In 1999, 22% of children were not up-to-date for the basic vaccines recommended by the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices.1 Community primary care providers, pediatricians, and family physicians who are either employed or in private practice are now the principal providers of vaccines to children.2 Because most children are immunized in the private sector, continued improvement in immunization rates will require solutions that are appropriate and practical for community practices. There are many reasons for children to lack complete immunization coverage, so each practice team first needs to look at the practice's immunization rates, policies, and procedures. This article presents practice-related recommendations to improve immunization delivery in the pediatric office.
THE INCREASING ROLE OF THE COMMUNITY PRACTICE
The measles epidemic of 1989-1991 resulted in more than 55,000 cases and 123 deaths.3 Since then, the public health, academic, and private practice communities have worked together to determine the barriers to immunization and increase the number of children immunized. The National Invmunization Survey for 1999 reported that 78% of 2-year-old children were fully immunized.1 Practice teams have improved significantly, so more children are protected from vaccine-preventable diseases than ever before. Nevertheless, 1 in 5 preschool children is still missing one or more recommended vaccine doses.
Currently, 85% of all children in the United States receive their care from physician offices, private clinics, and health maintenance organizations.4 In contrast, delivery of vaccines was divided almost evenly between the public sector and the private sector in the past. However, with the advent of managed care, especially for those enrolled in Medicaid, and the Vaccines for Children (VFC) program, approximately 3 in 4 children now receive their vaccines from community-based practices.2 Thus, practice teams have the greatest potential to deliver immunizations and protect children. The barriers to timely immunization are better known now. More importantly, the solutions to overcome the barriers have been evaluated, and recommendations have been developed.5,6
If practice teams have the greatest potential, and if the barriers and solutions are known, why is it that practices have not done a better job of implementing the solutions? Are the attitudes of physicians and parents a factor? Physicians want to provide the highest quality care for their patients, including protecting them from vaccinepreventable diseases. Although some physicians may adopt new vaccines more quickly than others, most believe in the benefits of immunization and agree with the recommended vaccine schedule. Although there are parents who refuse immunizations for religious or philosophical reasons, this is estimated to be no more than 2% to 5% of the population.7 Thus, most parents support immunizations. In summary, the attitudes of neither physicians nor parents fully explain the current immunization rates.
Why is it that more pediatricians and family physicians have not implemented the immunization recommendations? Rodewald described an "information gap" as a major obstacle.2 Physicians often do not believe that they have low immunization rates. Even after physicians realize that they need to improve their rates, they may not have the time, staff, or knowledge necessary to implement a solution. This is not unique to immunizations. Many articles demonstrate the difficulty we have in applying recommended guidelines for both preventive care and specific diseases.8
Fortunately, solutions are starting to emerge that can help pediatricians develop a practical, organized approach to quality improvement and implementation of guidelines.8"16 The information in this article is based on a review of the literature and our experience with the EPIC (Educating Physicians In their Communities) Immunization Education Program developed by the Pennsylvania Chapter of the AAP and the Pennsylvania Department of Health.
BARRIERS TO IMMUNIZATION DELIVERY AND SOLUTIONS
Santoli et al.5 identified the major barriers as (1) socioeconomic, including poverty and the cost of vaccines to families and to providers; (2) the late start of vaccines; (3) a lack of information about immunizations for both parents and physicians; (4) physician practices, including missed opportunities, lack of tracking, lack of reminder or recall systems, and difficulty implementing standards; and (5) office or clinic factors, including requirements for appointments and physical examinations, long waiting times, and inconvenient office or clinic hours.
Several authors6,9,13,15-18 and the Task Force on Community Preventive Services19 have listed practice-based interventions that have been shown to improve immunization rates. The interventions pertinent to the practice setting that were based on fair to good evidence, found to be effective, and strongly recommended include (1) assessment and feedback for vaccine providers about immunization practices; (2) reducing the cost of vaccines to families; (3) patient reminder and recall systems; and (4) physician reminder systems.
Two other interventions were strongly recommended and possibly effective. These were expanding access in health care settings as part of a multicomponent intervention and multicomponent interventions that include education. They were listed as possibly effective because the actual effect of expanding access and education could not be clearly separated from the other interventions, especially when implemented at the same time. Finally, standing orders for immunizations were effective for adults, but there was insufficient evidence to support them for children.
STEPS IN A QUALITY IMPROVEMENT PROGRAM
Table 1 lists five practical steps to improve immunization rates and the quality of care or service delivered. Although changing office procedures (or habits) can be difficult, the keys are to get the entire staff on board and take it one step at a time.
