Vaccines are among the greatest achievements of modern medicine. The Partnership for Prevention recently ranked the health effects and cost effectiveness of recommended clinical preventive services, and childhood immunization was tied for first place with a perfect score. It received this perfect score because not only do individual children benefit from receiving an immunization but, as a result, other children and adults who are not vaccinated have decreased illness. Additionally, immunization is both cost effective and cost saving. Childhood immunization saves not just money but lives, even among adults.
As the number of vaccines routinely recommended for children grows, the challenge of delivering this important health benefit becomes increasingly complex. We learned from the measles resurgence of 1989-1991 about the dangers of not immunizing on time, yet an analysis of the 2000 National Immunization Survey showed that 9 out of 10 2-year-olds received at least one vaccine dose outside the recommended age ranges.
Improving vaccine delivery in practice settings has been shown to improve delivery of other preventive services. Receipt of immunizations is simpler to measure but should also be considered an indirect assessment of other recommended services . Vaccines are best delivered in a medical home, not only because it results in higher immunization rates but also because patients benefit from these other services. Therefore, efforts to improve immunization rates must begin in the practice setting.
Provider education quality improvement programs bring the principles of improvement directly into an office or clinic. By partnering with professional organizations, such as the state chapter of the American Academy of Pediatrics, state public health agencies are better able to address the issues facing primary care physicians, especially in private practice. Partnerships between public health and private practice also benefit the community in times of disaster and disease outbreaks.
Every child brought up-to-date in the medical home reduces the number needing other more costly (on a per-child basis) community public health interventions, such as case management or home visitation. Therefore, improving immunization rates in office settings is the most cost-effective strategy to raise rates in a community.
Use of an immunization registry is a powerful tool to implement improvement strategies in medical offices. However, the two main challenges for pediatricians are incorporating a new process into their practice and entering historical patient immunization records. Eventually, a mature registry will streamline vaccine delivery in office settings, decrease unnecessary immunization, decrease work for schools and office staff obtaining shot records, identify community "pockets of need," and eliminate the habit of providers asking parents, "Are your child's shots up to date?" Few parents have memorized the harmonized 2006 Recommended Childhood and Adolescent Immunization Schedules. Rather, at every visit, parents should be asking their physician or nurse, "Are my child's immunizations up to date?" We should be able to look them up quickly via an immunization registry or electronic health record and with a glance have the system tell us whether the answer is yes or no, without counting doses or calculating minimum intervals, an increasingly time-consuming process.
A mature community registry or an electronic health record that links to a registry can be used by office staff to check immunization status at every patient visit to avoid missed opportunities for immunization. Many parents are surprised to find their child is delayed for immunizations, even though they have been to the office many times for illness. Vaccines can be given to children with minor illnesses.
In spite of the great value of immunizations, they are not free. Financial pressures on providers have forced some of them to look at their immunization delivery and determine its effect on the practice's bottom line. Those who discover they are providing vaccines at a loss are finding it difficult to continue to do so. A reimbursement system that pays the same dollar amount for each injection discourages the use of combination vaccines, which can decrease patient discomfort and parental resistance and have been shown to increase immunization rates. As a result, physicians being paid below their cost for vaccine products are looking more closely at payment for vaccine administration, sometimes choosing not to use combination vaccines.
As vaccines become safer and more effective, paradoxically, some parents are increasingly questioning their safety and efficacy. As vaccinepreventable diseases decline, parents find themselves trying to balance the benefit of vaccine for their child versus the risk of a rare adverse event. Although most parents eventually agree to immunizations, the amount of time spent by pediatricians discussing these concerns has increased substantially in recent years.
In the past, some pediatricians viewed vaccine delivery as an added benefit provided even at a financial loss because of its importance, with costs shifted to other parts of the practice. However, with increasing complexity of the schedule, increasing time spent discussing vaccines with parents, strict storage and handling requirements, multiple-payer insurance policies, and less ability to shift costs, pediatricians must consider vaccine delivery a major business line of their practice. Increasingly, significant capital is tied up in vaccine inventory alone. Vaccine product purchase rivals wages and salaries for the typical office.
IN THIS ISSUE
This issue of Pediatrie Annals focuses on the practical aspects of vaccine delivery, including strategies to improve rates in office practice and in communities, especially with the help of an immunization registry. Equally important are articles reviewing coding and payment for immunization and nursing issues related to vaccine administration.
In addition, the complete 2006 Recommended Childhood and Adolescent Immunization Schedules are provided on pages 485-489. Printed in both English and Spanish, these schedules include the catchup schedule for children who are behind on their immunizations. A "pocket-sized" version in English is also provided and can be laminated and saved for quick reference.
Vaccines are a great public health achievement only if we can deliver those vaccines to individual patients. It is impressive that gradually increasing immunization rates are so consistent in spite of a new birth cohort every year, complexity of the schedule, shortages, changes in reimbursement policies, and vaccine news stories. Pediatricians have always embraced their public health role, especially as immunization providers. By helping practices improve their immunization delivery system, rates can be raised throughout a community by first maximizing office-based immunization.