Missed opportunities for adult immunization in diverse primary care office settings☆
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.
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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.
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Pharmacists’ impact on older adults’ access to vaccines in the United States
2020, VaccineCitation Excerpt :Their findings suggest that the handout not only helped to initiate communication between the physician and patient to improve patient knowledge, but also increased pneumococcal vaccination rates [8]. Another barrier is the lack of opportunities to be immunized [1,9]. An increasing number of older adults seek care directly from specialists rather than primary care physicians, with 95% of older adults seeking care from a specialists every year and <66% seeking care from a primary care physician within the same time period [10].
RCT of Centralized Vaccine Reminder/Recall for Adults
2018, American Journal of Preventive MedicineCitation Excerpt :It is encouraging that there were statistically fewer missed opportunities for the high-risk group aged 19–64 years in the intervention versus the control group. Missed opportunities for adult vaccination have been well documented.28–32 Multifaceted approaches to reduce missed opportunities for vaccination have been recommended by the Task Force on Community Preventive Services33 and the Standards for Adult Immunization Practice34 and have been shown to be successful in practice.35
Using information technology to improve adult immunization delivery in an integrated urban health system
2012, Joint Commission Journal on Quality and Patient SafetyUse of standing orders for adult influenza vaccination: A national survey of primary care physicians
2011, American Journal of Preventive MedicineCitation Excerpt :However, adult vaccination rates are moderate at 67% for those aged ≥65 years, 42% for those aged 50–64 years, and 32% for those aged 18–49 years with high-risk conditions, with racial disparities in rates.2 Missed opportunities, namely, failure to vaccinate at all visit types, and infrequent preventive care visits contribute to low rates.3,4 Standing orders programs (SOPs) are a powerful way to reduce missed opportunities and to raise rates, as they enable nonphysician medical personnel to assess patient immunization status and administer vaccines without direct physician involvement.
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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.