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Reducing Missed Opportunities for Immunizations: Easier Said Than Done

Reducing Missed Opportunities for Immunizations: Easier Said Than Done Abstract Background: Missed opportunities for immunizations are associated with underimmunization of preschool-age children. Practice policies limiting immunizations to scheduled preventive visits and guidelines requiring legal guardians to sign consent forms for vaccinations are 2 factors contributing to missed opportunities. However, methods to change these policies have not been sufficiently evaluated. Objective: To measure the effectiveness of (1) changing practice policies to incorporate the new national standard to screen and vaccinate eligible children at all office visits and (2) eliminating legal guardian signature requirements. Design: A randomized controlled trial of 2 interventions: (1) changing practice policy and routine to have office nurses screen for immunization status at all visits, attach immunization reminder cards to medical charts for eligible patients, and have providers vaccinate eligible children ("no missed opportunities" intervention) and (2) changing practice guidelines to allow vaccinations without a legal guardian's signature. The first intervention was performed at both sites; the second only at the neighborhood health center (NHC). Setting: A Pediatric Continuity Clinic in a teaching hospital (hereafter referred to as Clinic), and an NHC. Patients: Enrolled in the trial were 1005 Clinic patients and 983 NHC patients, 0 to 2 years of age. Main Outcome Measures: Missed opportunity rates, immunization rates, and rates of preventive services. Results: Eliminating the requirement for a legal guardian's signature had no effect on any of the outcome measures. The no missed opportunities intervention was partially effective. Study patients had slightly fewer missed opportunities than control patients at each site: (0.60 vs 0.90 per patient per year at the Clinic, P=.01; 1.1 vs 1.3 per patient per year at the NHC, P=.02). For study group patients, immunization reminder cards were attached to medical charts in only one third of vaccine-eligible visits; when attached, they markedly increased vaccination by providers (odds ratio for vaccinating at a visit was 6.9 comparing visits when immunization reminder cards were attached vs not attached). However, at the end of the study, immunization rates were similar for study and control groups at each site. The number of undervaccinated days was slightly lower for the no missed opportunities study group at the Clinic than for the control group (56 days vs 77 days, P<.001), but they were similar for both groups at the NHC. There were no differences in rates of preventive visits or screening tests between study and control groups. Conclusions: The interventions evaluated to reduce missed opportunities did not increase immunization rates. The key problem was failure to screen for immunization status at all visits. More effective interventions will be needed to overcome barriers within busy primary care practices to substantially reduce missed opportunities.Arch Pediatr Adolesc Med. 1996;150:1193-1200 References 1. Williams BC. Immunization coverage among preschool children: the United States and selected European countries . Pediatrics . 1990;86( (suppl) ):1052-1056. 2. Expanded Programme on Immunization. Programme Report for 1993 . Geneva, Switzerland: World Health Organization; 1994. 3. Centers for Disease Control and Prevention. Vaccination coverage of 2-year-old children—United States, 1993 . MMWR Morb Mortal Wkly Rep . 1994;43: 705-709. 4. Zell ER, Dietz V, Stevenson J, Cochi S, Bruce RH. Low vaccination levels of US preschool and school-age children: retrospective assessments of vaccination coverage, 1991-1992 . JAMA . 1994;271:833-839.Crossref 5. Centers for Disease Control. Measles immunization levels among selected groups of preschool-aged children—United States . MMWR Morb Mortal Wkly Rep . 1991;40:36-39. 6. Szilagyi PG, Rodewald LE, Humiston SG, et al. Missed opportunities for childhood immunizations in office practices and the effect on immunization status . Pediatrics . 1993;91:1-7. 7. Hutchins SS, Escolan J, Markowitz LE, et al. Measles outbreak among unvaccinated preschool-aged children: opportunities missed by health care providers to administer measles vaccine . Pediatrics . 1989;83:369-374. 8. McConnochie KM, Roghmann KJ. Immunization opportunities missed among urban poor children . Pediatrics . 1992;89:1019-1026. 9. Centers for Disease Control and Prevention. Missed opportunities to vaccinate preschool-aged children: impact on vaccination coverage levels . MMWR Morb Mortal Wkly Rep . 