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Kempe A, Saville AW, Beaty B, Dickinson LM, Gurfinkel D, Eisert S, Roth H, Herrero D, Trefren L, Herlihy R. Centralized Reminder/Recall to Increase Immunization Rates in Young Children: How Much Bang for the Buck? Acad Pediatr 2017; 17:330-338. [PMID: 27913163 DOI: 10.1016/j.acap.2016.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the child's provider. METHODS We conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates. RESULTS C-R/R was more effective in trials 1 to 3 (relative risk = 1.11; 95% confidence interval 1.01-1.20; P = .009). Effectiveness did not decrease with decreasing intervention intensity (P = .59). Costs decreased with decreasing intensity in the C-R/R arm, from $18.72 per child brought UTD in trial 1 to $10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from $20.63 to $237.81 per child brought UTD. C-R/R was significantly more effective if the child's practice name was included (P < .0001). CONCLUSIONS C-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child's provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials.
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Affiliation(s)
- Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, and The Children's Hospital, Denver, Colo; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Denver, Colo.
| | - Alison W Saville
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, and The Children's Hospital, Denver, Colo
| | - Brenda Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, and The Children's Hospital, Denver, Colo
| | - L Miriam Dickinson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, and The Children's Hospital, Denver, Colo; Department of Family Medicine, University of Colorado Anschutz Medical Campus, Denver, Colo
| | - Dennis Gurfinkel
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, and The Children's Hospital, Denver, Colo
| | - Sheri Eisert
- Department of Health Policy and Management and Department of Pediatrics, University of South Florida, Tampa, Fla
| | - Heather Roth
- Colorado Immunization Information System, Colorado Department of Public Health and Environment, Denver, Colo
| | - Diana Herrero
- Colorado Immunization Information System, Colorado Department of Public Health and Environment, Denver, Colo
| | - Lynn Trefren
- Colorado Immunization Information System, Colorado Department of Public Health and Environment, Denver, Colo
| | - Rachel Herlihy
- Colorado Immunization Information System, Colorado Department of Public Health and Environment, Denver, Colo
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Zweigoron RT, Roberts JR, Levin M, Chia J, Ebeling M, Binns HJ. Influence of Office Systems on Pediatric Vaccination Rates. Clin Pediatr (Phila) 2017; 56:231-237. [PMID: 27242379 DOI: 10.1177/0009922816650396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study seeks to better understand the impact of practice-level factors on up-to-date (UTD) rates in children. We compared practice-level vaccination rates for 54 practices to survey data regarding office practices for staffing, vaccine delivery, reminder-recall, and quality improvement. Vaccination rates at 24 and 35 months were analyzed using t tests, analysis of variance, and linear regression. Private practices and those using standing orders had higher UTD rates at 24 months ( P = .01; P = .03), but not at 35 months. Having a pediatrician in the office was associated with higher UTD rates at both 24 and 35 months ( P < .01). Participating in a network and taking walk-in patients were associated with lower UTD rates ( P = .03; P = .03). As the percentage of publicly insured patients decreases, the UTD rate rises at 24 and 35 months ( r = -0.43, P = .001; r = -0.037, P = .007). Reported use of reminder recall-systems, night/evening hours, and taking walk-in patients were not associated with increased UTD rates.
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Affiliation(s)
| | | | - Marcia Levin
- 2 Chicago Department of Public Health, Chicago, IL, USA
| | - Jean Chia
- 3 NYU Langone Medical Center and School of Medicine, New York, NY, USA
| | - Myla Ebeling
- 1 Medical University of South Carolina, Charleston, SC, USA
| | - Helen J Binns
- 4 Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,5 Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Tarwa C, De Villiers FPR. The use of the Road to Health Card in monitoring child health. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2007.10873497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Moss JL, Gilkey MB, Griffith T, Bowling JM, Dayton A, Grimshaw A, Quinn B, Brewer NT. Organizational correlates of adolescent immunization: findings of a state-wide study of primary care clinics in North Carolina. Vaccine 2013; 31:4436-41. [PMID: 23845803 PMCID: PMC3798154 DOI: 10.1016/j.vaccine.2013.06.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 06/06/2013] [Accepted: 06/25/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze organizational correlates of immunization coverage among adolescents served by high-volume primary care providers in North Carolina. METHODS We randomly selected 91 clinics with at least 200 active records for patients ages 11-18 in the North Carolina Immunization Registry. For the 105,121 adolescents served by these clinics, we obtained immunization status for 6 vaccines, including human papillomavirus (HPV) vaccine (females only); meningococcal conjugate; and tetanus, diphtheria, and pertussis booster (Tdap). RESULTS Clinics specializing in pediatrics had higher coverage for meningococcal vaccine (OR=1.79, 95% CI: 1.25-2.55), Tdap vaccine (OR=1.22, 95% CI: 1.00-1.50), and childhood vaccines. However, pediatric clinics had lower coverage for HPV vaccine initiation (OR=0.70, 95% CI: 0.52-0.94). Other correlates, which varied by vaccine, included policies related to vaccine documentation and the age at which clinics recommended vaccines. CONCLUSION Overall, adolescents were more likely to receive vaccines, except HPV vaccine, if they attended a pediatric clinic with supportive clinical policies.
