Electronic Immunization Alerts and Spillover Effects on Other Preventive Care

Pediatric Hospitalizations: Are We Missing an Opportunity to Immunize?

OBJECTIVES

Fewer than half of children receive all recommended immunizations on time. Hospitalizations may be opportunities to address delayed immunizations. Our objectives were to assess (1) prevalence of delayed immunizations among hospitalized patients, (2) missed opportunities to administer delayed immunizations, and (3) time to catch up after discharge.

METHODS

We conducted a retrospective cohort study investigating immunization status of patients 0 to 21 years of age admitted to an academic children's center from 2012 to 2013 at the time of admission, at discharge, and 18 months postdischarge. Immunization catch-up at 18 months postdischarge was defined as having received immunizations due on discharge per Centers for Disease Control and Prevention recommendations. χ² and t test analyses compared characteristics among patients caught up and not caught up at 18 months postdischarge. Analysis of variance and logistic regression analyses compared mean number of immunizations needed and odds of immunization catch-up among age groups. Kaplan-Meier and Cox proportional hazards analyses compared catch-up time by age, race, sex, and insurance.

RESULTS

Among 166 hospitalized patients, 80 were not up to date on immunizations at admission, and only 1 received catch-up immunizations before discharge. Ninety-nine percent (79 of 80) were not up to date on discharge per Centers for Disease Control and Prevention recommendations. Thirty percent (24 of 79), mostly adolescents, were not caught up at 18 months postdischarge. Median postdischarge catch-up time was 3.5 months (range: 0.03-18.0 months). Patients 0 to 35 months of age were more likely to catch up compared with those of other ages (hazard ratio = 2.73; P = .001), with no differences seen when comparing race, sex, or insurance.

CONCLUSIONS

Pediatric hospitalizations provide important opportunities to screen and immunize children.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.