Reducing missed opportunities for immunizations. Easier said than done
P. G. Szilagyi, L. E. Rodewald, S. G. Humiston, L. Pollard, K. Klossner, A. M. Jones, R. Barth and K. A. Woodin
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, NY, USA.
BACKGROUND: Missed opportunities for immunizations are associated with
underimmunization of preschool-age children. Practice policies limiting
immunizations to scheduled preventive visits and guidelines requiring legal
guardians to sign consent forms for vaccinations are 2 factors contributing
to missed opportunities. However, methods to change these policies have not
been sufficiently evaluated. OBJECTIVE: To measure the effectiveness of (1)
changing practice policies to incorporate the new national standard to
screen and vaccinate eligible children at all office visits and (2)
eliminating legal guardian signature requirements. DESIGN: A randomized
controlled trial of 2 interventions: (1) changing practice policy and
routine to have office nurses screen for immunization status at all visits,
attach immunization reminder cards to medical charts for eligible patients,
and have providers vaccinate eligible children ("no missed opportunities"
intervention) and (2) changing practice guidelines to allow vaccinations
without a legal guardian's signature. The first intervention was performed
at both sites; the second only at the neighborhood health center (NHC).
SETTING: A Pediatric Continuity Clinic in a teaching hospital (hereafter
referred to as Clinic), and an NHC. PATIENTS: Enrolled in the trial were
1005 Clinic patients and 983 NHC patients, 0 to 2 years of age. MAIN
OUTCOME MEASURES: Missed opportunity rates, immunization rates, and rates
of preventive services. RESULTS: Eliminating the requirement for a legal
guardian's signature had no effect on any of the outcome measures. The no
missed opportunities intervention was partially effective. Study patients
had slightly fewer missed opportunities than control patients at each site:
(0.60 vs 0.90 per patient per year at the Clinic, P = .01; 1.1 vs 1.3 per
patient per year at the NHC, P = .02). For study group patients,
immunization reminder cards were attached to medical charts in only one
third of vaccine-eligible visits; when attached, they markedly increased
vaccination by providers (odds ratio for vaccinating at a visit was 6.9
comparing visits when immunization reminder cards were attached vs not
attached). However, at the end of the study, immunization rates were
similar for study and control groups at each site. The number of
undervaccinated days was slightly lower for the no missed opportunities
study group at the Clinic than for the control group (56 days vs 77 days, P
< .001), but they were similar for both groups at the NHC. There were no
differences in rates of preventive visits or screening tests between study
and control groups. CONCLUSIONS: The interventions evaluated to reduce
missed opportunities did not increase immunization rates. The key problem
was failure to screen for immunization status at all visits. More effective
interventions will be needed to overcome barriers within busy primary care
practices to substantially reduce missed opportunities.
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