Primary Care Determinants of Vaccination

Primary care – determinants of vaccination

Zimmerman RK, Nowalk MP, Bardella IJ, Fine MJ, Janosky JE, Santibanez TA, Wilson SA, Raymund M. American Journal of Preventive Medicine, 26(1): 2004

- Objective – examine provider feactors that affect patient-reported influenza vaccination rates among a diverse sample of older patients. - Cross-sectional design - Survey methods o Primary care practices, physicians, and patients – stratified random sample. – rural, suburban, VA, and inner-city practices. o Elderly only o Physician survey – PRECEDE-PROCEED framework . Predisposing factors (e.g.: concern about side effects)  Awareness, agreement, importance  Physician smoking, physician recommends tetanus- diphtheria vaccine . Reinforcing factors (e.g.: feedback) . Enabling factors (e.g.: reminders)  Flushot clinics or other programs, provider prompts  Has had influenza vaccination rates calculated . Environmental factors (e.g.: cost)  Distance from primary admitting hospital  Concern about Medicare reimbursement levels  Likelihood to out-refer a Medicaid / uninsured / insured adult for vaccination.  Degree to which practice focuses on acuities  Nurse staffing patterns o Patient survey – Triandis model – facilitating conditions, bahvioral habits, value of the consequences, social influence, and attitudes. - 61 physicians (85% response), 925 patients - Results – receipt of vaccination – Regular clinician – 70% – Other sites = flu shot clinic, health department, other physicians, non-traditional sites. - Results – PRECEDE-PROCEDE o 95% were very or somewhat familiar with CDC guidelines, 90% agreed. o Predisposing factors not well associated – possible ceiling effects. o Reinforcing factors – those with practice immunization rates calculated had higher rates of vaccination. o Enabling factors . Prevalence of QI  Posters/education (44%)  Express vaccination services (39%)  Provider-oriented procedures like prompts (34%)  Personal encouragement to patients (23%)  Reminders / public notes (20%)  Other (16%) . Such programs were associated with improved vaccination status o Environmental factors . Logistical / economic  Concerns about reimbursement – lower vaccination rates.  Out-referral of Medicaid patients – lower vaccination rates. . Competing demands – Those spending very much focus on handling emergencies had lower vaccination rates than those focusing an “intermediate extent” – however, those focusing very little on emergencies performed worst. - Results – multivariate analysis o Strongest predictor was patient intention to be vaccinated in the next season. o Other patient factors – belief in vaccine efficacy, having been screened for colon cancer. o Physician factors – awareness and agreement with asthma recommendations. o Practice type/ setting – VA stratum – highest vaccination rates. - Physician agreement with and increased perception of importance associated with better vaccination rates – But negative correlation for awareness (multivariable). - VA institutions performed the best – multimodal program to increase rates – patient reminders, standing orders, free standing vaccination clinics, assessment of vaccination status with feedback and incentives. - References suggest that physician recommendation is an important, if not the most important, determinant of vaccination. Patient education can only do so much – but there will always be a central role for the physician. This is also supported by evidence on lower vaccination rates if physicians out-refer patients for vaccination, and on lower vaccination rates in regions with lower primary care physician density. - Other key messages o Practice QI makes a difference o Evidence for Medicare reimbursement policies impacting vaccination rates. - Patient intention to receive vaccination – strong predictor. Physicians should support by o Establishing an office culture of prevention o Understanding current vaccination guidelines – appropriate recommendations o Developing office systems to facilitate vaccination

O’Malley AS, Forrest CB. Immunization disparities in odler Americans: determinants and future research needs. American Journal of Preventive Medicine, 21(2): 2006.