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Affiliation(s)
- Jennifer L. Moss
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
| | - Melissa B. Gilkey
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599
| | - Turquoise Griffith
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
| | - J. Michael Bowling
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
| | - Amanda Dayton
- North Carolina Immunization Branch, Raleigh, NC 27699
| | - Amy Grimshaw
- North Carolina Immunization Branch, Raleigh, NC 27699
| | - Beth Quinn
- North Carolina Immunization Branch, Raleigh, NC 27699
| | - Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599
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Rodewald LE, Orenstein WA, Hinman AR, Schuchat A. Immunization in the United States. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Poehling KA, Fairbrother G, Zhu Y, Donauer S, Ambrose S, Edwards KM, Staat MA, Prill MM, Finelli L, Allred NJ, Bardenheier B, Szilagyi PG. Practice and child characteristics associated with influenza vaccine uptake in young children. Pediatrics 2010; 126:665-73. [PMID: 20819893 PMCID: PMC3673003 DOI: 10.1542/peds.2009-2620] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this study was to determine both practice and child characteristics and practice strategies associated with receipt of influenza vaccine in young children during the 2004-2005 influenza season, the first season for the universal influenza vaccination recommendation for all children who are aged 6 to 23 months. METHODS Clinical and demographic data from randomly selected children who were aged 6 to 23 months were obtained by chart review from a community-based cohort study in 3 US counties. The proportion of children who were vaccinated by April 5, 2005, in each practice was obtained. For assessment of practice characteristics and strategies, sampled practices received a self-administered practice survey. Practice and child characteristics that predicted complete influenza vaccination were determined by using multinomial logistic regression. RESULTS Forty-six (88%) of 52 sampled practices completed the survey and permitted chart reviews. Of 2384 children who were aged 6 to 23 months and were studied, 27% were completely vaccinated. The proportion of children who were completely vaccinated varied widely among practices (0%-71%). Most (87%) practices implemented ≥1 vaccination strategy. Complete influenza vaccination was associated with 3 practice characteristics: suburban location, lower patient volume, and vaccination strategies of evening/weekend vaccine clinics; with child characteristics of younger age, existing high-risk conditions, ≥6 well visits to the practice by 3 years of age, and any practice visit from October through January. CONCLUSIONS Modifiable factors that were associated with increased influenza vaccination coverage included October to January practice visits and evening/weekend vaccine clinics.
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Affiliation(s)
- Katherine A Poehling
- Wake Forest University Medical Center, Department of Pediatrics, Winston-Salem, NC 27157, USA.
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Mennito SH, Darden PM. Impact of practice policies on pediatric immunization rates. J Pediatr 2010; 156:618-22. [PMID: 20056238 DOI: 10.1016/j.jpeds.2009.10.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 10/05/2009] [Accepted: 10/29/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the relationship between practice policies and rates of up-to-date (UTD). STUDY DESIGN Analysis of data from the 2004-2006 National Immunization Survey (NIS). Practice policies evaluated are immunization provider involvement in a vaccine registry, participation in the Vaccines for Children (VFC) program, and administration of hepatitis B vaccine at birth. The primary outcome is rates of being UTD with the 4:3:1:3:3 vaccination series for children age 19 through 35 months. RESULTS The overall rate of UTD is 80.8%; 53.3% of children had providers administer hepatitis B vaccine at birth, which was associated with significantly higher rates of UTD (79.9% vs. 83.1%, P < .01). Children with multiple vaccine providers had lower rates of UTD versus those with only 1 vaccine provider (77.3% vs 82.5%; P < .01). In multivariable analysis, participation in VFC (OR 1.59, 95%, CI 1.16-2.2) and administration of hepatitis B at birth (OR 1.25, 95% CI 1.05-1.5) increased the odds of UTD. Provider participation in a vaccine registry did not significantly impact rates or likelihood of UTD. CONCLUSIONS Immunization provider policy decisions, including administration of hepatitis B at birth, participation in VFC, and a focus on continuity of care, can improve rates of UTD for children in their practice.
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Affiliation(s)
- Sarah H Mennito
- Medical University of South Carolina, Department of Pediatrics, Division of General Pediatrics, Charleston, South Carolina, USA.
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Salmon DA, Pan WK, Omer SB, Navar AM, Orenstein W, Marcuse EK, Taylor J, deHart MP, Stokley S, Carter T, Halsey NA. Vaccine knowledge and practices of primary care providers of exempt vs. vaccinated children. HUMAN VACCINES 2008; 4:286-91. [PMID: 18424918 PMCID: PMC5833987 DOI: 10.4161/hv.4.4.5752] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Compare vaccine knowledge, attitudes and practices of primary care providers for fully vaccinated children and children who are exempt from school immunization requirements. METHODS We conducted a mailed survey of parent-identified primary care providers from four states to measure perceived risks and benefits of vaccination and other key immunization beliefs. Frequencies of responses were stratified by type of provider, identified by exempt versus vaccinated children. Logistic regression was used to calculate odds ratios for responses by provider type. RESULTS 551 surveys were completed (84.3% response rate). Providers for exempt children had similar attitudes to providers for non-exempt children. However, there were statistically significant increased concerns among providers for exempt children regarding vaccine safety and lack of perceived individual and community benefits for vaccines compared to other providers. CONCLUSIONS The great majority of providers for exempt children had similar attitudes about vaccine safety, effectiveness and benefits as providers of non-exempt children. Although providers for exempt children were more likely to believe that multiple vaccines weaken a child's immune system and were concerned about vaccine safety and less likely to consider vaccines were beneficial, a substantial proportion of providers of both exempt and vaccinated children have concerns about vaccine safety and believe that CDC underestimates the frequency of vaccine side effects. Effective continuing education of providers about the risks and benefits of immunization and including in vaccine recommendations more information on pre and post licensing vaccine safety evaluations may help address these concerns.
