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Effectiveness of a Practice-Based Intervention to Increase Vaccination Rates and Reduce Missed Opportunities
Cynthia S. Minkovitz, MD, MPP;
Amy D. Belote, MHS, CHES;
Susan M. Higman;
Janet R. Serwint, MD;
Jonathan P. Weiner, DrPH
Arch Pediatr Adolesc Med. 2001;155:382-386.
ABSTRACT
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Background Although provider feedback and recall/reminder systems have been shown
to increase vaccination rates for children, little is known about the effectiveness
of less intensive interventions.
Objective To determine whether provider prompting at acute care visits in an urban
hospital-based outpatient clinic can increase vaccination rates and decrease
missed opportunities.
Design and Methods Study participants, 3 years or younger, were identified from a managed
care organization as receiving primary care at the clinic. Eligibility criteria
included 1 or more visits to the clinic without regard to continuity of enrollment.
Patients' vaccination records were generated at nursing triage and attached
to the encounter sheet. Vaccination and visit data were abstracted from medical
records, and comparisons were made between baseline (n = 521) and postintervention
(n = 642) groups for up-to-date vaccination rates, missed opportunity rates,
and mean numbers of visits.
Results Up-to-date rates at the age of 24 months for 4 diphtheria and tetanus
toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and
3 Haemophilus influenzae type b vaccines changed
from 70% to 78% (P = .07). Up-to-date rates increased
significantly to 87% among the subset of children continuously enrolled in
the managed care organization and the practice (P<.01).
Overall, mean numbers of visits were similar. Missed opportunity rates among
children not up-to-date for 4 diphtheria and tetanus toxoids and pertussis,
3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccines at the age of 24 months declined
from 65% to 45% (P = .04). Similar trends were noted
at the age of 10 months.
Conclusions In the absence of increased funding, minor changes in standard operating
procedures may improve vaccination delivery. Further improvements may require
efforts to ensure continuity of provider and plan assignment.
INTRODUCTION
INCREASING THE proportion of children with up-to-date (UTD) vaccinations
to 90% by the age of 2 years remains a national objective of Healthy People
2010.1 Failure to achieve this goal has been
attributed, in part, to ineffective provider practices, which lead to missed
opportunities.2, 3, 4, 5, 6, 7, 8, 9
Provider recall/reminder and assessment and feedback interventions have been
shown to improve childhood vaccination rates10
and have been strongly recommended by the US Task Force on Community Preventive
Services.11 However, limitations of these established
interventions include high resource intensity and the retrospective nature
of assessment and feedback once the patient has left the office.
Variation in immunization status measures also contributes to the difficulty
of interpreting results across intervention studies. These variations include
differences in selected combination measures, acceptable timing for receipt
of vaccinations, ages used to calculate measures, and sources of vaccination
histories.12 In addition, prior studies often
limit evaluations to active patients with a minimum number of visits and continuous
enrollment in a health plan or practice. The degree to which such inclusion
criteria impact vaccination rates remains unknown. However, such inclusion
criteria may lead to an overestimate of program effectiveness and vaccination
rates by excluding children who are at high risk for being not UTD.
This study determines (1) whether low-intensity provider prompting at
acute care visits can increase vaccination rates and decrease missed opportunities
for young children receiving care at an urban primary care pediatric clinic
and (2) the impact of continuous enrollment in a health plan and pediatric
practice on vaccination rates and effectiveness of the intervention.
PARTICIPANTS AND METHODS
STUDY POPULATION AND SETTING
This prospective study took place in an urban hospital-based pediatric
clinic in which acute care is provided by a team of residents, medical students,
nurse practitioners, and preceptors, including general pediatrics fellows
and faculty. The residents and students providing acute care rotate on a monthly
basis. Patients receiving care at the clinic were predominantly low-income
children who qualified for mandatory Medicaid managed care and were enrolled
in 1 of several health plans.