- Examine potential determinants of racial disparities in immunization rates among Medicare beneficiaries. - Survey methods o Data sources . Medicare Current Beneficiary Surveys, 2000 to 2002. . Medicare claims, census data, area resource file. o Elderly patients with a usual physician. o Outcomes = patient-reported receipt of influenza vaccine in the past year, ever receipt of PPV. o Independent variables . Patient . Provider and delivery system . Area - Results o Vaccination rates – White = 71.6%, Black = 54.7%. o PPV – Whites = 69.8%, Black = 52.1%. o Predictors of vaccination – Beneficiary (multi-level adjusted) . Race . Age > 75, Higher education, higher income, fair-poor health status, >= 2 vs < 2 chronic conditions, currently married, rural, more favorable care seeking attitudes, private supplementary insurance, higher exposure (number of outpatient visits) to usual physician. o Predictors of vaccination – Provider (multi-level adjusted) . Higher accessibility of one’s provider . Continuity (same physician >= 3 years) – PPV only. . Better rating of provider information giving  Influenza OR = 1.17 [1.07, 1.28]  PPV OR = 1.11 [1.02, 1.21] . Primary care generalist vs specialist  Influenza OR = 1.15 [1.04, 1.28]  PPV OR = 1.22 [1.11, 1.34] o Predictors of vaccination – Area . Density of PCPs per elderly – high vs low  Influenza OR = 1.40 [1.25, 1.56]  PPV OR = 1.12 [1.00, 1.27] . Higher Proportion of ZIP code living at or below poverty level o Substantial unexplained racial variance . Broad-based depression in immunization rates within strata of patient characteristics for Black vs White. . Not a patient knowledge issue – NS for differences in patient knowledge and attitudes among non-vaccinated MCBS respondents. . Adjusted OR for multi-level factors – White vs Black  Influenza = 1.92 [1.74, 2.12]  PPV = 2.11 [1.91, 2.33] - Recent research suggests that Black beneficiaries use providers who are less likely to deliver influenza vaccination than those seen by white beneficiaries – physician or environment factors. - Good evidence for importance of primary care. - Further research areas highlighted, to explore racial gap.

Santibanez TA, Zimmerman RK, Nowalk MP, Jewell IK, Bardella IJ. Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status. Annals of Family Medicine, 2(1): 2004.

- Objective – Examine further the clinician factors that affect PPV rates among a diverse sample of physicians from rural, suburban, VA, and inner-city practices. - Survey methods o See (Zimmerman RK, Nowalk MP, Bardella IJ, Fine MJ, Janosky JE, Santibanez TA, Wilson SA, Raymund M. American Journal of Preventive Medicine, 26(1): 2004) - 60 physicians (92% response) – 925 patients. - Results o PPV vaccination rate = 67% o No associations with predisposing or reinforcing factors. o Practice QI appears to make a difference – having an immunization-oriented program – 76% vs 63%. o Prevalence of practice QI – all significantly associated univariate: . Office PPV prompts = 33% . Immunization clinics or other specific programs = 45% . Influenza-related programs – 16% to 45%. o Financial factors – predictors of decreased vaccination rates . Out-referral of Medicaid patient / adult without insurance / insured adult. . Physician concerns with Medicare reimbursement levels associated with fewer vaccinations. o Environmental factors . Satisfaction with managing practice – Intermediate satisfaction associated with lowest vaccination rates. - Results – Multiple regression o Out-referral – adult with commercial insurance – OR = 1.78 [1.49, 2.14] o Bothered by stress . Never vs always – OR = 0.35 [0.23, 0.54] . Intermediate vs always – OR = 0.93 [0.74, 1.16] o Other predictors of vaccination – not having received complaints about influenza vaccination, perception that out-referral is inconvenient to patients. - Awareness-to-adherence model factors do not appear to make a difference. Most physicians report routinely providing PPV, so it appears they are aware, and have already adopted and adhered. - Vaccinated patients were more likely to be from practices that enabled physicians to provide immunizations more easily. - Economic considerations emerged as important, assuming out-referral is an indicator for inadequate resourcing or reimbursement for vaccination in primary care. May also be an indicator of administrative hassle. - Stress levels – dose-related trend – evidence for competing demands on primary care.

