5

Support for Improving Provider Practices

Improving the delivery of immunization services by health care providers is an especially effective way to raise immunization rates among preschool children and should be a high priority for providers and policymakers. Changes are needed both to increase the availability of providers and to ensure that children receive the appropriate immunizations when they visit these providers. The Standards for Pediatric Immunization Practices (CDC, 1993b) gives providers guidance on 18 points (see box), including ensuring that immunization services are available at places and times that facilitate access to them, observing only true contraindications to immunization, and operating tracking systems that can identify children who are due, or overdue, for immunizations.

All providers who do, or could, deliver primary care or immunization services to children should be part of efforts to improve provider practices. The American Academy of Pediatrics (AAP) has been an active proponent of better immunization practices, and pediatricians have been the target audience for many immunization messages. Richard Zimmerman, from the University of Pittsburgh School of Medicine, urged greater efforts to include a broader spectrum of providers in conferences and other immunization-related activities. He emphasized that family physicians provide primary care to many children, especially in smaller communities, and also drew attention to the contributions of osteopathic providers. Nurses and nurse practitioners clearly must be included in these activities as well.

Although efforts to improve provider practices center on physicians and nurses, they should not neglect other office and clinic staff members. Administrative procedures such as appointment scheduling and record keeping can contribute to the successful delivery of immunization services. Office staff



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Overcoming Barriers to Immunization: A Workshop Summary 5 Support for Improving Provider Practices Improving the delivery of immunization services by health care providers is an especially effective way to raise immunization rates among preschool children and should be a high priority for providers and policymakers. Changes are needed both to increase the availability of providers and to ensure that children receive the appropriate immunizations when they visit these providers. The Standards for Pediatric Immunization Practices (CDC, 1993b) gives providers guidance on 18 points (see box), including ensuring that immunization services are available at places and times that facilitate access to them, observing only true contraindications to immunization, and operating tracking systems that can identify children who are due, or overdue, for immunizations. All providers who do, or could, deliver primary care or immunization services to children should be part of efforts to improve provider practices. The American Academy of Pediatrics (AAP) has been an active proponent of better immunization practices, and pediatricians have been the target audience for many immunization messages. Richard Zimmerman, from the University of Pittsburgh School of Medicine, urged greater efforts to include a broader spectrum of providers in conferences and other immunization-related activities. He emphasized that family physicians provide primary care to many children, especially in smaller communities, and also drew attention to the contributions of osteopathic providers. Nurses and nurse practitioners clearly must be included in these activities as well. Although efforts to improve provider practices center on physicians and nurses, they should not neglect other office and clinic staff members. Administrative procedures such as appointment scheduling and record keeping can contribute to the successful delivery of immunization services. Office staff

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Overcoming Barriers to Immunization: A Workshop Summary need training and information resources to track changes in vaccines and vaccination schedules and to maintain office practices that support those schedules. Some concerns regarding immunization practices are common to many providers, but the responses to them may vary. The resources in public health clinics or community and migrant health centers may differ from those in HMOs or private practices. Providers in urban and rural areas may find different opportunities and constraints. Differences in the mix of providers in communities and states will also affect how immunization practices are addressed. In states where public health clinics are common, those clinics are primary care providers for some children and a source of free or lower-cost immunizations for other children who receive most of their care from private providers. Massachusetts, however, does not have the public health clinics that exist elsewhere. It relies largely on private providers and some community health centers; of 2,500 health care provider sites, 1,000 are individual practices. Federally funded community and migrant health centers provide primary care to a highly mobile population in underserved rural and urban communities where children are at high risk for delayed immunization. INITIATING CHANGES The complex mix of public and private providers and the diversity of settings in which immunization services are delivered argue for emphasizing provider-based changes and for offering providers resources that facilitate change. Regulatory steps can be taken but are neither desirable nor sufficient in many cases. Providers need to recognize that immunization rates for preschool children are too low and that changes in their immunization practices can improve those rates. Peter Szilagyi, from the University of Rochester School of Medicine and Dentistry, told the workshop that a national survey of pediatricians and family physicians (Szilagyi et al., in press) suggested that pediatricians, younger physicians, and providers in urban areas tended to have more aggressive immunization practices. He cautioned, however, that survey responses may overstate actual practice. In fact, many providers overestimate their success in immunizing children and need better information about their actual performance. For example, Susan Lett reported that providers in Massachusetts estimated that 86–100 percent of children in their practices were fully immunized, but measured coverage was only 37–83 percent. Szilagyi noted that the national survey found that nearly 50 percent of the pediatricians and nearly 70 percent of the family physicians had no mechanism to identify children in their practices who were behind on their immunizations.