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Affiliation(s)
- Daniel A. Salmon
- Institute for Vaccine Safety; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
| | - William K.Y. Pan
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
| | - Saad B. Omer
- Institute for Vaccine Safety; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
| | - Ann Marie Navar
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
- Duke University; School of Medicine; Durham, North Carolina USA
| | | | | | - James Taylor
- University of Washington; Child Health Institute; Seattle, Washington USA
| | - M. Patricia deHart
- Washington State Department of Health; Immunization Program; Olympia, Washington USA
| | - Shannon Stokley
- Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases; Atlanta, Georgia USA
| | - Terrell Carter
- The PATH Malaria Vaccine Initiative; Seattle, Washington USA
| | - Neal A. Halsey
- Institute for Vaccine Safety; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore, Maryland USA
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Orenstein WA, Rodewald LE, Hinman AR, Schuchat A. Immunization in the United States. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50071-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Moran CM, Panzarino VM, Darden PM, Reigart JR. Preventive services: blood pressure checks at well child visits. Clin Pediatr (Phila) 2003; 42:627-34. [PMID: 14552522 DOI: 10.1177/000992280304200709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to determine rates of blood pressure (BP) screening at well-child visits as recommended by the Task Force on Blood Pressure Control in Children. The 1985 and 1996 National Ambulatory Medical Care Surveys were analyzed for changes in proportion of well visits for children aged 3-18 years at which BP was checked. Patient and physician demographics are described. BP screening increased from 50% in 1985 to 61% in 1996. For pediatricians, the estimates were 50% (95% CI, 43-57) and 60% (95% CI, 53-68). For family/general medicine the estimates were 51% (95% CI, 34-69) and 58% (95% CI, 43-74). Age, geographic location, and length of a visit were significant in predicting BP screening. Gender, race, ethnicity, or urban location were not. A stepwise logistic regression confirmed these results. Rates of screening BP at well-child visits have increased but fall short of current recommendations. High-risk children are not screened at a rate different from their lower risk peers.
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Affiliation(s)
- Colleen M Moran
- Medical University of South Carolina, Department of Pediatrics, Division of General Pediatrics, 165 Cannon Street, Suite 503, P.O. Box 250853, Charleston, SC 29425, USA
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Findley SE, Irigoyen M, See D, Sanchez M, Chen S, Sternfels P, Caesar A. Community-provider partnerships to reduce immunization disparities: field report from northern Manhattan. Am J Public Health 2003; 93:1041-4. [PMID: 12835176 PMCID: PMC1447900 DOI: 10.2105/ajph.93.7.1041] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In 1996 we launched a community-provider partnership to raise immunization coverage for children aged younger than 3 years in Northern Manhattan, New York City. The partnership was aimed at fostering provider knowledge and accountability, practice improvements, and community outreach. By 1999 the partnership included 26 practices and 20 community groups. Between 1996 and 1999, immunization coverage rates increased in Northern Manhattan 5 times faster than in New York City and 8 times faster than in the United States (respectively, 3.4% vs 0.4% [t = 6.05, p < 0.001] and vs 0.6% [t = 5.65, p < 0.001]). The coverage rate for Northern Manhattan stayed constant through 2000, although it declined during this period for the United States and New York City. We attribute the success at reducing the gap to the effectiveness of our partnership.
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Affiliation(s)
- Sally E Findley
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, New York 10032, USA
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Schaffer SJ, Szilagyi PG, Shone LP, Ambrose SJ, Dunn MK, Barth RD, Edwards K, Weinberg GA, Balter S, Schwartz B. Physician perspectives regarding pneumococcal conjugate vaccine. Pediatrics 2002; 110:e68. [PMID: 12456935 DOI: 10.1542/peds.110.6.e68] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Pneumococcal conjugate vaccine (PCV) was first licensed for routine administration to young children in February 2000. The objective of this study was to assess physician perspectives about the use of PCV, to ascertain which children were being given the vaccine soon after licensure, and to determine how the addition of PCV to the schedule of recommended childhood vaccines may affect the timing of other vaccinations. METHODS A 30-item survey containing questions about the use of PCV was sent to all pediatricians and family physicians who provide primary care to young children in Monroe County (Rochester, NY) and Davidson County (Nashville, TN) in October 2000. As many as 3 subsequent mailings were sent to nonresponders. Descriptive and chi(2) statistical analyses and logistic regression were used to evaluate the responses. RESULTS Response rates were 82% in Rochester and 78% in Nashville. Eighty-two percent of responding physicians, including 92% of pediatricians and 55% of family physicians, indicated that they were giving PCV to their patients at the time of the survey. Sixty percent noted that an initial lack of insurance reimbursement for the cost of the vaccine caused them to delay introducing PCV. Fifty-one percent delayed initially offering the vaccine to any of their patients because the Vaccines for Children (VFC) program did not begin to offer PCV until several months later. The vast majority routinely vaccinated healthy children who are younger than 2 years as well as older children who had defined chronic medical conditions that put them at high risk of invasive pneumococcal disease. Fewer than 15% were recalling patients for PCV, with most recall efforts focused on patients who had chronic medical conditions. When discussing PCV with parents, 78% of physicians primarily emphasized the vaccine's potential to decrease the risk of sepsis and/or meningitis, whereas smaller percentages primarily emphasized the vaccine's potential to decrease the risk of pneumonia or ear infections. Approximately 20% of physicians who gave PCV delayed other vaccinations (primarily varicella vaccine, hepatitis B vaccine, or polio vaccine) because of concern about administering 4 or more vaccines simultaneously. Similarly, 40% of physicians indicated that they considered PCV to be more important than varicella vaccine or hepatitis B vaccine, whereas 26% percent considered PCV to be more important than polio vaccine. CONCLUSIONS PCV has been widely accepted by physicians in both Rochester and Nashville. However, many physicians delayed introducing the vaccine for reasons that were ultimately related to financial considerations. For privately insured patients, delays were related to when coverage for PCV was added to benefit packages. For patients who receive publicly purchased vaccine via the VFC program, delays were related to availability of the vaccine through the VFC program. In addition, after the introduction of PCV, some physicians began delaying the administration of other vaccines because of the need to give multiple vaccinations simultaneously. Although lack of insurance or VFC coverage and concerns about multiple simultaneous injections may somewhat delay the initial use of newly recommended vaccines, physicians rapidly begin to provide new vaccines that they believe to be beneficial once those vaccines are incorporated into existing payment mechanisms.