Zimmerman 2005 – Age >50 - PPV patters did not differ by race - Age, number of physician visits, last complete physical examination (planned care) (bivariable). Education was not multivariate significant. Income and employment not factored into multivariable model. Effects of age and physician visit frequency disappeared in a model with 2 Triandis factors (attitudes and social influences, pneumonia risk and vaccine efficacy). Room for patient education, importance of planned care that cannot be explained away by patient education. - Reason for non-vaccination – most common did not know they needed it (50% / physician did not recommend. Prevalence of this higher for aged 50-64 vs 65+. All other reasons relatively infrequent by comparison. - Attitudes and social influences – not just knowledge. OR = 8.24! May include provider recommendations as a key social influence.

Szilagyi PG, Shone LP, Barth R, Kouides RW, Long C, Humiston SG, Jennings J, Bennett NM. Physician practices and attitudes regarding adult immunizations. Prev Med, 40(2): 2005

- Objective: Assess, on a national level, practices and attitudes of primary care physicians regarding adult influenza and pneumococcal vaccinations. - National physician survey, focus on practice-level barriers. 316 of 688 eligible physicians responded. 220 analyzed. - Response rate 33% – but demographic characteristics resemble those of primary care physicians nation-wide. - CDC Community Guide Framework – Interventions that increased community demand, enhanced access, and provider-based interventions. - Physician practices generally good for self-reported routine vaccination practices in the elderly, but lower for <65. - Results – Reported barriers – prevalence > 10% noted here. o PPV – Urgent concerns dominate visits (44%), not knowing patient immunization history (36%), patient concerned about vaccine safety (31%), inadequate reimbursement (25%), difficulty identifying eligible patients (21%), lack of patient-oriented vaccine information (20%), physician concern about revaccination (16%). o Influenza – Patient concern about vaccine safety (58%), urgent concerns dominate visits (43%), inadequate reimbursement (26%), lack of patient- oriented vaccine information (20%), difficulty identifying eligible patients (13%), not knowing patients immunization history (12%). o PPV vs influenza – not knowing patient immunization history, difficulty identifying eligible patients, physician concerns about revaccination, and ambiguous vaccination guidelines more likely to be a concern for PPV. o Both vaccinations were equally impeded by urgent concerns, reimbursement issues, and lack of patient-oriented vaccine information materials. o Liability concerns noted by very few physicians. - Results – prevalence of QI strategies o High prevalence of preventive services flow sheets in patient charts (71%), walk-in immunization service (67%), policies to assess vaccination status at each visit (48%), and distribution of patient education materials (46%) (>45% listed). o Low prevalence of other techniques, especially registries (External) (7%). o Resistance to standing orders and audit and feedback – nearly one-third saying they would not try them – although more physicians said that they would try them. o Most popular QI strategies – those physicians say they would try – more likely to be external than internal, with exceptions – those with support > 45% listed. . Lists of unimmunized patients sent to physician (external) . Improved tracking systems (office) . Reminders from registry to eligible patients (external) . Immunization registries (external) . Stamped chart reminders (office) . Patient education materials (external) . Computerized medical records (office) . Reminders to patients (office) . Clearer vaccination guidelines (external) (51%) . Provider education materials (external) (49%) . Audit or feedback (external) . Distribute patient education materials (office) . Training for nurses and office staff (external). o Strategies physicians would try first – reminders to patients, improved tracking, reminders to patients from external agencies, and lists of unimmunized patients sent from external agencies. - Results – Estimated achievable vaccination rates reported given various scenarios about Medicare administration fees for vaccination. o Price-elasticity – Physicians believed higher administration fees would result in higher vaccination rates. o But it is also the case that most physicians could not identify the current vaccine administration fee. - Results – physician characteristics – predictive of support for vaccination, perceived barriers, or desirable strategies. o Family versus internal medicine – was not predictive – although both were primary care physicians, since this was the sample. o Other differences – rural vs urban, practice settings. o No differences on multivariate regression – except for physicians in large group practices more likely to report influenza vaccination for those <65 years old. - Vast majority of primary care internists and family physicians support and provide vaccinations routinely to the elderly, and patients of any age who have chronic disease indications. - Sub-optimal adult immunization rates not due to lack of interest among primary care physicians. Importance rated fairly high. Interest in developing new strategies for improving vaccinations. Interest particularly high for strategies originating outside of physician offices – perhaps in light of limited office resources. - Note the apparent price elasticity of vaccination coverage. Authors suggest that responses to hypothetical scenarios support payment reform.

