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

Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review

BACKGROUND

Hospital settings represent an opportunity to offer and/or promote childhood vaccination. The purpose of the systematic review was to assess the effectiveness of different hospital-based strategies for improving childhood vaccination coverage.

METHODS

A systematic search of multiple bibliographic databases, thesis databases, and relevant websites was conducted to identify peer-reviewed articles published up to September 20, 2021. Articles were included if they evaluated the impact of a hospital (inpatient or emergency department)-based intervention on childhood vaccination coverage, were published in English or French, and were conducted in high-income countries. High quality studies were included in a narrative synthesis.

RESULTS

We included 25 high quality studies out of 7,845 unique citations. Studies focused on routine, outbreak, and influenza vaccines, and interventions included opportunistic vaccination (i.e. vaccination during hospital visit) (n = 7), patient education (n = 2), community connection (n = 2), patient reminders (n = 2), and opportunistic vaccination combined with patient education and/or reminders (n = 12). Opportunistic vaccination interventions were generally successful at improving vaccine coverage, though results ranged from no impact to vaccinating 71 % of eligible children with routine vaccines and 9-61 % of eligible children with influenza vaccines. Interventions that aimed to increase vaccination after hospital discharge (community connection, patient education, reminders) were less successful.

CONCLUSIONS

Some interventions that provide vaccination to children accessing hospitals improved vaccine coverage; however, the baseline coverage level of the population, as well as implementation strategies used impact success. There is limited evidence that interventions promoting vaccination after hospital discharge are more successful if they are tailored to the individual.

Facilitators and Barriers to Providing Vaccinations During Hospital Visits

BACKGROUND

Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization.

METHODS

We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model.

RESULTS

Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians' perceived lack of skills to effectively communicate with vaccine-hesitant parents.

CONCLUSIONS

Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

Accuracy of Provider-Documented Child Immunization Status at Hospital Presentation for Acute Respiratory Illness

OBJECTIVES

To assess (1) the accuracy of child immunization status documented by providers at hospital presentation for acute respiratory illness and (2) the association of provider-documented up-to-date (UTD) status with immunization receipt during and after hospitalization.

METHODS

We conducted a retrospective cohort analysis of children ≤16 years old treated for asthma, croup, bronchiolitis, or pneumonia at a children's hospital between July 2014 and June 2016. Demographics, clinical characteristics, and provider-documented UTD immunization status (yes or no) at presentation were obtained from the medical record. We compared provider-documented UTD status to the gold standard: the child's UTD status as documented in the Washington State Immunization Information System (WAIIS). The sensitivity, specificity, and positive predictive value of provider-documented UTD status were calculated. We assessed the association of provider-documented UTD status and immunization during and within 30 days posthospitalization using multivariable logistic regression.

RESULTS

Among 478 eligible children, 450 (94%) had provider-documented UTD status at hospital presentation and an active WAIIS record. Overall, 92% and 42% were UTD by provider documentation and WAIIS records, respectively, with provider-documented UTD status having 98.4% sensitivity (95% confidence interval [CI]: 95.4%-99.7%), 12.2% specificity (95% CI: 8.5%-16.8%), and 44.6% positive predictive value (95% CI: 39.7%-49.5%). Per WAIIS records, 20% and 44% of children who were due for vaccines received a vaccine during or within 30 days posthospitalization, respectively. There was no significant association between provider-documented UTD status and immunization during or after hospitalization.

CONCLUSIONS

Provider-documented UTD immunization status at hospital presentation for children with respiratory illnesses overestimates UTD status, creating missed opportunities for immunization during and after hospitalization.

Improving immunization rates in a hospital-based primary care practice

OBJECTIVE

We implemented a quality improvement initiative aimed at reaching a 95% immunization rate for patients aged 24 months. The setting was a hospital-based pediatric primary care practice in Boston, Massachusetts. We defined immunization as full receipt of the vaccine series as recommended by the Centers for Disease Control and Prevention.

METHODS

The initiative was team-based and structured around 3 core interventions: systematic identification and capture of target patients, use of a patient-tracking registry, and patient outreach and care coordination. We measured monthly overall and modified immunization rates for patients aged 24 months. The modified rate excluded vaccine refusals and practice transfers. We plotted monthly overall and modified immunization rates on statistical process control charts to monitor progress and evaluate impact.

RESULTS

We measured immunization rates for 3298 patients aged 24 months between January 2009 and December 2012. Patients were 48% (n = 1576) female, 77.3% (n = 2548) were African American or Hispanic, and 70.2% (n = 2015) were publicly insured. Using control charts, we established mean overall and modified immunization rates of 90% and 93%, respectively. After implementation, we observed an increase in the mean modified immunization rate to 95%.