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Affiliation(s)
- Stanley J Schaffer
- New Vaccine Surveillance Network, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Szilagyi PG, Schaffer S, Shone L, Barth R, Humiston SG, Sandler M, Rodewald LE. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002; 110:e58. [PMID: 12415064 DOI: 10.1542/peds.110.5.e58] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations. Disparities in US childhood immunization rates persist, with inner-city, black, and Hispanic children having lower rates. Although practice or clinic-based interventions, such as patient reminder/recall systems, have been found to improve immunization rates in specific settings, there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level. OBJECTIVE To assess the effect of a community-wide reminder, recall, and outreach (RRO) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban populations and among white, black, and Hispanic children within an entire county. SETTING Monroe County, New York (birth cohort: 10 000, total population: 750 000), which includes the city of Rochester. Three geographic regions within the county were compared: the inner city of Rochester, which contains the greatest concentration of poverty (among 2-year-old children, 64% have Medicaid); the rest of the city of Rochester (38% have Medicaid); and the suburbs of the county (8% have Medicaid). INTERVENTIONS An RRO system was implemented in 8 city practices in 1995 (covering 64% of inner-city children) and was expanded to 10 city practices by 1999 (covering 74% of inner-city children, 61% of rest-of-city children, and 9% of suburban children). The RRO intervention involved lay community-based outreach workers who were assigned to city practices to track immunization rates of all 0- to 2-year-olds, and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations (tracking for all children, mail, or telephone reminders for most children, assistance with transportation or scheduling for some children, and home visits for 5% of children who were most behind in immunizations and who faced complex barriers). STUDY PARTICIPANTS Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993, 1996, and 1999. STUDY DESIGN Immunization rates were measured for each geographic region in Monroe County at 3 time periods: before the implementation of a systematic RRO system (1993), during early phases of implementation of the RRO system (1996), and after implementation of the RRO system in 10 city practices (1999). Immunization rates were compared for children living in the 3 geographic regions, and for white, black, and Hispanic children. Immunization rates were measured by the same methodology in each of the 3 time periods. A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practices in the county (covering 85% to 89% of county children). A random sample of children (>500 from the suburbs and >1200 from the city for each sampling period) was then selected for medical chart review at practices to determine demographic characteristics (including race and ethnicity) and immunization rates. City children were oversampled to allow detection of effects by geographic region and race. Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling. MAIN OUTCOME MEASURES Immunization rates at 12 and 24 months for recommended vaccines (4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella: > or =1 Haemophilus influenzae type b on or after 12 months of age). RESULTS DISPARITIES BY GEOGRAPHIC REGION: Baseline immunization rates (1993) for 24-month-olds were as follows: inner city (55%), rest of city (64%), and suburbs (73%), with an 18% difference in rates between the inner city and suburbs. By 1996, immunization rates rose faster in the inner city (+21% points) than in the suburbs (+14% points) so that the difference in rates between the inner city and suburbs had narrowed to 11%. In 1999, rates were similar across geographic regions: inner city (84%), rest of city (81%), and suburbs (88%), with a 4% difference between the inner city and suburbs. DISPARITIES BY RACE AND ETHNICITY: Immunization rates were available in 1996 and 1999 by race and ethnicity. Twenty-four-month immunization rates in 1996 showed disparities: white (89%), black (76%), and Hispanic (74%), with a 13% difference between rates for white and black children and a 15% difference between white and Hispanic children. In 1999, rates were similar across the groups: white (88%), black (81%), and Hispanic (87%), with a 7% difference between rates for white and black children, and a 1% difference between white and Hispanic children. CONCLUSIONS A community-wide intervention of patient RRO raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority populations. By targeting a relatively manageable number of primary care practices that serve city children and using an effective strategy to increase immunization rates in each practice, it is possible to eliminate disparities in immunizations for vulnerable children.
