WASHINGTON — Using ancillary staff to obtain patient immunization and medication histories before the patient sees the physician could go a long way toward improving immunization rates among high-risk adults, Linda Hill, M.D., said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.
Despite long-standing recommendations for annual influenza vaccine and one-time pneumococcal vaccination for adults aged 18–49 with chronic lung, cardiovascular, metabolic, and immunosuppressive conditions, overall coverage levels are only 20% for influenza vaccine and 8% for Pneumovax. Rates are just slightly better for diabetic patients, at 27% and 15%.
The Healthy People 2010 goal is 60% for both vaccines, said Dr. Hill of the department of preventive and family medicine at the University of California, San Diego.
In an effort to determine what types of preventive health issues are addressed during a typical office visit, Dr. Hill and her associates audiotaped 37 visits of patients aged 20–50 years old with chronic conditions.
Patients were seen at three community health centers and one private practice between September 2003 and January 2005.
The average visit lasted about 13 minutes. About 5 minutes were spent taking the patient's history, half a minute on providing generic health information, another 1–2 minutes on evaluations such as explaining test results, and about a half minute on the physical exam. Only fractions of minutes each were spent offering health recommendations, such as “you should get more exercise”; discussing preventive services other than immunizations, such as mammograms; and discussing and/or planning immunizations.
Of the 24 visits in which immunizations were discussed, the discussion took a little over a minute. But when immunizations were discussed and the patient actually got a shot, less than half a minute was spent on the discussion. And during those 24 visits, no other preventive health issues were discussed, noted Dr. Hill, who is also associate director of the Center for Behavioral Epidemiology and Community Health at San Diego State University.
Of interest, on average more than half of the visit (8 of the 13 minutes) was spent discussing the history, mostly the patient's medications.
Although this isn't surprising, the actual discussion tended to be more about trying to figure out what the patient was taking and in what dose than about assessing the appropriateness of the dose or explaining to the patient what it was for.
Previous data have shown that, more than any patient characteristic, physician advice is the greatest predictor of receipt of immunizations. Moreover, physician immunization advice is more likely to occur when the physician to staff ratio is at least 1:4 and when the time spent with the physician is at least half of the total visit time.
It would make sense to have ancillary staff members obtain and document immunization and medication histories prior to seeing the physician, thereby leaving the physician more time for more complex decisions and for talking with the patient about important preventive health measures such as immunization, Dr. Hill said.