Improving immunization rates in private pediatric practices through physician leadership

Application of quality improvement approaches in health-care settings to reduce missed opportunities for childhood vaccination: a scoping review

Missed opportunities for vaccination (MOV) is a poor reflection of the quality of care for children attending health facilities. It also contributes to a reduction in overall immunization coverage. Although there is a growing interest in the use of quality improvement (QI) in complex health systems to improve health outcomes, the degree to which this approach has been used to address MOV is poorly understood. We conducted a scoping review using Arksey and O'Malley's framework to investigate the extent to which QI has been used in health facilities to reduce MOV. The review followed five stages as follows: (1) identifying the research question; (2) identifying the relevant studies; (3) selecting the studies; (4) charting data; and (5) collating, summarizing, and reporting results. The search strategy included electronic databases and gray literature. A total of 12 literatures on QI projects focused on addressing MOV were identified. Eleven were published manuscripts, and one was a conference presentation. All the QI projects published were conducted in the United States and majority were between 2014 and 2018. In these projects, 45 change ideas targeting providers, clients, and health system were used. This study generated important evidence on the use of QI in health facilities to reduce MOV. In addition, the result suggests that there is a growing interest in the use of this approach to address MOV in recent years. However, no literature was found in low- and middle-income countries especially sub-Saharan Africa.

Improving Immunizations in Children: A Clinical Break-even Analysis

INTRODUCTION

Immunizing the population is a vital public health priority. This article describes a resident-led continuous quality improvement project to improve the immunization rates of children under 3 years of age at two urban family medicine residency clinics in Salt Lake City, Utah, as well as a break-even cost analysis to the clinics for the intervention.

METHODS

Immunization records were distributed to provider-medical assistant teamlets daily for each pediatric patient scheduled in clinic to decrease missed opportunities. An outreach intervention by letter, followed by telephone call reminders, was conducted to reach children under 3 years of age who were behind on recommended immunizations for age (total n=457; those behind on immunizations n=101). Immunization rates were monitored at 3 months following start of intervention. A break-even analysis to the clinics for the outreach intervention was performed.

RESULTS

Immunizations were improved from a baseline of 75.1% (n=133) and 79.6% (n=223) at the two clinics to 92.1% (n=163) and 89.6% (n=251), respectively, at 3 months following the start of intervention (P<0.01). The average revenue per immunization given was $81.57. The financial break-even point required 36 immunizations to be administered.

CONCLUSION

Significant improvement in the immunization rate of patients under 3 years of age at two family medicine residency training clinics was achieved through decreasing missed opportunities for immunization in clinic, and with outreach through letters and follow-up phone calls. The intervention showed positive revenue to both clinics.

Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review

Objectives

To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries.

Design

Systematic review.

Setting

Developed countries

Participants

Preschool children who were due, or overdue, one or more of their routine primary immunisations.

Main outcome measures

Increase in the proportion of the target population up to date with standard recommended universal vaccinations.

Results

Forty-six studies were included for analysis, published between 1980 and 2009. Twenty-six studies were randomized controlled trials, 11 were before and after trials, and nine were controlled intervention trials. Parental reminders showed a statistically significant increase in immunisation rates in 34% of included intervention arms. These effects were reported with both generic and specific reminders and with all methods of reminders and recall. Strategies aimed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7% when reminders were used, 8% when educational programmes were used and 19% when feedback programmes were used.

Conclusion

General practitioners are uniquely positioned to influence parental decisions on childhood immunisation. A variety of strategies studied in primary care settings have been shown to improve immunisation rates, including parental and healthcare provider reminders.

Utilizing Peer Academic Detailing to Improve Childhood Immunization Coverage Levels

Interventions that utilize academic detailing to improve childhood immunization have been implemented across the country. This study evaluates the effectiveness of an academic detailing intervention to increase childhood immunization rates in pediatric and family medicine practices in a major metropolitan area. Educational teams of one physician, nurse, and office manager delivered 83 peer education sessions at practices in the intervention group. Postintervention immunization rates for children 12-23 months of age increased 1% in the intervention group and decreased 3% in the control group. Postintervention coverage levels for children 12-23 months of age did not differ between the intervention and control groups. Results indicated this office-based intervention was not sufficient to effect measurable changes in immunization coverage levels after 1 year of participation. Future interventions need to provide initial feedback regarding practice immunization coverage levels prior to the educational interventions and include multiple encounters.

Effects of continuity of care in infancy on receipt of lead, anemia, and tuberculosis screening

OBJECTIVES

The goals were (1) to examine the influence of continuity of care on delivery of lead, anemia, and tuberculosis screening in a cohort of Medicaid-enrolled children, (2) to determine whether well-child care continuity had a greater effect than continuity for all ambulatory visits, and (3) to investigate which aspects of continuity were most associated with receipt of these screening services.

METHODS

A prospective birth cohort of 1564 Medicaid-enrolled infants was studied. Continuity of care scores for the first 6 months of life were calculated for total ambulatory visits and well-child care visits. Outcomes of interest were performance of > or = 1 screening for lead toxicity, anemia, and tuberculosis during the first 24 months of life.