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Affiliation(s)
- Peter G Szilagyi
- Department of Pediatrics and Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Prislin R, Sawyer MH, Nader PR, Goerlitz M, De Guire M, Ho S. Provider-staff discrepancies in reported immunization knowledge and practices. Prev Med 2002; 34:554-61. [PMID: 11969357 DOI: 10.1006/pmed.2002.1019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of the study was to compare immunization-relevant knowledge, certainty about knowledge, self-efficacy, vested interest, and reported practices of providers and clinical staff in the same clinics. METHODS A valid and reliable instrument measuring the aforementioned issues was developed and administered to a sample of 50 providers and 60 members of the clinical staff. RESULTS Providers were significantly more knowledgeable than staff (P < 0.001); however, they were not more certain about their knowledge (P = 0.52) nor were they more confident in their capability to properly immunize all children in their practice (P = 0.10). Providers reported lower vested interest in immunizations than clinical staff (P < 0.05). Both groups were equally likely to immunize a child with a cold. Providers were less likely to defer needed immunizations for a 15-month-old child, and they were more likely to administer multiple injections to an 18-month-old (both P < 0.05). Providers were more likely than staff to immunize during acute and chronic illness visits (both P < 0.001), and both groups were equally likely to immunize during preventive visits. CONCLUSIONS Discrepancies in reported immunization practices between providers and staff may be a barrier to full immunization.
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Affiliation(s)
- Radmila Prislin
- Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, California 92182-4611, USA.
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Taylor JA, Darden PM, Brooks DA, Hendricks JW, Baker AE, Wasserman RC. Practitioner policies and beliefs and practice immunization rates: a study from Pediatric Research in Office Settings and the National Medical Association. Pediatrics 2002; 109:294-300. [PMID: 11826210 DOI: 10.1542/peds.109.2.294] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify vaccination policies and beliefs associated with practice immunization rates (PIR) among office-based pediatricians. METHODS Primary care pediatricians recruited from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics or the Pediatric Section of the National Medical Association abstracted immunization data from a consecutive sample of children who were 8 to 35 months old and seen in the office for any reason; 1 provider per practice collected this information. PIR were determined at 8 and 19 months of age by calculating the percentage of children in the sample who were fully immunized at that age. Before collecting the immunization data, all practitioners in each participating practice completed a questionnaire detailing his or her policies and beliefs regarding the administration of vaccines. Part of the questionnaire was a scenario involving a 4-month-old child who was due for a diphtheria-tetanus-acellular pertussis immunization at a health supervision visit. A list of 13 possible clinical conditions in this hypothetical patient were presented; practitioners were asked which of these were a contraindication to vaccination. One set of policies and beliefs was computed for each practice using a weighted average of the responses of each provider in a particular practice. Regression analyses were used to assess the association between each policy and belief and PIR at 8 and 19 months, after controlling for potentially confounding sociodemographic characteristics. RESULTS Data were analyzed from 112 practices; median PIR at 8 and 19 months were 85% and 71%, respectively. The following policies and beliefs were not statistically associated with PIR at either 8 or 19 months: use of acute visits for vaccinations, conducting an immunization audit within the previous 12 months, perceived difficulties in implementing new vaccine recommendations or staying informed about new recommendations, conducting practice meetings to discuss immunization policies, perception of profitability of providing vaccinations, appointment reminders for scheduled visits, and specific tracking mechanisms for patients who are due for or behind in immunizations. After controlling for sociodemographic characteristics, recommending inactivated poliovirus vaccine and having fewer contraindications to vaccination were associated with statistically higher PIR at 8 months and 19 months. Increasing the maximum number of injections administered at 1 visit was associated with a higher PIR at 8 months but not 19 months of age. CONCLUSION Policies and beliefs linked to many official recommendations for increasing immunization rates were not associated with higher PIR. However, accepting fewer contraindications to vaccination, administering all vaccines for which an infant is eligible at each health supervision visit, and adopting recommended changes in immunization schedules may help providers fully vaccinate a higher percentage of their patients.
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Affiliation(s)
- James A Taylor
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.
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Abstract
BACKGROUND Most studies of immunization behaviors measure adherence to standard immunization practices, relying on surveys without linking reported behaviors to objectively measured immunization rates. This study attempts to close that gap. METHODS In 1997, pediatric, family, and general providers in Pennsylvania serving children aged < 36 months (N = 251) completed immunization behavior surveys. We linked these responses to patient chart audits for practice-level immunization rates. RESULTS Immunization rates for our sample fell short of national goals (average up-to-date immunization status at 12 months = 69%). They were significantly higher for pediatricians than for family/general practitioners (78% vs 58%, p < 0.001) and for practices treating > or = 100 children in the past 30 working days than for those treating < 100 children (77% vs 62%, p < 0.001). Behaviors with significant associations to higher immunization coverage were: (1) appropriately giving diphtheria, tetanus toxoids, and pertussis immunization under false contraindications versus withholding it (73% vs 66%, p < 0.05); (2) willingness to give at least four injections at one visit versus fewer injections (74% vs 65%, p < 0.01); and (3) holding immunization in-service training versus no training (71% vs 65%, p < 0.05). However, multivariate analysis showed that only provider specialty remained a significant predictor of coverage. CONCLUSIONS Pediatricians have higher coverage rates than family/general practitioners. Although pediatricians see more children, the number of immunization-delayed children at 12 months is approximately the same for both provider groups. Therefore, efforts to improve coverage should continue to be directed toward both groups.
