Effectiveness of a chart prompt about immunizations in an urban health center

,

Original Research

Effectiveness of a chart prompt about immunizations in an urban health center

J Fam Pract. 2002 December;51(12):1-1

By

Ilene Timko Burns, MD, MPH

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References

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Address reprint requests to Ilene Timko Burns, MD, MPH, Department of Family Medicine, University of Pittsburgh School of Medicine, 3518 Fifth Avenue, Pittsburgh, PA 15261. E-mail address: ileneb@pitt.edu.

To submit a letter to the editor on this topic, click here: jfp@fammed.uc.edu.

ABSTRACT

OBJECTIVE: To determine whether a nurse-initiated chart review and prompt to physicians is an effective method to increase immunization rates.

STUDY DESIGN: This study was a controlled trial with systematic assignment of children to intervention or control groups based on chart number. Each day, a nurse reviewed the charts of children to be seen that day who were in the intervention group. The nurse prepared a 1-page form about the child’s immunization status that requested permission from the physician to administer needed vaccines and attached the form to the chart. The duration of the study period was 1 year.

POPULATION: Nine hundred ninety-seven pediatric patients attending 2 inner-city primary care health centers.

OUTCOME MEASURED: On-time immunization rates in both groups.

RESULTS: Among children eligible to receive vaccines during the study period, a higher percentage in the intervention group received on-time vaccines for diphtheria/tetanus/pertussis-4 (DTP4; 51% vs 36%; P = .03), oral polio vaccine-3 (OPV3; 70% vs 56%, P = .04), and measles/mumps/rubella-1 (42% vs 26%; P = .01) than did children in the control group. No statistically significant differences were noted for DTP3, DTP5, hepatitis B3, or OPV4. No statistically significant difference was noted for the combined series (ie, all age-appropriate immunizations as recommended by the 1995 Childhood Immunization Schedule of the Centers for Disease Control and Prevention).

CONCLUSIONS: The chart prompt increased on-time immunizations for some antigens.

Although immunization rates have increased to record levels, they remain suboptimal. State laws requiring immunizations for school entry help ensure that school-aged children are adequately immunized, but younger children are at risk of inadequate immunization. In 1995, only 74% of children in the United States between the ages of 19 and 35 months had received all immunizations recommended for children 18 months of age.¹ A number of studies have focused on the causes of low immunization rates, which include poverty, inadequate clinician knowledge of contraindications, and missed opportunities to vaccinate.^2-8 In contrast, higher rates have been found when proactive office procedures-such as reminder systems,^9-12 audit and feedback systems,¹³ and provider prompts,^11,14-16-are implemented. The Task Force on Community Preventive Services found that provider reminder/recall systems improve vaccination coverage in adults, adolescents, and children and strongly recommends their use.¹⁷

The aim of this study was to determine whether a chart prompt, ie, a reminder to the patients’ physicians, is an effective method to increase pediatric immunization rates by decreasing missed opportunities. The physicians’ offices in this study had neither a reminder system in place for immunizations nor an existing database that would permit computer generation of such a reminder system for existing pediatric patients. Manual chart review offered the only method to determine immunization rates and to generate prompts.

Methods

Study population

The setting for this study was the St. Margaret Memorial Hospital Family Practice Residency Program. During the study period, 36 residents and 4 fellows saw patients in the 2 Family Health Centers (FHC) of the program. The Lawrenceville Family Health Center (LFHC) is located in the financially disadvantaged Lawrenceville neighborhood of urban Pittsburgh, serving a predominantly white population. In 1994, staff at the LFHC provided care for approximately 715 children younger than 6 years. The Bloomfield-Garfield Family Health Center (BGFHC) serves the urban Pittsburgh neighborhoods of Bloomfield and Garfield. The population served by this FHC is predominantly African American with significant minorities of Asian American and white patients. In 1994, staff at the BGFHC provided care for approximately 315 children younger than 6 years. Previous assessments of immunization rates showed that the LFHC and the BGFHC had significantly different pediatric immunization rates (47% of children fully immunized by their second birthday at LFHC compared with 33% at BGFHC; chart audit performed by I.T.B. in 1993, unpublished data). Charts of children born on or after May 1, 1989, were included in the study. The Institutional Review Board of the University of Pittsburgh approved the study.

Study protocol

The intervention phase of the project was initiated on July 1, 1995, and completed on June 30, 1996. Each patient chart was systematically assigned to the control or intervention group based on the chart number. A random-number table was used to generate the following scheme: children with a chart number ending in 0, 1, 2, 5, or 6 were assigned to the intervention group, and children with a chart number ending in 3, 4, 7, 8, or 9 were assigned to the control group. Each morning, a designated nurse at each FHC generated a list of patients scheduled to be seen that day. The names of patients eligible for the study were highlighted. For each child in the intervention group, the nurse reviewed the immunization record present on the child’s chart. Each participating nurse received instruction in chart review and immunization guidelines from the principal investigator. Based on this chart review, the nurse determined if the child was eligible for any immunizations on that day’s office visit. The 1995 Recommended Childhood Immunization Schedule of the Centers for Disease Control and Prevention¹⁸Table 1 was used as the primary guideline. The 1994 RedBook¹⁹ was used as the source for answers to questions about the eligibility for immunizations when the 1995 schedule was ambiguous or inappropriate (eg, for a child with delayed immunization or special medical circumstances).