RESULTS

For total ambulatory visits, children with complete continuity of care (the same practitioner seen for every visit) were more than twice as likely to receive lead screening, compared with children who saw a different practitioner for every visit, irrespective of the measurement technique used. Similarly, children with complete continuity were 1.5 to 2 times more likely to have been screened for tuberculosis. Continuity showed a lesser, but still significant, effect on anemia screening. Well-child care visit continuity of care had less impact on screening performance than did total visit continuity of care.

CONCLUSIONS

In this study, greater continuity of care in infancy was associated with increased likelihood of receiving screening for lead toxicity, anemia, and tuberculosis in the first 24 months of life. The dimension of continuity of care that was most influential in this population was dispersion of visits among different practitioners.

Cost-effectiveness analysis of a practice-based immunization education intervention

OBJECTIVE

To evaluate the cost-effectiveness of academic detailing programs to improve immunization coverage in communities through implementation and evaluation of the Raising Immunizations Thru Education (RITE) program in the Greater Houston area.

METHODS

RITE was a preintervention and postintervention pilot study with randomized intervention and control sites implemented in private practices in pediatrics and family medicine. Changes in self-reported provider behaviors (n = 186) and comparisons of immunization coverage levels between intervention (n = 61) and control (n = 62) practices were evaluated. Intervention costs, computed from the perspective of an agency wanting to replicate the intervention, included direct expenses and time costs, based on time logs and compensation. Sensitivity analysis describes variations in costs. The cost-effectiveness ratio was computed as dollars per additional outcome unit.

RESULTS

The RITE intervention improved self-reported provider behavior. The immunization rates in the intervention group increased by 1 per cent, whereas immunization rates in the control group decreased by 2 per cent -3 per cent, but the 3 per cent - 4 per cent difference was not significant. A 1 per cent increase in practice immunization rates costs $424-$550, depending on the up-to-date criteria used and the targeted age group.

CONCLUSIONS

The costs for 1 additional child with up-to-date immunization status are higher than potential societal savings, as reported in the literature. This intervention does not have a favorable cost-benefit ratio.

Improvement in provider immunization knowledge and behaviors following a peer education intervention

Provider education programs that use academic detailing to improve childhood immunization have been implemented in several states. The purpose of this study was to evaluate the impact of these types of programs to improve immunization-related behaviors in private provider offices. The intervention included peer-based academic detailing in which teams of 1 physician, 1 nurse, and 1 office manager visited pediatric and family practices to deliver an educational presentation and develop practice-specific action plans. Comparison of pre-post intervention surveys showed that providers' willingness to give the maximum number of immunizations due at 1 visit (P < .001) increased. More providers reported routinely screening immunization records at sickness or injury visits (P < .05) and using minimum intervals (P < .001) postintervention. Mean change in baseline and postintervention overall scores was significant for pediatric practices (0.40, P < .05), small practices (0.64, P < .01), Vaccines for Children (VFC) practices (0.74, P < .05), and non-VFC provider practices (0.67, P < .01) but not for family or large practices.

Improving immunization rates in practice settings

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.

What providers from general emergency departments say about implementing a pediatric asthma pathway

The goal of this study was to assess institutional climate and providers' readiness to adopt pediatric pathways for asthma treatment and management. Twelve focus groups were held with 24 physicians/physicians' assistants, 20 nurses, and 17 emergency medical technicians from emergency departments in 4 general hospitals from July to October 2002. Positive experience with previous pathways, open communication and buy-in from clinicians and administrators, comprehensive training on pathways, and adapting standards to fit specific emergency department environments were identified as necessary elements for pathway adoption. Providers were optimistic about successfully implementing an asthma pathway (95%) and supportive of pathway implementation (87%).

Volume matters: physician practice characteristics and immunization coverage among young children insured through a universal health plan

OBJECTIVES

We studied the association between immunization coverage for a cohort of 2-year-old children covered by a universal health insurance plan and pediatric provider and other health services characteristics.

METHODS

We assembled a cohort of 101,570 infants born in urban areas in Ontario, Canada, between July 1, 1997, and June 31, 1998. Children were considered to have up-to-date (UTD) immunization coverage if they had > or =5 immunizations by 2 years of age, ie, the recommended 3 doses and 1 booster of diphtheria-polio-tetanus-pertussis/Haemophilus influenzae type b vaccine and 1 dose of measles-mumps-rubella vaccine. Provider practice characteristics were derived from outpatient billing records, and 1996 census data were used to derive neighborhood income quintiles. The association between UTD immunization status and provider characteristics was assessed with multilevel regression models, controlling for patient characteristics.

RESULTS

Overall, the rate of complete UTD immunization coverage was low (66.3%) despite a large number of primary care visits (median: 19 visits). Children whose usual provider had a low volume of pediatric primary care were less than one half as likely to be UTD. Other factors associated with not being UTD included very low continuity of care, low continuity of care, and usual provider in practice for <5 years. With adjustment for patient and provider characteristics, there was no difference in immunization coverage for general practitioners versus pediatricians. Children from low-income neighborhoods were less likely to be UTD.

