Pediatric Annals

Improving Immunization Rates in Practice Settings

Christopher Rizzo, MD, FAAP

Abstract

Many provider education programs exist across the country to help practices improve their immunization rates using quality improvement. Many of these programs are statewide services of the state department of public health, the state chapter of the American Academy of Pediatrics (AAP), or a partnership between the two. An online education program, Teaching Immunization Delivery and Evaluation (TIDE) is provided by the Medical University of South Carolina and is located at http://www. musc.edu/tide. Examples of statewide programs are shown in the Table.

Ohio's provider education quality improvement program, Maximizing Office Based Immunization (MOBI), is a partnership between the Ohio Department of Health and the Ohio Chapter of the AAR MOBI teaches immunization quality improvement by first assessing a practice or clinic's immunization adherence to 12 MOBI Best Practices (Sidebar 2, see page 495). Then, a 1-hour presentation is given in the office to all practice physicians and staff. The presentation stresses the importance of identifying an office immunization expert or champion, measuring the office immunization rate by AFIX, avoiding missed opportunities for immunization (Sidebar 3), instituting a reminder/recall system, reducing barriers to immunization, and re-measuring to assess progress. MOBI also recommends the office immunization expert or champion receive two free e-mail reports, Morbidity and Mortality Weekly Report from the CDC (http:// www.cdc.gov/mmwr/mmwrsubscribe. html) and the Immunization Action Coalition (IAC) Express weekly newsletter (http://www.immunize.0rg/genr.d/ntn. htm). In 2005, 400 practices and clinics in Ohio received MOBI training, with half of them also using AFIX.

AVOIDING MISSED OPPORTUNITIES

Missed opportunities are a major source of under-immunization. A missed opportunity occurs when a child due for a vaccine is in the medical office, and even though a contraindication or precaution does not exist, the child leaves without being vaccinated. In many cases, neither the physician nor parent knew a shot was due, usually because the visit focused on an acute problem, and immunization status was not considered.

The most common missed opportunities for vaccination occur when the immunization record is not examined during an office visit that is not a preventive visit or when one or more vaccines are deferred due to a mild illness. Valid contraindications and precautions include moderate to severe acute illness (with or without fever). Vaccines can be safely given to children with low-grade fever, upper respiratory infection, diarrhea, and other mild illnesses.13

Another major missed opportunity is the failure to give all vaccines that are due.14 To keep children on schedule, four or five injections may be necessary at a visit. More injections may be needed if the child's immunizations are delayed. Using combination vaccinations has been shown to increase immunization rates.15

IMPROVING IMMUNIZATION RATES

A reminder-recall system is the most effective way to raise immunization rates in a practice. Simple, inexpensive postcard systems ("tickler files") can be used for routine reminder and recall, as well as for tracking deferred vaccines during a shortage. Many immunization registries have reminder-recall capability.

Barriers to immunization can be reduced by allowing patients delayed for immunizations to receive them even if a preventive visit is due. Also, where feasible based on staffing and state Iicensure rules, patients who are delayed should be encouraged to come into the office the same day for an immunization-only nurse visit. Having additional evening and weekend hours, especially for influenza vaccination, increases patient convenience.

Finally, continuous improvement in managing office-based immunization requires repeating the measurement to determine the effect of the changes made. This process repeats until your goal is reached and maintained.

An immunization registry is a powerful tool to help achieve high immunization rates using the strategies discussed in this article. Most have been designed to…

The medical home for children and adolescents is defined as medical care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. ' Providing immunization services via a medical home is cost-effective for communities, convenient for families, and leads to improved delivery of other preventive services to children. Efforts aimed at improving immunization rates in medical homes results in a lower need for more expensive community strategies to reach children with delayed immunization.