In addition to these steps, the entire practice team must recognize and apply several general principles. These include the use of a team-based approach, the value of an open dialogue about what needs to be changed, and quality improvement processes based on plan-do-study-act cycles.
Practical Steps to Improve Practice Immunization Rates
Team-Based Approach. Senge20 described the process and value of team learning, team dialogue, and team-based solutions. Every member of the staff - the receptionist in the front office, the nurses, the billing staff, the office manager, and the pediatrician - affects the immunization delivery system. When all members of the staff know the immunization rates, have learned how to improve those rates, and work together to develop and implement solutions, there is a shared goal and a shared approach to attain that goal. All of the staff members should be involved from the beginning so that they consider themselves an integral component of the system and the solution (which they are).
By training, most physicians are more comfortable being the captain and directing their staff. It may take a conscious effort for a physician to become a team player and see the value of team dialogue and team learning. Physicians often do not see or know what the problems are in the delivery of care, especially in the reception area and the billing office. For credible solutions to be created, accepted, and implemented, the team members involved in a function must play a role in their development. Solutions can be maintained only when team members are invested in reaching the goals, continuing to apply the new policies and procedures, and reminding each other of the change.
Open Dialogue. One of the critical aspects of this process is the open dialogue. All staff members must be able to speak and to know that others are listening. Many good ideas are not presented because a staff member was mtirnidated or never had the opportunity to fully present his or her ideas.
Quality Improvement Process. An organized process with clear steps helps practices solve problems. In addition, it is helpful to try one change at a time rather than implementing several new processes at once. Langley et al.21 outlined a process called plan-do-study-act cycles. This process converts learning and ideas into action. Once a practice immunization leader has been chosen, the staff should meet to examine the practice's immunization system. Performing an immunization assessment prior to the meeting can provide the needed data, but the assessment can also be the first activity. The staff first has to ask three questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What change can we make that will result in improvement?
Each area that the practice identifies as a quality improvement project can be approached by using the plan-do-study-act cycles. The practice team assesses the problem, determines the solution, tests the solution, evaluates the outcome, and then applies the solution to the entire practice.
RECOMMENDED PRACTICE-BASED INTERVENTIONS
Assessment and Feedback for Vaccine Providers About Immunization Practices
Assessment. Some pediatricians and family physicians have already examined their practice immunization policies and made changes to improve them. However, many physicians either do not believe that their patients are behind on immunizations or have not even thought about their immunization rates. Others believe they are being evaluated all the time and thus do no evaluation themselves. The first step in changing a person's behavior or improving a practice's performance is to determine the current behavior or performance.
Table 2 lists examples of practice-based immunization assessments. Often, the first assessment is focused on rates of immunization coverage. Immunization rates that are greater than 90% to 95% are considered exceptional. However, most physicians overestimate their rates when using intuition alone, and therefore an assessment is recommended.22 The assessment can be done by the staff, using the Clinic Assessment Software Application (CASA).23 This computerized software program is available from the Centers for Disease Control and Prevention (CDC). It provides an assessment of the practice immunization rates and identifies potential areas for improvement. The software can also be downloaded from the CDC web site (www.cdc.gov/nip).
Immunization assessments may be performed by state, county, or city departments of health (including the VFC program and others), managed care organizations, and provider organizations such as independent physician associations, physician-hospital organizations, or an integrated delivery system. In some counties and states, the immunization registry is able to perform an assessment.
Examples of Practice-Based Immunization Assessments
Physicians can also evaluate several other aspects of their immunization delivery system, such as (1) whether written policies and procedures exist and, if so, what they say and what they are used for; (2) whether immunizations are documented in the chart; (3) whether the most recent Vaccine Information Statements (VISs) are being distributed; (4) whether the initial VFC program assessment has been completed; (5) whether storage and handling of vaccines meets the VFC program requirements; and (6) whether procedures are in place to ensure that all vaccines and administration fees are properly billed.
Feedback. Using the information from assessments is key to improving the immunization delivery system. Performing the assessment is only the first step. Staff members need to receive feedback about how well they are doing and what steps they can take to improve. Several studies have documented the value of using such assessment and feedback.81517'24 The CDC has included it as a major component of the VFC Assessment, Feedback, Incentive, and eXchange of information program.
Reducing the Cost of Vaccines to Families
Some of the most important barriers to the immunization of preschool children have been the socioeconomic factors of poverty and the cost to families and providers. Although practices cannot directly affect the cost of vaccines, the VFC program has made it possible for pediatricians and family physicians to provide vaccines, without cost, for uninsured children and those who are enrolled in Medicaid, including Alaskan Natives or American Indians. Some states also provide vaccine for underinsured children (ie, children who have health insurance that does not cover vaccines). This helps practices to maintain the concept of the medical home by ensuring that they can provide all preventive services, including immunizations, instead of referring patients to public health clinics for vaccines.
