How ‘shared decision making’ for kids’ vaccines could limit access : NPR

A child holds a toy bear with a band-aid after receiving a flu shot during an immunization event in Los Angeles. Flu is one of six vaccines that will no longer be given routinely but now require a consultation with a doctor.

PATRICK T. FALLON/AFP/Getty Images

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PATRICK T. FALLON/AFP/Getty Images

In a major change in vaccine policy, the Trump administration recently dropped recommendations that all kids get six immunizations long considered routine. Instead, they’re now in a category called “shared clinical decision-making.”

That’s when the patient (or the parents if the patient’s a child) has a conversation with a health care provider to decide if a treatment is appropriate, says Wendy Parmetwho studies health care policy at Northeastern University in Boston.

“In theory, shared clinical decision-making sounds great,” she says. But the approach is usually reserved for complicated medical decisions where the answer is often muddy, not for routine vaccines that have been clearly shown to be safe and effective.

Some examples include: Should someone get surgery or physical therapy for back pain? Which men need regular PSA prostate cancer testing?

But many doctors say there’s no ambiguity when it comes to these vaccines, which protect against hepatitis A, hepatitis Bthe flu, meningitis, respiratory syncytial virus (RSV)and rotavirusa dangerous gastrointestinal infection.

“These vaccines have clear evidence of benefit for all children,” says Jake Scottan infectious disease researcher at Stanford University. “So moving them to shared decision-making doesn’t reflect the scientific uncertainty that the category exists for. It manufactures this sort of uncertainty where no uncertainty really exists.”

The problem with shared decision making in this context, is “you’re suggesting that both options are equally valid,” says Dr. Lainie Friedman Rossa pediatrician and bioethicist at the University of Rochester School of Medicine. “And the fact is: Not getting vaccinated puts your own child at risk, puts you at risk and puts your community at risk. So it is not an equal decision.”

Vaccine critics argue there’s enough nuance about these immunizations to warrant moving them to the shared clinical decision-making category. And administration officials say the change is designed to restore trust in vaccines.

But Ross and others argue that dropping these vaccines to a lower spot in the new CDC vaccine hierarchy sows dangerous confusion and doubt, especially at a time when vaccine hesitancy is already on the rise and vaccination rates are already falling.

“It’s a huge embarrassment for U.S. public health and a disaster for public trust, and most of all for children,” says Dr. Douglas Opela professor of pediatrics at the Washington School of Medicine.

They also point out that doctors already routinely answer any questions parents may have, in addition to providing detailed handouts about each vaccine.

New hurdles to vaccine access

And there are many practical implications that could become hurdles to kids getting the shots, even if their parents do want them, Scott says. That includes deleting automatic electronic medical record alerts when shots are due and canceling standing orders for nurses and pharmacists to vaccinate kids without getting a doctor involved.

“Moving it from routinely recommended to shared clinical decision-making has a dramatic effect on the practical delivery of vaccination,” Scott says.

And while the administration says the decision shouldn’t affect whether government programs or private insurance pay for the immunizations, some legal experts say that may not be guaranteed.

“The administration says that there’s not going to be insurance implications. But there are a number of problems there,” says Dorit Reisswho studies vaccine policies at UC Law San Francisco. “First of all they can change their interpretation later. Second, if a private insurer wanted to challenge this and say, ‘This vaccine is no longer recommended. I don’t have to cover it,’ they probably have some good arguments.”

Even with insurance, parents may now get hit with co-pays for those extra conversations with swamped pediatricians, according to Dr. Molly O’Shea, a Detroit-area pediatrician who serves as a spokesperson for the American Academy of Pediatrics.

“Before, if it was a vaccination that we didn’t have to have a conversation about, we could feel safe allowing families to schedule a vaccine-only appointment,” O’Shea says. “Because shared-decision making is required now, that takes time and that now is going to be billed for.”

New liability concerns for drugmakers

Another one big question is: Does this make vaccine makers and doctors vulnerable to getting sued? Many lawyers don’t think so.

“On a legal standpoint, nothing has changed,” says David Carneya Philadelphia lawyer who’s the president of the Vaccine Injured Petitioners Bar Association.

But some lawyers argue that the change does open the door to more litigation over vaccine injuries.

“The immunity under the National Childhood Vaccine Injury Act of 1986 (the 1986 Act), which shields pharma and physicians from liability when vaccines cause serious harms and deaths, only applies to vaccines that are recommended for routine administration to children and/or pregnant women,” Aaron Sirimanaging partner at Siri & Glimstad, wrote in an email to NPR.

Siri is a close ally of Health Secretary Robert F. Kennedy Jr. and has been extensively involved in litigation against federal agencies and vaccine manufacturers.

Some legal experts say that this uncertainty is alarming. Without liability protection, vaccines could become unavailable, says Parmet.

“We don’t quite really know whether shared clinical decision-making will be considered as sufficient enough of a recommendation to provide the liability protection,” Parmet says. “And if it doesn’t do that, then there are real concerns about whether the manufacturers will continue to make vaccines.”

A chilling effect on prescribers

Even if the change doesn’t lead to an increase in successful lawsuits involving vaccines, just the possibility of lawsuits could be enough to intimidate doctors, some say.

“They’re worried about stepping on a landmine if one thing goes wrong,” Parmet says. “One kid gets sick. The next day — even if it has nothing to do with the vaccine — are they going to be the ones held responsible? And someone’s going to say, ‘You had the nurse do it without talking to the doctor?'”

