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Release: April 26, 2001

UI studies show support for adult immunization by non-physicians

IOWA CITY, Iowa -- Iowa family physicians and their patients overall support having adults receive immunizations from non-physician health care professionals at sites outside of physician offices, according to two related studies by University of Iowa researchers.

In addition, physicians and patients were supportive of having children receive immunizations at certain non-physician locations such as community health centers, but were less supportive of using locations such as pharmacies for childhood shots. There also was some concern about the record keeping and safety of out-of-office immunizations.

The studies, which were published in two journals earlier this year, have implications for ways to increase immunization rates in Iowa and possibly other states with similar populations.

Other studies have shown that using non-physicians, such as nurses, nurse practitioners, physician assistants and pharmacists, to provide immunizations may help more people keep their immunizations up to date. However, little has been known about primary care physicians' interest in working with other health care providers on immunization efforts, or patients' interest in getting immunizations from non-physicians at locations such as community health centers, schools and pharmacies.

The tandem studies were the collaborative work of three researchers: George Bergus, M.D., associate professor of family medicine in the UI College of Medicine; Michael Ernst, Pharm.D., assistant professor (clinical) in the UI College of Pharmacy and pharmacist in the UI Family Medicine Clinic; and Bernard Sorofman, Ph.D., associate professor in the UI College of Pharmacy.

Iowa and the United States as a whole did not meet the adult immunization rates for influenza and pneumonia set by Healthy People 2000, a national health promotion and disease prevention initiative. The target for pneumococcal vaccinations, for example, was set at 60 percent of seniors (age 65 and older) during their lifetime. However, by 1997 the national rate was 43 percent and no single state had met the 60 percent target.

"The unmet Healthy People 2000 goal raises the question of what will happen for Healthy People 2010, which has set goals of 90 percent for influenza and pneumococcal vaccine for people age 65 and older," said Bergus, who authored the study that focused on the survey responses of 476 members of the Iowa Academy of Family Physicians.

The majority of the family physicians surveyed indicated that some of their patients already are using non-physician providers, and many family practioners said they are willing to work collaboratively with non-traditional immunization providers.

Three of four physicians reported they already have worked with a provider outside their office on patient immunizations. Nearly all the physicians (95 percent) expressed interest in working with non-physician providers in the future, including 92 percent considering collaboration with a nurse practitioner, 89 percent with a school or public health nurse and 50 percent with a pharmacist.

Physicians in towns with populations of 20,000 or less were more likely than physicians in more populous cities to report adult patients already getting their shots outside of doctors' offices.

Two of three physicians also supported school-age children getting immunizations (such as boosters for diphtheria-tetanus) from school nurses or community health departments. While fewer than one in 10 physicians thought children should get shots from pharmacists, many physicians thought adults could effectively use pharmacies for immunization against the flu or pneumonia.

This finding about pharmacies was supported by the related study, authored by Ernst, which was based on 420 surveys returned by people who had immunizations at 22 sites, including family physician offices, community health departments and pharmacies.

Adults reported that for flu and pneumonia immunizations they were most likely to support using a physician's office followed by pharmacies and community health departments. The National Vaccine Advisory Committee of the federal Centers for Disease Control and Prevention recently supported the use of pharmacists to provide adult immunizations such as flu and pneumonia shots.

"Our findings confirmed that people are using a variety of sites to receive immunizations," Ernst said. "More importantly, we found that people are very likely to again use some of these sites."

The UI research also showed that physicians' biggest concern is being kept informed of their patients' immunizations, and patients want easy access to their immunization records. However, only one-third of the physicians said they usually or always received notification when a patient received an out-of-office immunization.

"Physicians in small towns were generally kept better informed about the out-of-office immunizations of their patients than physicians elsewhere were, regardless of formal collaborative relationships," Bergus said. "However, even in cities such as Iowa City, pharmacists routinely 'close the loop' and send physicians immunization updates about their patients. Patients often ask their physicians for their immunization history, regardless of where they may have gotten their shots."

At the same time, most doctors were not interested in a statewide immunization database, he added. Although the team did not study the underlying reasons for the lack of support, Bergus said it could be due to concerns about additional bureaucracy.

Physicians also felt non-physician providers need the skills and knowledge to deal with any complications that might arise during an immunization. Fainting is the most common problem associated with immunizations, while allergic reactions are relatively uncommon.

"Physicians were also concerned that if a patient goes elsewhere for immunizations, they may lose out on opportunities to deliver preventive health care such as mammograms," Bergus said.

Ernst added that while fragmentation of health care is a legitimate concern, many non-physician health care providers already make it a point to remind adults who come in for a vaccination to check in with their physician for routine care.

"As we involve more non-physicians in immunizations, it's important that these health care providers use the opportunities to plug people back into the health care system," Ernst said. "Non-traditional immunizers shouldn't just give people their shots and let them walk out the door."

Ernst and Bergus both said that the studies did not examine whether programs promoting the use of non-physician for immunizations actually would increase immunization rates.

"The next step would be to examine whether increasing immunization availability through use of non-traditional immunizers in Iowa actually increases immunization rates," Ernst said.

The researchers also said that the applicability of their findings to other states may be limited, given that Iowa has a relatively large rural population and a relatively homogenous population (more than 90 percent white).

The investigators added that the study would not have been possible without the cooperation of the Iowa Pharmacy Association (IPA) and the Iowa Academy of Family Physicians (IAFP), both based in Des Moines. In addition, the IPA and the Family Health Foundation of the IAFP provided grants for both studies.

The research on "Physician Perceptions about Administration of Immunizations Outside of Physician Offices" appeared in the March issue of Preventive Medicine. The research on "Patients Acceptance of Traditional and Nontraditional Immunization Providers" appeared in the January/February issue of the Journal of the American Pharmaceutical Association.

Healthy People 2010 can be visited online at http://web.health.gov/healthypeople/

University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.