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Overcoming Barriers to Immunization: A Workshop Summary STANDARDS FOR PEDIATRIC IMMUNIZATION PRACTICES Immunization services are readily available. There are no barriers or unnecessary prerequisites to the receipt of vaccines. Immunization services are available free or for a minimal fee. Providers utilize all clinical encounters to screen and, when indicated, vaccinate children. Providers educate parents and guardians about immunization in general terms. Providers question parents or guardians about contra-indications and, before vaccinating a child, inform them in specific terms about the risks and benefits of the vaccinations their child is to receive. Providers follow only true contraindications. Providers administer simultaneously all vaccine doses for which a child is eligible at the time of each visit. Providers use accurate and complete recording procedures. Providers coschedule immunization appointments in conjunction with appointments for other child health services. Providers report adverse events following vaccination promptly. Providers operate a tracking system. Providers adhere to appropriate procedures for vaccine management. Providers conduct semiannual audits to assess immunization coverage levels and to review immunization records in the patient populations they serve. Providers maintain up-to-date, easily retrievable medical protocols at all locations where vaccines are administered. Providers practice patient-oriented and community-based approaches. Vaccines are administered by properly trained persons. Providers receive ongoing education and training regarding current immunization recommendations. SOURCE: CDC (1993b, p. 3).

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Overcoming Barriers to Immunization: A Workshop Summary Jeffrey Goldhaggen, a developer of Cleveland's All Kids Count project, pointed out that discussions among Cleveland pediatricians revealed a lack of consensus about the relative importance of immunizations. It is likely to be harder to influence the practices of providers who assign immunization a relatively low priority among their health care responsibilities. David Salisbury noted that the immunization program in the United Kingdom relied on the change in the provider payment scheme to make immunization a much higher priority than it had been. Roger Bernier, with the National Immunization Program at CDC, and other workshop participants felt that the Standards for Pediatric Immunization Practices (CDC, 1993b) could be used more extensively to influence provider practices. The 18 standards provide clear and common reference points and have been endorsed by major professional organizations. They are already being used in immunization promotion efforts, for provider in-service education, and as performance standards. Bernier noted that the table on valid and invalid contraindications to immunizations seems to be especially useful.1 HRSA's Bureau of Primary Health Care is collaborating with CDC to evaluate the effect on immunization rates of implementing the standards. In five community and migrant health centers, immunization levels and provider practices assessed at the beginning of the study will be compared with results after a 1-year period, during which CDC staff are providing technical assistance in making changes in immunization procedures. Effective presentation of the immunization practice standards remains a concern. They may need to receive more publicity among providers, and those standards that are considered to be the highest priority should be identified so that they receive attention first. Provider education efforts in Massachusetts specifically address application of the standards in the private setting. Workshop participants agreed that providers' professional organizations should encourage their members to adopt effective immunization practices. AAP and its Committee on Infectious Diseases produce authoritative materials that inform members about vaccines and immunization (e.g., AAP, 1991) as well as educational materials that pediatricians can give to families. Massachusetts has used IAP funding to help the state AAP chapter support an immunization coordinator who is a liaison to other professional groups and to individual providers. In response to a proposal from the NVPO, the Group Health Association of America (GHAA) has agreed to work with its member HMOs and other managed care organizations to develop practices that can improve immunization rates, such as tracking immunization systems. David Siegel, of 1   The table has been reproduced as a wall chart, which is available from the Immunization Education and Action Committee of the Healthy Mothers, Healthy Babies Coalition.

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Overcoming Barriers to Immunization: A Workshop Summary the Health Alliance Plan of Michigan, noted that GHAA anticipates that these efforts will enable its members to reach the 1996 target of 90 percent immunization coverage among preschool children. TARGETS FOR IMPROVEMENT Workshop discussion emphasized that providers can improve immunization rates by reducing missed opportunities to immunize children who are being seen by a health care provider and, to a lesser extent, by reducing children's missed visits to health care providers to receive immunizations. Missed Opportunities Missed opportunities to immunize children, such as those discussed earlier in the report, are a serious concern. To avoid them, providers need to be able to identify children who require immunizations and need to administer the immunizations that those children should receive. Identifying Children Assessment of immunization status needs to be a routine part of a provider's care for every young child. Providers should not assume that the preschool children they encounter have received recommended immunizations on time. Compliance with the recommended immunization schedule generally is best in the first 6 months of life. Because many children then miss immunizations at recommended ages, assessment of immunization status is especially important at each health care visit between 6 months and 2 years of age. Making an accurate assessment may not be easy, however, if a child's immunization record is not available. Providers also must be able to identify an individual child's requirements amid an increasing number of vaccines, changes in vaccine formulations, changes in the recommended vaccination schedule, and differences in the vaccination schedules issued by different groups and required by different vaccine products (e.g., Hib vaccines). Better record-keeping systems could help providers track each child 's specific immunization requirements. James Feist described the success in his rural Montana pediatrics practice with record books that families hold and that they bring with them to the doctor's office each time their children are seen. Immunization record books are available from several sources. Some books include immunizations as part of a more comprehensive record of a child's health care. The Public Health Service, for example, has produced the Child