Straits-Troster 2006

- VA SHEPS complex patient survey, 117614 patients >= 50 years old. - Racial differences maintained in fully adjusted model (OR 0.67 for black, 0.91 for Hispanic/Latino, etc..), adjusting for age, gender, marital status, education level, employment, having a PCP, level confidence/trust in PCP, and overall health status. However, no consistent measurement of knowledge/attitude constructs. - Other significant predictors: Married, higher income, retiried/home-maker/unable to work, having a VA PCP, having complete trust, and non-“good” self-reported health status. - Very high vaccination rates in the VA. Use of automated evidence-based practices, perhaps.

Singleton 2005

- Objective: Gain insight into reasons for racial/ethnic disparities in vaccination coverage. - National Adult Immunization Survey (NAIS) 2003 – complex survey of elderly >= 65, 1891 adults interviewed – CASRO response rate = 58.2%, but the number of completed interview divided by the number of sampled eligible respondents (ignores those who could not be screened for eligibility) was 78.3%. - Vaccinations – influenza and PPV - Those not vaccinated were asked to choose a reason for non-vaccination, if they were aware that vaccination was recommended, and if a health care professional had recommended that they get vaccinated. - Tables 1 and 2 are mislabeled in the paper. - Results – influenza o Coverage – 67.8% in the 2002-03. o Location = doctor’s office – 58% of vaccinees. o Blacks (53%) and Hispanics (56%) reported lower proportions than Whites (70%) receiving influenza vaccine. o Adjusting for recent doctor visit and age group, a significant racial/ethnic disparity was only apparent in among those with < high school education. o Most common reasons for non-vaccination . Side effect concerns (24%) – hearing about others who got sick, side effects from a previous shot, believing that vaccine may give them the flu, concerns about an unknown ingredient of the shot. . Didn’t think vaccine was needed – 14.9% (Black) to 36.5% (Other). . Allergy (10%) - Results – PPV o Coverage – 60%. o Blacks (42%) and Hispanics (44%) lower proportions than Whites (63%). o Adjusting for recent doctor visit, age, and education level reduced the disparity – RD Hispanics and Whites 7%, RD Blacks and Whites 18%. o Most common reasons for non-vaccination . Not knowing that they needed a PPV – 19.0% (Hispanic) to 33% (White) . Not knowing that the shot existed – 20% (White) to 40% (Black) . Of those with unawareness (combination of the two responses above)  Not being likely to get pneumonia (39%)  Not having a PPV recommended (32%) - Results – Missed opportunities o Potential missed opportunities estimated by patients with recent doctor visit but did not receive flu shot or recommendation . Blacks – 26.9% . Whites – 16.2% - Great breakdown of location of vaccination for both influenza and PPV – however, stratified by race – also unclear if the second most prevalent category, “clinic or health center”, refers to physician primary care or public health vaccination unit. - Possible reasons for racial disparity – higher prevalence of lower education, lower likelihood of vaccination in nonmedical settings (Blacks), lower prevalence of awareness, and possibly higher overall prevalence of missed opportunities.

Nichol KL, MacDonald R, Hauge M. Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. Journal of General Internal Medicine, 11(11): 1996.