1994;43:709-718. 10. Hanes A. Immunization status of reviews, efforts, and results in Georgia. In: Proceedings of the 22nd National Immunization Conference; June 6,1988; San Antonio, Tex. 11. Jones JE, White KE, Campbell KL, Farrell JB. Simultaneous childhood vaccine administration: a strategy to improve primary vaccine series completion. In: Proceedings of the 22nd National Immunization Conference; June 6,1988; San Antonio, Tex. 12. Farizo KM, Stehr-Green PA, Markowitz LE, Patriarca PA. Immunization levels and missed opportunities for measles immunization: a record audit in a public pediatric clinic . Pediatrics . 1992;89:589-592. 13. Hutchins SS, Gindler JS, Atkinson WL, et al. Preschool children at high risk for measles: opportunities to vaccinate . Am J Public Health . 1993;83:862-867.Crossref 14. Lindegren ML, Atkinson W, Farizo KM, Stehr-Green PA. Measles vaccination in pediatric emergency departments during a measles outbreak . JAMA . 1993; 270:2185-2189.Crossref 15. Szilagyi PG, Rodewald LE. Missed opportunities for influenza vaccination among children with asthma . Pediatr Infect Dis J . 1992;11:705-708.Crossref 16. Tifft CJ, Lederman HM. Immunization status of hospitalized preschool-age children: the need for hospital-based immunization programs . AJDC . 1988:142: 719-720. 17. National Vaccine Advisory Committee. The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;266:1547-1552.Crossref 18. US Dept of Health and Human Services, Public Health Service. Standards for Pediatric Immunization Practices . Washington, DC: US Dept of Health and Human Services; 1992. 19. Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United States . Pediatrics . 1994:94:517-523. 20. Humiston SG, Rodewald LE, Woodin MS, Carges MS, Szilagyi PG. Parental comprehension and opinion of one-page vaccine information material . Arch Pediatr Adolesc Med . 1994;148( (suppl) ):P49. 21. Szilagyi PG, Roghmann KJ, Campbell JR, et al. Immunization practices of primary care practitioners and their relation to immunization levels . Arch Pediatr Adolesc Med . 1994;148:158-166.Crossref 22. Hughart N, Guyer B, Stanton B, et al. Do provider practices conform to the new pediatric immunization standards? Arch Pediatr Adolesc Med . 1994;148: 930-935.Crossref 23. Campbell JR, Szilagyi PG, Rodewald LE, Winter NL, Humiston SG, Roghmann KJ. Intent to immunize among pediatric and family medicine residents . Arch Pediatr Adolesc Med . 1994;148:926-929.Crossref 24. Woodin KA, Rodewald LE, Humiston SG, Carges MS, Schaffer SJ, Szilagyi PG. Physician and parent opinions: are children becoming pincushions from immunizations? Arch Pediatr Adolesc Med . 1995;149:845-849.Crossref 25. Rodewald LE, Roghmann KJ, Szilagyi PG, Winter NL, Campbell JR, Humiston SG. The school-based immunization survey: strengths and weaknesses of an inexpensive tool for measuring vaccine coverage . Am J Public Health . 1993; 83:1749-1751.Crossref 26. Advisory Committee on Immunization Practices, Centers for Disease Control. General recommendations on immunizations . MMWR Morb Mortal Wkly Rep . 1989;38:205-214, 219-227. 27. American Academy of Pediatrics Committee on Infectious Diseases. Report of the Committee on Infectious Diseases . Elk Grove Village, III; American Academy of Pediatrics; 1988. 28. Raubertas RF, Rodewald LE, Humiston SG, et al. Defining and measuring undervaccination. In: Proceedings of the 25th National Immunization Conference; June 10, 1991; Washington, DC. 29. Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME: a review of 50 randomized controlled trials . JAMA . 1992;268: 1111-1117.Crossref 30. Cohen SJ, Halvorson HW, Gosselink CA. Changing physician behavior to improve disease prevention . Prev Med . 1994;23:284-291.Crossref 31. Greco PJ, Eisenberg JM. Changing physicians' practices . N Engl J Med . 1993; 329:1271-1274.Crossref 32. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? the effect of a consensus statement on the practice of physicians . N Engl J Med . 1989;321:1306-1311.Crossref 33. Bennett NM, Lewis B, Doniger AS, et al. A coordinated, communitywide program in Monroe County, New York, to increase influenza immunization rates in the elderly . Arch Intern Med . 1994;154:1741-1745.Crossref 34. Kouides RW, Lewis B, Bennett NM, et al. A performance-based incentive program for influenza immunization in the elderly . Am J Prev Med . 1993:9:250-254. 35. Prislin MD, Vandenbark MS, Clarkson QD. The impact of a health screening flowsheet on the performance and documentation of health screening procedures . Fam Med . 1986;18:290-292. 36. Campbell JR, Szilagyi PG, Rodewald LE, et al. Patient-specific reminder letters and pediatric well-child care show rates . Clin Pediatr (Phila) . 1994;33:268-272.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.1996.02170360083014