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Overcoming Barriers to Immunization: A Workshop Summary Health Guide (USDHHS, 1993) as part of its broader “Put Prevention Into Practice” initiative to promote preventive care of all kinds (and for people of all ages). The Health Diary (USDHHS, 1992) from HRSA's Maternal and Child Health Bureau focuses specifically on a mother 's prenatal care and her child's care up to 2 years of age. Improvements in providers' own record-keeping systems could help them make more comprehensive assessments. For example, easily located immunization charts or computer-generated reminders eliminate the need for providers to read children's full records to determine their current immunization requirements. Providers and their staffs also need clear information about current immunization recommendations and how changes in the recommendations affect care for partially immunized children. The CDC standards support the use of every clinical encounter as an opportunity to immunize a child, but some clinics and providers in private practice will not immunize children during acute care visits. Peter Szilagyi noted that this included about two-thirds of the pediatricians and family physicians in the national survey that he conducted, but he pointed out that the survey was conducted before the CDC standards were published. Some survey respondents said that immunizations and other preventive services were not the focus of acute care visits, and nearly half had specific policies in their practices not to immunize children at acute care visits. Although immunization is not appropriate during some illnesses, a policy of never providing immunizations at acute care visits can cause needless delays for some children. The issue of true contraindications to immunization is discussed in the next section. Some suggest that children be immunized during emergency department visits, especially children who are not receiving primary care services elsewhere (e.g., Fleisher et al., 1992; Lindegren et al., 1993; Bell et al., 1994), but difficulty obtaining accurate immunization histories leads others to question the appropriateness of immunizing children during emergency department visits (e.g., Goldstein et al., 1993; Olson, 1993). Although not likely to be harmful, immunizations administered without access to accurate records may be inappropriately timed or may duplicate ones a child has already received. Computer-based immunization registries in communities or states have the potential to give emergency department personnel ready access to the necessary information. Szilagyi noted, however, that only 29 percent of the pediatricians and family physicians in the national survey favored immunization of their patients during emergency department visits. Whether or not immunizations are given, emergency department personnel should promote children's links to comprehensive primary care services that can routinely provide immunizations and other important preventive care (Rodewald et al., 1993; Bell et al., 1994). Similarly, immunization clinics and other services developed specifically to provide immunizations should attend to a

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Overcoming Barriers to Immunization: A Workshop Summary child's broader primary care needs and help children establish a medical home for comprehensive and continuing care. Giving Recommended Immunizations Providers who know that children need immunizations may miss opportunities to administer them for at least two reasons. First, some providers are reluctant to give all of the recommended vaccines at one time because of concerns about discomfort for the child, adverse interactions of the vaccines, parental objections, and cost. Under the CDC standards, simultaneous administration of all medically appropriate vaccines is recommended and is reported to be safe and effective (CDC, 1993b). Second, providers often do not give immunizations to children with mild illnesses that they incorrectly believe constitute contraindications to immunization. Workshop participants generally agreed that providers need to be better informed about the true contraindications to immunizations. Those accepted by the Advisory Committee on Immunization Practices (ACIP) and the Committee on Infectious Diseases of AAP (e.g., an anaphylactic reaction to a previous dose of a vaccine) have been published with the CDC standards (CDC, 1993b). Specific conditions that do not constitute true contraindications are identified as well (e.g., mild illness). Differences in the guidance given by ACIP, AAP, and vaccine companies contribute to provider confusion, however. Jeffrey Goldhaggen and others pointed out that resources must be devoted to education for providers if desired changes in immunization practices are to be achieved. What many providers learned about contraindications in the past is not consistent with current guidelines. Providers also must learn about new vaccines that have been added to the immunization schedule. The recommendation for simultaneous administration of up to four vaccines in a single visit may be difficult for providers to reconcile with previously established norms of administering only one or two vaccines per visit. Richard Zimmerman noted that the Association of Teachers of Preventive Medicine (ATPM) is developing curriculum materials on immunization suitable for medical school, residency, and continuing medical education programs. ATPM also is beginning work on curriculum materials on immunization for nursing programs. Cost-Related Referrals Cost factors that lead private providers to refer children to public health clinics and other sources of free or low-cost immunizations contribute to missed immunization opportunities. If families do not follow through on the referral, children may never get to the clinic to receive the necessary immunization. Schulte and colleagues (1991) showed that the number of Dallas physicians

