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Good scheduling can link vaccinations to well-child visits

A column about keeping your practice in good health

By — Posted June 1, 2009.

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A pair of studies suggests that the way a physician runs a practice can impact whether families bring in their children for immunizations on time. And while vaccination timing generally does not impact your payments, at least one state is offering a bonus for keeping pediatric patients on schedule.

Two papers presented May 5 at the Pediatric Academic Societies annual meeting in Baltimore revealed that when families have negative vaccination experiences -- such as encountering poor staff attitudes or long wait times -- their children are twice as likely to be underimmunized. Children also are more likely to miss immunization visits if their families had a hard time making appointments or felt their physicians were not listening to them.

"We need to realize that parent experience during a physician visit may have a long-lasting effect," said Melissa S. Stockwell, MD, MPH, lead author on both papers and assistant professor of clinical pediatrics and population family health at Columbia University College of Physicians and Surgeons in New York.

Experts cautioned that because the research was carried out among a primarily Medicaid population in New York, it may not generalize to other practice settings. But they also pointed out that keeping vaccinations on schedule and coordinated with the well-child visit calendar can make any practice run smoother. When immunizations are missed, issues that would have been caught in a well-child visit can be missed as well.

"Avoiding having to do catch-up is important, because that's always difficult," said Doug Campos-Outcalt, MD, associate chair of the Dept. of Family and Community Medicine at the University of Arizona College of Medicine and a scientific analyst for the American Academy of Family Physicians.

One state is encouraging doctors to ensure children are vaccinated on time by using payment as a carrot.

In June 2008, Louisiana's Medicaid program launched a pay-for-performance initiative. Doctors who enrolled as CommunityCARE primary care physicians, and who are participating in the Vaccines for Children program and the Louisiana Immunization Network for Kids Statewide immunization registry, are eligible for additional payment if certain standards are met.

If a practice shows at least 90% of patients younger than 24 months are up to date with their vaccines, physicians will receive an additional dollar per Medicaid recipient younger than 21. No data are available yet on the program.

To meet these high vaccination rates, experts advise taking every appointment, whether for an acute illness or a well-child check-up, as an opportunity to review vaccination records and assess any gaps that need to be filled.

Expanding physician hours, establishing immunization-only visits, offering open scheduling for this service and writing standing orders also may increase the number of children getting vaccines at the appropriate time.

"We need to make it easy for kids to get immunized," Dr. Stockwell said.

Addressing concerns

Vaccine Information Statements, issued by the Centers for Disease Control and Prevention, are required by federal law to be handed out before an immunization is administered. Copies can be given to parents when they are in the waiting room. Physicians also can attempt to streamline the informed consent process and address parents' concerns by encouraging them to review the information in advance, online (link).

The resources help a family make "a medically sound decision on how to keep their child safe and the community safe at the same time," said Jon Almquist, MD, a pediatrician in Seattle and chair of the American Academy of Pediatrics' Task Force on Immunization.

Taking advantage of immunization registries is also highly recommended, and the American Medical Association encourages their use. Such systems, however, are in widely different stages of development across the country, and many physicians complain that they are not always that accessible or easy to use, particularly for those in private practice.

"Most states don't have a registry that is dynamic or robust enough. The majority don't have feedback. They take information, but there are no mechanisms to give it back. And there's poor participation in the private sector," said Gary Freed, MD, MPH, director of the division of general pediatrics at the University of Michigan Health System. "But many states are working to improve them."

Physicians recommended setting up some form of reminder or recall system. Patients can be e-mailed, telephoned, sent alerts on various social network Web sites or all of the above. Some practices have patients fill out self-addressed postcards to be sent out at the appropriate time.

"All these methods have been shown to be successful, and they are most successful when used in combination," said Edward Rothstein, MD, a pediatrician in Sellersville, Pa.

A way of recalling patients is particularly important when vaccine supplies don't match demand. This has been a recurrent problem over the past decade. A shortage of Haemophilus influenzae type b vaccine during the past year, for example, prompted the CDC to ask physicians to defer the final dose in the series for children who are not at high risk of the infection. Supplies are expected to return to normal before the end of the year. Practices will need to notify families of deferred children when shots are available.

Most children get their shots eventually, but experts are concerned about underimmunized kids leading to outbreaks of vaccine-preventable diseases.

A paper in the Jan. 30 Morbidity and Mortality Weekly Report documented five cases of invasive Hib disease in young children linked to the current vaccine shortage.

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ADDITIONAL INFORMATION

Administering vaccines on time

Most children receive nearly all the vaccines they are supposed to, although many don't get them when they are supposed to. To get kids vaccinated on schedule, experts recommend:

  • Reviewing a patient's vaccination status at every appointment, whether for well-child or acute care.
  • Expanding the hours vaccinations are available by keeping the office open late or on weekends.
  • Allowing immunization-only visits.
  • Permitting those who need vaccines to drop in without an appointment.
  • Setting up standing orders.
  • Providing federally mandated Vaccine Information Statements to parents in the waiting room or directing them to Web sites where they can access the information before the appointment.
  • Participating in immunization registries, where available.
  • Creating recall/reminder systems using several communication modalities such as self-addressed postcards, e-mail, telephone calls or social networking alerts.

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External links

Vaccine Information Statements, Immunization Action Coalition (link)

American Medical Association's vaccination resources (link)

American Academy of Family Physicians' immunization resources (link)

Childhood Immunization Support Program, American Academy of Pediatrics (link)

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