Kellyn A. Pearson

Implementation of universal influenza immunization recommendations for healthy young children : Results of a randomized, controlled trial with registry-based recall

Background. An Advisory Committee on Immunization Practices policy of encouraging influenza vaccination for healthy 6- to 23-month-old children was in effect during the 2003–2004 influenza season, which was unusually severe in Colorado. We collaborated with 5 pediatric practices to attempt universal influenza immunization in this age group. Objectives. The objectives were (1) to assess the maximal influenza immunization rates that could be achieved for healthy young children in private practice settings, (2) to evaluate the efficacy of registry-based reminder/recall for influenza vaccination, and (3) to describe methods used by private practices to implement the recommendations. Methods. The study was conducted in 5 private pediatric practices in Denver, Colorado, with a common billing system and immunization registry. Although recommendations by the Advisory Committee on Immunization Practices included children who were 6 to 23 months of age at any point during the influenza season, our practices chose not to recall children 22 to 23 months of age, because they would have become >24 months of age during the study period. Therefore, our study population consisted of all healthy children 6 to 21 months of age from the 5 practices (N = 5193), who were randomized to intervention groups (n = 2595) that received up to 3 reminder/recall letters or to control groups (n = 2598) that received usual care. The primary outcome was receipt of ≥1 influenza immunization, as noted either in the immunization registry or in billing data. Results. Immunization rates for ≥1 dose of influenza vaccine for the intervention groups in the 5 practices were 75.9%, 75.4%, 68.1%, 55.6%, and 44.3% at the end of the season. Overall, 62.4% of children in the intervention groups and 58.0% of children in the control groups were immunized (4.4% absolute difference), with absolute differences, compared with control values, ranging from 1.0% to 9.1% according to practice. However, before intensive media coverage of the influenza outbreak began (November 15, 2003), absolute differences, compared with control values, ranged from 5.1% to 15.3% and were 9.6% overall. Before November 15, significant effects of recall were seen for children in the intervention groups, in both the 12- to 21-month age category (10.4% increase over control) and the 6- to 11-month category (8.1% increase over control); at the end of the season, however, significant effects of recall were seen only for the older age group (6.2% increase over control). The rates of receipt of 2 vaccine doses ≥1 month apart for eligible children ranged from 21% to 48% among the practices. Four of the 5 practices held influenza immunization clinics during office hours, evenings, or weekends, and these clinics achieved higher coverage rates. Conclusions. These results demonstrated that, in an epidemic influenza year, private practices were able to immunize the majority of 6- to 21-month-old children in a timely manner. Although media coverage regarding the epidemic blunted the effect of registry-based recall, recall was effective in increasing rates early in the epidemic, especially for children between 1 and 2 years of age. The practices that achieved the highest immunization rates were proactive in planning influenza clinics to handle the extra volume of immunizations required.

Quality Improvement in Immunization Delivery Following an Unsuccessful Immunization Recall

OBJECTIVES Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI. METHODS A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall. RESULTS UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P <.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P <.0001); 19-25 month olds 18% before to 33% after (P <.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P <.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS). CONCLUSIONS Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.

Using an Immunization Registry: Effect on Practice Costs and Time

INTRODUCTION Immunization registries can consolidate immunization records scattered among different providers, allowing immunization documentation for legal purposes, generation of needed-immunization lists, inventory management, and outreach for underimmunized children. They have been endorsed by the Centers for Disease Control and Prevention and health professionals as a means of sustaining high immunization rates. However, some providers perceive the cost of registry use as a barrier to participation. We sought to determine the effects of registry use on cost and time. METHODS We used a pre-post design and a cost-accounting approach to measure labor costs and time for immunization-related activities possibly affected by registry use before development of a regional registry in Colorado and after the registry was being fully used. Two rural family practices, 2 rural community health centers (CHCs), 3 urban pediatric practices, and 2 rural public health agencies participated in both periods. RESULTS Cost per shot increased slightly in the postregistry period for private practices and CHCs (

Provider Adoption of Pneumococcal Conjugate Vaccine and the Impact of Vaccine Shortages

0.56 per shot in 2001 dollars) and public health agencies (

Identification and Recall of Children With Chronic Medical Conditions for Influenza Vaccination

0.38). Since costs can increase for several reasons, including salary increases above inflation, we analyzed time spent per shot and found that staff time decreased for private practices and CHCs but increased substantially for public health agencies. CONCLUSIONS The study findings suggest to private practices that registry participation can provide a net benefit by making the vaccination process more efficient and, absent above-average salary increases, less costly. Public health agencies, however, would have to rely exclusively on the registry and eschew the use of paper vaccination records to realize efficiencies seen by other practice types.

Missed opportunities for influenza vaccination in children with chronic medical conditions

OBJECTIVES To 1) determine the factors associated with provider acceptance of pneumococcal conjugate vaccine and 2) describe how providers prioritize pneumococcal conjugate vaccine during shortages. DESIGN/METHODS During April-November 2002, we conducted a mailed survey of rural and urban Colorado practitioners who provided routine pediatric immunizations. Three groups were surveyed: 1) all immunization providers (n = 51) in 2 geographically large rural areas, identified through a regional immunization registry; 2) all providers (n = 61) from private pediatric practices in metropolitan Denver that were actively participating in the same registry; and 3) all family physicians (n = 244) from the same urban areas as the pediatric practices. RESULTS Response rate was 60%. Provider adoption of pneumococcal conjugate vaccine was strong: 66% of urban family physicians, 84% of rural providers, and 98% of urban pediatric providers always recommended pneumococcal conjugate vaccine to healthy children < or = 23 months old when vaccine supplies were adequate. In multivariate analysis, vaccine nonadopters were significantly more likely than adopters to report financial barriers to vaccination (odds ratio [OR] 3.17, 95% confidence interval [CI] 1.58, 6.35) and concerns about vaccine safety (OR 3.37, 95% CI 1.37, 8.26). Eighty-nine percent of respondents had encountered pneumococcal conjugate vaccine shortages. During shortages, children <5 years old with a chronic medical condition were considered the highest priority for vaccination. CONCLUSIONS While provider acceptance of pneumococcal conjugate vaccine appears high, concerns about vaccine safety, cost, and availability exist, and these concerns will need to be addressed to maximize prevention of invasive pneumococcal disease in children.