Elsevier

Vaccine

Volume 22, Issues 25–26, 3 September 2004, Pages 3457-3463
Vaccine

Missed opportunities for adult immunization in diverse primary care office settings

https://doi.org/10.1016/j.vaccine.2004.02.022Get rights and content

Abstract

Adult vaccination rates are well below national goals of 90%. We examined medical records of 810 adults ≥65 years to determine number and type of visits, discussion and patient refusals of vaccines, influenza vaccinations over three seasons, and pneumococcal and tetanus vaccinations over 5 years. From the medical record, immunization rates were 24.1% for annual influenza, 49.1% for pneumococcal polysaccharide and 28.6% for tetanus vaccine. During the 27 month study period, patients averaged 1.3±1.9 acute visits, 6.9±5.1 chronic visits and 0.48±0.91 preventive visits (mean±S.D.). Missed opportunities to vaccinate ranged from 38.4 to 94.5% of visits. Vaccination rates were higher if medical records included health maintenance flow sheets. Failure to discuss vaccination, to vaccinate at acute care visits, and low frequency of preventive visits resulted in missed opportunities to vaccinate. A health maintenance flow sheet can prompt providers to discuss vaccination and record vaccines as they are administered.

Introduction

Despite the unqualified success of vaccines in preventing certain infectious diseases, vaccination rates for some vaccines remain suboptimal. For instance, both influenza and pneumococcal vaccines have been shown to be efficacious [1], [2], but vaccination rates among adults for both vaccines are substantially lower than recommended rates. The most recent national rates based on self-report for adults ≥65 years are 63% for influenza and 55% for pneumococcal polysaccharide vaccine (PPV) [3], compared with the 90% goal set by Healthy People 2010 [4]. Unfortunately, influenza and pneumonia continue to be the fifth leading cause of death among this age group and are significant contributors to excess morbidity and hospitalizations in the United States [5]. The American Medical Association, in collaboration with the American Academy of Family Physicians, the American Geriatrics Society and others, has recommended that immunization status be assessed during any health care encounter, whenever feasible [6]. Furthermore, the ACIP recommends that during the influenza season, unvaccinated, high risk adults be offered vaccination at any contact with regular providers offering ongoing care [7], unless there is a clear contraindication such as a prior adverse reaction or allergy to a vaccine component. Low vaccination rates among older populations in light of these recommendations suggests a problem. An examination of outpatient medical records may provide insight into missed opportunities to assess and vaccinate and perhaps, ways to increase adult immunizations.

The purpose of this study was to identify missed opportunities for vaccination and determine what aspects of the medical record or visits were related to adult influenza, pneumococcal and tetanus vaccination status. We reviewed medical records of patients in a variety of geographic, socioeconomic and practice settings, including rural, inner-city, Veterans’ Affairs (VA) and urban/suburban practices and with different methods of recording immunizations, including handwritten and dictated progress notes, stickers, health maintenance flow sheets and electronic medical records.

Section snippets

Materials and method

The data presented in this study are a subset of those collected from a multi-modal study of physicians, nurses, office managers and patients. Data for the larger study were collected using self-administered questionnaires, telephone surveys, physician and patient observations and medical record review. Detailed descriptions of the overall methods used and results of this study have been previously published [8], [9], [10].

Demographics

Of the original 1007 participants in the survey, 810 consented to and had useable medical record data available for a response rate of 80.4%. Of those whose medical record data were not used, a greater proportion were female, African-American, younger and of lower income. Among those whose medical records were used, equal numbers of males and females participated (51% males) and their average age was 73.9±5.5 years.

The average total number of visits during the 27 month study period was 8.7±6.0,

Discussion

This retrospective review of outpatient medical records revealed that only one-fourth of patients’ medical records documented that they had received an annual influenza vaccine, and one-half that they had ever received a PPV, well below Healthy People 2010 goals of 90% [4]. One-fourth of patients’ medical records documented receipt of tetanus vaccine. These rates were considerably lower than self-reported rates of 79% for influenza and 70% for PPV previously reported among the same patient

Acknowledgements

The authors would like to acknowledge Anne Medsger, RN, and Michael J. Fine, MD, for their efforts in facilitating data collection. This project/publication was funded by HS09874-01A1 from the Agency for Healthcare Research and Quality.

References (19)

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This project was approved by the Institutional Review Board of the University of Pittsburgh and the Human Subjects Use Subcommittee of the Institutional Review Board of the Veterans’ Affairs Healthcare System of Pittsburgh.

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