Vaccine burden is 'downward spiral'.

I own a small private pediatric practice, and I agree that the costs of vaccines are staggering ("Plethora of Shots Burdens Providers," June 2008, p. 1).

Factors not included in the study add to the burden: time spent ordering vaccines, time spent on catch-up vaccines, and time spent in discussions with parents who wish to alter or delay vaccines--this total has gone up tremendously for both physicians and nurses, who must investigate which vaccines are needed. Also add extra visits to split up vaccines, front office time, check-in, pulling charts, rooming, and the effort needed to keep adequate stock of vaccines on hand.

On top of all this, vaccine reimbursement is declining, with some vaccines actually being reimbursed below their actual cost.

I constantly worry that this is a downward spiral that cannot be stopped.

Kelly Thorstad, M.D.

Austin, Tex.