MEDICAL HOME AS THE IMMUNIZATION SAFETY NET

During the 1980s, school entry requirements for immunizations led to all-time high vaccination rates among 6-year-old children. Vaccine-preventable diseases were at all-time low levels, and the United States stopped measuring immunization rates in preschool children.2

This false sense of security ended in 1989. From 1989 through 1991, the US experienced more than 55,000 cases of measles, leading to more than 11,000 hospitalizations and 123 deaths. The majority of cases occurred among children younger than 5, 85% of whom were not immunized for measles.3

The main lesson learned from this outbreak was that communities cannot wait until school entry to ensure children are immunized. Although school entry requirements are important for maintaining high immunization rates, the safety net had to be moved to a younger age to ensure that immunizations are given closer to (ideally, at) the recommended ages.

The federal Childhood Immunization Initiative of 19934 stressed the importance of the medical home as the immunization safety net for 2-year-old children. Along with efforts to develop community-based immunization registries and coalitions, this initiative led to the Vaccines for Children (VFC) program, which increased delivery of vaccines in practice settings by providing vaccine at no cost for eligible children.

Providers of primary health care for young children play an essential role in protecting communities by ensuring childhood immunization. As the immunization schedule changes and becomes more complicated, it is unlikely that parents will know whether their child is up-to-date. A medical home should not rely on parents knowing the immunization schedule.

By the late 1990s, providing more children with vaccines in the medical home (rather than in public health clinics) led to higher immunization rates in young children (ages 19 to 35 months), as measured by the National Immunization Survey (NIS).5 However, the 2000 NIS rate of 73% of 19- to 35-month-old children up-to-date had not reached the Healthy People 2000 goal of 80%.6 New vaccines added to the schedule increased the challenge of ensuring high immunization rates for a new birth cohort of children year after year. Additionally, further analysis of the 2000 NIS showed that only 18% of US children younger than 2 received all vaccines on time.7 To attain and maintain high immunization rates among 2-year-olds and improve on-time immunization, there was a need to improve immunization delivery within practices.

QUALITY IMPROVEMENT IN PRACTICE SETTINGS

Most pediatricians have busy practices, with nearly half their patients each day experiencing an acute medical problem. To improve delivery of ontime immunization to children, simply "trying harder" adds to existing work and usually is not sustainable. To maintain improvement, practices must make changes to office systems, policies, and procedures.

Unless it has been measured, most pediatricians do not know the immunization rate of patients in their practice. Measurement of the immunization rate in a practice provides a baseline to stimulate improvement and determine the effect of changes to office systems. Practices with electronic billing systems may be able to use them to measure rates; however, an actual chart review is the best method for measuring immunization rates. Some public health departments provide confidential measurement for practices at no cost. Electronic health records or an immunization registry also can be used to measure rates in a practice. It is important to measure periodically to determine the success of improvement efforts.

Evidence-based, effective office strategies proven to raise immunization rates have been reviewed8 and include measurement and feedback for providers, provider reminder-recall systems, reduction of out-of-pocket costs for families, patient reminder-recall systems (Sidebar 1, see page 494), and improvement of convenience for families. In addition, the National Vaccine Advisory Committee (NVAC) issued 17 Standards for Child and Adolescent Immunization Practices9 in 2003. These include recommendations that providers assess immunization status at every patient visit, follow true contraindications and precautions for vaccine deferral, establish written protocols for vaccines, administer all vaccine doses that are due, and practice with community-wide protection in mind. Practices interested in improving their immunization rates should first measure their rates and compare their current policies and procedures to the NVAC standards to identify potential changes to incorporate into their immunization delivery system.

The Centers for Disease Control and Prevention (CDC) created an immunization quality improvement tool, Assessment-Feedback-Incentive-Exchange (AFIX). AFIX often is conducted in practice settings at no cost by public health personnel for the benefit of the practice. The immunization records of a sample of 100 children are used to determine immunization rates, as well as to produce specific suggestions for improvement. Some immunization registries also are capable of performing AFIX, which a practice can perform on its own, without additional assistance. Using AFIX to measure rates and identify opportunities for improvement has been shown to increase immunization rates.10,11

The presence of an immunization/improvement champion or expert within the practice has also been shown to increase the likelihood of improvement.12 This person should review office policies and procedures, lead an effort to establish a consistent immunization and product use schedule within the practice, and stay up to date on immunization issues.