That could make doctors hesitant to recommend these immunizations, which means imposing shared clinical decision-making could leave more kids more vulnerable to dangerous infections.

“I do think many physicians will be chilled in their behavior around recommending vaccination,” says Michelle Melloa professor of health policy and law at Stanford. “We’ve got this change now that plunges us into a situation of chaotic uncertainty.”

How can shared decision making reduce vaccination rates for children?

how ‘Shared Decision Making’ for Kids’ Vaccines Could Limit Access

The concept of “shared decision making” (SDM) in pediatric vaccine recommendations is gaining traction, fueled by a desire to respect parental autonomy. However, a growing body of evidence suggests this approach, while well-intentioned, could inadvertently create new barriers to childhood immunization, notably for vulnerable populations. This article explores the potential pitfalls of SDM in vaccine uptake, examining how it differs from informed consent and the practical challenges it presents for healthcare providers and families.

Understanding Shared Decision Making vs. Informed Consent

It’s crucial to differentiate between informed consent – a long-established ethical and legal principle – and shared decision making.

* Informed Consent: Traditionally, informed consent involves a healthcare provider presenting information about a medical intervention (like a vaccine), including benefits, risks, and alternatives, allowing the patient (or parent, in the case of a child) to make a decision. The provider offers their expert recommendation.

* Shared Decision Making: SDM emphasizes a more collaborative process, where the provider and parent jointly weigh the pros and cons, considering the parent’s values and preferences equally with medical evidence.This can lead to a situation where parental hesitancy, even if based on misinformation, carries the same weight as scientific consensus.

The shift towards SDM isn’t necessarily about denying vaccines; it’s about how the conversation around vaccines is framed. But framing matters – and can have notable consequences.

The Potential for Decreased vaccine Uptake

Several factors suggest SDM could lower vaccination rates:

* Amplifying Misinformation: SDM provides a platform for discussing unproven claims and anxieties about vaccines. Providers, already stretched for time, may struggle to effectively debunk myths during every consultation.

* Increased Provider Burden: Engaging in lengthy, nuanced discussions with every parent about every vaccine takes time – time many pediatricians simply don’t have, especially in busy practices. This can lead to providers avoiding the topic altogether or offering less robust recommendations.

* Equity Concerns: families with higher levels of health literacy and access to reliable information are better equipped to navigate SDM effectively. Those from marginalized communities, with limited access to healthcare or facing language barriers, may be more susceptible to misinformation and less able to advocate for their children’s health.

* The “False Balance” Effect: Presenting both sides of a debate, even when one side is overwhelmingly supported by evidence, can create a perception of equal validity. This “false balance” can undermine trust in medical expertise.

Real-World Examples & Emerging Trends

Recent data from several states indicate a correlation between the implementation of SDM policies and slight declines in vaccination rates for certain childhood diseases. While correlation doesn’t equal causation, the trend is concerning.

For instance, in Oregon, a pilot programme emphasizing SDM for the HPV vaccine saw a modest decrease in uptake among adolescent girls. Researchers noted that providers expressed discomfort addressing parental concerns about the vaccine, leading to less assertive recommendations.

Furthermore, the rise of online “parenting communities” – ofen rife with anti-vaccine sentiment – is exacerbating the challenge. Parents are increasingly seeking information from non-medical sources, bringing pre-conceived notions into the SDM conversation.

The Role of Time constraints & Provider Training

A significant obstacle to effective SDM is the sheer time commitment required. A typical pediatric appointment is already packed with well-child checks, sick visits, and administrative tasks. Adding a lengthy vaccine discussion to the mix can be unrealistic.

To mitigate this,several solutions are being explored:

* Decision aids: Developing standardized,evidence-based materials that parents can review before their appointment. Thes aids should clearly outline the benefits and risks of vaccines, address common concerns, and provide links to reliable resources.

* Enhanced Provider Training: Equipping pediatricians and nurses with the skills to confidently address vaccine hesitancy, debunk myths, and engage in respectful but firm conversations with parents. Training should focus on motivational interviewing techniques and effective communication strategies.

* Streamlined Processes: Implementing systems that allow for pre-visit vaccine education, such as online modules or informational videos. This can free up valuable time during the appointment for focused discussion.

Addressing Parental Concerns Effectively

It’s vital to acknowledge and validate parental concerns without compromising medical recommendations. Here’s how:

1. listen actively: Allow parents to express their fears and anxieties without interruption.
2. Empathize: Acknowledge that it’s natural to be concerned about your child’s health.
3. Provide Evidence-Based Information: Present clear, concise information about the benefits and risks of vaccines, using language that is easy to understand.
4. Address Misconceptions: Gently correct any misinformation, providing credible sources to support your claims.
5. Reiterate Your Recommendation: Clearly state your professional opinion, emphasizing the importance of vaccination for protecting their child and the community.

The Impact on Community Immunity (Herd immunity)

Decreased vaccination rates don’t just put individual children at risk; they also threaten community immunity,also known as herd immunity. When a significant portion of the population is vaccinated, it protects those who cannot be vaccinated (e.g., infants too young to recieve certain vaccines, individuals with compromised immune systems). SDM, if it leads to lower uptake, could erode this crucial protection, increasing the risk of outbreaks of preventable diseases.

Looking Ahead: Balancing Autonomy and Public health

Finding the right balance between respecting parental autonomy and protecting public health is a complex challenge. While SDM has the potential to empower families, it’s crucial to implement it thoughtfully and strategically, with a focus on ensuring equitable access to accurate information and robust