Provider Chart Audits and Outreach to Parents: Impact in Improving Childhood Immunization Coverage and Immunization Information System Completeness Maureen S. Kolasa, James P. Lutz, Abbey Cofsky, and Tanya Jones rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Objective: Examine impact of provider chart audits and parental outreach in improving immunization coverage among children not up-to-date (NUTD) for immunizations in Philadelphia’s immunization information system (IIS). Methods: We identified 10-month-old children NUTD for age-appropriate immunizations using Philadelphia’s IIS. Immunization rates at 10, 13, and 19 months were compared before and after contact with providers and parents. Results: Of 5 610 children NUTD in the IIS at 10 months and living in areas with populations at risk for underimmunization, provider chart audits indicated that 3 612 (64%) were actually up-to-date (UTD); the majority of these (2 203) received additional age-appropriate immunizations and were also UTD at 19 months. Of 1 998 children truly NUTD at 10 months, half received overdue immunizations by 13 months following contact with parents via telephone, postcards, and home visits, but only 23 percent were UTD for age-appropriate vaccines at 19 months. Conclusions: Provider chart audits improved IIS data completeness, indicating that providers need to submit more complete and timely data to the IIS. Outreach to parents likely contributed to half of the children NUTD at 10 months receiving overdue immunizations by 13 months. However, most were again NUTD at 19 months, indicating that outreach efforts should be continued through 19 months or until children are brought UTD. Furthermore, in spite of outreach, about half of the NUTD children were not brought UTD by 13 or 19 months. New strategies should be developed to ensure that these children receive recommended vaccinations.
KEY WORDS: immunization, health services, registries,
vaccination
A variety of strategies are recommended to improve childhood immunization coverage, including reminding parents when their child’s vaccinations are coming due and recall of parents whose child has fallen behind the recommended immunization schedule.1–3 Immunization information systems (IIS) can be useful in implementing these strategies on a large scale by allowing for identification of cohorts of children due for agebased vaccinations, individual children who are past due for age-appropriate vaccinations, and by providing contact information for parents and providers.1,4–9 IIS can therefore assist healthcare providers and public health professionals in promoting timely receipt of
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, US Department of Health and Human Services. The authors thank Yuan Kong and Fan Zhang for their work in conducting data analysis. The authors also thank Alexandra E. Ossa, MPH, for her review of this work. Corresponding Author: Maureen S. Kolasa, BSN, MPH, Health Services Research and Evaluation Branch, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mail Stop E-52, Atlanta, GA 30333 (
[email protected]).
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Maureen S. Kolasa, BSN, MPH, is Child Team Lead, Health Services Research and Evaluation Branch, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, Georgia. James P. Lutz, MPA, is Public Health Advisor, Program Operations Branch, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Philadelphia, Pennsylvania. Abbey Cofsky, MPH, is Program Associate, Robert Wood Johnson Foundation, Princeton, New Jersey.
J Public Health Management Practice, 2009, 15(6), 459–463 Copyright C 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Tanya Jones is Outreach Coordinator, Division of Disease Control, Philadelphia Department of Public Health, Pennsylvania.
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460 ❘ Journal of Public Health Management and Practice childhood immunizations and allowing for outreach to children who may be at risk for underimmunization. This study evaluated the extent to which Philadelphia’s IIS accurately identified 10-month-old children who had not received all age-appropriate immunizations through comparing data in the IIS to provider charts. We also examined the impact of outreach to parents via telephone, postcard, and home visits in ensuring that children received immunizations overdue at 10 months by 13 months of age. We then looked at the impact of the provider chart audits and parental outreach in relationship to up-to-date (UTD) immunization coverage by 19 months of age.
