Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance.

Fewer than 10% of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practices Advisory Committee that all such children be vaccinated annually. Patient, provider, and system factors leading to this poor vaccination rate are not well understood. This study tested the effectiveness of a computerized reminder system in improving influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital. A computer database identified 124 children with moderate or severe asthma. Patients were randomly assigned either to study group (n = 63), who were sent a personalized letter reminder about the need for an influenza vaccination, or to a control group (n = 61), who received no reminder. Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination, including demographic features, parental worry about asthma and vaccine side effects, the four dimensions of the Health Belief Model, and health locus of control beliefs. Nineteen study group patients (30%) received an influenza vaccination, compared with only 4 control patients (7%) (P < .01). Forty-three mothers of children in the study group were interviewed; 14 (33%) of these children had received the vaccination. Of the characteristics investigated, two significantly correlated with vaccination compliance: high levels of parental worry about asthma (positively correlated: odds ratio = 23.3, P < .01) and high levels of parental worry about vaccine side effects (negatively correlated: odds ratio = 0.087, P = .025).(ABSTRACT TRUNCATED AT 250 WORDS)

Is an emergency department visit a marker for undervaccination and missed vaccination opportunities among children who have access to primary care?

The purpose of this study was to determine: (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient's ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neighborhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Overall, the odds ratio of ED patients' being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunization practices of pediatricians and family physicians in the United States.

OBJECTIVE: To assess current practices and attitudes among pediatricians and family physicians across the United States regarding immunizations. DESIGN: Survey of a random sample of pediatricians and family physicians. SUBJECTS: Fellows of the American Academy of Pediatrics (N = 746) and American Academy of Family Medicine (N = 429). SURVEY TOPICS: General immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC). RESULTS: Pediatricians and family physicians (combined) reported the following: immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations: missed preventive visits (40%), vaccine costs (24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatricians and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings. CONCLUSIONS: Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunization practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards.

Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status.

To determine the rate of childhood under-vaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever > 60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Missed opportunities for influenza vaccination among children with asthma.

Influenza vaccination is recommended for children with moderate to severe asthma. However, most children with asthma are not vaccinated, in part because many do not make an office visit during the vaccination time period. We studied 247 urban children with asthma to determine the maximum number that could have been vaccinated during a medical visit to a clinic or emergency department. One hundred thirty-nine patients (56%) had at least one visit during the study period. Sixty-five patients (26%) received the influenza vaccination; 74 patients (30%) did not receive the vaccination despite being seen in the clinic or emergency department. One-half of the missed vaccination opportunities at the clinic occurred during nonacute visits. Influenza vaccination rates could be substantially improved by efforts to increase primary care visits during the vaccination time period and to minimize missed vaccination opportunities.

Profile of uninsured children in the United States.

OBJECTIVES: To describe the demographic characteristics, utilization of medical services, and health status of uninsured children compared with insured children in the United States and to assess the factors associated with lack of health insurance among children. An estimated 8 million children in the United States are uninsured. Medicaid expansions and tax credits have had little impact on the overall problem. An understanding of the characteristics of uninsured children is essential for the design of appropriate outreach and enrollment strategies, benefit packages, and health care provision arrangements for uninsured children. METHODS: Analysis of the 1988 Child Health Supplement of the National Health Interview Survey. RESULTS: Diverse groups of children in the United States lack health insurance. Residence in the South (odds ratio [OR], 2.3) and West (OR, 1.9. [corrected]) and being poor (OR, 2.2) or nearly poor (OR, 2.1) are independently associated with being uninsured. Substantial differences in both sources of care and utilization of medical services exist between uninsured and insured children. Uninsured children lack usual sources of routine care (OR, 3.1) and sick care (OR, 3.8) and also lack appropriate well-child care (OR, 1.5) compared with insured children. Neither being in fair or poor health nor emergency department use are significant independent predictors of being uninsured among children. Children who have a chronic disease, such as asthma, face difficulties of access to care and utilize substantially fewer outpatient and inpatient services. CONCLUSIONS: Universal health insurance, rather than efforts directed at specific groups, appears to be the only way to provide health insurance for all US children. Uninsured and insured children reveal marked discrepancies in access to and utilization of medical services, including preventive services, but have similar rates of chronic health conditions and limitations of activity. Uninsured children do not appear to form a population that will incur higher mean annual expenditures for medical care compared with insured children.

