Overcoming Barriers to Vaccine Timeliness and Coverage

Part 3 of 3

MediCal “hOMelessness”—and OTher OBsTaCles TO VaCCinaTiOnChildren without a medical home present a major challenge to improving vaccine timeliness and coverage. In 1 study, children eligible for the Vaccines for Children (VFC) program who did not have a medical home were significantly less likely than those who did to be up-to-date with immunizations.1 VFC-eligible children who received vaccinations in a medical home had vaccine coverage rates similar to those of non-VFC-eligible children.1 Lack of a medical home complicates record-keeping and tracking of a child’s vaccination history, because immu-nization records from other providers may be unavailable or difficult to track down.

Failure to vaccinate during acute care visits is another source of missed opportunities. Not all practitioners (or parents) are comfortable vaccinating a child who appears even mildly ill, and “mild illness” may be defined differently by individual practitioners (see box on page 3). The Centers for Disease Control and Prevention (CDC) provides guidance on what constitutes true contraindications to vaccination and when it is safe to vaccinate a sick child—for example, in cases of mild illness with or without fever2 (see box on page 2).

Due to the challenges in producing biologics, shortages of vaccines sometimes occur. Vaccine

shortages can severely disrupt childhood immu-nizations, leaving children incompletely vacci-nated and necessitating time-consuming recalls by clinicians. During the past decade, shortages of pneumococcal and meningococcal conju-gate vaccines and vaccines against Haemophilus influenzae type b (Hib), hepatitis A and B, influenza, and varicella have caused missed immunization opportunities and imposed a heavy administrative burden on the vaccine delivery system.3

ParenTal Barriers TO TiMely iMMunizaTiOn For many parents, access to health care presents a major impediment to their children being vacci-nated. Despite growth in the pediatric primary-care workforce, a nationwide maldistribution of pediatricians has left about 1 in 5 children living in areas with only 22 child-care physi-cians per 100,000 population.4 Approximately 18% of children live in rural America, yet only about 9% of pediatricians and about 22% of family physicians practice there.4

Uninsured or underinsured children have inad-equate access to health care no matter where they live. According to a study based on the 2007 National Survey of Children’s Health, an estimated 15% of children do not have health insurance for all or part of the year, and about 20% who have

ediTOrial BOard

stephen i. Pelton, Md, Moderator

Pasquale G. Bernardi, Md

stan l. Block, Md

Gary s. Marshall, Md

donald B. Middleton, Md

audrey M. stevenson, Phd, MPh, Msn, FnP-BC

In a series of 3 newsletters

for clinicians and their office

staff, a panel of experts offers

practical strategies for improving

immunization coverage and

timeliness in infants and young

children—and explores what

can happen when patients are

underimmunized. Part 1 focused

on the importance of staying on

schedule and the consequences

of delayed vaccine doses. Part 2

discussed combination vaccines

and their potential impact on the

quality of immunization care. Part

3 details some of the challenges to

achieving vaccine timeliness and

coverage, as well as successful

approaches to overcoming those

challenges.

V accination against infectious diseases is one of the great public health triumphs of the 20th century. Sustaining that success

in the 21st century depends on meeting a number of formidable challenges to the timely immunization of young children. In this final installment in the 3-part series, we examine factors that impede immunization of young patients and present strategies that can help achieve higher coverage rates with fewer delays.

© IAN HOOTON/Science Photo Library/Getty Images

insurance are underinsured. That is, they have inadequate coverage as defined by insufficient benefits, provider choices, or coverage of costs from the perspective of parents or guardians.5 Uninsured children are eligible for the VFC program; underinsured children are not.

Concerns about vaccine safety have prompt-ed some parents to delay vaccination or refuse it altogether.6 In a recent national survey of primary-care physicians, 79% reported at least 1 vaccine refusal by a parent in a typical month, and 89% reported at least 1 request to spread out vaccines over time.7 A majority said that parental concern about vaccines has moderately or greatly increased in the past 5 years and that significant time is spent discussing vaccine safety with parents at well-child visits.7

Inaccurate or biased information on the Internet and celebrities’ opposition to vaccina-tion can exacerbate parental anxiety.3 So can the mention of rare but potentially frightening side effects in the vaccine information materials. Parents who refuse altogether to vaccinate their children are more likely to be well-educated and affluent with a high rate of vaccine safety concerns and are unlikely to follow physician recommendations.8

As well-versed as parents often are about the potential hazards of vaccination, they may be unaware of the dangers posed by the diseases that vaccines help prevent. The relative rarity of once-common diseases such as measles, tetanus, and Hib meningitis can breed a cavalier attitude toward the need for immunizations.

