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Table 1.  Individual Physician Practices and Office Policies for Addressing Vaccine Refusal (N = 303)
Individual Physician Practices and Office Policies for Addressing Vaccine Refusal (N = 303)
Table 2.  Bivariable and Multivariable Analyses of Pediatric Offices With a Policy to Dismiss Families for Refusing Vaccines (N = 276)a
Bivariable and Multivariable Analyses of Pediatric Offices With a Policy to Dismiss Families for Refusing Vaccines (N = 276)a
1.
World Health Organization. Ten threats to global health in 2019. Accessed December 10, 2019. https://www.who.int/emergencies/ten-threats-to-global-health-in-2019
2.
O’Leary  ST, Allison  MA, Fisher  A,  et al.  Characteristics of physicians who dismiss families for refusing vaccines.   Pediatrics. 2015;136(6):1103-1111. doi:10.1542/peds.2015-2086PubMedGoogle ScholarCrossref
3.
Crane  LA, Daley  MF, Barrow  J,  et al.  Sentinel physician networks as a technique for rapid immunization policy surveys.   Eval Health Prof. 2008;31(1):43-64. doi:10.1177/0163278707311872PubMedGoogle ScholarCrossref
4.
Blank  NR, Caplan  AL, Constable  C.  Exempting schoolchildren from immunizations: states with few barriers had highest rates of nonmedical exemptions.   Health Aff (Millwood). 2013;32(7):1282-1290. doi:10.1377/hlthaff.2013.0239PubMedGoogle ScholarCrossref
5.
Lessin  HR, Hackell  JM.  Real world vaccine ethics.   J Pediatr. 2016;175:243-244. doi:10.1016/j.jpeds.2016.04.035PubMedGoogle ScholarCrossref
6.
Glanz  JM, Newcomer  SR, Narwaney  KJ,  et al.  A population-based cohort study of undervaccination in 8 managed care organizations across the United States.   JAMA Pediatr. 2013;167(3):274-281. doi:10.1001/jamapediatrics.2013.502PubMedGoogle ScholarCrossref
Research Letter
September 15, 2020

Policies Among US Pediatricians for Dismissing Patients for Delaying or Refusing Vaccination

Author Affiliations
  • 1Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora
  • 2National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 3Division of General Internal Medicine, Denver Health, Denver, Colorado
  • 4Department of Community and Behavioral Health, Colorado School of Public Health, Denver
JAMA. 2020;324(11):1105-1107. doi:10.1001/jama.2020.10658

In January 2019, the World Health Organization declared vaccine hesitancy one of the top 10 threats to global health.1 Some US pediatricians dismiss children from their practice whose parents refuse vaccination.2 However, little is known about the current prevalence of this practice.

Methods

We conducted a survey from April to July 2019 among US pediatricians using a physician survey network. Physicians were recruited to fill sampling quotas representative of American Academy of Pediatrics membership with respect to region, practice location, and practice setting and asked to complete 2 to 4 surveys each year.3

The survey assessed pediatricians’ current practices, experiences, and office policies regarding dismissal of families who refuse or ask to “spread out” either vaccines in the primary series or any vaccines using a series of 4-point Likert scales (never, rarely, sometimes, often/always) and yes-or-no questions. The survey was pilot tested in national samples of pediatricians. The survey was administered via mail or internet (Vovici) using Dillman’s tailored approach.

We compared respondents with nonrespondents using t test and χ2 analyses. We conducted a multivariable analysis with the dependent variable of having an office policy to dismiss families for vaccine refusal of 1 or more vaccines in the primary vaccine series. Independent variables included practice characteristics, presence of a state philosophical exemption, and state’s degree of difficulty in obtaining an exemption (easy vs medium/difficult).4 We used log-binomial regression to obtain risk ratios and 95% CIs. P values were 2-sided and P < .05 was considered significant. Analyses were performed using SAS software, version 9.4 (SAS Institute Inc).

The human subjects review board at the University of Colorado approved this study as exempt.

Results

The response rate was 68% (303/448). The mean age of respondents was 53 years, 36% were male, and 79% were in private practice. Respondents were not significantly different than nonrespondents with respect to age, sex, practice setting, census location, and size of practice.

Office policies for dismissal because of vaccine refusal or “spreading out” were more commonly reported than individual physician dismissal behaviors (Table 1). For example, 51% of pediatricians reported that their office had a policy to dismiss families if they refused vaccines in the primary series, while 37% of physicians reported often/always doing this themselves. Physicians more frequently dismissed families for refusing (37%) than for spreading out (6%) vaccines in the primary series, and a similar pattern was seen for office policies (51% for refusal vs 28% for spreading out).