Physicians who are not enrolled in the VFC program may want to consider this as another quality improvement cycle. As per the plan-do-study-act cycle, the number of children in the practice who would benefit from the VFC program could be determined. If a physician decides to enroll in the VFC program, he or she can appoint a VFC practice coordinator. Although a physician alone can make the decision to enroll in the state VFC program, it is important that he or she discuss this with the staff. Providing them with the information about why and how this is to be done will help merge the VFC program into the practice's immunization delivery system. Although the program requires some increase in paperwork and the reimbursement for vaccine administration varies among states and managed care organizations, the value to patients and their parents is worth the extra effort.
Patient Reminder or Recall Systems
An integral part of an assessment of a practice is to examine systems that are in place to support appropriate and timely delivery of vaccines. Studies to assess the effectiveness of reminder or recall systems found that properly implemented systems led to significant improvement in kept appointments. In one such study, patients scheduled for a vaccination visit received a single autodialer-based reminder call the night before. Their attendance was 57% compared with 20% for the control group, which did not receive a phone call.25 In this study, 41% of the patients who received a vaccination recall message visited the office within 30 days compared with 28% of those who did not receive a recall message. This is just one example. In the past 20 years, more than 70 controlled trials have demonstrated similar results.2
Despite this, a 1992 national study revealed that only 14% of pediatricians and 10% of family practitioners had implemented any type of reminder or recall system in their practices.26 These rates increased to 35% and 23%, respectively, in a separate study completed in 1995.27 Another AAP Periodic Survey of Fellows found that systematic recall or reminder systems to identify children behind on their vaccines existed in fewer than 20% of practices in 1992 and there was no change by 1999.2
The reminder component of such a system consists of mail, telephone messages, or both to remind parents or guardians of vaccination dates for their children. Reminder messages improve parents' awareness that vaccinations are due and emphasize the importance of keeping appointments. They also increase the efficiency of the office by reducing "no show" appointments. The recall component consists of mail, telephone messages, or both to decrease vaccination drop-out rates and reduce the time children remain at risk for vaccine-preventable diseases.
These systems can range from simple manual tickler systems to fully automated computerbased programs or phone systems with autodialers. They are set up to indicate the date that the next vaccine is due and provide a list of patients to be contacted. The recall can be a telephone call, a postcard, a computer-generated letter, or another mechanism that prompts the patient to schedule an appointment for the vaccine. These can also be used for annual influenza vaccines.
If these systems are so effective, then why is it that more practices are not using them? There are several barriers to reminder or recall systems. Often, physicians may not believe that patients need to be reminded about vaccines. Some believe that all patients are reviewed for immunizations and that vaccines are provided when needed, so no extra effort is required. This may be true for those patients who schedule and keep appointments for well-child visits or who are seen frequently in the office. But what about children who come in only when they are sick and whose sick visits are few and far between? What if the parents of these children are not aware of vaccination schedules or new age-appropriate vaccines? How up-to-date are the adolescents in the practice?
To overcome this barrier, physicians need to evaluate the practice immunization rates and the ability to recall patients. What are the immunization rates? How many children are not being seen for preventive care? Are children who might benefit not receiving influenza vaccine? Each member of the staff must understand his or her role and the importance of investing in a reminder or recall system.
Another barrier is the time and labor required to adequately follow through with these systems. This is difficult for physicians and staff members who are already feeling the stress and demands of the current health care environment, but an upfront reminder or recall effort will save time in the long run and improve efficiency.
Finally, the implementation of a reminder or recall system has potential benefits beyond improved vaccination coverage. Patients of all ages who are due or overdue for recommended vaccinations may also have fallen behind in health supervision visits. Reminder or recall systems help identify these patients and bring them in.
Physician Reminder Systems
Another system is in-office prompts to remind the practice team to check the patient's immunization status at every visit. Office prompts help decrease missed opportunities, which occur when a child is due for an immunization, visits the office, and, although there are no valid contraindications, does not receive the vaccine. Studies of prompting systems show their positive effects on improving preventive care and decreasing missed opportunities.91315'28 Prompts come in all shapes and sizes. The following are a few examples being used in immunization programs.