The complexity of the recommended vac-cination schedule can be another challenge for parents as well as clinicians. Parents of toddlers often need reminders to return for vaccinations due at 15 months of age, for example, because they tend to be less aware of the vaccination schedule after their child’s first year of life. Many families do not know which vaccinations their children need and when, assuming that the health-care provider will tell them.

Informed consent can present another stum-bling block to timely immunization. When someone other than the parent or legal guard-ian—a babysitter, grandparent, or stepparent, for example—brings the child to the clinician’s office, that person may not be able to provide informed consent. The rules vary by state and even from institution to institution.

helPinG ParenTs TO aCCePT rOuTine ChildhOOd VaCCinesThe most powerful influence on parental acceptance of childhood vaccination is the physician’s strong recommendation. Studies confirm that physicians and other health-care

providers are the most frequent and trusted source of vaccine information for parents.9-11 One study found that parents with doubts about vaccines most often cited “information or assurances from health-care provider” as the primary reason they changed their minds about delaying or refusing vaccination.6

School entry requirements often have the second greatest impact on vaccination.11 Among parents opposed to immunization, those requirements may be the primary influ-ence.11 Evidence supports the effectiveness of vaccination requirements for enrollment in child care, school, and college.3,12

Belief in vaccine efficacy strongly influences parental acceptance of vaccination.13 Parents who have confidence that vaccines are impor-tant and effective are more likely to want to immunize their children.11

Parents, especially if they have doubts about immunization, may need to be convinced that the severity of the disease outweighs their concerns about the vaccine designed to help prevent it. In one study, severity of infection was the second most powerful influence after vac-cine efficacy on willingness to vaccinate.13

Finally, parents need to be convinced that vaccines are generally safe, despite what they

may have heard or read. Parents who believe that vaccines are safe are likely to support vaccination.11

eCOnOMiC Barriers TO iMMunizaTiOn deliVeryImmunizing children can be costly for health-care providers. The CDC estimates that vaccine acquisition costs to immunize an otherwise healthy child through 18 years of age have increased more than 6-fold since 1995.3 Moreover, the acquisition cost for the same vaccine can vary widely from practice to practice, as can reimbursement for both vaccine and administration.14 This disparity is especially acute for smaller pediatric practices and family physicians, who often cannot take advantage of bulk discounts. Storing vaccines—with the attendant risks of power outages and refrigera-tor malfunction—adds to the expense.

Administrative payment levels vary greatly, and reimbursement from third-party payers often fails to cover costs entirely.3 The major-ity of physicians in a recent study believed that their practice did not receive adequate payment for combination vaccines, and 1 in 5 reported that insufficient reimbursement precluded their use of 1 or more combination vaccines.15

Private payers often delay covering new vac-cines and do not increase payment as the prices of vaccines rise.3 Insurers may postpone covering a new vaccine already approved by the United States Food and Drug Administration until the CDC’s Advisory Committee on Immunization Practices issues recommendations for its use. There may be additional delays before claims for newly covered vaccines begin to be paid.16

Half of pediatricians and family practitioners surveyed said they had postponed buying some new vaccines for financial reasons. Five percent of pediatricians and 21% of family physicians reported giving serious thought to discontinu-ing vaccination of privately insured patients because of issues with vaccine acquisition costs, administration, and reimbursement.3,17

The costs of vaccination are measured in time as well as money. For physicians, a significant portion of their limited time with each patient may be spent explaining the importance of immunization and the possible adverse effects of the vaccine. Immunizations also absorb a great deal of nursing time, both to administer vaccines and document all the pertinent information. As the number of recommended vaccines grows, so do the time demands on physicians, nurses, and other office staff. New antigen-based Current Procedural Terminology (CPT®)a codes issued

2 | Overcoming Barriers to Vaccine Timeliness and Coverage

All vaccines may be administered under the following conditions, which are commonly misperceived as contraindications:

Mild acute illness with or without • fever

Mild-to-moderate local reaction • (ie, swelling, redness, soreness), low-grade or moderate fever after previous dose

Lack of previous physical • examination in well-appearing person

Current antimicrobial therapy•

Convalescent phase of illness•

Preterm birth•

Recent exposure to an infectious • disease

History of penicillin allergy, other • nonvaccine allergies, relatives with allergies, or receiving allergen extract immunotherapy