The predominant managed care organization (MCO) serving the clinic provided
a list of names and dates of birth for the 654 children at baseline who were
3 years or younger as of March 1, 1998, and were assigned to receive care
at the Harriet Lane Pediatric Clinic (HLPC), The Johns Hopkins Hospital, Baltimore,
Md. The MCO also provided a postintervention list of 930 enrollees who were
3 years or younger as of June 30, 1999, and were assigned to receive care
at HLPC. Baseline and postintervention lists were manually examined and compared
to identify duplicate entries within and between the lists. Medical record
numbers for each child were sought through a systematic search of the computerized
patient record that documents all patient encounters.
Since 1995, all vaccinations delivered in the clinic were ordered electronically,
with dates and types of vaccines entered into a computerized patient record.
Vaccination histories for individual children are printed on the Maryland
Vaccination History form, which records vaccination type and date of administration.
As part of a city immunization registry initiative, local health department
staff entered historical vaccination records into the computerized patient
record for children younger than 6 years. This back data entry included vaccinations
provided in HLPC before 1996 and those documented (with vaccine type and date)
as being given by other providers.
The study was approved by the Committee on Human Research at The Johns
Hopkins University School of Hygiene and Public Health.
INTERVENTION
The intervention took place between May 1998 and July 1999. Triage nurses
generated computerized printouts of each child's vaccination record and prominently
attached them to the encounter form during each acute care visit. As part
of this intervention, the acute care team was instructed to review the vaccination
history during the visit and offer age-appropriate vaccinations as appropriate.
Study investigators (C.S.M. and J.R.S.) educated the acute care team monthly
regarding this policy and the need to assess vaccination status at each visit.
During these sessions, clinicians and staff received chocolate bars labeled
"Immunize On Time, Every Time" to reinforce compliance. In addition, clinic
vaccination rates were reviewed with staff and providers at several monthly
staff meetings and at quarterly preceptor meetings.
DATA COLLECTION
Medical records were abstracted from the outpatient clinic at baseline
and postintervention. Paper and electronic medical records were used to gather
and verify immunization data. Four trained abstractors recorded demographic
information, vaccinations, and visit data, including date, diagnoses, and
temperature. Diagnoses and temperature were recorded to identify contraindications
to vaccination. Up to 3 attempts were made to locate each missing record.
DATA ANALYSIS AND MEASURES
Medical record data were entered, verified, and checked for internal
consistency. Several outcome measures were defined.
Timely Vaccinations by the Ages of 10 and 24 Months
Receipt of timely vaccinations included 3 diphtheria and tetanus toxoids
and pertussis, 2 polio, 3 hepatitis B, and 3 Haemophilus
influenzae type b vaccines by the age of 10 months, and 4 diphtheria
and tetanus toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis
B, and 3 Haemophilus influenzae type b vaccines by
the age of 24 months. Definitions of UTD are based on the Red Book recommendations of the American Academy of Pediatrics.13
Missed Opportunities
A missed opportunity occurred when the child was age eligible for a
vaccine and had no contraindication for the vaccine, but the vaccine was not
administered. Missed opportunities may occur at any type of visit, including
sick visits, and were counted for those children not UTD for immunizations.
Age eligibility and contraindications also were based on the Red Book recommendations.6
Mean Visits and Percentage of Well-Child Visits
Well-child visits included visits for health supervision, and acute
care visits included visits (first time and follow-up) for injury or illness.
Visits for completion of forms or prescription refills were excluded. The
percentage of visits for well-child care also was determined.
Children Continuously Enrolled
Children were continuously enrolled in the MCO and clinic if they were
included in the baseline and postintervention MCO enrollment files and assigned
to the clinic for primary care. Analysis was limited to those children with
at least 1 visit to the clinic during the intervention period.