CONCLUSIONS

A quality improvement initiative enabled our pediatric practice to increase its modified immunization rate to 95% for children aged 24 months. We attribute the improvement to the incorporation of medical home elements including a multidisciplinary team, patient registry, and care coordination.

Access and care issues in urban urgent care clinic patients

Background

Although primary care should be the cornerstone of medical practice, inappropriate use of urgent care for non-urgent patients is a growing problem that has significant economic and healthcare consequences. The characteristics of patients who choose the urgent care setting, as well as the reasoning behind their decisions, is not well established. The purpose of this study was to determine the motivation behind, and characteristics of, adult patients who choose to access health care in our urgent care clinic. The relevance of understanding the motivation driving this patient population is especially pertinent given recent trends towards universal healthcare and the unclear impact it may have on the demands of urgent care.

Methods

We conducted a cross-sectional survey of patients seeking care at an urgent care clinic (UCC) within a large acute care safety-net urban hospital over a six-week period. Survey data included demographics, social and economic information, reasons that patients chose a UCC, previous primary care exposure, reasons for delaying care, and preventive care needs.

Results

A total of 1, 006 patients were randomly surveyed. Twenty-five percent of patients identified Spanish as their preferred language. Fifty-four percent of patients reported choosing the UCC due to not having to make an appointment, 51.2% because it was convenient, 43.9% because of same day test results, 42.7% because of ability to get same-day medications and 15.1% because co-payment was not mandatory. Lack of a regular physician was reported by 67.9% of patients and 57.2% lacked a regular source of care. Patients reported delaying access to care for a variety of reasons.

Conclusion

Despite a common belief that patients seek care in the urgent care setting primarily for economic reasons, this study suggests that patients choose the urgent care setting based largely on convenience and more timely care. This information is especially applicable to the potential increase in urgent care volume in a universal healthcare system. Additionally, this study adds to the body of literature supporting the important role of timely primary care in healthcare maintenance.

How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

OBJECTIVES

Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents.

METHODS

A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations.

RESULTS

Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent.

CONCLUSIONS

With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.

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.

A reexamination of the feasibility of the administration of routine childhood vaccines in emergency departments in the era of electronic vaccine registries

OBJECTIVES

To determine if electronic vaccine records facilitate successful routine childhood vaccination in the emergency department (ED).

METHODS

We sampled consecutively over 2 calendar months children younger than 24 months presenting to the ED. Parents and legal guardians of eligible children were offered enrollment. Those consenting completed a parental survey after a nurse conducted an initial assessment of eligibility. Attending physicians then completed the assessment, and after the visit, the electronic vaccination records, when available, were accessed. No actual routine childhood vaccines were given during the study.

RESULTS

Three hundred thirty-four were approached: 17 (5.1%) declined participation; 10 (3.0%) were enrolled, but the data were lost, and 7 (2.1%) were excluded. Of the 300 remaining, 235 (78.3%) had available electronic vaccine records. Only 38 (16.2%) of the 235 were late for at least 1 vaccine. Of note, physicians assessed 22 (57.9%) of the 38 as medically appropriate for vaccination in the ED. The overwhelming majority (81.8%) of the 22 parents and guardians would have assented to vaccination in the ED. Of the 38 patients found late for vaccination, 31 (81.6%) of parents incorrectly reported their children to be up-to-date on their immunizations.

CONCLUSIONS

Assuming that the electronic vaccination record performed such as an online vaccine registry, the effort to access the registry might find a substantial number of children late for a routine childhood vaccination. In this setting, we found that approximately one sixth of the children with electronic vaccine records would be found late for vaccination, and based on physician assessment and parental survey, one half of those children would receive that vaccination if available in the ED. These rates offer health care planners a sense of the magnitude of the vaccination rates in the ED as we move toward regional vaccination registries with online capabilities to be accessed by EDs.

A report card on quality improvement for children's health care

OBJECTIVE

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research.

METHODS

To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program.

RESULTS

We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults.

CONCLUSIONS

Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

Patients' acceptance of traditional and nontraditional immunization providers

OBJECTIVE

To examine patients' acceptance and reported use of traditional and nontraditional immunization providers and settings.

DESIGN

Survey.

SETTING

Stratified sample of private family physician clinics, family medicine residency training programs, community pharmacies that provide immunizations under standing order protocols, and nonimmunizing community pharmacies, all located in Iowa.

PATIENTS OR OTHER PARTICIPANTS

Individuals presenting for medical care or pharmacy services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sources of past immunizations, 'access to immunizations, importance of immunization records, and future use of different health care providers and settings for immunizations. Univariate and multivariate analyses were performed to examine the relationships between patient demographics and recruitment site on the question responses.

