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September 1, 2016

Doc group: When parents refuse to vaccinate their kids, it's sometimes OK to dismiss them as patients

Daily Briefing

    As a new paper spotlights an increase in parents' refusing vaccinations for their children, the American Academy of Pediatrics (AAP) is trying to help providers respond.

    For the paper, published Monday in Pediatrics, AAP asked pediatricians about parents' attitudes toward vaccinating their children. The paper compared responses from a random sampling of about 630 AAP members in 2006 with responses from 2013.

    Study: 'Parental noncompliance ... is an increasing public health concern'

    AAP found that in 2013, 87 percent of pediatricians reported encountering a parent who refused at least one vaccination for their child, up from about 75 percent of pediatricians in 2006. Overall, pediatricians reported that the rate of patients who refused at least one vaccine increased from 4.5 percent in 2006 to 8.6 percent in 2013. Similarly, the rate of parents who refused all vaccines for their child also increased, from 2.1 percent in 2006 to 3.3 percent in 2013.

    AAP said, "[P]arental noncompliance ... is an increasing public health concern."

    According to AAP, about 73 percent of parents who refused vaccines in 2013 cited the belief that vaccination is unnecessary as their reasoning, up from about 63 percent in 2006.

    About 75 percent of physicians in 2013 said they had encountered parents who delayed vaccination out of concern for the child's comfort, while about 73 percent said parents delayed vaccination because they thought the vaccines would overwhelm a child's immune system.

    Even so, fewer parents cited a debunked claim linking vaccination and autism as a reason not to vaccinate their children. In 2006, 74 percent of parents who refused to vaccinate their child cited the supposed autism link, making it the most commonly cited reason for refusal at the time. In contrast, in 2013, 64 percent of parents cited it as a reason for refusal.

    Moreover, AAP also found that about one-third of parents who initially opted against vaccinating their child changed their minds after discussing the issue with their provider. Pediatricians said it took about 16 weeks on average to win parents' permission for vaccination.

    But about 9 percent of pediatricians said their efforts to educate parents had been unsuccessful. And when providers are faced with noncompliant parents, they are increasingly likely to dismiss the patient. AAP found that in 2013, about 12 percent of pediatricians said they "always" dismissed patients whose parents continued to refuse vaccine, up from about 6 percent in 2006.

    AMA: No more non-medical vaccination exemptions

    AAP advises thoughtful response, but accepts patient dismissal

    In a related report in Pediatrics, AAP offered recommendations for how pediatricians can respond when parents refuse to vaccinate their children. The report accompanied AAP's separate statement affirming the importance of routine childhood vaccinations and calling for the removal of all non-medical exemptions to vaccination, Andrew Seaman reports for Reuters.

    The AAP report stressed the importance of listening to parents' concerns and responding with factual evidence. According to AAP, clinicians should provide parents with data on vaccines' efficacy, as well as information on the harm of contracting vaccine-preventable diseases.

    Further, AAP advised providers to approach the conversation as if parents' support for vaccination is a given. Scott Krugman, director of the department of pediatrics at MedStar Franklin Medical Center in Baltimore, endorsed that strategy: Instead of asking parents about vaccination, Krugman said he assumes parents' cooperation off the bat, using phrases such as "These are the vaccines we are giving today."

    The states with most (and least) strict vaccine policies

    But for the first time, AAP in its report acknowledged circumstances in which a physician may dismiss a patient after unsuccessful attempts to vaccinate the child. AAP nonetheless stressed that providers must comply with state law and ensure another provider is available to care for the patient. If another provider is not available, the pediatrician should continue providing care.

    "The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view," AAP stated. "Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option."

    Providers divided over dismissal stance

    Alla Gordina, a pediatrician at Global Pediatrics and Family Medicine in New Jersey, praised the acknowledgment about dismissal. Gordina, whose practice does not accept patients who opt against vaccination, cited in an interview with Forbes a need to protect patients who are too young to be vaccinated or can't be vaccinated because of medical reasons.

    Separately, Phil Boucher, a Nebraska-based pediatrician who also supports the acknowledgement, told Forbes, "The pediatrician-parent-patient relationship is built on trust. If parents don't trust my medical opinion, it is difficult to maintain that relationship."

    But not everyone is convinced dismissal is the right move.

    Dan Flanders—director of Kindercare Pediatrics in Canada, which does not dismiss children who are unvaccinated—told Forbes he "fail[s] to see" how dismissal policies "build trusting and family-centered relationships between doctors and patients." He added, "I worry that when pediatricians dismiss vaccine-hesitant families, it is the children who suffer for their parents' poor, uninformed choices" (Castellucci, Modern Healthcare, 8/29; Haelle, Forbes, 8/29; Eunjung Cha, "To Your Health," Washington Post, 8/29; Seaman, Reuters, 8/29; Hough-Telford et al., Pediatrics, August 2016).

    Are you leading an evidence-based organization?

    Despite the shift toward broad acceptance of evidence-based practice (EBP) among medical staff, over half of physicians report not actually using guidelines day-to-day when they are available. As a result, organizations continue to see tremendous variation in clinical practice—as well as in costs and outcomes.

    Our infographic outlines four principles you can use to support EBP at your organization, along with action steps to implement each one and pitfalls to avoid along the way.


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