Conditions commonly misperceived as contraindications to vaccination2

a CPT® is a registered trademark of the American Medical Association.

in 2011 take into account the professional time required to educate parents about each com-ponent of combination vaccines and remove some reimbursement disincentives to their use. (For more information about the 2011 CPT coding changes, see Part 2 in this newsletter series.)

suCCessFul aPPrOaChes TO iMMunizaTiOn in The sMall GrOuP PraCTiCeSmall group practices can lower vaccine acqui-sition costs by creating a buying group with other small practices, joining an existing buying group, or partnering with vaccine manufacturers for non-contract vaccine discounts.

Electronic medical records (EMRs) can improve immunization coverage and timeliness by facilitating chart review and aiding with targeted parent reminders and recalls. However, implementation of EMRs requires a significant investment in staff education and time.

One of the simplest and least resource-intensive ways to avoid missed immunization opportunities is to think of vaccinations as a vital sign: A child’s vaccination status should be checked at every visit, just like temperature or blood pressure. All vaccines due should be administered or, if the child is too sick to be vaccinated, another appointment scheduled.

Parents should be engaged in conversa-tion about vaccines early and often. A shared decision-making model can prove helpful.18 Clinicians should address parental concerns or questions,19 discussing the risks of not receiving the vaccine as well as the benefits and potential adverse effects of vaccination.18 Sharing per-sonal stories with parents—such as physicians’ own decisions to immunize their children—can be particularly effective.7 Parents who refuse vaccinations should formally acknowledge that they have read the information, and a note made that the parent has declined the vaccine. The signed form can be scanned into the EMR or inserted in the paper chart.

Using combination vaccines can lessen some of the problems inherent in the complex vaccine schedule by reducing the number of shots, easing child and parent distress, and decreasing delayed doses. (For a detailed dis-cussion of combination vaccines, see Part 2 in this newsletter series.)

suCCessFul aPPrOaChes TO iMMunizaTiOn in The larGe GrOuP PraCTiCe Additional approaches to immunization can be implemented in a large group practice. A

physician, nurse, or other staff member can be recruited to serve as an office vaccine cham-pion to oversee and coordinate vaccine policy for the practice. A vaccine champion can keep up with new vaccination recommendations, develop support and cooperation among staff, and deal with issues related to purchasing and implementing vaccine schedules.

Immunization targets for each provider for every visit, not just well visits, should be incorporated into quality improvement reviews. Salary penalties for low scores and monetary rewards and recognition for high scores can provide incentives for positive change.

EMR data collection tools can not only monitor performance but also facilitate out-reach to patients with delayed immunizations. Missed opportunities reports, for example, can identify patients between 17 and 24 months of age with incomplete vaccination records.

Clinical support staff should be engaged as part of the team. Using standing orders enables staff to give immunizations if needed without having to consult a physician. A reward system for staff might be used, similar to that used for providers.

The practice may have a managed care organization (MCO) that can act as a partner in reaching out to patients. Community outreach workers and case managers on the MCO staff can screen immunization records and

perform outreach using “opportunity lists” of patients who are missing vaccinations based on Healthcare Effectiveness Data and Information Set (HEDIS) criteria. Some practices bring MCO staff into the office as part of the team with access to the EMR and scheduling system so that they can contact patients and schedule appointments directly, which improves com-munication and access and saves time.

Practitioners may want to contract with manufacturers for vaccine purchases. Vaccine contracts can result in significant cost savings and simplify decision making. Ordering deci-sions should be discussed with all clinicians in the practice before entering into a contract to ensure everyone is comfortable with the purchasing decision.

iniTiaTiVes FOr PuBliC healTh and PriVaTe PraCTiCeAt least 11 states have developed public health initiatives to improve immunization compliance and timeliness. Some emphasize completing the recommended vaccination schedule in the first and second years of life. Others focus specifically on the antibody-reinforcing dose (also called the booster, toddler, or fourth dose) of diphtheria, tetanus, and acellular pertussis (DTaP) and other vaccines.

“Fourth Dose DTaP” programs in states including Florida, North Carolina, and

Overcoming Barriers to Vaccine Timeliness and Coverage | 3

As defined by the panel of experts for this newsletter series, “mild illness” may include such conditions as upper respiratory infection, acute otitis media, vomit-ing and diarrhea without dehydration, pharyngitis, rhinorrhea, cough without pneumonia, non-petechial/non-purpural rash, conjunctivitis, minor cellulitis, cystitis, and non-infectious processes like minor physical trauma or asthma.