Is underimmunization a marker for insufficient utilization of preventive and primary care?

OBJECTIVE: To test the hypothesis that the underimmunization of young children is a marker for the lack of preventive and acute primary care. SETTING: Primary care center serving an impoverished population (90% Medicaid). DESIGN: Historical cohort study (N = 1178) of children aged 12 to 30 months that determined each child's immunization status, anemia, tuberculosis, and lead screening status; and office utilization history. Screening delay was defined as missing a recommended screening by more than 3 months past the standard screening age. RESULTS: Thirty-four percent of the population were underimmunized at 12 months of age. Compared with fully immunized children, these children were at greater risk for screening delay: anemia, 38% vs 5% (risk ratio [RR], 7.5; 95% confidence interval [CI], 5.4 to 10.4); tuberculosis, 76% vs 44% (RR, 1.7; CI, 1.6 to 1.9); and lead, 69% vs 33% (RR, 2.1; CI, 1.9 to 2.4). These RRs increased with greater immunization delay. Compared with fully immunized children, the underimmunized group made 47% fewer preventive health visits (2.5 vs 4.7 visits per infant per year, P < .001) and 43% fewer illness visits (2.5 vs 4.4, P < .001) and had 50% more missed appointments (2.1 vs 1.4, P < .001). Logistic regression, predicting anemia screening delay at 12 months of age, showed that underimmunization had an effect independent of utilization, with an odds ratio of 7.7 (CI, 5.2 to 12.0). CONCLUSION: Underimmunization was a powerful, independent marker for inadequate health supervision in this population. IMPLICATIONS: The current emphasis on immunizations has the benefit of targeting children at risk of lack of preventive and acute care. Improving immunization rates may have the potential to improve other aspects of primary care if immunization provision is not uncoupled from primary care.

Health insurance for low-income working families. Effect on the provision of immunizations to preschool-age children.

BACKGROUND: The out-of-pocket cost for immunizations is a cause for referral to public health department clinics and is associated with delayed immunization. In 1991, New York State started Child Health Plus (CHPlus), an insurance program that covers ambulatory care and immunization services for children of families earning less than 222% of the poverty level. OBJECTIVE: To determine the effect of CHPlus on the provision of immunizations. DESIGN: A before-and-after design was used to compare the year immediately before enrollment in CHPlus with the first year after enrollment in CHPlus. A mixed-model analysis of variance was used to control for the effects of age. SETTING: All area primary care practices (n = 164) and public health department clinics (n = 6). SUBJECTS: Children (n = 1730) younger than 6 years who were enrolled in CHPlus. MAIN OUTCOME MEASURES: Number of immunization visits; types of providers (public health department clinics or primary care providers [pediatricians and family physicians]); and series-complete immunization coverage, including the diphtheria toxoid, tetanus toxoid, and pertussis vaccine, the oral poliovirus vaccine, and the measles, mumps, and rubella vaccine. RESULTS: The average age of the children was 37.7 months, 85% were white, 50% had been uninsured for immunizations before enrollment in CHPlus, and 16% previously received Medicaid. For infants, CHPlus decreased immunization visits to public health department clinics by 37% (from 0.14 to 0.09 visits per child, P = .009), increased immunization visits to primary care providers' offices by 15% (from 2.3 to 2.7 visits per child, P = .001), and increased immunization coverage by 7% (from 76% to 83%, P = .03). For children aged 1 to 5 years, CHPlus decreased visits to public health department clinics by 67% (from 0.06 to 0.02 visits per child, P < .001), increased visits to primary care providers' offices by 27% (from 0.46 to 0.59 visits per child, P < .001), and increased immunization coverage by 5% (from 83% to 88%, P < .001). The effects were greatest among previously uninsured children and among those with a gap in insurance coverage that was longer than 6 months. CONCLUSIONS: Insurance coverage for low-income working families resulted in a shift in the provision of immunizations from the health department to primary care providers and in increased immunization coverage.

Reducing missed opportunities for immunizations. Easier said than done.

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.

Effect of 2 urban emergency department immunization programs on childhood immunization rates.