- Objective – See title. - Setting – VAMC in Minneapolis – Influenza and PPV – standing nurse orders, walk-in clinics from mid-October to mid-December, standardized forms, and annual mailings. - Survey – cross-sectional – 456 patients – >95% White – no race questions – 68% response of 671 eligible. - Results o Influenza . Awareness – high – over 87%. . Vaccination rate – 74%. . Significant predictors of vaccination - Univariate  Would get a shot if recommended (willingness to comply) – OR = 3.4 [1.8, 6.5]  Flu shots good idea – OR = 2.7 [1.4, 5.3]  Nurse or physician recommendation o Prevalence = 77% o OR = 2.2 [1.7, 3.0]  Influenza is serious – OR = 2.0 [1.3, 3.1]  Vaccine effective – OR = 1.4 [1.2, 1.7]  Vaccine is safe (no flu due to flu shot) – OR = 1.1 [1.0, 1.3]  Safety concerns – get sick due to flu shot – OR = 0.4 [0.3, 0.6]  Composite – Positive attitudes – influenza is a serious, vaccine is safe and effective, and vaccination is a good idea – 1.4 [1.2, 1.6]  Current health NS. . Multivariate  Provider recommendation – OR = 6.4 [3.4, 11.2]  Positive attitudes – OR = 1.9 [1.0, 3.4]  Willingness to comply – OR = 6.7 [2.1, 20.8]  Smoking – OR = 0.4 [0.2, 0.8] o PPV . Awareness – high – almost three quarters. . Vaccination rate – 63%. . Significant predictors of vaccination - Univariate  Nurse / doctor recommendation o Prevalence = 63% o OR = 3.7 [2.7, 5.0]  PPV is a good idea – OR = 2.7 [1.6, 4.4]  Pneumonia is serious – OR = 2.2 [1.0, 5.1]  Would get a shot if recommended – OR = 1.9 [1.3, 2.8]  Current smoker – OR = 0.8 [0.6, 1.0]  Sickness due to PPV – OR = 0.6 [0.5, 0.8]  Composite – Positive attitudes – OR = 1.6 [1.4, 1.9]  Current health NS. . Multivariate  Provider recommendation – OR = 14.9 [8.5, 26.1]  Having positive attitudes – OR = 1.9 [1.1, 3.4] o Interaction of attitudes and having a provider recommendation . Provider recommendation – high immunization rates – positive attitudes NS  Influenza – 87.1% vs 82%.  PPV – 85.3% vs 85.1% . No provider recommendation – positive attitudes significant predictor  Influenza – 73.7% vs 27.0%, p < 0.001.  PPV – 46.9% vs 15.8%, p < 0.001. - Note – low number of significant variables in multivariable regression likely due not only to the importance of provider recommendations, but also to the use of the composite “positive attitudes” term. - Physician’s recommendations central – vaccination rates exceeded 80% regardless of patient’s own attitudes in the presence of a provider recommendation. - Importance of physicians’ recommendations support emphasis on strategies directed towards clinical practices of health care providers.

Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high- risk patients: a nationwide survey. Archives of Internal Medicine, 161(22): 2001.

