Two in Five Pediatricians Don’t Use Standing Orders for Vaccinations

(Reuters Health) – Many pediatricians don’t use standing orders for vaccinations because they believe physicians should be involved in discussing vaccines with patients and they’re concerned that patients might receive the wrong vaccine, a U.S. study suggests.

Researchers conducted an internet and mail survey among a nationally-representative sample of pediatricians from June to September 2017. The response rate was 79% (373 of 471).

Overall, 59% of respondents reported using standing orders for vaccinations. Among those who didn’t, the most common reason was concern that patients might mistakenly get the wrong vaccine; 68% of those who didn’t use standing orders said this was a “major barrier” or “somewhat of a barrier.”

In addition, 62% of pediatricians who didn’t use standing orders said concern that patients and parents would prefer to discuss vaccination with a physician was a “major barrier” or “somewhat of a barrier,” while 57% cited the idea that doctors should be the ones to discuss vaccinations as a “major barrier” or “somewhat of a barrier.”

“With the disruption to primary care that has come with Covid-19, pediatric immunization rates are dropping and doctors are concerned that we could see secondary outbreaks of vaccine-preventable diseases in the future,” said coauthor Dr. Jessica Cataldi, an assistant professor of pediatrics at the University of Colorado School of Medicine in Aurora.

Standing orders are one evidence-based practice that has been shown to help increase immunization rates and get more children vaccinated on time, Dr. Cataldi said by email.

“Standing orders allow for a more streamlined process in primary care offices by shifting vaccination tasks to non-physician staff members,” Dr. Cataldi added. “Standing orders also make it more likely that children receive vaccinations when they are due for them by creating a more automatic workflow.”

Among the pediatricians who did use standing orders, 36% said they do so for all routinely recommended vaccinations, while 23% said they only used standing orders some of the time.

One in five pediatricians who use standing orders nonetheless expressed concerns about the potential for errors as a “major barrier” or “somewhat of a barrier” to using standing orders, the study also found.

Even though some pediatricians in the survey worried about vaccination errors, there isn’t any evidence that more errors occur with standing orders, Dr. Cataldi noted. Still, clinics that are new to using standing orders may need to educate staff and providers to ensure that the process works as intended and make a physician available to respond to any vaccine questions that arise, Dr. Cataldi added.

One limitation of the study, Dr. Cataldi and her coauthors note in Pediatrics, is that the survey didn’t ask pediatricians what proportion of their patients were vaccinated or unvaccinated, whether they used electronic medical records, or about the age distribution of their patients.

It’s also not clear to what extent the pediatricians’ views reflect the beliefs or concerns of parents, who make decisions about vaccination for children, said Angela Shen, a retired captain for the U.S. Public Health Service and consultant and visiting research scientist at the Children’s Hospital of Philadelphia. Parents may think differently about vaccines based on their child’s age or what the immunization is for, Shen who wasn’t involved in the study, said by email.

“The potential benefit of implementing standing orders is in targeting vaccines with low coverage, raising the rates for vaccines like human papillomavirus (HPV) vaccine, which is really important to get because HPV causes cervical cancer and is linked to a handful of other cancers,” Shen said. “On the flip side, parents and pediatricians in certain practices may wish to have conversations in the parent-provider dyad, particularly for young children and infants where vaccinations are so routinized in the well-child visit.”

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