BACKGROUND: Emergency departments (EDs) are recommended as sites for immunizing children. However, there is little information about the effect of ED immunization programs on immunization rates. OBJECTIVES: To assess the ability of 2 ED immunization programs to vaccinate children and to measure the effect of the programs on immunization rates after the ED visit and 6 months later. DESIGN: A prospective cohort study. Emergency department patients were screened for immunization status, and vaccinations were offered to patients who either were documented to be eligible or were eligible by age and had no documented records. A systematic, sequential sample of those accepting vaccinations (study patients) was compared with a systematic, sequential sample of those not vaccinated (control subjects). Telephone interviews and medical record reviews were performed 6 months after the ED visit to verify dates of immunizations. Results were weighted to reflect the sampling frames of patients screened by the 2 programs. SETTING: Two EDs in New York City (in Manhattan and the Bronx) and the surrounding primary care offices. PATIENTS: Children (aged 0-6 years) screened for immunization status by the ED immunization program during a 10-week period; these included 210 children from the Manhattan ED (106 vaccinated in the ED) and 274 children from the Bronx ED (129 vaccinated in the ED). INTERVENTION: Emergency department immunizations. MAIN OUTCOME MEASURES: Proportion of patients (vaccinated, not vaccinated, and ED population) up-to-date for immunizations (1) at the time of the ED visit, (2) 1 day later, and (3) 6 months later. RESULTS: Two thirds of the patients in each ED had Medicaid, and one tenth were uninsured. At the time of the ED visit, 20% of the vaccinated children in each ED were actually up-to-date and were unnecessarily vaccinated; 74% (Manhattan ED) and 72% (Bronx ED) of the not vaccinated children were up-to-date (the remainder were later determined to have been eligible for vaccinations). One day after the ED visit, and 6 months later, the immunization rates of the vaccinated and not vaccinated children were similar. The results of the weighted analysis were as follows: for the entire ED population screened for immunization status, compared with up-to-date rates at the time of the ED visit, rates 1 day later were 11% (Manhattan ED) and 8% (Bronx ED) higher in each ED (P < .05); and rates 6 months later were the same in the Manhattan ED and 10% lower in the Bronx ED (P < .01). Eighteen percent of all children screened for immunization status were vaccinated; 10 to 15 children were screened and 2 to 4 children were vaccinated per 8-hour ED shift. CONCLUSIONS: This ED immunization program temporarily improved the immunization rates of the ED population, but substantial personnel time was required to achieve these small gains. Urban ED immunization programs are unlikely to be cost-effective.

Intent to immunize among pediatric and family medicine residents.

OBJECTIVE: To determine whether contraindications to immunization are inappropriately broadened for children with a fever or a neurologic condition. PARTICIPANTS: Pediatric and family medicine residents (N = 52 and 23, respectively) at the University of Rochester (NY). DESIGN: Cross-sectional survey. Residents rated how likely they would be to administer a diphtheria-tetanus-pertussis or measles-mumps-rubella vaccine in 17 clinical scenarios according to a rating scale ranging from 1 (never) to 5 (always). For all scenarios, the immunization was recommended by the American Academy of Pediatrics or the Immunization Practices Advisory Committee. RESULTS: In only five and three of 17 scenarios would 90% or more of the pediatric residents and family medicine residents, respectively, have administered an immunization. For diphtheria-tetanus-pertussis vaccine, pediatric residents reported a lower likelihood of vaccinating a 2-month-old child with a low fever (temperature, 38.1 degrees C) than an afebrile child (mean score, 3.0 vs 4.7; P < .01). A 2-year-old child with idiopathic epilepsy, a 2-month-old child with intraventricular hemorrhage, and a 2-month-old child who had a parent with a seizure disorder each had a lower reported likelihood to be vaccinated than a same-aged child without a neurologic condition (2.8 vs 4.5; 4.1 vs 4.7; and 4.3 vs 4.7, respectively; each P < .01). For measles-mumps-rubella, pediatric residents reported a lower likelihood of vaccinating a 15-month-old child with a low fever than an afebrile child (4.2 vs 4.9; P < .01). A child with a progressive neurologic disease had a lower reported likelihood to be vaccinated than a child without a neurologic condition (3.5 vs 4.9; P < .01). CONCLUSIONS: Residents reported a lower likelihood of immunizing children with a fever or neurologic condition. Such practice styles may contribute to underimmunization. Residents need to be educated regarding which medical conditions contraindicate an immunization.