CONCLUSIONS

Despite universal access to primary care services, rates of complete immunization coverage among 2-year-old children in Ontario are low. Because visit rates are high, primary care reform should include interventions directed at provider immunization practices to reduce missed opportunities.

Status of Quality Improvement Activities to Improve Immunization Practices and Delivery

The Centers for Disease Control and Prevention convened a symposium on 22-23 October 2003 to bring together investigators and stakeholders working to apply the quality improvement (QI) approaches to immunization delivery in individual medical practices. The goal was to identify effective program components and further development of model programs. A call for projects was widely disseminated; of 61 submissions received, eight projects were selected. Three of the eight programs used the "train the trainer" approach, three used site-specific training, one used a "practice collaborative" approach, and one employed the use of tracking and outreach workers to effect change. At the symposium, invited experts reviewed each program. Common program features that appeared effective included involvement of a variety of staff within the office environment, collection and review of site-specific performance measurements to identify gaps in delivery, periodic monitoring of performance measurement to revise interventions and maintain the improvements, and provision of formal continuing education credits. While research is needed on ways to promote and integrate QI into practices, it is likely that a variety of QI strategies will be shown to be effective, depending on the clinical settings. The field will benefit from standardized outcome measures, cost analysis, and evaluation, so comparisons can be made among different programs.

Compliance with national immunization guidelines for children younger than 2 years, 1996-1999

OBJECTIVES

To evaluate compliance with national immunization guidelines among a large cohort of children cared for at health maintenance organizations (HMOs) and to examine effects on immunization status.

METHODS

A cohort study of 176134 children born between January 1, 1994, and December 31, 1997, and monitored from birth to the second birthday was performed. Subjects belonged to the Vaccine Safety Datalink Project, a study of children enrolled in 1 of 4 HMOs. Children were continuously enrolled in a HMO for the first 2 years of life. Prevailing recommendations regarding optimal ages of immunization and intervals between doses were applied to define appropriate immunization timing and immunization status. Noncompliance was defined as having a missing or late immunization or an immunization error. Immunization errors included invalid immunizations (too early to be acceptable), extra immunizations (superfluous immunizations or make-up immunizations for invalid immunizations), and missed opportunities resulting in late or missing immunizations.

RESULTS

Although 75.4% of children in these HMOs were up to date for all immunizations at 2 years, only 35.6% of children were fully compliant with recommended immunization practices. Less than 8% of children received all immunizations in accordance with strict interpretation of recommended guidelines. Fifty-one percent of children had at least 1 immunization error by age 2 years; 29.7% had a missed opportunity with subsequent late or missing immunization, 20.4% had an invalid immunization, and 11.6% had an extra immunization. Common reasons for noncompliance included missed opportunities for the fourth Haemophilus influenzae type b vaccine (14.6%), invalid fourth diphtheria-tetanus-pertussis/acellular pertussis immunizations (11.0%), and superfluous polio immunizations (9.8%).

CONCLUSIONS

Approximately 35.6% of children were compliant with prevailing childhood immunization recommendations from 1996 to 1999. Efforts to improve compliance with guidelines are recommended, to optimize childhood infectious disease prevention.

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.

Increasing immunization coverage. American Academy of Pediatrics Committee on Community Health Services. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine

Despite many recent advances in vaccine delivery, the goal for universal immunization set in 1977 has not been reached. In 2001, only 77.2% of US toddlers 19 to 35 months of age had received their basic immunization series of 4 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, 3 doses of inactivated poliovirus vaccine, 1 dose of measles-mumps-rubella (MMR) vaccine, and 3 doses of Haemophilus influenzae type b (Hib) vaccine. Children who are members of a racial or ethnic minority, who are poor, or who live in inner-city or rural areas have lower immunization rates than do children in the general population. Additional challenges to vaccine delivery include the introduction of new childhood vaccines, ensuring a dependable supply of vaccines, bolstering public confidence in vaccine safety, and sufficient compensation for vaccine administration. Recent research has demonstrated specific and practical changes physicians can make to improve their practices' effectiveness in immunizing children, including the following: 1) sending parent reminders for upcoming visits and recall notices; 2) using prompts during all office visits to remind parents and staff about immunizations needed at that visit; 3) repeatedly measuring practice-wide immunization rates over time as part of a quality improvement effort; and 4) having in place standing orders for registered nurses, physician assistants, and medical assistants to identify opportunities to administer vaccines. Pediatricians should work individually and collectively at local and national levels to ensure that all children receive all childhood immunizations on time. Pediatricians also can proactively communicate with parents to ensure they understand the overall safety and efficacy of vaccines.

Improving preventive service delivery through office systems

OBJECTIVE

Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study.

METHODS

All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked on-site with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flow-sheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff.

RESULTS

All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices.

CONCLUSIONS

Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.