Increasing engagement of clinicians in adult immunizations: reflections on a decade and a half of research.
Increasing engagement of clinicians in adult immunizations: reflections on a decade and a half of research.
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DOI：
10.1016/j.vaccine.2014.10.028
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发表时间：
2014-12-12
期刊：
影响因子：
5.5
通讯作者：
Zimmerman RK
中科院分区：
文献类型：
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作者：
Zimmerman RK
美国存在全国成人免疫接种率较低的问题，且随着时间的推移相对持平。例如，2012年美国65岁及以上成年人的肺炎球菌免疫率为59.9%，高危成年人为20.0%，远低于健康人群2020年疫苗接种目标90%和60%。 2012-13 年流感疫苗接种率也较低，18-49 岁人群为 31%，50-64 岁人群为 45%，65 岁以上人群为 66%；总体而言，比率存在九个百分点的种族差异[1]。美国的免疫率问题是多因素的，包括患者、提供者、药品制造商和系统领域的障碍。在这篇文章中，我重点关注问题的一部分：初级保健机构的动力不足。尽管大多数临床医生支持并提供免疫接种，但他们缺乏最大限度提高初级保健机构免疫接种率的承诺。实践之间的比率差异、患者去看初级保健临床医生但未接种疫苗时错过疫苗接种机会的高比例、患者报告在临床医生建议的情况下对疫苗接种的开放程度以及干预研究的不同效果都证明了这一点。在根据电子病历对疫苗接种率进行审查时，我看到疫苗接种率从 2% 到 100% 不等（个人交流，C. Lin 博士，2014 年）。一些做法取得了很高的成功率，这在一定程度上可以归因于常规订单计划 (SOP) 的使用[2]。在一项为期 3.25 年的初级保健医疗记录研究中，流感疫苗错失就诊机会的概率是流感疫苗的 3.4 倍，PPV 错失就诊机会的概率是 10.7 倍 [3]。另一项研究发现，根据疫苗和环境的不同，38% 至 94% 的就诊机会被错失 [4]。此外，如果临床医生办公室有人推荐，成年人接受 PPSV 的可能性会增加 12 倍 [5]。最后，干预研究提供了进一步的见解。一项研究发现，简短的员工培训、提供表格和两次干预提醒不足以显着改变标准操作程序下的办公室做法，显示出员工积极性不高的影响[6]。在另一项干预研究中，工具包的实际实施和疫苗接种率因实践而异，高危成人（18-64 岁；25% 对 40%）的 PPSV 率总体显着增加，但老年人则没有显着增加（44% 对 52%），并且在高危成人和老年人的四项实践中，有两项（p<.05）[7]。四个地点中的三个地点的流感疫苗接种率显着提高，总体提高了 11%。
The United States has a national adult immunization problem of modest rates that are relatively flat over time. For instance, pneumococcal immunization rates in the United States in 2012 among adults 65 years of age and older were 59.9%, and among high-risk adults were 20.0%, significantly below Healthy People 2020 vaccination goals of 90% and 60%, respectively. Influenza vaccination rates in 2012–13 were also modest at 31% among 18–49 year-olds, 45% among 50–64 year-olds, and 66% among those≥ 65 years; overall, a ninepoint racial disparity in rates was noted [1].The US immunization rate problem is multifactorial and includes barriers in the patient, provider, pharmaceutical manufacturer, and system spheres. For this essay, I focus on a segment of the problem: insufficient motivation in the primary care setting. Although most clinicians support and provide immunizations, they lack the commitment to maximize rates in the primary care setting. This is demonstrated by the variability in rates between practices, in the high rate of missed vaccination opportunities that occur when a patient visits their primary care clinician but is not vaccinated, in patient reports about openness to vaccination if their clinician so recommended, and in variable effects of intervention studies. In reviews of vaccination rates according to the electronic medical record, I have seen rates range from 2% to 100%(personal communication, C. Lin PhD, 2014). Some practices achieve high rates, which can be attributed in part to use of standing orders programs (SOPs)[2]. In a study of primary care medical records over 3.25 years, missed opportunities at medical visits occurred 3.4 times for influenza vaccine and 10.7 times for PPV [3]. Another study found missed opportunities in 38% to 94% of office visits, depending on the vaccine and setting [4]. Furthermore, adults report being 12 times more likely to have received PPSV if someone in the clinician’s office recommended it [5]. Finally, intervention studies provide further insight. One study found that brief staff training, provision of forms and two reminders of the intervention were insufficient to significantly change office practices under SOPs, showing the impact of unmotivated staff [6]. In another intervention study, actual implementation of a toolkit and vaccination rates varied by practice PPSV rates increased significantly overall for high-risk adults (18–64 years; 25% vs. 40%) but not for older adults (44% vs. 52%) and in two of four practices among both high-risk and older adults (p<. 05)[7]. Influenza vaccination rates increased significantly in three of four sites and overall by 11%.