Correlates of Effective Standing Orders for Influenza Vaccination

Background: Primary care practices have been slow to implement standing orders (SO) for influenza vaccination of adults.   

Objectives: To identify primary care physicians’ perceptions of barriers to adoption and implementation of SO.

Methods: National  survey of family and internal medicine physicians drawn from AMA files, and surveys were mailed in two waves, followed by telephone contact.  Four groups were identified: (i) physicians who do not use and do not plan to adopt SO, (ii) physicians who do not use SO but are planning to do so, (iii) physicians who have SO but report inconsistent use, and (iv) physicians who report consistent use of SO.  The groups were compared in preliminary logistic regression models to assess differences in physician training, clinic organization, community setting, physician decision-making styles, perceived barriers, and attitudes of physicians toward SO.

Results: 71% of physicians (n=1015) participated in the survey.  In comparing consistent use of SO to the other three groups, significant independent predictors included physician awareness of CDC/ACIP recommendations (OR, 2.5 [95% CI, 1.7-3.6]), physician perception of the efficacy of SO (1.3 [1.1-1.6]), and perceived barriers to adoption (e.g., insufficient patient care staff) (0.72 [.68-.77] for each additional barrier).  For practices not using SO, practices with an electronic medical record (2.0 [1.2-3.4]) and physician perception of the efficacy of SO (1.6 [1.3-2.0]) were associated with plans to adopt SO.  Among practices with SO, consistent use was associated with fewer perceived barriers to implementation (0.79 [.73-.86]), a more open-decision-making style in the practice 1.4 [1.04-1.8]), and having access to a medical assistant (2.3 [1.3-4.1]). 

Conclusions:  Use of SO is correlated with physician awareness and perceptions as well as organizational factors.  Better dissemination of SO guidelines may be most important for adoption; organizational factors appear critical for effective use.