Public health in private practice: the challenge of immunizing preschool children.
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Child, Preschool↗
Biomedical subjects
L E Rodewald
Publications and source records attributed to L E Rodewald.
Missed opportunities for immunizations: a review of the evidence.
Employing a literature review approach, this article explores the evidence about missed opportunities for childhood immunizations, their impact on immunization rates, and potential solutions. It concludes that missed opportunities contribute significantly to the underimmunization of children. A concerted effort to reduce missed opportunities, particularly those that are relatively easy to eliminate, could yield measurable improvements in immunization levels of children. Missed opportunities for vaccinations have been found to occur in virtually all primary care settings, and their impact is greater for populations having low baseline immunization rates. Coverage levels could be improved by up to 30% in many settings by eliminating missed opportunities. Major reasons for missed opportunities include providers lacking knowledge about immunization status, provider or practice policies resulting in failure to vaccinate, and inappropriate contraindications. Solutions include promulgation and acceptance of useful guidelines for delivery of immunizations, provider and patient education, assessment and feedback about a practice's missed opportunities, and modification of routine practice styles within primary care and other health care settings.
Health Services Accessibility↗
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.
Child Health Services↗
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.
Adolescent↗
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.
Adult↗
Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center.
STUDY OBJECTIVE: To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data. DESIGN: Retrospective review of trauma transfers and deaths during a 4-year period. SETTING: Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center. PARTICIPANTS: Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of < or = 11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED. RESULTS: There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, -.710. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps = .32, Ps = .49) and 1 unexpected death (Ps = .52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps = .66, Ps = .55). The predicted number of deaths was 5.4 whereas the actual number was 7. CONCLUSION: Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs.
Adolescent↗
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.
Adolescent↗
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.
Attitude of Health Personnel↗
Immunization practices of pediatric residents: are they meeting current standards?
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Child↗
Patient-specific reminder letters and pediatric well-child-care show rates.
The objective of this study was to determine whether patient-specific letters, which describe the content of an upcoming well-child appointment, improve the show rate of well-child appointments better than postcard reminders. In this prospective clinical trial conducted at a pediatric continuity clinic in a teaching hospital, 288 newborns were randomized to a letter, postcard, or control group. For every well-child appointment, families were sent either a letter pertaining to the particular well-child appointment or a postcard; the control group received no reminders. There were no differences in demographics among the groups. The show rates between the letter and postcard groups were not different, but were significantly higher than the show rate for the control group (75.0%, 73.7%, and 67.5%, respectively; P < .05). A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former. We concluded postcard reminders are effective in improving show rates for well-child-care visits, and that patient-specific letters have no additional benefit above that of postcard reminders.
Adult↗
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.
Acute Disease↗
Accuracy of documented vaccination status of patients in pediatric emergency departments.
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Emergency Service, Hospital↗
Decision rules for predicting vaccination status of preschool-age emergency department patients.
We produced and tested rules to predict undervaccination among preschool-age emergency department (ED) patients. Data were gathered on demographics, vaccination status, health status, and health care utilization from parents, ED physicians, and ED charts at an urban teaching hospital in Rochester, N.Y. Primary care charts were reviewed to verify vaccination status. Using recursive partitioning, we developed decision rules to predict undervaccination. Decision rules were developed on a sample of 602 ED patients 4 to 48 months of age and then prospectively tested on 1832 ED patients aged 6 to 36 months. Factors associated with undervaccination for any vaccine included parental report of vaccination delay (odds ratio = 8.1; p < 0.001), inability to report the receipt of the appropriate number of vaccines (odds ratio = 4.5; p < 0.001), lack of health insurance (odds ratio = 3.6, p < 0.001), elapsed time since the last visit to primary care provider (p < 0.001), household size (p < 0.001), and maternal age (p < 0.01). Eight decision rules were produced that varied in their number of questions (one to six), sensitivity (0.27 to 0.87), and specificity (0.54 to 0.98). No single rule was both highly sensitive and highly specific. The rules' sensitivities and specificities were similar for the validation sample of 1832 patients. Thus a decision rule could not be produced that was both sensitive and specific. Identification of undervaccinated children by means of information available at an ED visit is inherently difficult. Interventions in the ED may be inefficient unless better methods of assessing vaccination status can be developed.
Child↗
Compliance with antibiotic therapy: a comparison of deuterium oxide tracer, urine bioassay, bottle weights, and parental reports.
OBJECTIVE: To compare three traditional measures of compliance with antibiotic therapy (parent report diary, preregimen and postregimen bottle-weight difference, and urine bioassay for antibiotic activity), with a deuterium oxide tracer measure of compliance. METHODS: Clinical trial in which all four compliance measures were used for subjects participating in a comparison of the efficacy of azithromycin and penicillin in treating group A beta-hemolytic streptococcal infection. Subjects were 41 children, aged 3 to 15 years (average age, 7.9 years), in a suburban pediatric private practice, who had positive rapid streptococcal antigen test results. RESULTS: Of the 41 subjects, 20 children were randomly assigned to receive azithromycin and 21 to receive penicillin. Compliance was uniformly high by all four measures. Parent diaries indicated that all doses were administered. Urine bioassays were obtained for 40 subjects, and all showed antibiotic activity. Differences in bottle weights were obtained for 27 subjects and showed that 142% of the prescribed medication was missing from the bottles at the end of the regimen. The deuterium oxide measure was obtained for 40 subjects and showed that 107% of the prescribed azithromycin and 92% of the prescribed penicillin were ingested. The correlation coefficient between measured and expected deuterium enrichment was 0.89. There was no significant correlation between the bottle-weight measure and the deuterium oxide tracer. CONCLUSIONS: The bottle-weight measure overestimates compliance; the deuterium oxide tracer is feasible for use in an office setting and produces a high correlation between the expected urinary enrichment and the measured enrichment. Increased use of this quantitative and direct measure would improve the accuracy of compliance measurement in trials of pediatric liquid medications.
Adolescent↗
Managed health care for children.
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Ambulatory Care Facilities↗
The school-based immunization survey: an inexpensive tool for measuring vaccine coverage.
A school-based immunization survey was conducted among the 36 Rochester, NY, elementary schools (n = 5584 children) to determine (1) the vaccination rates at 2 years of age by type of primary care provider and (2) the accuracy of school immunization records (by comparing them with medical charts for children attending hospital-based clinics). These rates varied by provider type from 58% to 86% and were all below the national goal of 90%. In comparison with medical chart review, the school data had error rates of 15%; however, these errors occurred in both directions and were thus unbiased. School-based surveys include children who lack connections to the primary care system. With minimal effort these surveys can help identify populations in need of intervention.
Bias↗
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)
Child Health Services↗
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)
Child, Preschool↗