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Abstract

Abstract Background: Missed opportunities for immunizations are associated with underimmunization of preschool-age children. Practice policies limiting immunizations to scheduled preventive visits and guidelines requiring legal guardians to sign consent forms for vaccinations are 2 factors contributing to missed opportunities. However, methods to change these policies have not been sufficiently evaluated. Objective: To measure the effectiveness of (1) changing practice policies to incorporate the new national standard to screen and vaccinate eligible children at all office visits and (2) eliminating legal guardian signature requirements. Design: A randomized controlled trial of 2 interventions: (1) changing practice policy and routine to have office nurses screen for immunization status at all visits, attach immunization reminder cards to medical charts for eligible patients, and have providers vaccinate eligible children ("no missed opportunities" intervention) and (2) changing practice guidelines to allow vaccinations without a legal guardian's signature. The first intervention was performed at both sites; the second only at the neighborhood health center (NHC). Setting: A Pediatric Continuity Clinic in a teaching hospital (hereafter referred to as Clinic), and an NHC. Patients: Enrolled in the trial were 1005 Clinic patients and 983 NHC patients, 0 to 2 years of age. Main Outcome Measures: Missed opportunity rates, immunization rates, and rates of preventive services. Results: Eliminating the requirement for a legal guardian's signature had no effect on any of the outcome measures. The no missed opportunities intervention was partially effective. Study patients had slightly fewer missed opportunities than control patients at each site: (0.60 vs 0.90 per patient per year at the Clinic, P=.01; 1.1 vs 1.3 per patient per year at the NHC, P=.02). For study group patients, immunization reminder cards were attached to medical charts in only one third of vaccine-eligible visits; when attached, they markedly increased vaccination by providers (odds ratio for vaccinating at a visit was 6.9 comparing visits when immunization reminder cards were attached vs not attached). However, at the end of the study, immunization rates were similar for study and control groups at each site. The number of undervaccinated days was slightly lower for the no missed opportunities study group at the Clinic than for the control group (56 days vs 77 days, P<.001), but they were similar for both groups at the NHC. There were no differences in rates of preventive visits or screening tests between study and control groups. Conclusions: The interventions evaluated to reduce missed opportunities did not increase immunization rates. The key problem was failure to screen for immunization status at all visits. More effective interventions will be needed to overcome barriers within busy primary care practices to substantially reduce missed opportunities.Arch Pediatr Adolesc Med. 1996;150:1193-1200 References 1. Williams BC. Immunization coverage among preschool children: the United States and selected European countries . Pediatrics . 1990;86( (suppl) ):1052-1056. 2. Expanded Programme on Immunization. Programme Report for 1993 . Geneva, Switzerland: World Health Organization; 1994. 3. Centers for Disease Control and Prevention. Vaccination coverage of 2-year-old children—United States, 1993 . MMWR Morb Mortal Wkly Rep . 1994;43: 705-709. 4. Zell ER, Dietz V, Stevenson J, Cochi S, Bruce RH. Low vaccination levels of US preschool and school-age children: retrospective assessments of vaccination coverage, 1991-1992 . JAMA . 1994;271:833-839.Crossref 5. Centers for Disease Control. Measles immunization levels among selected groups of preschool-aged children—United States . MMWR Morb Mortal Wkly Rep . 1991;40:36-39. 6. Szilagyi PG, Rodewald LE, Humiston SG, et al. Missed opportunities for childhood immunizations in office practices and the effect on immunization status . Pediatrics . 1993;91:1-7. 7. Hutchins SS, Escolan J, Markowitz LE, et al. Measles outbreak among unvaccinated preschool-aged children: opportunities missed by health care providers to administer measles vaccine . Pediatrics . 1989;83:369-374. 8. McConnochie KM, Roghmann KJ. Immunization opportunities missed among urban poor children . Pediatrics . 1992;89:1019-1026. 9. Centers for Disease Control and Prevention. Missed opportunities to vaccinate preschool-aged children: impact on vaccination coverage levels . MMWR Morb Mortal Wkly Rep . 1994;43:709-718. 