 1).18 For each question, respondents were asked to select the factors that were most and least important in the decision to stock vaccines in general. Respondents were randomized to 1 of 4 versions of the survey. Finally, survey respondents were presented with a list of 11 commonly used adult vaccines and asked which vaccines their practice stocks and the reasons for not stocking specific ones. We also collected information on each respondent’s role in their organization, practice type, organization affiliation, characteristics of the practice, and at what organizational level the decisions to stock vaccines are made.

The survey underwent cognitive pretesting to ensure that respondents understood the questions as intended. In April 2018, the survey was administered online to a standing panel (Qualtrics; Seattle, Washington) of US physicians, nurses, pharmacists, and administrators involved in vaccine stocking decisions. Although this was a convenience sample, respondents represented diverse regions across the United States.


 
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