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Overcoming Barriers to Immunization: A Workshop Summary making referrals was nearly four times as high in 1988 as in 1979. Cost becomes an issue in two ways: (1) some families find that the fees that private providers charge for vaccines and their administration are too high and (2) some providers find that Medicaid reimbursements are too low to cover the cost of vaccines and immunization services. Although the Vaccines for Children Program will reduce the financial burden on both families and providers, inadequate reimbursement for vaccine administration services and cumbersome paperwork may continue to discourage private providers from offering immunizations to Medicaid patients. Missed Visits Although providers cannot control whether families take their children to providers for immunizations, they can adopt practices that encourage families to make appointments and that include outreach and follow-up to encourage families to keep those appointments. A newborn child's first immunization appointment can be made in the hospital before the mother and child are discharged. When families bring their children for immunizations, making an appointment for the next immunizations before the family leaves reinforces the message that a child needs immunizations on a regular schedule and reduces the need for the family to remember the schedule on its own. As Elizabeth Holt pointed out, 25 percent of the inner-city families in CDC's Baltimore study lacked telephones, which made it much harder for them to schedule appointments after they left the provider's office. A voice mail system used in the Cleveland All Kids Count project is an innovative approach to resolving this problem. (The system is described more fully later in this report.) If services are limited (few providers, limited hours of operation), families that do call may find that they have to wait several weeks for the next available appointment, which could put children behind schedule for their immunizations. In some settings, immunizations can be given on a walk-in basis without any appointment. Rita Goodman noted that among a small group of community and migrant health centers, immunization rates are highest at the center that provides walk-in service (and that screens any accompanying siblings as well). Offering immunizations with other services, such as WIC, increases their availability and removes the need for separate appointments. The impact of such practices on the primary care services that children receive must be monitored, however. With a good record-keeping system and adequate staff resources, providers can initiate contact with families whose children need immunizations, can remind families about scheduled appointments, and can try to contact families who did not keep appointments. Although many individual providers have limited resources for such efforts, community-based programs such as the All Kids

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Overcoming Barriers to Immunization: A Workshop Summary Count registry projects can assist them with an information system and technology to contact families. The automated dialing devices described by Eugene Dini, from the National Immunization Program at CDC, enable providers in clinics or private practice to deliver taped reminders and follow-up messages to many families without using much staff time. Telephone numbers and other information can be entered into these devices manually or via a computer link. Tests at fourteen sites in Georgia showed that, among families whose children were overdue for immunizations, 31 percent who received such calls came to the clinic within thirty days, compared with 15 percent of those who received no calls. IMPROVING PROVIDER PRACTICES The committee emphasizes the benefits that can be gained from improved provider practices and the need to move ahead with steps such as those suggested here. Steps to Take in the Short Term Preparation for new immunization developments. CDC, state and local health departments, and professional organizations can do more to prepare providers for new developments regarding immunization. For example, providers would benefit from more information about new vaccines and how they fit into the recommended immunization schedule. Workshop participants mentioned that knowledge about the Hib vaccine has been slow to reach some providers. In contrast, the United Kingdom conducted an extensive provider education campaign followed by a strong public education program when it introduced this vaccine. Similarly, more can be done to educate providers about the Standards for Pediatric Immunization Practice (CDC, 1993b). In Massachusetts, for example, the state health department has adapted the standards for providers in private practice and prepared materials for presentations across the state. The satellite communication technology available in the Department of Agriculture's Cooperative Extension Service offices in each county could make immunization education programs available to providers across the country. Presentation of the Standards for Pediatric Immunization Practices. CDC could work with providers practicing in various settings to repackage the Standards for Pediatric Immunization Practices in ways that would be more useful in those settings. Identifying the standards that are considered the most important could help providers determine which of the 18 should receive