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Affiliation(s)
- C P Koepke
- Office for Children's Health Policy Research, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
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Santoli JM, Barker LE, Lyons BH, Gandhi NB, Phillips C, Rodewald LE. Health department clinics as pediatric immunization providers: a national survey. Am J Prev Med 2001; 20:266-71. [PMID: 11331114 DOI: 10.1016/s0749-3797(01)00299-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe a national sample of health department immunization clinics in terms of populations served, patient volume trends, services offered, and immunization practices. METHODS Telephone survey conducted with health departments sampled from a national database, using probability proportional to population size. RESULTS All (100%) 166 sampled and eligible clinics completed the survey. The majority of pediatric patients were uninsured (42%) or enrolled in Medicaid (34%). Most children (69%) and adolescents (70%) were referred to the health department, with only 12% using these clinics as a medical home. A number of clinics (72%) reported recent increases in adolescents served. Less than 25% of clinics offered comprehensive care, 47% conducted semiannual coverage assessments, and 76% and 38% operated recall systems for children and adolescents. Storage of records in an electronic database was common (83%). CONCLUSIONS Although the majority of these clinics do not provide comprehensive care, they continue to serve vulnerable children, including adolescents, Medicaid enrollees, and the uninsured, and may represent the main contact with the healthcare system for such patients. Because assuring the immunization of these children is essential to their health and the health of our nation as a whole, this immunization safety net must be preserved. Experience implementing key recommendations such as coverage assessment and feedback as well as reminder or recall may enable health department staff to assist private provider colleagues. Further research is needed to investigate how patient populations, services offered, and immunization practices vary by different clinic characteristics.
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Affiliation(s)
- J M Santoli
- National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Davis TC, Fredrickson DD, Arnold CL, Cross JT, Humiston SG, Green KW, Bocchini JA. Childhood vaccine risk/benefit communication in private practice office settings: a national survey. Pediatrics 2001; 107:E17. [PMID: 11158491 DOI: 10.1542/peds.107.2.e17] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED Communication about childhood vaccine risks and benefits has been legally required in pediatric health care for over a decade. However, little is known about the actual practice of vaccine risk/benefit communication. OBJECTIVES This study was conducted to identify current practices of childhood vaccine risk/benefit communication in private physician office settings nationally. Specifically, we wanted to determine what written materials were given, by whom, and when; what information providers thought parents wanted/needed to know, the content of nurse and doctor discussion with parents, and the time spent on discussion. We also wanted to quantify barriers to vaccine risk/benefit discussion and to prioritize materials and dissemination methods preferred as solutions to these barriers. METHODS We conducted 32 focus groups in 6 cities, and then administered a 27-question cross-sectional mailed survey from March to September 1998, to a random national sample of physicians and their office nurses who immunize children in private practices. Eligible survey respondents were active fellows of the American Academy of Pediatrics or American Academy of Family Physicians in private practice who immunized children and a nurse from each physician's office. After 3 mailings, the response rate was 71%. RESULTS Sixty-nine percent of pediatricians and 72% of family physicians self-reported their offices gave parents the Centers for Disease Control and Prevention Vaccine Information Statement, while 62% and 58%, respectively, gave it with every dose. In ~70% of immunization visits, physicians and nurses reported initiating discussion of the following: common side effects, when to call the clinic and the immunization schedule. However, physicians reported rarely initiating discussion regarding contraindications (<50%) and the National Vaccine Injury Compensation Program (<10%). Lack of time was considered the greatest barrier to vaccine risk/benefit communication. Nurses reported spending significantly more time discussing vaccines with parents than pediatricians or family physicians (mean: 3.89 vs 9.20 and 3.08 minutes, respectively). Both physicians and nurses indicated an additional 60 to 90 seconds was needed to optimally discuss immunization with parents under current conditions. Stratified analysis indicated nurses played a vital role in immunization delivery and risk/benefit communication. To improve vaccine risk/benefit communication, 80% of all providers recommended a preimmunization booklet for parents and approximately one half recommended a screening sheet for contraindications and poster for immunization reference. The learning method most highly endorsed by all providers was practical materials (80%). Other desirable learning methods varied significantly by provider type. CONCLUSIONS There was a mismatch between the legal mandate for Vaccine Information Statement distribution and the actual practice in private office settings. The majority of providers reported discussing some aspect of vaccine communication but 40% indicated that they did not mention risks. Legal and professional guidelines for appropriate content and delivery of vaccine communication need to be clarified and to be made easily accessible for busy private practitioners. Efforts to improve risk/benefit communication in private practice should take into consideration the limited time available in an office well-infant visit and should be aimed at both the nurse and physician.
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Affiliation(s)
- T C Davis
- Departments of Pediatrics and Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71130, USA.
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Kahane SM, Watt JP, Newell K, Kellam S, Wight S, Smith NJ, Reingold A, Adler R. Immunization levels and risk factors for low immunization coverage among private practices. Pediatrics 2000; 105:E73. [PMID: 10835086 DOI: 10.1542/peds.105.6.e73] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Previous studies have indicated that provider characteristics are an important determinant of immunization coverage. The objectives of this study were to: 1) assess immunization coverage levels among 2-year-old children receiving care in private practices in 3 California counties; and 2) evaluate practice and patient risk factors for low immunization coverage. STUDY DESIGN Cross-sectional chart review of immunization histories and provider survey of immunization policies. SETTING Forty-five randomly selected, private medical practices in 3 counties in California. PATIENTS Children 12 to 35 months old, followed by the participating practices. METHODS Providers underwent a detailed assessment of their immunization coverage and completed a questionnaire describing their immunization policies and procedures. Immunization data were abstracted from randomly selected medical charts of children 12 to 35 months old. Only patients who met the criteria for active status (>/=2 visits and >/=1 visit during the preceding 18 months) were included in analyses. Immunization coverage levels were calculated and logistic regression was used to estimate the risk of underimmunization associated with different practice and child characteristics. RESULTS Of the 72 eligible practices that were contacted, 45 participated in the study, yielding a participation rate of 62%. The median immunization coverage of participating offices was 54% (range: 0%-91%). Multivariate analysis revealed 5 independent risk factors for underimmunization. The strongest predictors were having fewer than 50% active children in the practice and children having fewer than 8 visits to the provider. Other significant predictors were the percentage of patients in the practice on Medicaid, administering diphtheria-tetanus-pertussis 4 at a separate visit from the Haemophilus influenzae type b booster, and practice location. CONCLUSIONS These data provide new insights into immunization practices in an important clinical setting that has been poorly characterized previously. Immunization coverage levels were found to be low and significant risk factors for underimmunization were identified. Recommendations are made for immunization policy changes and targeting of immunization improvement interventions at practices that may be at risk for low immunization coverage. immunization, vaccination, immunization programs, primary prevention, private practice, child, preschool, pediatrics, family practice.