Table

TABLE.Examples of Statewide Immunization Provider Education Programs

TABLE.

Examples of Statewide Immunization Provider Education Programs

Many provider education programs exist across the country to help practices improve their immunization rates using quality improvement. Many of these programs are statewide services of the state department of public health, the state chapter of the American Academy of Pediatrics (AAP), or a partnership between the two. An online education program, Teaching Immunization Delivery and Evaluation (TIDE) is provided by the Medical University of South Carolina and is located at http://www. musc.edu/tide. Examples of statewide programs are shown in the Table.

Ohio's provider education quality improvement program, Maximizing Office Based Immunization (MOBI), is a partnership between the Ohio Department of Health and the Ohio Chapter of the AAR MOBI teaches immunization quality improvement by first assessing a practice or clinic's immunization adherence to 12 MOBI Best Practices (Sidebar 2, see page 495). Then, a 1-hour presentation is given in the office to all practice physicians and staff. The presentation stresses the importance of identifying an office immunization expert or champion, measuring the office immunization rate by AFIX, avoiding missed opportunities for immunization (Sidebar 3), instituting a reminder/recall system, reducing barriers to immunization, and re-measuring to assess progress. MOBI also recommends the office immunization expert or champion receive two free e-mail reports, Morbidity and Mortality Weekly Report from the CDC (http:// www.cdc.gov/mmwr/mmwrsubscribe. html) and the Immunization Action Coalition (IAC) Express weekly newsletter (http://www.immunize.0rg/genr.d/ntn. htm). In 2005, 400 practices and clinics in Ohio received MOBI training, with half of them also using AFIX.

AVOIDING MISSED OPPORTUNITIES

Missed opportunities are a major source of under-immunization. A missed opportunity occurs when a child due for a vaccine is in the medical office, and even though a contraindication or precaution does not exist, the child leaves without being vaccinated. In many cases, neither the physician nor parent knew a shot was due, usually because the visit focused on an acute problem, and immunization status was not considered.

The most common missed opportunities for vaccination occur when the immunization record is not examined during an office visit that is not a preventive visit or when one or more vaccines are deferred due to a mild illness. Valid contraindications and precautions include moderate to severe acute illness (with or without fever). Vaccines can be safely given to children with low-grade fever, upper respiratory infection, diarrhea, and other mild illnesses.13

Another major missed opportunity is the failure to give all vaccines that are due.14 To keep children on schedule, four or five injections may be necessary at a visit. More injections may be needed if the child's immunizations are delayed. Using combination vaccinations has been shown to increase immunization rates.15

IMPROVING IMMUNIZATION RATES

A reminder-recall system is the most effective way to raise immunization rates in a practice. Simple, inexpensive postcard systems ("tickler files") can be used for routine reminder and recall, as well as for tracking deferred vaccines during a shortage. Many immunization registries have reminder-recall capability.

Barriers to immunization can be reduced by allowing patients delayed for immunizations to receive them even if a preventive visit is due. Also, where feasible based on staffing and state Iicensure rules, patients who are delayed should be encouraged to come into the office the same day for an immunization-only nurse visit. Having additional evening and weekend hours, especially for influenza vaccination, increases patient convenience.

Finally, continuous improvement in managing office-based immunization requires repeating the measurement to determine the effect of the changes made. This process repeats until your goal is reached and maintained.

An immunization registry is a powerful tool to help achieve high immunization rates using the strategies discussed in this article. Most have been designed to save time in office practice. Immunization status at every visit can easily be determined even by reception staff. Default preferences including lot numbers can be preset so that documentation is streamlined. Reminder and recall notices can be generated.

FINANCIAL BARRIERS

As the number and cost of vaccines increase, the financial barriers to immunization delivery become more significant. Use of combination vaccines improves immunization rates, but receiving payment for administration of one vaccine instead of two or three is a disincentive to use of combinations.