Immunization practices of primary care practitioners and their relation to immunization levels.

OBJECTIVES: To assess variations in immunization practices and attitudes among primary care providers and to relate these characteristics to the immunization levels of their patients. SETTING: Monroe County, New York. DESIGN: Survey of pediatricians (n = 96) and family practitioners (n = 44) to assess immunization practices and attitudes and medical chart reviews for 1884 patients of 32 physicians who practice in the city of Rochester to measure immunization levels. ANALYSIS: Tabular analyses for survey responses (chi 2 test and Fisher's Exact Test); logistic regression to assess the relation between provider responses and measured immunization levels. RESULTS: Responses by pediatricians and family practitioners were similar. Most providers did not routinely immunize during acute-illness visits but did immunize during follow-up or chronic-illness visits. Few used tracking systems to identify underimmunized children. Most practitioners immunized children who had colds but withheld immunizations from children who had fevers or otitis media. Most providers agreed with expanding immunization programs to include sick visits, health department clinic visits, and community site visits, but most thought that they should not be provided at emergency department visits, except for very-high-risk children. Immunization levels at 10 months of age were positively correlated with private practice setting (P = .001) but negatively correlated with immunizing at acute- (P < .01) or chronic-illness (P < .05) visits, Medicaid coverage (P < .05), and high rates of appointments that were not kept (P < .001). CONCLUSIONS: Primary care providers' immunization practices and attitudes vary and do not always follow established guidelines for immunization delivery. Many providers of high-risk children are already attempting to improve immunization delivery by using patient reminders and by immunizing children at acute- or chronic-illness visits. Improving provider immunization practices to deliver childhood immunizations more effectively must be part of our efforts to resolve this nation's childhood immunization problem.

Physician and parent opinions. Are children becoming pincushions from immunizations?

OBJECTIVE: To determine parent and physician opinions regarding the administration of multiple childhood immunizations by injection. DESIGN: Confidential mailed survey to physicians and residents; interview of parents during office visits for immunizations. PARTICIPANTS: Physicians and parents from Rochester, NY. RESULTS: The survey included 215 practicing physicians and 74 residents; response rate was 82%. Of the 197 parents interviewed, 93% were mothers, 68% were white; the mean (+/- SD) age was 25.8 +/- 5.2 years, with 12.8 +/- 1.8 years of education; 59% had private insurance, and 35% had Medicaid coverage. Of the parents, 31% had strong concerns about their child receiving a single injection; an additional 10% (total, 41% vs 31%; chi 2 = 4.05, P = .04) had the same concerns about their child receiving three injections. More practicing physicians than parents had strong concerns about children 7 months old or younger receiving three injections (60% vs 41%; chi 2 = 7.71, P < or = .01). Physician concern increased further when physicians were asked about administration of four injections (80% vs 60%; chi 2 = 18.77, P < .001). Of the parents, 64% preferred one rather than two visits to have three injections administered, if their physician recommended it; 58% still preferred one visit even if four injections were needed. CONCLUSIONS: Physicians have more concerns than parents about the administration of multiple injections at a single visit. Pain for the child was the main concern of all respondents. While most physicians have strong concerns about administering three or more injections at one visit, most parents prefer this practice. Continued education and reassurance of parents and physicians is needed to address concerns about children becoming "pincushions" from immunizations.

Effect of emergency department immunizations on immunization rates and subsequent primary care visits.