Among physicians who reported they ever (rarely, sometimes, or often/always) dismiss families for refusing vaccines in the primary series (n = 154), 18% reported that those parents often/always change their mind and agree to vaccination when presented with the policy (48% sometimes, 29% rarely, and 5% never).

Offices in community/hospital-based clinic/health maintenance organization settings were less likely than private practices to have a dismissal policy (risk ratio, 0.28 [95% CI, 0.14-0.49]) as were practices in the Midwest (risk ratio, 0.66 [95% CI, 0.47-0.91]; referent to the South) (Table 2).

Discussion

This study among US pediatricians showed that the practice of dismissing families who refuse vaccines for their children was common, with half of pediatricians reporting their office has a dismissal policy, although fewer personally dismiss patients. A survey administered in 20122 using the same methodology as in the present study found that 21% of pediatricians reported they often/always dismissed families for refusing vaccines2 compared with 37% in the present study.

Some argue that having a dismissal policy for vaccination leads otherwise resistant parents to agree to vaccinate.5 This study showed some pediatricians perceive this to be true, with more than half of pediatricians with a dismissal policy reporting parents at least sometimes agreeing after learning of the policy.

Because vaccine refusal is common,6 the high prevalence of dismissal for families who refuse has important implications. Future work should explore the effect this practice has on vaccination rates, whether it results in parents changing their mind about vaccination, and whether it decreases access to medical care or erodes trust in clinicians.

Limitations of this study include that respondents may have differed from nonrespondents in unmeasured ways and that findings are based on reported rather than observed practices.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Corresponding Author: Sean T. O’Leary, MD, MPH, University of Colorado Anschutz Medical Campus, 13199 E Montview Blvd, Ste 300, Aurora, CO 80045 (sean.oleary@cuanschutz.edu).

Accepted for Publication: June 1, 2020.

Author Contributions: Ms Beaty had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O’Leary, Cataldi, Lindley, Hurley, Crane, Kempe.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: O’Leary, Cataldi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Beaty.

Obtained funding: Kempe.

Administrative, technical, or material support: Crane, Kempe.

Supervision: Kempe.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the Centers for Disease Control and Prevention (grant U01 IP001072-01).

Role of the Funder/Sponsor: The funder had input on the design and conduct of the study; the funder did not have input on the collection, management, or analysis of the data, but did assist with interpretation of the data; the funder was not involved in preparation of the manuscript, but did review and approve the manuscript and agreed with the decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Additional Contributions: We thank Michaela Brtnikova, PhD, and Carol Gorman, BA, at the Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), both of whom received salary support from the aforementioned grant, for their assistance with data acquisition.

References
1.
World Health Organization. Ten threats to global health in 2019. Accessed December 10, 2019. https://www.who.int/emergencies/ten-threats-to-global-health-in-2019
2.
O’Leary  ST, Allison  MA, Fisher  A,  et al.  Characteristics of physicians who dismiss families for refusing vaccines.   Pediatrics. 2015;136(6):1103-1111. doi:10.1542/peds.2015-2086PubMedGoogle ScholarCrossref
3.
Crane  LA, Daley  MF, Barrow  J,  et al.  Sentinel physician networks as a technique for rapid immunization policy surveys.   Eval Health Prof. 2008;31(1):43-64. doi:10.1177/0163278707311872PubMedGoogle ScholarCrossref
4.
Blank  NR, Caplan  AL, Constable  C.  Exempting schoolchildren from immunizations: states with few barriers had highest rates of nonmedical exemptions.   Health Aff (Millwood). 2013;32(7):1282-1290. doi:10.1377/hlthaff.2013.0239PubMedGoogle ScholarCrossref
5.
Lessin  HR, Hackell  JM.  Real world vaccine ethics.   J Pediatr. 2016;175:243-244. doi:10.1016/j.jpeds.2016.04.035PubMedGoogle ScholarCrossref
6.
Glanz  JM, Newcomer  SR, Narwaney  KJ,  et al.  A population-based cohort study of undervaccination in 8 managed care organizations across the United States.   JAMA Pediatr. 2013;167(3):274-281. doi:10.1001/jamapediatrics.2013.502PubMedGoogle ScholarCrossref
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