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Affiliation(s)
- S M Kahane
- School of Public Health, University of California, Berkeley, California, USA.
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Abstract
INTRODUCTION Recent evaluations of computer-generated reminder/recall messages have suggested that they are an inexpensive, labor-saving method of improving office visitation rates of childhood immunization providers. This study assesses the sustained impact of computer-generated messages on immunization coverage during the first two years of life. DESIGN Randomized, controlled trial. SETTING County health department in the Denver metropolitan area. STUDY PARTICIPANTS Children (n = 1227) 60 to 90 days of age who had received the first dose of diphtheria-tetanus-pertussis (DTP) and/or poliovirus vaccines. INTERVENTION Households of children were randomized into four groups to receive: telephone messages followed by letters (Group A); telephone messages alone (Group B); letters only (Group C); or no notification (Group D). Households in the intervention groups (A, B, and C) received up to five computer-generated telephone messages and/or up to four letters each time their children became due for immunization(s). MAIN OUTCOME MEASURE Immunization series completion at 24 months of age. RESULTS Children whose families were randomized to receive any of the interventions were 21% more likely to have completed the immunization series by 24 months of age than were children randomized into the control group (49.2% vs 40.9%; RR [rate ratio] = .21; CI [confidence interval] = 1.01, 1.44). While not statistically significant, children in Group A were 23% more likely to complete their immunization series by 24 months of age than those in the control group (50.2% vs 40.9%; RR = 1.23; CI = 1.00, 1.52). No differences were detected among the intervention groups. The costs per additional child completing the series by 24 months of age in Group A was $226 ($79 after start-up costs were discounted). CONCLUSION Computer-generated contacts, either by phone or by mail (or both combined), used each time vaccines become due, are efficacious in increasing immunization coverage of children under 2 years of age.
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Affiliation(s)
- E F Dini
- National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Clayton MF, Boegel E. Missed immunization opportunities: a comparison of nurse practitioners and physicians. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 1999; 11:423-9. [PMID: 10690092 DOI: 10.1111/j.1745-7599.1999.tb01236.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vivier PM, Alario AJ, Simon P, Flanagan P, O'Haire C, Peter G. Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration. Pediatr Infect Dis J 1999; 18:783-8. [PMID: 10493338 DOI: 10.1097/00006454-199909000-00008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates. DESIGN AND METHODS The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment"). RESULTS With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series. CONCLUSIONS When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.
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Affiliation(s)
- P M Vivier
- Department of Pediatrics, Brown University, Providence, RI, USA.
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Massoudi MS, Walsh J, Stokley S, Rosenthal J, Stevenson J, Miljanovic B, Mann J, Dini E. Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy. Pediatrics 1999; 103:1218-23. [PMID: 10353932 DOI: 10.1542/peds.103.6.1218] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers. METHODS Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines. RESULTS Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 21/2 person-days of effort. CONCLUSIONS We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis. IMPLICATIONS Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.
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Affiliation(s)
- M S Massoudi
- Centers for Disease Control and Prevention, National Immunization Program, Atlanta, Georgia, USA.
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Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RF. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999; 103:31-8. [PMID: 9917436 DOI: 10.1542/peds.103.1.31] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare and measure the effects and cost-effectiveness of two interventions designed to raise immunization rates. SETTINGS Nine primary care sites serving impoverished and middle-class children. SUBJECTS Complete birth cohorts (ages 0 to 12 months; n = 3015) from these sites. INTERVENTIONS Two 18-month duration interventions: 1) tracking with outreach [tracking/outreach] to bring underimmunized children to their primary care provider office, and 2) a primary care provider office policy change to identify and reduce missed immunization opportunities (prompting). DESIGN Randomized, controlled trial, randomizing within sites using a two-by-two factorial design. Subjects were allocated to one of four study groups: control, prompting only, tracking/outreach only, and combined prompting with tracking/outreach. Outcomes were obtained by blinded chart abstraction. MEASURES Immunization status for age; number of days of delay in immunization; primary care utilization; and rates of screening for occult disease. RESULTS Out of 3015 subjects, 274 subjects (9%) transferred out of the participating sites or had incomplete charts and were excluded. The 2741 (91%) remaining subjects were assessed. At baseline, study groups did not differ in age, gender, insurance type, or immunization status. Of the remaining subjects, 63% received Medicaid. Final series-complete immunization coverage levels were: control, 74%; prompting-only, 76%; tracking/outreach-only 95%; and combined tracking/outreach with prompting, 95%. Analysis of variance showed that: 1) tracking/outreach increased immunization rates 20 percentage points; 2) tracking/outreach decreased mean immunization delay 63 days; 3) tracking/outreach increased mean health supervision visits 0.44 visits per child; 4) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child; 5) impact of tracking/outreach was greatest for uninsured and impoverished patients; and 6) the prompting intervention had no impact on the studied outcomes, and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted. Using tracking/outreach, the cost per additional child fully immunized was $474. Each $1000 spent on the tracking/outreach intervention resulted in: 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider; and 1.8 additional anemia screenings and 1.3 additional lead screenings. CONCLUSIONS Outreach directed toward children not up-to-date on immunizations improves not only immunization status, but also health supervision visit attendance and screening rates. The cost per additional child immunized was high, but should be interpreted in view of the spillover benefits that accompanied improved immunization. Effective means to improve coverage by reducing missed immunization opportunities still need to be identified.
