For months, I've wanted to know: how many pediatric offices have policies requiring their patients to be vaccinated? It started with an article a friend of mine from Portland, OR wrote for The Oregonian in 2013. I realized, when talking about the issue with him, that I didn't have a great grasp of the data. Then, national vaccine crisis #5 hit the paper and the question came up again. Time to make a survey.

Let's start with a quick overview of the survey itself. First, it went out to thousands of pediatric contacts I have - from SOAPM to PartnerTalk to various pediatric coding lists to PCC's marketing list. Although it's possible that we have some selection bias, I think we've got a pretty good spread of pediatric practices in the results.

Second, I made a mistake with one question that limited its utility, but not to the point that I wanted to toss it.

Who did we hear from?
We had just hair under 500 responses.  43 of the 50 states.  The most responses were from CA, GA, NJ, FL, NY, DE, PA, and TX.

In terms of practice size distribution, our results reflected what we expected to see:
18% of the respondents were solo practices, 42% have 2-4 physicians, 31% have 5-10,
and 9% have 11 or more.

Let's get to the big question:

Does your practice have a policy which requires families to be vaccinated in order to remain members of your practice?
54% say yes. So there it is - among our respondents the majority have a vaccine requirement. I have to admit that my guess put it at ~35-40%. 54% is higher than the popular vote in most presidential elections. I feel safe saying that vaccination requirements are the norm.

I dug around to look for state level patterns. Sample size is, of course, an issue, but a few states in the top 10 had a significant deviation from the average:

NY - 34%
FL - 62%
DE - 39%
PA - 81%
TX - 80%
NC - 88%

What about practice size? Solo practices had vaccine requirements 40% of the time and practices with 5-10 physicians clocked in at 62%. The other groups were in the 50-55% range.  I'm not sure what, if anything,  to make of that.  Perhaps the smallest practices feel that they are more convincing?

Next, I wanted to get a sense of whether vaccine requirements are a fairly new or established concept.  Of those who have vaccine requirement policies, 10% were new within the last year, 23% were 1-3 years old, 40% were 3-10 years old, and 27% were at least a decade old.  Clearly, vaccine requirements have not only been part of the pediatric practice fabric for some time, the rate at which practices are adding this requirement is worth noting.

Next, I wanted to find out what happened when practices add vaccine requirements. Do practices lose a lot of patients? Do patients now agree to be vaccinated? The results are fascinating.

If you were part of this practice when the policy was enacted, what was the effect on your patient panel?
We lost a few patients: 58%
We lost essentially no patients: 42%
We lost many patients: 0%
The conclusion here is quite clear: the negative effect of of the implementation of a vaccine requirement policy is negligible among those who have done so.

If you were part of this practice when the policy was enacted, what was the reaction from the remaining families?
We received a positive reaction: 61%
Didn't care: 37%
We received a negative reaction: 2%
The conclusion here is again quite clear: the negative effect of of the implementation of a vaccine requirement policy is negligible among those who have done so and there is a marked positive response from your vaccinating families.

Now for the kicker.  I've seen the studies showing that allowing non-vaccinators only solidifies their distrust of vaccines (and science in general). What has the real-world experience been?
If you were part of this practice when the policy was enacted, what was the effect on the vaccination rates of those who had previously refused?
Some new families vaccinated - 68%
Many new families vaccinated - 17%
No new families vaccinated - 15%
These results seem remarkably positive.

As I alluded to before, I made a mistake in the survey - I forgot to check the box which would allowed multiple answers to the question, "What are the reasons for having a policy that requires vaccination from your patients?"  I assume that the results reflect a prioritized list of the reasons:
Disagreement with my clinical guidance - 38%
Safety of my other patients - 25%
Didn't improve vaccine rates - 8%
I did allow for an "Other" answer, to which the overwhelming response was "all of the above" (no surprise).  One other answer appeared enough to be added to the consideration: liability.  As the AAP considers its policy on this issue, it needs to take into account obligations of the practice to protect its legitimately unvaccinated kids.

I wondered how good practices are about stating their position.   Is your vaccine policy clearly spelled out for your patients (WWW page, hand outs, printed throughout the office, etc.)?
Yes - 76%
I did spend an afternoon last week looking at client WWW sites to see if reality matches perception.  Non-scientifically, I'd say that "clearly spelled out" is a little broad, especially in the area of WWW design as it was hard to ascertain the vaccine philosophy of practices in some cases.  Some practices, however, make this information available front-and-center.

Does your practice allow a delayed schedule?
58% - yes
Clearly, there is more to learn here, but a majority of those who have vaccine requirements do allow a delayed schedule.  Some day we may have the EHR functionality to determine which policies are the most effective.

I also wondered which vaccines/vaccine families are required.  Very few practices require a flu shot, for example.
98% - MMR
97% - DTP
94% - Hib
93% - Pneumococcal
92% - Polio
87% - Varicella
80% - Hep B
77% - Meningococcal
63% - Rotavirus
45% - Hep A
17% - HPV
11% - Flu

Finally, what about those who don't have a policy?  For those who said no...55% have considered changing their policy in the last year.

What obstacles have they identified for not having a policy?
43% - Feel that they do a better job convincing patients to immunize
if they don't have requirements
11% - Lack of sufficient local coverage for patients forced to leave
7% - Requiring vaccines doesn't fit with our clinical philosophy
6 - Legal concerns
Within the comments, "disagreement among partners" was so commonly stated that I suspect it might have been the #1 answer had I considered it.  There were also a number of comments about requiring vaccines contradicting AAP policy...
Questions, comments welcomed!