BACKGROUND: The Standards for Pediatric Immunization Practices recommend the routine use of emergency department (ED) encounters for screening the immunization status of children and, if indicated, immunizing them. OBJECTIVE: To test the hypothesis that ED immunizations will improve immunization rates without decreasing subsequent primary care visits. DESIGN: A randomized controlled trial of 2 interventions. Children (aged 6-36 months) (n = 1835) were enrolled in the study in the ED; informed consent was obtained from their parents. They were randomized into 1 of 3 groups: (1) the control group (n = 614), in which no intervention was undertaken; (2) the letter group (n = 610), in which a letter to the primary care physician was written indicating the child's estimated likelihood of being underimmunized; and (3) the ED vaccination group (n = 611), in which, based on a decision rule, those likely to be underimmunized were offered immunizations in the ED. After randomization, parents were interviewed in the ED using a decision rule to estimate the likelihood of the child being underimmunized. One year after enrollment in the study, the medical records of the children at their primary care sites were reviewed to determine the immunization status of the children and primary care use patterns. SETTING: An urban ED and 54 primary care sites in Monroe County, New York. RESULTS: The mean age of the participants was 17.9 months. Medical record review-verified underimmunization rates at the time of the ED visit were 33%, 31%, and 28% for the control, letter, and ED vaccination groups, respectively. The demographic characteristics and baseline immunization rates were not different among study groups. According to the decision rule, 248 children (41%) in the ED vaccination group were likely to be underimmunized. Parents of these 248 children were offered immunizations for their children; 117 (47%) accepted, and their children were immunized (with 230 separate immunizations). One month after the ED visits, the underimmunization rates of the study groups were 31%, 28% (P = .40 compared with the control group), and 23% (P = .002). One year later, these rates were 28%, 25% (P = .20), and 25% (P = .20). No clinically meaningful differences were present at either of these times. One year after the ED visit, no differences in the rates of primary care use were found among groups. CONCLUSIONS: This study provides evidence that the immunization of children in this ED was ineffective at raising their immunization rates; primary care attendance was also unaltered. Major obstacles were as follows: (1) an inability to ascertain accurately the immunization status in the ED and (2) a high rate of parental refusal to accept immunizations in the ED. The standards should be modified to de-emphasize the ED as a routine immunization site for children with access to primary care. Efforts and resources should be directed toward strengthening the primary care system and tracking immunization status.

Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing.

BACKGROUND: Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services. OBJECTIVE: To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms. DESIGN: In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals. SETTING/ PARTICIPANTS: Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%). RESULTS: The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial-60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law. CONCLUSIONS: Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.

Immunization pockets of need: science and practice.

Despite high overall immunization coverage levels among U.S. preschool children, areas of underimmunization, called pockets of need, remain. These areas, which pose both a personal health and a public health risk, are typically poor, crowded, urban areas in which barriers to immunization are difficult to overcome and health care resources are limited. The purpose of this report is to review barriers to immunization of preschool children living in pockets of need and to discuss current issues in the identification of and implementation of interventions within these areas. The Centers for Disease Control and Prevention administers a federal grants program that funds state and metropolitan immunization programs. This program promotes a three-pronged approach for addressing pockets of need: (1) identification of target areas, (2) selection and implementation of programmatic strategies to improve immunization coverage, and (3) evaluation of progress or impact. At each step, scientific evidence can guide programmatic efforts. While there is evidence that state and metropolitan immunization programs are currently making efforts to address pockets of need, much work remains to be done to improve immunization coverage levels in pockets of need. Public health agencies must take on a broadened role of accountability, new partnerships must be forged, and it may be necessary to strengthen the oversight authority of public health. These tasks will require a concentration and redirection of resources to support the development of an immunization delivery infrastructure capable of ensuring the timely delivery of immunizations to the most vulnerable of America's children.

Impact of multiple injections on immunization rates among vulnerable children.

BACKGROUND: In 1997, the Advisory Committee on Immunization Practices (ACIP) recommended a switch from oral polio vaccine (OPV) to inactivated polio vaccine (IPV) for the first two infant doses. The ACIP also recommended use of diphtheria, tetanus, and acellular pertussis vaccine (DTaP) for infants. These recommendations resulted in two additional injections at the 2- and 4-month immunization visits. This study evaluates the implementation of new IPV and DTaP immunization recommendations and their impact on immunization coverage levels. METHODS: Immunization coverage was assessed in public clinics in three urban areas before and after the recommendations. One pre- and three post-recommendation cohorts were followed to 12 months of age. RESULTS: Almost all (> or = 88%) infants in the pre-recommendation cohort received OPV, DTP, and only one or two injections. Almost all (> or = 78%) infants in the post-recommendation cohorts received IPV, DTaP, and three or four injections. The percentage of infants in the post-recommendation cohorts up-to-date for immunizations at 12 months of age was slightly higher than those in the pre-recommendation cohort. CONCLUSIONS: Providers rapidly switched from OPV and DTP to IPV and DTaP. Coverage at 12 months of age was higher among IPV/DTaP recipients than among OPV/DTP recipients. Provider and parent acceptance of four injections at a visit was high. The recent pneumococcal conjugate vaccine recommendations potentially add a fifth injection at 2 and 4 months of age. Acceptance or rejection of five injections by providers and parents needs early assessment.

