Davis Matthew M, Ndiaye Serigne M, Freed Gary L, Kim Christopher S, Clark Sarah J
Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor 48109-0456, USA.
Pediatrics. 2003 Sep;112(3 Pt 1):521-6. doi: 10.1542/peds.112.3.521.
In 2000, heptavalent pneumococcal conjugate vaccine (PCV7) was recommended for children younger than 2 years, but its high cost relative to other universally recommended childhood immunizations and variability in insurance coverage for the vaccine raised concerns. We investigated the influence of PCV7 cost and insurance coverage on physician recommendation of PCV7 to their patients and administration of PCV7 in their practices.
We conducted a mail survey from April to July 2001 of a random sample of 833 pediatricians and 788 family physicians in 24 states with different vaccine financing strategies (Vaccines for Children [VFC]-only; enhanced VFC; universal purchase). Physicians specified the proportion of children in their practice with insurance coverage for PCV7, where they recommend administering PCV7, and whether they have concerns about the cost of PCV7.
The response rate was 60%. Overall, 87% of physicians recommend PCV7 for children younger than 2 years (99% pediatricians; 68% family physicians). Among physicians who recommend PCV7, 98% said that they would administer the vaccine in their own practices for children whose insurance covers the vaccine. However, only 56% of physicians who recommend PCV7 reported that all children in their practices had insurance coverage for the vaccine, whereas 24% of physicians reported 86% to 99% of children with coverage and 20% reported <or=85% of children with coverage. Among physicians in the last group with the lowest PCV7 insurance coverage rates in their practices, only 44% said that they would administer the vaccine in their own practices to children without PCV7 coverage, compared with 62% of physicians who provide care to children with higher rates of PCV7 coverage. Physicians in states with VFC-only vaccine financing strategies for PCV7 are less likely to administer PCV7 in their own practices to children without coverage than physicians in states with enhanced VFC and universal purchase strategies (48% vs 64% vs 74%). Almost one third of physicians who recommend PCV7 are concerned about the cost of PCV7; those with cost concerns are more likely to recommend that children without insurance coverage for PCV7 receive the vaccine at a public health clinic rather than in their own practices (45% vs 29%). Physicians with cost concerns are also more likely to say that they now screen children for insurance coverage more than for previously recommended vaccines (52% vs 21% for physicians without cost concerns).
Nationwide, physician adoption of PCV7 recommendations is high, but where physicians recommend that PCV7 be administered differs significantly by children's variable insurance coverage for the vaccine and by state vaccine financing strategies. Physicians' concerns about the cost of PCV7 may foreshadow their responses to future children's vaccines that may be even more expensive.
2000年，七价肺炎球菌结合疫苗（PCV7）被推荐用于2岁以下儿童，但相对于其他普遍推荐的儿童免疫接种，其成本较高，且该疫苗的保险覆盖范围存在差异，这引发了人们的担忧。我们调查了PCV7成本和保险覆盖范围对医生向患者推荐PCV7以及在其诊疗中使用PCV7的影响。
2001年4月至7月，我们对24个州的833名儿科医生和788名家庭医生进行了随机抽样邮件调查，这些州采用了不同的疫苗筹资策略（仅儿童疫苗计划[VFC]；强化VFC；普遍购买）。医生们明确了其诊疗中PCV7有保险覆盖的儿童比例、他们推荐接种PCV7的情况以及他们是否担心PCV7的成本。
回复率为60%。总体而言，87%的医生推荐2岁以下儿童接种PCV7（99%的儿科医生；68%的家庭医生）。在推荐PCV7的医生中，98%表示他们会在自己的诊疗中为保险涵盖该疫苗的儿童接种疫苗。然而，在推荐PCV7的医生中，只有56%报告称其诊疗中的所有儿童都有该疫苗的保险覆盖，而24%的医生报告称86%至99%的儿童有保险覆盖，20%的医生报告称保险覆盖儿童比例≤85%。在PCV7保险覆盖率最低的最后一组医生中，只有44%表示他们会在自己的诊疗中为没有PCV7保险覆盖的儿童接种疫苗，而在PCV7保险覆盖率较高的儿童诊疗中，这一比例为62%。对于PCV7仅采用VFC疫苗筹资策略的州的医生，相比采用强化VFC和普遍购买策略的州的医生，在自己的诊疗中为没有保险覆盖的儿童接种PCV7的可能性更小（分别为48%、64%和74%）。几乎三分之一推荐PCV7的医生担心PCV7的成本；有成本担忧的医生更有可能建议没有PCV7保险覆盖的儿童在公共卫生诊所而非在他们自己的诊疗中接种疫苗（分别为45%和29%）。有成本担忧的医生也更有可能表示，他们现在比之前推荐的疫苗更关注筛查儿童的保险覆盖情况（有成本担忧的医生为52%，无成本担忧的医生为21%）。
在全国范围内，医生对PCV7推荐的采纳率很高，但医生推荐接种PCV7的情况因儿童对该疫苗的保险覆盖情况不同以及州疫苗筹资策略而异。医生对PCV7成本的担忧可能预示着他们对未来可能更昂贵的儿童疫苗的反应。