Data analyses were conducted using the Clinical Assessment Software
Application and EPI-Info6 (both from the Centers
for Disease Control and Prevention, Atlanta, Ga) and commercially available
software (Microsoft Access 1997; Microsoft Corporation, Seattle, Wash). Proportions
were compared using  2 analyses, and means were compared using
analysis of variance. Comparisons were made between baseline and postintervention
groups for 2 groups of children: those aged 10 to 23 months and those aged
24 months and older. The postintervention sample was identified as the total
sample and the subset of children continuously enrolled.
RESULTS
Of the 654 baseline and 930 postintervention children identified by
the MCO as receiving primary care at the outpatient hospital-based clinic,
records were reviewed for 521 baseline and 642 postintervention children (Figure 1). Children excluded from analyses
included those with duplicate listings in the MCO enrollment file, those without
a documented visit to the institution, those not assigned to HLPC but assigned
to an alternate source of care within the institution, and those for whom
medical records were unable to be located.
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Sample identification. MCO indicates managed care organization; ED,
emergency department.
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The baseline and postintervention samples were similar with regard to
gender, race, number of siblings, and birth weight (Table 1). However, the groups differed regarding age, with the baseline
group having a greater proportion of older children than the total postintervention
group. Only children aged 12 months or older are eligible for inclusion in
the continuously enrolled group.
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Table 1. Sample Characteristics*
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For children aged 24 months and older and continuously enrolled in the
MCO and the clinic, there is an increase in 4 diphtheria and tetanus toxoids
and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccination rates from 70%
to 87% (Table 2). As expected,
this group experienced a higher number of mean visits, with no difference
in the proportion of visits for well-child care and a decrease in missed opportunities
among those not UTD. Similar trends of increased vaccination rate and decreased
missed opportunities from baseline to postintervention were found for all
children in the postintervention group, although the change in vaccination
rate was not significant. Among children aged 24 months and older, the proportion
completing a visit within the first 2 months of life was higher in the postintervention
than in the baseline group. However, there was no difference in UTD rates
for the first diphtheria and tetanus toxoids and pertussis vaccine at 3 months
between the baseline (79.3%) and postintervention (80.7%) groups (P>.05).
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Table 2. Vaccination Coverage and Visit Characteristics for Children
Aged 24 Months and Older*
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For children aged 10 to 23 months, only missed opportunities were significantly
changed in the total postintervention group, with a decrease from 60% at baseline
to 42% postintervention. However, trends of increased vaccination rates, without
a change in mean visits or percentage well-child visits, were similar to those
for the aged 24 months and older group (Table 3).
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Table 3. Vaccination Coverage and Visit Characteristics for Children
Aged 10 to 23 Months*
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COMMENT
Our study demonstrates the effectiveness of a low-intensity intervention,
provider prompting during acute care visits, in an urban hospital-based pediatric
clinic among continuously enrolled children. Such an intervention may be adopted
more readily than previously described efforts. Rodewald14
and Wood15 and colleagues described hiring
of nonclinical personnel to enhance vaccination delivery; however, the use
of outreach workers or case managers was associated with high costs. External
audits of practice vaccination rates by local health officers also have been
shown to be effective,16 but may not be generalizable
in localities with minimal public health infrastructure. Several interventions
have relied on reallocation of responsibilities of existing clinical staff
to assess vaccination status and remind providers about needed vaccinations14, 17; foregone tasks and the impact on
remaining personnel are not identified. Other investigators18, 19
have used financial incentives to improve vaccination delivery among adults;
however, such practices require additional resources and have not been shown
to be effective in at least 1 pediatric setting.20
Our proposed intervention was implemented easily by existing staff with minimal
extra time.
Our study reveals that limiting analyses to those children continuously
enrolled in the managed care plan and assigned to the clinic for primary care
leads to higher vaccination rates and a larger reported intervention effect.
As such, we suspect that performance measures, such as those adopted by the
Health Plan Employer Data Information Set, which examines vaccination rates
among children without lapses in coverage or receipt of care, may overestimate
population-based receipt of vaccinations by excluding those children at highest
risk of undervaccination.
