Qualitative study of clinic staff members' experiences using an immunization registry

OBJECTIVES

To examine individual clinic staff members' experiences with using an immunization registry and to compare staff members' perceptions of immunization registries across different provider sites.

DESIGN

Cross-sectional survey using in-depth interviews and direct observation.

SETTINGS

The pediatric department of an urban community health center and 2 urban hospital-based pediatric primary care clinics.

PARTICIPANTS

Twenty-five subjects were recruited using maximum variation sampling at each site. The subjects included clerks, clinic assistants, licensed practical nurses, a nurse practitioner, and registered nurses.

MAIN OUTCOME MEASURES

Clinic staff members' perceptions of an immunization registry and frequency of registry use.

RESULTS

Differences were observed in subjects' perceptions of an immunization registry across provider sites. Although most subjects had positive attitudes toward the registry, they did not necessarily believe that the registry decreased their workload. The ability to access immunization registry data and actual use of the registry seem to be related to training of clinic personnel, location of the registry terminal, and helpfulness and availability of registry staff.

CONCLUSION

Obtaining the opinions of immunization registry users is an important strategy to evaluate the usefulness of a registry in a site and target possible areas for improvement.

The cost to providers of participating in an immunization registry

INTRODUCTION

The medical and public health communities advocate immunization registries as one tool to achieve national immunization goals. Although substantial resources have been expended to establish registries across the nation, minimal research has been conducted to evaluate provider participation costs.

METHODS

The objective of this study was to identify the direct costs to participate in an immunization registry. To estimate labor and equipment costs, we conducted interviews and direct observation at four sites that were participating in one of two immunization registries. We calculated mean data-entry times from direct observation of clinic personnel.

RESULTS

The annual cost of participating in a registry varied extremely, ranging from $6083 to $24,246, with the annual cost per patient ranging from $0.65 to $7. 74. Annual per-patient costs were lowest in the site that used an automated data-entry interface. Of the sites requiring a separate data-entry step, costs were lowest for the site participating in the registry that provided more intensive training and had a higher proportion of the target population entered into the registry.

CONCLUSIONS

Ease of registry interface, data-entry times, and target population coverage affect provider participation costs. Designing the registry to accept electronic transfers of records and to avoid duplicative data-entry tasks may decrease provider costs.

Measuring immunization registry costs: promises and pitfalls

INTRODUCTION

The medical and public health communities advocate the use of immunization registries as one tool to achieve national goals for immunization. Despite the considerable investment of resources into registry development, little information is available about the costs of developing or maintaining a registry.

METHODS

The objective of this study was to measure the direct costs of maintaining one immunization registry. Cost and resource-use data were collected by interviewing registry personnel and staff at participating pediatric practices, collecting available financial records, and direct observation.

RESULTS

The estimated direct cost for maintaining the registry during the 3 calendar years 1995 through 1997 was $439,232. In 1997, this represented an annual cost of $5.26 per child immunized whose record was entered into the registry. In all years, personnel expenses represented at least three fourths of the total costs, with the majority of administrative effort donated. Yearly costs increased over time largely because of growing administrative personnel requirements as the registry became fully operational.

CONCLUSION

Considerable resources are required to establish and maintain immunization registries. Because personnel costs, particularly nontechnical personnel, represent a large portion of total registry costs, it is important to accurately account for donated effort. Recommendations for future registry cost studies include prospective data collection and focusing upon the costs of providing specific outreach or surveillance functions rather than overall registry costs. In addition, registry effectiveness evaluations are needed to translate registry costs into cost-effectiveness ratios.

Impact of resident feedback on immunization outcomes

OBJECTIVE

To investigate the effect on immunization levels of retrospective written feedback to residents regarding missed immunization opportunities.

DESIGN

Randomized trial with control group.

SETTING

Pediatric resident continuity clinic in an urban hospital-based primary care clinic.

PARTICIPANTS

Thirty-two postgraduate level 2 and postgraduate level 3 pediatric residents.

INTERVENTION

Monthly retrospective written feedback mailed to residents detailing their missed immunization opportunities and appointment failure rates over a 12-month period beginning in February 1997.

MAIN OUTCOME MEASURES

The immunization level of 2-year-old children in the resident clinic was the main outcome of interest. Secondary outcomes included missed immunization opportunity rates and appointment failure rates.

RESULTS

Postintervention immunization levels were 71.4% (95% confidence limits [CLs]: 63.2%, 78.7%) for patients from the intervention group and 68.5% (95% CLs: 60.8%, 75.4%) for patients from the control group. The immunization level for patients of both groups who had fewer than 2 visits during the second year of life was 47.2% (95% CLs: 38.2%, 56.3%). This compares with an immunization level of 78.1% (95% CLs: 66.0%, 87.5%) for patients from both groups who had 2 visits during the second year of life, and with an immunization level of 88.2% (95% CLs: 81.0%, 93.4%) for patients of both groups who had more than 2 visits during the second year of life (P<.001).

CONCLUSIONS

In this setting, written retrospective feedback to residents was an ineffective strategy for improving immunization levels. Adequate follow-up during the second year of life is critical in achieving high immunization levels.

Patient appointment failures in pediatric resident continuity clinics

OBJECTIVES

To determine appointment failure rates in pediatric resident continuity clinics nationally, and to identify characteristics of clinics with respect to factors that may affect appointment failure rates.

DESIGN

A one-page questionnaire administered via facsimile machine to pediatric residencies' continuity clinic directors.

RESULTS

Of 200 continuity clinic directors, 160 (80%) returned the survey. The mean no-show percentage was 30.9%, with a range of 3% to 80%. Among the factors studied, only mode of payment emerged as an independent predictor.

CONCLUSIONS

Appointment failure is a substantial problem in pediatric resident continuity clinics, which needs attention if resident learning, patient care, and clinic efficiency are to be optimized.