The child should appear alert, with no acute or evolving changes in cognition or neu-rologic function; should be able to drink well; should exhibit no abdominal guarding or major tenderness; and have no trismus or severe pharyngitis with tonsillar exudates.

Vital signs, with the exception of fever, should be stable or improving (in the opinion of the health-care provider). Fever should generally be ≤102º F, and respi-ratory rate <40 for an infant less than 12 months of age and <30 for a child.

Other factors to consider: Will the common side effects of the vaccine poten-tially interfere with parental evaluation of a sick child? Will the illness mask the side effects of the vaccine? Might the illness combined with the vaccine side effects worsen some underlying risks, eg, febrile seizures in children who receive measles, mumps, rubella, and varicella (MMRV) vaccine compared with MMR and varicella vaccine administered separately?

Case examples: Suggestions on when to vaccinate and when to defer immunization 1. Temperature of 102.2º F, cough, conjunctival injection, generalized morbil-

liform rash: Defer

2. Runny nose, temperature 100.4º F, mild cough but feeding well: Vaccinate

3. Pulling at left ear, fussy, feeding well, loose stools: Vaccinate

4. Acute influenza-like illness with temperature 103.0º F, myalgias, decreased appetite, sore throat, watery eyes: Defer

What constitutes “mild acute illness”?

Washington encourage parents and providers to make sure children receive the fourth dose on time.20-22 The Washington State health depart-ment’s Health Education Resource Exchange (HERE) program offers 8 practice points to help providers increase coverage rates for the fourth DTaP dose.22

Under various names, “Done by One” initiatives in 8 states (Louisiana, Montana, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania, and Virginia) focus on ensuring that children receive vaccines at the earliest recommended ages for routine administration, with emphasis on giving the fourth dose of DTaP at 12 months of age. Timely immuni-zation at 2, 4, and 6 months of age is vital to ensure that children can get the fourth DTaP dose at 12 months of age and still meet the recommended 6-month interval between the third and fourth doses.

Ohio has partnered with its state chapter of the American Academy of Pediatrics (AAP) to offer a free in-office education and train-ing program—Maximizing Office Based Immunization, or MOBI. The program teaches physicians and their staffs evidence-based strategies to overcome barriers to immunization and promotes the Ohio Timely Immunization Schedule, or OTIS.23

Building on approaches that use offices of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to review children’s immunization records, the WIC/Imms initiative by the Salt Lake Valley Health Department in Salt Lake County, Utah, offers vouchers as an incentive for timely vaccination of children 2 years of age and younger. Families of children who catch up on their vaccinations receive 3 months of vouchers rather than the single month of vouchers given to families of children who are behind.

The National Vaccine Advisory Committee and the AAP recommend increased participa-tion by providers and patients in registries to

improve immunization coverage.3 Centralized vaccination databases can keep track of chil-dren’s immunization histories, especially those of children who receive vaccinations outside a medical home. They can consolidate fragmented records, track children in need of vaccine doses, provide automated reminder-recall, and generate vaccination records for providers, par-ents, and schools. Establishing effective interfaces between provider EMRs and registries remains a considerable challenge, however.

A number of the public health initiatives mentioned here have developed materials that can be downloaded and used in private practice settings, such as posters and bro-chures for both parents and providers. Practices may be able to partner with their local or state health department in meeting the shared goal of protecting the community at large, and young children in particular, against vaccine-preventable diseases.

reFerenCes 1. SmithPJ,SantoliJM,ChuSY.Theassociationbetween

havingamedicalhomeandvaccinationcoverageamongchildreneligiblefortheVaccinesforChildrenprogram.Pediatrics.2005;116(1):130-139.

2. CentersforDiseaseControlandPrevention(CDC).Generalrecommendationsonimmunization:recommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).MMWR.2011;60(RR-2):1-64.

3. AmericanAcademyofPediatricsCommitteeonPracticeandAmbulatoryMedicineandCouncilonCommunityPediatrics.Policystatement—increasingimmunizationcoverage.Pediatrics.2010;125(6):1295-1304.

Brought to you as an educational service by Sanofi Pasteur Inc.