RESULTS

420 surveys were returned (67% response rate). Respondents frequently received immunizations at sites other than physician offices. Younger patients and those living in smaller towns were more likely to report receiving an immunization from a nonphysician. Patients recruited in immunizing pharmacies more often reported previous immunization by a pharmacist (P < .001), most often for influenza. Respondents often reported that it was more convenient to receive an immunization outside a physician office. Greater support was noted for receiving adult immunizations from nonphysicians and in nontraditional settings, whereas traditional settings and providers (physician offices, community health departments) were preferred for childhood immunizations.

CONCLUSION

Iowans report accessing different health care providers and settings for their routine immunizations. In general, they are more likely to support using traditional immunization providers and settings for childhood immunizations but are less exclusive about where they receive adult immunizations. Pharmacists should consider focusing initial efforts on administering adult immunizations, due to greater patient acceptance of nontraditional immunizers for adult immunizations.

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration

OBJECTIVES

To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates.

DESIGN AND METHODS

The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment").

RESULTS

With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series.

CONCLUSIONS

When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.

Parent reports on willingness to accept childhood immunizations during urgent care visits

OBJECTIVES

To 1) describe whether parents would be willing to accept childhood immunizations at urgent care visits; and 2) identify predictors of parents' willingness to accept childhood immunizations at urgent care visits.

DESIGN AND PARTICIPANTS

Cross-sectional telephone survey of parents of children aged 18 to 24 months who were underimmunized according to a computerized immunization tracking system and who had recently made an urgent care visit in a regional group-model health maintenance organization in Northern California. Chart review was conducted to confirm immunization status and to identify contraindications to vaccination.

RESULTS

Of the 424 eligible participants, 351 (83%) completed interviews. Children with contraindications to vaccination and children who were actually up-to-date at the time of the urgent care visit were excluded, leaving 263 families in the final analysis. Among these parents, 75% said they would have been willing to have their child immunized at the urgent care visit in question if the physician had suggested it. An additional 11% said they would have accepted vaccination if the physician told them that the shot would be safe and strongly encouraged them to accept it. Overall, 86% reported they theoretically would have accepted an immunization during the urgent care visit. In the multivariate analysis, the strongest predictors of stated willingness to accept shots at the urgent care visit were the parent: 1) not being aware that their child was underimmunized (odds ratio [OR] 3.5, 95% confidence interval [CI], 1.6-7.7); 2) perceiving that the child was not very sick at the visit (OR 1.8, 95% CI, 1.1-3.0); 3) being less concerned about the risk of shots (OR 1.8, 95% CI, 1.2-2.5); and 4) being of nonwhite race (OR 3.6, 95% CI, 1.6-7.7). Income and education were not significantly associated with reported willingness to accept immunization.

CONCLUSIONS

We conclude that most parents of underimmunized toddlers report being willing to accept immunizations during urgent care visits if the clinician recommends it. More effective ways of alerting providers in urgent care settings when immunizations are due, such as indications on a chart or registration form, hold promise for improving immunization coverage rates.

Evaluation of failure to follow vaccination recommendations as a marker for failure to follow other health recommendations

OBJECTIVE

To determine whether families who fail to vaccinate their children also fail to follow other health recommendations.

SETTING

US civilian noninstitutionalized population.

DESIGN

National survey with a stratified cluster design.

PARTICIPANTS

Adult respondents for children 19 to 35 months of age surveyed in the 1991 National Health Interview Survey with documented vaccination history.

MEASUREMENTS

Comparison of responses to 23 questions related to health behaviors between respondents of up-to-date (UTD), i.e. having received 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of polio vaccine and one measles vaccine, and non-UTD children.

RESULTS

Of the 781 studied children, non-UTD (n = 357) and UTD (n = 424) children, or their respondents, did not differ in 18 of the 23 studied health behaviors. However, although non-UTD and UTD children were equally likely to have car seats, non-UTD children were less likely to use them always (84.3% vs. 92.9%, P = 0.002). National Health Interview Survey respondents of non-UTD children were more likely than their counterparts never to read food labels for ingredients (28.9% vs. 20.5%, P = 0.04) or for fat/cholesterol content (33.6% vs. 22.3%, P = 0.02) and never to buy low salt foods (37.5% vs. 21.5%, P = 0.001). Multivariate analyses showed that parental education level, not a child's vaccination status, was associated with compliance with the studied health behaviors.

CONCLUSION

Failure to vaccinate children on time is not consistently related to the likelihood of family member's following of other health recommendations. However, these data suggest that although mediated via parental educational levels, a child's immunization status helps to define families at risk for poor nutrition-related behaviors and those who are in need of counseling on seat belt use.