10. Hanes A. Immunization status of reviews, efforts, and results in Georgia. In: Proceedings of the 22nd National Immunization Conference; June 6,1988; San Antonio, Tex. 11. Jones JE, White KE, Campbell KL, Farrell JB. Simultaneous childhood vaccine administration: a strategy to improve primary vaccine series completion. In: Proceedings of the 22nd National Immunization Conference; June 6,1988; San Antonio, Tex. 12. Farizo KM, Stehr-Green PA, Markowitz LE, Patriarca PA. Immunization levels and missed opportunities for measles immunization: a record audit in a public pediatric clinic . Pediatrics . 1992;89:589-592. 13. Hutchins SS, Gindler JS, Atkinson WL, et al. Preschool children at high risk for measles: opportunities to vaccinate . Am J Public Health . 1993;83:862-867.Crossref 14. Lindegren ML, Atkinson W, Farizo KM, Stehr-Green PA. Measles vaccination in pediatric emergency departments during a measles outbreak . JAMA . 1993; 270:2185-2189.Crossref 15. Szilagyi PG, Rodewald LE. Missed opportunities for influenza vaccination among children with asthma . Pediatr Infect Dis J . 1992;11:705-708.Crossref 16. Tifft CJ, Lederman HM. Immunization status of hospitalized preschool-age children: the need for hospital-based immunization programs . AJDC . 1988:142: 719-720. 17. National Vaccine Advisory Committee. The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;266:1547-1552.Crossref 18. US Dept of Health and Human Services, Public Health Service. Standards for Pediatric Immunization Practices . Washington, DC: US Dept of Health and Human Services; 1992. 19. Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United States . Pediatrics . 1994:94:517-523. 20. Humiston SG, Rodewald LE, Woodin MS, Carges MS, Szilagyi PG. Parental comprehension and opinion of one-page vaccine information material . Arch Pediatr Adolesc Med . 1994;148( (suppl) ):P49. 21. Szilagyi PG, Roghmann KJ, Campbell JR, et al. Immunization practices of primary care practitioners and their relation to immunization levels . Arch Pediatr Adolesc Med . 1994;148:158-166.Crossref 22. Hughart N, Guyer B, Stanton B, et al. Do provider practices conform to the new pediatric immunization standards? Arch Pediatr Adolesc Med . 1994;148: 930-935.Crossref 23. Campbell JR, Szilagyi PG, Rodewald LE, Winter NL, Humiston SG, Roghmann KJ. Intent to immunize among pediatric and family medicine residents . Arch Pediatr Adolesc Med . 1994;148:926-929.Crossref 24. Woodin KA, Rodewald LE, Humiston SG, Carges MS, Schaffer SJ, Szilagyi PG. Physician and parent opinions: are children becoming pincushions from immunizations? Arch Pediatr Adolesc Med . 1995;149:845-849.Crossref 25. Rodewald LE, Roghmann KJ, Szilagyi PG, Winter NL, Campbell JR, Humiston SG. The school-based immunization survey: strengths and weaknesses of an inexpensive tool for measuring vaccine coverage . Am J Public Health . 1993; 83:1749-1751.Crossref 26. Advisory Committee on Immunization Practices, Centers for Disease Control. General recommendations on immunizations . MMWR Morb Mortal Wkly Rep . 1989;38:205-214, 219-227. 27. American Academy of Pediatrics Committee on Infectious Diseases. Report of the Committee on Infectious Diseases . Elk Grove Village, III; American Academy of Pediatrics; 1988. 28. Raubertas RF, Rodewald LE, Humiston SG, et al. Defining and measuring undervaccination. In: Proceedings of the 25th National Immunization Conference; June 10, 1991; Washington, DC. 29. Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME: a review of 50 randomized controlled trials . JAMA . 1992;268: 1111-1117.Crossref 30. Cohen SJ, Halvorson HW, Gosselink CA. Changing physician behavior to improve disease prevention . Prev Med . 1994;23:284-291.Crossref 31. Greco PJ, Eisenberg JM. Changing physicians' practices . N Engl J Med . 1993; 329:1271-1274.Crossref 32. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? the effect of a consensus statement on the practice of physicians . N Engl J Med . 1989;321:1306-1311.Crossref 33. Bennett NM, Lewis B, Doniger AS, et al. A coordinated, communitywide program in Monroe County, New York, to increase influenza immunization rates in the elderly . Arch Intern Med . 1994;154:1741-1745.Crossref 34. Kouides RW, Lewis B, Bennett NM, et al. A performance-based incentive program for influenza immunization in the elderly . Am J Prev Med . 1993:9:250-254. 35. Prislin MD, Vandenbark MS, Clarkson QD. The impact of a health screening flowsheet on the performance and documentation of health screening procedures . Fam Med . 1986;18:290-292. 36. Campbell JR, Szilagyi PG, Rodewald LE, et al. Patient-specific reminder letters and pediatric well-child care show rates . Clin Pediatr (Phila) . 1994;33:268-272.Crossref

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Nov 1, 1996

References