Health department clinics as pediatric immunization providers: a national survey.

OBJECTIVE: To describe a national sample of health department immunization clinics in terms of populations served, patient volume trends, services offered, and immunization practices. METHODS: Telephone survey conducted with health departments sampled from a national database, using probability proportional to population size. RESULTS: All (100%) 166 sampled and eligible clinics completed the survey. The majority of pediatric patients were uninsured (42%) or enrolled in Medicaid (34%). Most children (69%) and adolescents (70%) were referred to the health department, with only 12% using these clinics as a medical home. A number of clinics (72%) reported recent increases in adolescents served. Less than 25% of clinics offered comprehensive care, 47% conducted semiannual coverage assessments, and 76% and 38% operated recall systems for children and adolescents. Storage of records in an electronic database was common (83%). CONCLUSIONS: Although the majority of these clinics do not provide comprehensive care, they continue to serve vulnerable children, including adolescents, Medicaid enrollees, and the uninsured, and may represent the main contact with the healthcare system for such patients. Because assuring the immunization of these children is essential to their health and the health of our nation as a whole, this immunization safety net must be preserved. Experience implementing key recommendations such as coverage assessment and feedback as well as reminder or recall may enable health department staff to assist private provider colleagues. Further research is needed to investigate how patient populations, services offered, and immunization practices vary by different clinic characteristics.

Vaccination status of children in the Women, Infants, and Children (WIC) Program: are we doing enough to improve coverage?

BACKGROUND: Vaccination-promoting strategies in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) have been shown to produce dramatic improvements in coverage and other health outcomes. OBJECTIVES: To determine national and state-specific population-based vaccine coverage rates among preschool children who participate in the WIC program, and to describe the strategies for promoting vaccination in WIC. DESIGN/METHODS: Demographic data, WIC participation, and vaccination histories for children aged 24 to 35 months in 1999 were collected from parents through the National Immunization Survey. The healthcare providers for the children in the survey were contacted to verify and complete vaccination information. We defined children as up-to-date (UTD) if they had received four doses of diphtheria and tetanus toxoids and pertussis vaccine (DPT), three doses of poliovirus vaccine, one dose of measles-mumps-rubella vaccine (MMR), and three doses of Haemophilus influenzae type b vaccine (Hib) by 24 months. Description of state-level vaccination-promoting activities in WIC was collected through an annual survey completed by the state WIC and immunization program directors. RESULTS: Complete data were collected on 15,766 children, of whom 7783 (49%) participated in WIC sometime in their lives. Nationally, children who had ever participated in WIC were less well-immunized at 24 months compared to children who had not: 72.9% UTD (95% CI, 71.3-74.5) versus 80.8% UTD (95% CI, 79.5-82.1), respectively. In 42 states, 24-month coverage among WIC participants was less than among non-WIC participants, including 13 states where the difference was > or = 10%. Vaccination activities linked with WIC were reported from 76% of 8287 WIC sites nationwide. States conducting more-frequent interventions and reaching a higher proportion of WIC participants had 40% higher vaccination coverage levels for the WIC participants in that state (p<0.05). CONCLUSIONS: Children served by WIC remain less well-immunized than the nation's more-affluent children who do not participate in WIC. Thus, WIC remains a good place to target these children. This study provides evidence that fully implemented WIC linkage works to improve vaccination rates. Strategies that have been shown to improve the vaccination coverage levels of WIC participants should be expanded and adequately funded to protect these children.

National, state and urban-area vaccination-coverage levels among children aged 19-35 months, United States, 1999.

BACKGROUND: Assessment of vaccination coverage is an important component of the U.S. vaccination program and is primarily measured by the National Immunization Survey (NIS). METHODS: The 1999 NIS is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. Coverage estimates are calculated for the nation, states, and selected urban areas for recommended vaccines and selected vaccine series. RESULTS: Coverage estimates are presented by a variety of demographic and healthcare-related factors: overall, by poverty status, race/ethnicity, selected milestone ages, participation in WIC, level of urbanicity, provider participation in VFC, and by provider facility type. In 1999, national coverage estimates were high for most vaccines and among most demographic groups. State and urban-area level estimates varied.