- Objective – See title. - National physician survey – 1874 respondents of 5858 eligible – 32% response. - Results o Generalists more likely to consider vaccination important – Influenza 97% vs 89%, PPV – 96% vs 90%, p < 0.001 for both vaccinations. o Responses regarding safety and cost-effectiveness . Influenza – NS . PPV – generalists more likely to estimate fewer adverse symptoms, more likely to consider vaccination cost-savings. . However – differences not large – authors report both groups had similar responses. - Results – QI intervention prevalence o Generalists more likely to use QI interventions – p < 0.001 for most – counseling during routine visits, posters and patient information materials, reminders for providers on medical charts, standing orders for clinic nurses, special clinics, reminders to patients, frequency of standing orders, patient reminders. o Mean number of major strategies . Influenza – 1.18 vs 0.70, p < 0.001 . PPV – 0.79 vs 0.51, p < 0.001 - Results – Very important factors – recommendation decision – barriers o Costs – mentioned by fewer than 30%. o Other issues more important . Ease of targeting high-risk patients (60% to 64%) . Remembering (60% to 64%) . Having sufficient time (36% to 37%) . Having sufficient personnel (40% to 37%) - Results – multivariate predictors of practitioners strongly recommending vaccination – attitudes o Certain physician knowledge and attitudes associated with providing very strong recommendations (Table 4). o Similar for both vaccinations. . Provider having received influenza vaccination . Belief that it is important for HCWs . Belief that vaccinations are cost-saving . Gender (female twice as likely) . Patient’s risk for disease . Vaccine effectiveness . Concern for liability issues . Vaccination rates monitored as part of performance assessment o Some differences . Influenza – Ease of targeting high-risk patients . PPV – concerns about drug resistance, sufficient time to counsel patients, recommendations of expert groups - Strongly recommending a vaccination is expected to be predictive of actual behaviors. - A large number of physicians report that they do not strongly recommend vaccination – approximately 15% to 36% depending on type of physician and vaccination. - Importance – Provider recommendation is a strong predictor of vaccination – unvaccinated patients often cite lack of a recommendation. - Barriers as very important factors – reinforce the importance of systems that minimize workload burden on physicians. - Physicians – especially primary care physicians – play a critical role in the delivery of vaccinations. Many opportunities are likely being missed. Davis MM, McMahon SR, Santoli JM, Schwartz B, Clark SJ. A national survey of physician practices regarding influenza vaccine. Journal of General Internal Medicine, 17(9): 2002.

- Objective – Characterize US physicians’ practices regarding influenza vaccine, particularly regarding their use of reminder systems and capacity to identify high- risk patients. - National physician survey of primary care physicians – 969/1606 (60%) responded. - Results – capacity to contact high-risk patients o Physicians report providing the vast majority of influenza vaccine doses – not other health professionals in their practice. o Over 90% of physicians relied on office visits – in whole or in part – to target high-risk patients. o List generating ability – thought to exist for . Elderly – 75% . Specific chronic diseases – half. o Use of mail or telephone reminders in the past – 26%. o Physician networks (e.g.: staff-model MCO, multi-site group practice) vs other sites (private independent, university, hospital, or public clinics) – more likely to have used reminders – 41% vs 24% – OR = 2.04 [1.17, 3.55] adjusted - Data suggests that 18% and 24% of of FPs and Gen. Internists have not adopted recommendations – do not routinely administer vaccination. - Insufficient database infrastructure, minimal experience with reminder systems, and hesitancy to administer vaccine after the onset of influenza activity may limit physicians’ abilities to identify and protect high-risk individuals in future influenza seasons.

Poel - Quoted in Davis 2002 – In 1998-1999, about one half of all influenza vaccine doses overall, and nearly two thirds of doses for elderly, are administered in physician offices. About 2-% of doses overall are administered at workplaces. The remainder is composed of community centers, local public health clinics, and health departments.

CDC. Adult immunization: knowledge, attitudes, and practices – DeKalb and Fulton Counties, Georgia, 1988. MMWR, 37(43): 1988.

- Objective – Assess knowledge, attitudes, and behaviors regarding influenza and pneumococcal vaccinations. - Subjects selected from a reverse telephone directory, and from those living in housing communities for older adults – unsure if sample is representative of all elderly in the two communities – focus on predictors only. - Vaccination rate – 55%. - Awareness rate – 90%. - Results – factors associated with vaccination status o Most important = recommendation from health-care provider . Influenza – 75% vs 7% – prevalence ratio = 11.2 [8.1, 15.5] . PPV – 76% vs 6% – prevalence ratio = 12.5 [8.4, 18.6] Hbert PL, Frick KD, Kane RL, McBean AM. The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries. Health Services Research, 40(2): 2005.

