We Need to Simplify Getting A Flu Shot

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This year's influenza season was a long and hard one. We had a longer season with more complications and more hospitalizations than usual. As we are finally finished with flu this time around, one looks back and wonders why. Doctors always complain that too few people get vaccinated and that too many patients call for antivirals at the first sign of a respiratory infection.

Patients are unhappy that it's so hard to get to see their doctor on short notice, whether they are sick or trying to prevent an illness.

Some numbers: each year about 30,000 people in the U.S. die from influenza or its complications. These are usually the very old or the very young, and often those with heart, lung, or immune system conditions. Many more get sick and miss work or school. By early November 2017, less than 40% of U.S. infants, children and adults had received a flu vaccine, which was in line with recent years. Finally, in the past 10 years, the effectiveness of the influenza vaccine has ranged from 37 to 60% according to the CDC. As it is always hard to estimate this until a season is over or close to over, let's agree on an average 50% vaccine effectiveness against "real" influenza (not against colds and stomach viruses). This means that for every two people who get the vaccine, one will not get the flu (and the other person will) if they are exposed.

To get this 50% benefit, patients have to: make an appointment with your doctor, likely miss some work, show up (although they may have to wait anyway), and get a shot, unless they qualify for a nasal spray. Or they could go to CVS, Walgreen or one of the many other places that offer flu vaccines. These are called retail clinics, or what I like to call quick-serve healthcare and immunization providers, or Q-SHIPs. Here, they still get their shot or spray, but it's on their own time, and likely will still be covered by their health insurance. Some lucky employees may even have flu vaccine provided by their workplace.

Many doctors much prefer that patients get vaccinated at our office. Why? First, it works on our schedules and we get paid (a little) to provide the service. Second, given the duration of illness of about a week, there is no question that preventing flu with a vaccine costs much less that treating it with medication or missing work, or both.

Even if patients aren't vaccinated at the office, doctors want our patients to get their flu shot. It is very good at preventing severe illness, and vaccinating people helps to prevent epidemic outbreaks in places where people congregate, such as at school, work, daycare, nursing homes, hospitals, etc.

On the other hand, our patients often prefer the "I'll take the risk" approach. Why? First, the patient decision makers are usually adults, and they are often employed. This means that scheduling a visit to a doctor's office usually involves missing work. So even if the vaccination is free, there is an opportunity cost associated with lost work or vacation time. Second, the effectiveness of about 50% leaves a lot of people underwhelmed. Also, many people who get vaccinated may later get a seasonal cold virus, which flu vaccine does NOT prevent. This may lead one to presume that the vaccine didn't work for them.

Also, many otherwise healthy adults feel that medication can be used instead, IF they get sick, and this can often be gotten over the phone, without the pain, time or expense of vaccination. Although the cost of a course of an antiviral for influenza may be hundreds of dollars, an insured patient's much lower copay insulates them from this cost, so that medication costs are a tiny consideration for many. Of course, all those who got vaccinated and don't get sick don't really know if this was due to vaccination or just luck.

Due to these issues, overall many patients feel that the value they get from a flu vaccine is low. When a busy doctor looks at it from the busy patient point of view, it makes sense.

So how to meet in the middle?

A few simple suggestions to reduce the pain for everyone, both literally and figuratively:

  • Many pediatric offices offer flu vaccines on weekends. Offices serving adults should consider doing the same.
  • Medical offices should offer flu vaccines at ALL appointments to ALL patients during flu vaccination season (August through May). Vaccinating today means that your patient need not come through the office again for a vaccination visit this season.

    Encourage patients to accept this offer of vaccination (and no, August is not too early).

  • Medical offices should use the nasal spray influenza vaccine when possible. This was not used for the past two years due to effectiveness issues, but it has been placed on the list of likely vaccines for the upcoming 2018–2019 season. It is approved for use in people from two to 49 years old. If you get some for free from your state's Department of Public Health, all the better.
  • Doctors should encourage patients to use Q-SHIPs for vaccination, and should work to get documentation of these vaccinations. Rather than worry about lost business, we should be HAPPY when a patient receives a vaccine at CVS or another pharmacy_-_it preserves office supply for others who will need it. Instead of worrying that business is going elsewhere, seek more of these partnerships and make sure that you have a system in place to document the vaccination.
  • Remember, in the end the goal is more vaccinated patients and less influenza along with its complications.

    Marc Grella, MD, FAAP is a primary-care pediatrician at Massachusetts General Hospital in Boston, where he lives with his wife and 2 sons. He blogs at PediatricVaccineConsultant.com.

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