MY 30 YEARS IN PEDIATRICS: THE IMPACT OF VACCINES
I began practicing on July 1, 1978. I felt privileged to be a pediatrician in the golden age of vaccines. I felt confident that there were several infectious diseases that I would probably never have to treat because of the fine array of vaccines in the physician’s arsenal. I had seen occasional cases of measles, mumps, rubella, tetanus, and pertussis during my training— but far fewer than were seen by pediatricians who had begun to practice in 1958 or even in 1968. I had studied diphtheria, polio, and smallpox but had seen not a single case of any of these diseases throughout my medical school and residency years.
Despite the wonders of lifesaving vaccines, patients were still dying of diseases caused by Streptococcus pneumoniae and Haemophilus influenzae. Like all other pediatricians of the time, I lived in fear of the middle-of-the-night phone call from parents concerned about their child’s unusual cough. Was it croup caused by a virus or could it be epiglottitis caused by H influenzae? My son suffered with croup and I spent many a night under our “army tent” (sheets placed over a bridge table with two vaporizers working), fearful that I might miss the diagnosis of epiglottitis.
Newborn nursery and pediatric unit beds were still occupied by patients with bacterial meningitis. I remember as if it were yesterday informing the parents of children with meningitis that even after survival there were potential complications that could occur—complications such as brain abscess, loss of vision or hearing, learning disabilities, motor impairments, and more.
Today, in 2008, we have cut the number of cases of H influenzae infection significantly, and annual cases of S pneumoniae pneumonia in the United States are down to about 40,000.1 Meningococcal disease has also been radically reduced to fewer than 1000 cases a year.2 The annual incidence of hepatitis A is down to about 20,000 cases3 and varicella to about 32,000 cases4; the numbers of cases of rotavirus infection and polio have fallen even more dramatically. Today we have influenza virus vaccines that have diminished the risk of vaccine-induced Guillain-Barré syndrome. Soon we will have the pleasure of seeing a significant drop in the incidence of cervical and anogenital cancers as a result of the recent introduction of a vaccine to protect against human papillomavirus (HPV) infection, currently the most prevalent sexually transmitted disease in the United States.
USE OF VACCINES STILL FAR FROM OPTIMAL
However, despite the availability of these vaccines, they are not reaching enough people. There are still 15 million to 60 million cases of influenza reported annually in the United States alone.5 Vaccines save approximately 3 million lives a year. This is a wonderful statistic, but it is not good enough. Close to 2 million lives a year are still lost to vaccine-preventable diseases.6
Suboptimal use of vaccines is the result of a variety of problems with vaccine delivery. These include problems related to the cost of vaccines, inadequate physician compensation by MCOs, the manufacture of vaccines, effects of new types of health insurance, changing patterns of use of the health care system, and the fractured nature of health care delivery to poor children. Each of these problems is discussed in greater detail below, and possible solutions are outlined.
EROSION OF THE MEDICAL HOME
In times past, it was primarily underprivileged persons who had difficulty establishing roots in a medical home. The local hospital’s emergency department was often their primary source of medical care. Today, however, many families have 2 working parents who must seek medical care after normal business hours. These families turn to urgent care centers, emergency departments, and retail-based clinics. Some of these facilities are open 24 hours a day, 7 days a week, and are being used for this convenience.
Many retail-based clinics make it possible to pick up a gallon of milk or a box of tissues while obtaining medical care from a nurse practitioner or physician’s assistant. Retailbased clinics also offer short waiting times, plenty of parking, and the convenience of proximity to patients’ homes. However, there is likely to be no physician on the premises of these clinics, and the supervising physician might be hundreds of miles away, leaving the nurse practitioner or medical assistant essentially unsupervised.
As of this writing, retail-based clinics have not yet offered vaccines, but the idea is under consideration.
Physicians can counter the movement to non–office-based care by extending office hours, by scheduling carefully in order to minimize waiting times for patients and, perhaps most important, by reminding patients of the benefits of the medical home. The benefits of a medical home include being examined and treated by a physician or by a nurse practitioner who is working under the close supervision of a physician; being able to speak directly to one’s physician after hours in the event of an emergency; and being able to rely on the physician to keep track of such things as drug allergies, significant aspects of medical or family history, and vaccinations received or needed.
THE RISE OF HIGH-DEDUCTIBLE HEALTH PLANS
Another recent phenomenon, high-deductible health plans, also impedes the optimal administration of vaccines. These plans require the patient to pay for the first $1100 to $3000 of health care each year. Now families must decide how to spend their health care dollars. Patients arrive in doctors’ offices sicker than they did previously because they want to save money by waiting to be seen.
Although some high-deductible health plans cover preventive care received before the deductible has been met, about two-thirds do not do so.7 Some patients are electing to skip the yearly health maintenance exam in an effort to save money. As a consequence, conditions such as developmental problems, diabetes, and heart issues may be missed. There is also a real fear that vaccinations will be skipped because of patients’ efforts to keep out-of-pocket costs to a minimum.