- Objective – Identify the causes of racial and ethnic disparities o Differences in resistant attitudes and beliefs o Differences in access to care o Discriminatory treatment - MCBS and Medicare Claims for 1995 to 1996 – response rate not reported. - MCBS analysis classified patients as resistant if they did not receive vaccination and answered attitude questions negatively. - Hypotheses o Differences in resistant attitudes and beliefs – measured by non-vaccinee reasons. o Differences in access to care – measured by health care utilization. o Discriminatory treatment – measured by differences in vaccinations among minority (Back and Hispanic) vs White patients for the same provider, matching subjects on influenza vaccination weeks of their medical encounters – accounted for potential differences in patient vaccination- initiation by measuring primary reasons for medical encounter. - Vaccination rates – for comparison among races, rates adjusted for age, gender, census region of residence, SES, supplemental insurance, and risk factors for influenza o Overall – 64.0% o White – 66.6% (66% adjusted) o Black – 43.4% (51% adjusted) o Hispanic – 53% (59% adjusted) - Results – resistant attitudes and beliefs o Reasons – nonresistant . Lack of knowledge (21.9%) . Did not think of it / missed it – 15.3% . Lack of physician recommendation – 6.5% . Others – e.g.: unable to get there (2.1%). o Reasons – resistant . Thought the flu shot could cause flu – 17.6% . Side effects – 14.2% . Lack of effectiveness – 10.4% . Though I was not at risk – 6.6% . Others – e.g.: do not like needs. o Overall resistance – Assuming that those who get vaccinated do not harbor resistant attitudes . Blacks than Whites – 30.2% vs 18.4%, p < 0.001 – RD = 11.8% . Hispanics vs Whites – 15.8% vs 18.4%, p = 0.357 – NS - Results – access to care o Vaccination-initiated encounters excluded. o Proportion with a medical encounter during vaccination weeks . Black vs White – 60.8% vs 68.5%, p < 0.001 . Hispanic vs White – 60.1% vs 68.5%, p = 0.003 . Differences NS after adjustment. - Results – provider discrimination o Matched 278 Black and 83 Hispanic beneficiaries to 1127 White beneficiaries by week of medical encounter and usual provider. o 974 beneficiaries after eliminating vaccination receipt elsewhere. o Receipt of a Medicare-paid vaccination . Black vs White – 70.4% vs 35.1%, p < 0.001 . Hispanic vs White – 61.1% vs 70.4%, p = 0.168 – NS o Differences mostly explained by higher vaccination-initiated visits according to primary code for medical encounter – 92% of these encounters – only procedure was vaccination. . White vs Black >5 times more likely. . White vs Hispanic 1.6 times as likely. o Adjunct vaccination rate – Vaccination mentioned as procedure during a visit with a non-vaccination primary reason. . 28.4% overall. . NS for differences by race – but possibly under-powered  White – 28.5% (adjusted)  Black – 26.4% (adjusted)  Hispanic – 34.0% (adjusted) o On the unmatched full cohort, however, the rate of vaccination given as an adjunct was higher in Whites (16.9%) than in Blacks (10.2%) or Hispanics (6.5%) – This likely reflects a situation in which minority beneficiaries tend to frequent providers who give fewer adjunct vaccinations, perhaps due to practice demands or setting – no individual provider discriminates. - Results – missed opportunities o 36.0% non-vaccinated. . 54.7% had a medical encounter. . 23.8% had both a medical encounter and non-resistant attitudes. . This represents 8.6% of the entire population eligible for vaccination. . Missed opportunities higher for minority beneficiaries – White vs minority – 7.6% vs 13.7 to 16.8% – Approximate RD = 7%. . The improvement in vaccination rates, especially for minorities, is substantial relative to current rates and desired targets. - Most common reason for non-vaccination was unawareness. - Resistant attitudes more common in minorities – but role may be overstated due to assumptions. - Access – not a significant cause of racial disparities. - Discrimination – no evidence to support - Motivated patients important – unknown why White patients more motivated. - Black patients may require interventions directed at overcoming resistant attitudes and building trust compared to Whites – but less so for Hispanics. - Primary reason for disparities – Missed opportunities – highly prevalent – more common among providers frequented by minorities – unable to evaluate further – need information on provider practice characteristics, or percent of minorities treated by provider that goes beyond the elderly.