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Overcoming Barriers to Immunization: A Workshop Summary attention first. Workshop discussion suggested that the identification of true contraindications to immunization should be a high priority. Implementation of the Standards for Pediatric Immunization Practices. CDC, professional organizations, or others could assist providers by producing specific materials and methods for implementing the practices suggested by the Standards for Pediatric Immunization Practice. Workshop participants felt that chart review, patient follow-up, use of all immunization opporunities, and parent education were particularly important. Providers and their staffs might be able to make changes more rapidly and more effectively if state or local health departments, or perhaps professional organizations, could provide consultants for on-site assistance and training. Immunization curricula in professional training. Academic health centers can ensure that the curricula of their training programs at all levels are consistent with the current Standards for Pediatric Immunization Practices. Special attention could be given to continuing education programs that inform providers about true contraindications to immunization. The Association of Teachers of Preventive Medicine is developing curriculum materials, but academic health centers need not wait until those materials are available to review the immunization education elements of their programs. Participation of providers' professional organizations. Providers' professional organizations, working from the national level down to local groups, can help inform their members about immunization issues and can promote good immunization practices. Meetings, official position statements and recommendations, and educational materials can all be used to influence individual providers. Through such organizations, CDC and state and local health departments can develop better working relationships with provider groups such as family physicians, osteopathic primary care physicians, or nurses and nurse practitioners who deliver primary care to children but who have not always been included in immunization activities. Participation in policy development. In addition to activities by their professional organizations, individual providers from all backgrounds need more and better opportunities to participate in the development of policies and materials that will directly affect how they deliver immunization services to children. Given such opportunities, providers can learn what is being developed rather than being presented with a finished product. Workshop discussions suggested that, in particular, more extensive consultation with the provider community would have been welcomed in the development of the Standards for Pediatric Immunization Practices and the Vaccine Information Pamphlets. Practice-based immunization information tools. Many providers find that their record-keeping systems make it difficult to review whether the children in their practices are receiving the immunizations that they need. CDC or other groups can help providers learn more about immunization levels in their

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Overcoming Barriers to Immunization: A Workshop Summary practices by developing methods and technologies (e.g., software or analytical services) that providers can use for procedures such as chart audits and patient tracking. Simultaneous administration of vaccines. Incentives are needed to encourage providers to follow the CDC standard calling for simultaneous administration of all medically indicated vaccines at one visit. Medicaid reimbursements, for example, could be adjusted to favor simultaneous administration of vaccines or use of combination products such as the measles-mumps-rubella vaccine over single-antigen products. Collaboration between the public and private sectors. Providers from both the public and private sectors are needed to deliver immunization services. Health departments can promote better services for their communities by developing good working relationships with private providers. Official health department representatives for immunization services can work with all providers to resolve problems and promote practices consistent with the CDC standards. Committee member Fernando Guerra noted the success that San Antonio has had with this approach and suggested using IAP funds to support such representatives. Participation in patient follow-up. New approaches to patient follow-up may involve the participation of additional health care providers in immunization services. Hospitals, for example, can ensure that the children born in their facilities have an appointment for their next immunizations before they leave the hospital. Hospitals can also follow up later to determine whether those children have actually received the appropriate immunizations. The NVPO has discussed such activities with the Catholic Health Association. Immunization practices bibliography. A comprehensive and annotated bibliography of studies on immunization practices would be of value to providers, policymakers, and researchers. Assembling published and unpublished studies of barriers to immunization and interventions to improve immunization coverage would help identify issues of special concern (e.g., missed opportunities for immunization) and suggest solutions (e.g., improving provider education about true contraindications to immunization). Steps to Take in the Longer Term Prevention curricula in professional training. Academic health centers can improve their education about immunization as part of a broader effort to improve education on all aspects of preventive health care. As vaccine-preventable diseases become less common, training programs must prepare providers to recognize these diseases when they do occur. Academic programs

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Overcoming Barriers to Immunization: A Workshop Summary can also help providers acquire a better understanding of the various communities they serve. Professional credentialing. In their credentialing role, professional organizations such as medical specialty boards can devote more attention to appropriate provider training regarding immunization. Providers can be required to demonstrate an understanding of the care embodied in the Standards for Pediatric Immunization Practices or comparable practice guidelines. Acceptance of new vaccines. CDC and other responsible organizations can plan for greater variation in provider acceptance of at least some new vaccines. Differences in provider acceptance of new vaccines may affect how the schedule of recommended immunizations is interpreted and how immunization levels are assessed.