We found a substantial proportion of children who had not received any
care at HLPC despite MCO administrative records documenting their assignment
to the clinic for primary care. Some of these children, in fact, were noted
to receive care through other hospital-based facilities, including specialty
clinics and other sites for primary care. However, we are unable to account
for primary care sites for many of these children. We suspect that many practices
and managed care plans lack systems and capacity to verify whether children
presumed to be assigned to a particular practice are, in fact, receiving care
at that site. While outreach plans are required by many state Medicaid managed
care contracts for identifying children not receiving primary care, effective
mechanisms for accountability may not be in place.
Several limitations of the study should be noted. First, the use of
a computerized immunization data system to generate printouts of vaccination
records at nursing triage may limit the generalizability of this study. However,
manual health maintenance checklists, including vaccinations, have been shown
to increase adult vaccinations.21, 22, 23, 24, 25
In addition, computer reminders have been shown to be more effective than
manual reminders26 and are likely to be more
time efficient and sustained beyond an initial evaluation period. Use of a
computerized system also minimizes the likelihood of intervention results
being attributable to increased documentation rather than improved performance
and actual delivery of vaccinations.
Second, the baseline vs postintervention design does not enable us to
determine causal relationships. The proportion of well-child visits did not
change during baseline and postintervention assessments, suggesting that increasing
numbers of health maintenance visits during which vaccination status was usually
assessed did not account for this change. In addition, National Immunization
Survey vaccination rates in Baltimore City were not shown to increase during
this period.27
Third, the higher proportion of children in the postintervention group
seen in the first 2 months of life also may contribute to increased vaccination
rates among those aged 24 months and older. Other studies7
have documented the importance of timely receipt of 2-month vaccinations for
achieving UTD status at the age of 2 years. However, we found no difference
in the timeliness of receipt of 2-month vaccinations among children aged 24
months and older. Moreover, early visits to pediatricians would not account
for the decrease in missed opportunities by the age of 24 months observed
in this study. Our observation of decreased missed opportunities without a
significant increase in vaccination rates among children aged 10 to 23 months
may reflect small sample sizes and expectations for fewer total vaccines than
for the group aged 24 months and older.
Although previously studied provider-based interventions have been shown
to improve vaccination rates, such interventions frequently require excess
capacity within practices or public health systems to audit performance. In
the absence of new dollars or extensive computerized systems, minor changes
in standard operating procedures may improve vaccination delivery, as we found
in our study. It is likely that the high degree of motivation of clinicians
and staff, reinforced through educational sessions and receipt of chocolate
bars, enhanced the effectiveness of these minor changes. Further improvements
to increase vaccination delivery to young children may require efforts to
ensure continuity of provider and plan assignment.
AUTHOR INFORMATION
Accepted for publication November 3, 2000.
This study was funded in part by the Pew Charitable Trusts, Philadelphia,
Pa.
Presented at the annual meeting of the Pediatric Academic Societies,
Boston, Mass, May 14, 2000.
We thank the managed care organization for providing the lists of study
children; Lee Bone, RN, MPH, for her contributions to the development of the
intervention; Bernard Guyer, MD, MPH, for his review of an earlier draft of
the manuscript; and Jeanne Wehage for her assistance with data abstraction.
From the Departments of Population and Family Health Sciences (Dr Minkovitz
and Ms Higman) and Health Policy and Management (Ms Belote and Dr Weiner),
The Johns Hopkins University School of Hygiene and Public Health, and The
Johns Hopkins Children's Center (Drs Minkovitz and Serwint), Baltimore, Md.
Corresponding author and reprints: Cynthia S. Minkovitz, MD, MPP,
Department of Population and Family Health Sciences, The Johns Hopkins University
School of Hygiene and Public Health, 624 N Broadway, Baltimore, MD 21205.
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