REDUCING MISSED OPPORTUNITIES FOR IMMUNIZATIONS - EASIER SAID THAN DONE

Background: Missed opportunities for immunizations are associated with underimmunization of preschool-age children. Practice policies limiti ng immunizations to scheduled preventive visits and guidelines requiri ng legal guardians to sign consent forms for vaccinations are 2 factor s contributing to missed opportunities. However, methods to change the se policies have not been sufficiently evaluated. Objective: To measur e the effectiveness of(1) changing practice policies to incorporate th e new national standard to screen and vaccinate eligible children at a ll office visits and (2) eliminating legal guardian signature requirem ents. Design: A randomized controlled trial of 2 interventions: (1) ch anging practice policy and routine to have office nurses screen for im munization status at all visits, attach immunization reminder cards to medical charts for eligible patients, and have providers vaccinate el igible children (''no missed opportunities'' intervention) and (2) cha nging practice guidelines to allow vaccinations without a legal guardi an's signature. The first intervention was performed at both sites; th e second only at the neighborhood health center (NHC). Setting: A Pedi atric Continuity Clinic in a teaching hospital (hereafter referred to as Clinic), and an NHC. Patients: Enrolled in the trial were 1005 Clin ic patients and 983 NHC patients, 0 to 2 years of age. Main Outcome Me asures: Missed opportunity rates, immunization rates, and rates of pre ventive services. Results: Eliminating the requirement for a legal gua rdian's signature had no effect on any of the outcome measures. The no missed opportunities intervention was partially effective. Study pati ents had slightly fewer missed opportunities than control patients at each site: (0.60 vs 0.90 per patient per year at the Clinic, P=.01; 1. 1 vs 1.3 per patient per year at the NHC, P=.02). For study group pati ents, immunization reminder cards were attached to medical charts in o nly one third of vaccine-eligible visits; when attached, they markedly increased vaccination by providers (odds ratio for vaccinating at a v isit was 6.9 comparing visits when immunization reminder cards were at tached vs not attached). However, at the end of the study, immunizatio n rates were similar for study and control groups at each site. The nu mber of undervaccinated days was slightly lower for the no missed oppo rtunities study group at the Clinic than for the control group (56 day s vs 77 days, P<.001), but they were similar for both groups at the NH C. There were no differences in rates of preventive visits or screenin g tests between study and control groups. Conclusions: The interventio ns evaluated to reduce missed opportunities did not increase immunizat ion rates. The key problem was failure to screen for immunization stat us at all visits. More effective interventions will be needed to overc ome barriers within busy primary care practices to substantially reduc e missed opportunities.