MKT21727-1 9/11 Printed in USA

4. ShipmanSA,LanJ,ChangC,etal.Geographicmaldistributionofprimarycareforchildren.Pediatrics.2011;127(1):19-27.

5. KoganMD,NewacheckPW,BlumbergSJ,etal.Underinsur-anceamongchildrenintheUnitedStates.NEnglJMed.2010;363(9):841-851.

6. GustDA,DarlingN,KennedyA,etal.Parentswithdoubtsaboutvaccines:whichvaccinesandreasonswhy.Pediatrics.2008;122(4):718-725.

7. KempeA,DaleyMF,McCauleyMM,etal.Prevalenceofparentalconcernsaboutchildhoodvaccines:theexperienceofprimarycarephysicians.AmJPrevMed.2011;40(5):548-555.

8. SmithPJ,ChuSY,BarkerLE.Childrenwhohavereceivednovaccines:whoaretheyandwheredotheylive?Pediatrics.2004;114(1):187-195.

9. FreedGL,ClarkSJ,ButchartAT,etal.Sourcesandperceivedcredibilityofvaccinesafetyinformationforparents.Pediat-rics.2011;127(Suppl1):S107-S112.

10. KeaneMT,WalterMV,PatelBI,etal.Confidenceinvaccina-tion:aparentmodel.Vaccine.2005;23(19):2486-2493.

11. DavisK,DickmanED,FerrisD,etal.Humanpapillomavirusvaccineacceptabilityamongparentsof10-to15-year-oldadolescents.JLowerGenTractDis.2004;8(3):188-194.

12. CDC,TaskForceonCommunityPreventiveServices.Recom-mendationsregardinginterventionstoimprovevaccinationcoverageinchildren,adolescents,andadults.AmJPrevMed.2000;18(1suppl):92-96.

13. ZimetGD,MaysRM,SturmLA,etal.Parentalattitudesaboutsexuallytransmittedinfectionvaccinationfortheiradoles-centchildren.ArchPediatrAdolescMed.2005;159(2):132-137.

14. FreedGL,CowanAE,GregoryS,etal.Variationinprovidervaccinepurchasepricesandpayerreimbursement.Pediatrics.2008;122(6):1325-1331.

15. GidengilCA,Dutta-LinnMM,MessonnierML,etal.Financialbarrierstotheadoptionofcombinationvaccinesbypediatri-cians.ArchPediatrAdolescMed.2010;164(12):1138-1144.

16. ShenAK,HunsakerJ,GazmararianJA,etal.RoleofhealthinsuranceinfinancingvaccinationsforchildrenandadolescentsintheUnitedStates.Pediatrics.2009;124(Suppl5):S522-S531.

17. FreedGL,CowanAE,ClarkSJ.Primarycarephysicianper-spectivesonreimbursementforchildhoodimmunizations.Pediatrics.2008;122(6):1319-1324.

18. AnhangR,GoodmanA,GoldieSJ.HPVcommunication:reviewofexistingresearchandrecommendationsforpatienteducation.CACancerJClin.2004;54(5):248-259.

19. ZimetGD.Improvingadolescenthealth:focusonHPVvac-cineacceptance.JAdolescHealth.2005;37(6Suppl):S17-S23.

20. FloridaHealthDepartment.Floridaimmunizationinitiative.http://www.doh.state.fl.us/disease_ctrl/immune/4Sure/index.htm.AccessedMay15,2011.

21. NorthCarolinaImmunizationBranch.ImmunizeNorthCaro-lina.http://www.immunizenc.com/PDFs/brochureFINAL.pdf.AccessedMay15,2011.

22. WashingtonStateDepartmentofHealth.HealthEducationResourceExchangeWebTeam.http://here.doh.wa.gov/materials/tips-to-increase-dtap-rates/15_DtapTips_E061.pdf.AccessedMay15,2011.

23. AmericanAcademyofPediatrics,OhioChapter.MaximizingOfficeBasedImmunization(MOBI).http://www.ohioaap.org/program-initiatives/maximizing-office-based-immuniza-tion-(mobi).AccessedMay15,2011.

This series of 3 newsletters for clini-cians and their office staff has focused on improving immunization timeliness and coverage in infants and young chil-dren. Choosing to stay up-to-date with the recommended vaccine schedule offers numerous advantages to chil-dren, parents, and health-care provid-ers. The importance of maintaining protective antibody levels and cellular immunity provides the scientific basis for this choice. The well-being of all in-volved provides the humanistic basis.