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Affiliation(s)
- L E Rodewald
- Department of Pediatrics, University of Rochester, Rochester, New York,USA
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Affiliation(s)
- P M Darden
- Department of Pediatrics, Medical University of South Carolina, Charleston 29425-0793, USA
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Affiliation(s)
- J M Santoli
- National Immunization Program, Centers for Disease Control, Atlanta, GA 30333, USA
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Affiliation(s)
- R W Linkins
- Systems Development Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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England L, Shelton R, Schubert CJ. Immunizing preschool children: beliefs and practices of pediatric residents. Clin Pediatr (Phila) 1997; 36:129-34. [PMID: 9078413 DOI: 10.1177/000992289703600302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Immunization practices and knowledge of vaccine contraindications among pediatric residents were assessed at five pediatric training facilities by surveying 227 pediatric residents. Residents administer vaccines even in the presence of an afebrile minor illness. They are less likely to vaccinate if a fever (< 102 degrees F) is present. Only 57% of residents report administering vaccines at the 15-month well-child checks. Many residents had difficulty recognizing true and false contraindications, though third-year residents did better than first-year residents. Failure during residency to utilize 15-month well visits and ill visits in the presence of a fever and the lack of knowledge of true and false vaccine contraindications may be causes of missed opportunities to vaccinate among residents. Immunization practices resulting in missed opportunities to vaccinate seen during during residency may influence later immunization practices.
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Affiliation(s)
- L England
- Division of Infectious Disease, Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Esernio-Jenssen D, Turow V. Parents' understanding of the CDC's vaccine information material. Am J Public Health 1996; 86:1648-9. [PMID: 8916537 PMCID: PMC1380706 DOI: 10.2105/ajph.86.11.1648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Siegel RM, Schubert CJ. Physician beliefs and knowledge about vaccinations. Are Cincinnati doctors giving their best shot? Clin Pediatr (Phila) 1996; 35:79-83. [PMID: 8775480 DOI: 10.1177/000992289603500205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to examine the immunization beliefs and practices of physicians in our community. A two-page descriptive survey of immunization practices and knowledge of vaccine contraindications was sent to all community physicians on the staff of Children's Hospital Medical Center in Cincinnati, Ohio. More than 90% of practitioners used well-child visits for immunization, even if the child was ill. Although 83% of respondents correctly identified illness with fever as a false contraindication to immunization, only 25% (if the child is due for a visit) and 36% (if the child is overdue) would use ill visits to immunize if a child had fever. The chief concern over using ill visits for immunization was that children would not return for regular well visits. We conclude that greater efforts are needed to convince physicians that using ill visits to immunize children will not interfere with routine well care.
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Affiliation(s)
- R M Siegel
- St. Luke Pediatric Centers, Bellevue, KY 41073, USA
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34
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Taylor JA, Cufley D. The association between parental health beliefs and immunization status among children followed by private pediatricians. Clin Pediatr (Phila) 1996; 35:18-22. [PMID: 8825846 DOI: 10.1177/000992289603500104] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To determine the association between parental health beliefs and the immunization status of their children, parents of children seen in two private pediatric practices completed a questionnaire on attitudes about immunizations. Five components of health beliefs were surveyed: perceived benefits of immunizations, susceptibility to diseases prevented by immunizations, severity of those diseases, parental feelings of self-efficacy in promoting their child's health, and barriers to immunization. Responses to the health-beliefs statements were transformed to an ordinal scale between 1 and 6, with "6" corresponding to strongly positive feelings about immunizations. Immunization data were abstracted from practice medical records. Overall, 162/194 (83.3%) study children were fully immunized. There were no significant differences between parents of fully immunized children and those of under-immunized children in total health-beliefs score or for the benefits, susceptibility, severity, or barriers components. Self-efficacy scores were significantly higher among parents of fully immunized children (P = 0.019); however, this was largely due to differences in the subgroup of children of mothers with lower education levels. The results of this study suggest that among parents of children followed by private pediatricians, health beliefs do not significantly influence immunization status.
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Affiliation(s)
- J A Taylor
- Department of Pediatrics, University of Washington, Seattle 98195-6320, USA
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Desguin BW, Holt IJ, McCarthy SM. Comprehensive care of the child with a chronic condition. Part 2. Primary care management. CURRENT PROBLEMS IN PEDIATRICS 1994; 24:230-48. [PMID: 7956321 DOI: 10.1016/0045-9380(94)90015-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B W Desguin
- Section of Special Programs in Chronic Illness and Disability, Children's Memorial Medical Center, Chicago, Illinois
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