Chart Flags. It is important that each person handling the patient's chart be reminded to check whether a vaccine is needed. Once this is established, chart reminders ensure that the vaccine is ordered and administered. Reminders can be as simple as a colored cardboard flag that is inserted in the chart with a note stating, "Vaccines due today." The Los Angeles County Immunization Program attaches a large blue paper clip to the chart. One side states, "Immunizations due today" and the other states, "Immunizations upto-date." Vendors of billing software may also have the capability of printing these statements in the header on the encounter form. Regardless of the method, the important goal is to ask each member of the staff to screen each child for current vaccines and place a reminder in the charts of those who need immunizations. This allows the next person who will be handling the chart to remind the physician that a vaccine is due. These cues are especially important when the visit is not for preventive care.
Visual Reminders. To assist the staff in recognizing that a vaccine is due, laminated copies of the recommended schedule of vaccines should be posted in prominent places in the office (eg, at the front desk, in nursing set-up areas, and in examination rooms). Other visual aids include posters to remind parents to ask about vaccines, and dose counters (a slide tool to help a staff member determine whether a child is up-to-date, which was developed by Susan Aronson, MD, for the Pennsylvania Chapter of the AAP). All of these tools are practical methods to remind staff members to think about immunizations during each patient visit.
Obtaining Records. A system to ensure that immunization records are presented at the time of the visit and updated before the patient leaves the office is important to the efficient and smooth delivery of vaccines. Most private primary care offices do not yet participate in vaccine registries, making it difficult and extremely time-consuming to obtain old records. Working with the staff to develop and implement a process to obtain these records is worthwhile.
At the time an appointment is scheduled, the parent should be told that vaccine records are needed to evaluate whether the child is up-todate. Posting a reminder in a visible spot will help the person who is scheduling appointments to remember to automatically ask for these records. If possible, these records should be sent to the office prior to the patient's appointment at the time of the reminder call. The parent should be asked to bring them to the appointment at the time of the reminder phone call. If a parent does not have the records, he or she should contact the previous physician to have the records faxed to the office prior to the visit. If a parent still arrives without the records, the staff may offer the use of a phone to allow the parent to call and have the records faxed.
Members of the staff need to educate parents about the importance of these records both prior to the first visit and on an ongoing basis. The records will be requested by many places throughout the lifetime of the child (eg, day care, school, employers, colleges, scout groups, and camps), so it is important that office policies reflect an educational process to make parents aware of this.
To support this policy, a child should be given an immunization "passport," which is a record of his or her past immunizations that is updated by the staff each time a new vaccine is given. This passport should be small enough to be carried by the parent during each visit and yet durable enough to withstand the years. A good example is the "health passport" developed by the Pennsylvania Department of Health in conjunction with the Immunization Education Program of the Pennsylvania Chapter of the AAP. It is a yellow card made from paper that is highly durable (resistant to water and tears) and it is small enough (approximately the size of a credit card) to be easily carried by the parent. This passport is presented at the time of the visit, updated, and then returned to the parent. The parent then has a small permanent record that can be used each time immunization information is requested. The overall principle is to share the responsibility with the parent and thereby free up the time of the office staff.
Expanding access in Health Care Settings
Many practices currently provide well-child visits in the evening and on weekends. This may vary with the time of the year and the size of the practice. The important point is the positive effect on family satisfaction when well-child visits and immunizations are provided outside of traditional hours.
Mulilcomponent Interventions That Include Education
All of the above recommendations include the necessity of educating the staff. This concept is so important, but so often overlooked. Without education, staff members may not understand why they are asked to change policies, how to change the policies, and the importance of their contributions. The education must include the entire staff, be presented in an interactive manner, and stimulate improvement in quality.
Although this education is often specific to each practice and its improvement process, there are generic immunization education programs that can be delivered in the practice setting. Several states have developed such immunization education programs. Most members of the office staff (and many physicians) have never seen cases of the vaccine-preventable diseases, so slide presentations may help them to understand the devastating effects of these diseases. Vaccine schedules change frequently and practice teams need information to keep up. When combined with assessment and feedback, interactive educational programs can be effective.29-32
Primary care practice teams are critical to quality care for children. Pediatricians and family physicians are interested in providing the best care possible. If a practice has low immunization rates, this may mean that many of its children are not receiving other important preventive care services. Using an assessment to deteiTriine rates and then implementing new practice policies and procedures may improve not only the delivery of immunizations, but also other aspects of preventive care.33 Participating in the VFC program will enable the practice to provide comprehensive preventive services for all, or almost all, children. The more comprehensive and the less fragmented the care, the better the quality of the medical home.
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Practical Steps to Improve Practice Immunization Rates
Examples of Practice-Based Immunization Assessments