Delays in coverage by third-party payers for new vaccines and for price increases of existing vaccines lead to delays in vaccine administration because adequate payment is not assured. Storage and handling requirements for a growing number of vaccines and combinations result in the need in some practices for separate, larger refrigerator/freezers, more office space, and more sophisticated temperature monitoring equipment. The financial outlay for vaccine inventory is a growing portion of office overhead. Uncertainty regarding vaccine payment and supply leads to cautious embrace of new recommendations for some vaccines, resulting in lower rates.

Physician reimbursement rates have been associated with higher immunization rates.16 Strategies to raise immunization rates in medical homes must consider the financial aspect of immunization delivery in order to achieve the necessary safety net communities need to prevent disease outbreaks.

SUMMARY

Many pediatricians do not know the immunization rate of patients in their practice. Evidence-based standards of practice have been established, leading to improved rates. Quality improvement efforts aimed at immunization are effective and may lead to improvement in other preventive health services. By providing more vaccines in the medical home, communities can decrease the need for higher cost case management and outreach services targeting patients with delayed immunizations.

REFERENCES

1. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. American Academy of Pediatrics. The medical home. Pediatrics. 2002;110(1 Pt 1): 1 84-1 86.

2. Hinman AR, Orenstein WA, Papania MJ. Evolution of measles elimination strategies in the United States. J infecí Dis. 2004;189 Suppl 1: S17-22.

3. Centers for Disease Control (CDC). Publicsector vaccination efforts in response to the resurgence of measles among preschool-aged children - United States, 1989-1991. MMWR Morb Mortal WkIy Rep. 1992;41(29):522-525.

4. CDC. Reported vaccine-preventable diseases - United States, 1993, and the childhood immunization initiative. MMWR Morb Mortal Wkly Rep. 1994;43(4):57-60.

5. CDC National Immunization Program. National Immunization Survey. Available at: http://www.cdc.gov/nip/coverage/SNIS. Accessed May 25, 2006.

6. Healthy People 2000: National Health Promotion and Disease Prevention Objectives - Final Review. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Available at: http://www.cdc.gov/ nchs/data/hp2000/hp2k01.pdf. Accessed June 15, 2006.

7. Luman ET, McCauley MM, Stokley S, et al. Timeliness of childhood immunizations. Pediairics. 2002;110(5): 935-939.

8. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Task Force on Community Preventive Services. Am J Prev Med. 2000;18(lSuppl):92-96.

9. Standards for child and adolescent immunization practices. National Vaccine Advisory Committee. Pediatrics. 2003;! 12(4):958-963.

10. LeBaron CW, Mercer JT, Massoudi MS, et al. Change in clinic vaccination coverage after institution of measurement and feedback in 4 states and 2 cities. Arch Pediatr Adolesc Med. 1999;153(8):879-886.

11. Massoudi MS, Walsh J, Stokley S, et al. AAssessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy. Pediatrics. 1999;103(6Pt 1):1218-1223.

12. Sinn JS, Morrow AL, Finch AB. Improving immunization rates in private pediatrie practices through physician leadership. Arch Pediatr Adolesc Med. 1999;153(6);597-603.

13. Atkinson WL, Pickering LK, Schwanz B, et al.; Centers for Disease Control and Prevention. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Recomm Rep. 2002;51(RR2): 1-35.

14. Meyerhoff AS, Jacobs RJ. Do too many shots due lead to missed vaccination opportunities? Does it matter? Prev Med. 2005;41(2):540-544.

15. Marshall GS, Happe LE, Russell A. Coverage rates among children receiving combination versus component vaccines in a state Medicaid program. Presented at: 40th National Immunization Conference; March 6-9, 2006; Atlanta, GA.

16. McInemy TK, Cull WL, Yudkowsky BK. Physician reimbursement levels and adherence to American Academy of Pediatrics well-visit and immunization recommendations. Pediatrics. 2005;115(4):833-838.

TABLE.

Examples of Statewide Immunization Provider Education Programs

10.3928/0090-4481-20060701-05

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