● Methods Philadelphia’s IIS seeks to record immunizations received by all children living in the City of Philadelphia. Of the annual birth cohort of approximately 22 000 children in the City of Philadelphia, 83 percent are eligible for vaccine through the Vaccines for Children program (Centers for Disease Control and Prevention, unpublished data, 2008).10 Almost all children (98.7%) are entered into the IIS through the input of birth registry data. Approximately 271 providers in Philadelphia submit immunization data to the IIS, including all providers who receive free vaccine through the Vaccines for Children program and almost all other childhood immunization providers known to the Philadelphia Department of Public Health (PDPH). Providers input data into the IIS via numerous methods, including direct link with the registry, providing electronic billing records, and sending paper records for manual entry by PDPH staff.11,12 PDPH reviews the IIS on a monthly basis to identify all children aged 10 months who are not up-todate (NUTD) for immunizations recommended to be received by 6 months of age.13 To be considered UTD at 10 months of age, a child needs to have received three doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, two doses of inactivated poliovirus (IPV) vaccine, two doses of Haemophilus influenzae type b (Hib) vaccine, and two doses of hepatitis B (Hep B) vaccine. In an effort to ensure the accuracy of the IIS, PDPH medical chart abstractionists visit a rotating list of immunization providers on a monthly basis. The abstractionists review the charts of NUTD children that the IIS indicated were last vaccinated by these providers. The chart audit allows the abstractionists to gather information on any immunizations not already in the IIS and ensure that patient contact information in the IIS matches the healthcare provider’s information. Children still NUTD after PDPH conducts a chart review at the last known provider are
referred to community-based outreach organizations contracted by PDPH. These outreach organizations are assigned to children living within zip codes that contain populations with lower socioeconomic status levels and a high density of minority populations. Currently, about 65 percent of children in the City of Philadelphia live within areas that are served by community-based outreach. The process followed by the two community-based outreach organizations evaluated in this project is the same. Upon receipt of the monthly list of NUTD children in their target neighborhoods, outreach staff review the IIS to ensure that no new information has been entered since the list was generated. Outreach staff then contact the last immunization provider as listed in the IIS in case the provider has vaccinated the child since the outreach list was generated. Outreach staff obtain records for any new vaccinations given by the provider. For children who still are NUTD after these steps are completed, outreach staff contact the parents through a personalized letter, a telephone call, or a home visit. A series of three telephone calls, three letters, and three visits to the address are made to reach parents or identify new contact information. Outreach staff attempt to determine if the child has moved out of the city, if the child is receiving care from a provider outside of the city or a provider that does not participate in the IIS, or if the child is truly behind on his/her immunizations. Parents of children in need of immunizations are encouraged to take the child to his/her primary care provider. Outreach staff may make the appointment with the primary care provider and also can provide transportation to the appointment. Outreach staff track their process on each child by entering codes into the IIS to indicate actions taken and information received. They record when additional immunization records were received from the primary provider, another provider, or the parent. They also record when a child was brought to care and whether or not all needed immunizations were received. The outreach staff enter other codes when a parent refuses contact or refuses to take the child for immunizations. Other codes include medical or religious exemption for immunization, child deceased, child moved out of the area, child cannot be located, and provider noncompliant or unwilling to collaborate with outreach staff. We compared immunization levels at 10 and 13 months of age for three doses of DTaP vaccine, two doses of IPV vaccine, two doses of Hib vaccine, and two doses of Hep B vaccine. We also calculated UTD immunization levels at 19 months; these children needed to have received four doses of DTaP vaccine, three doses of IPV vaccine, three doses of Hib vaccine, two doses of Hep B vaccine, one dose of measles-mumps-rubella (MMR) vaccine, and one dose of varicella vaccine. We
Provider Chart Audits and Outreach to Parents
considered two doses of Hep B vaccine to be UTD even though three doses are recommended because all birthing hospitals in Philadelphia routinely administer a birth dose but usually do not record this dose in the IIS. For this evaluation, we included all children born between November 1, 2003, and October 1, 2004, present in the Philadelphia IIS at 10 months of age, and living in areas served by two community-based outreach organizations. This study was reviewed by the Human Subjects Coordinator at the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, was determined to be an analysis of secondary data without identifiers, and did not require Centers for Disease Control and Prevention Institutional Review Board review.
● Results The Philadelphia IIS contained 21 858 children born between November 1, 2003, and October 1, 2004. According to the IIS, 16 017 (73 %) of these children were still NUTD for vaccinations due at 6 months of age by the time they reached 10 months of age. The two community-based outreach organizations in this study served areas containing 7 037 of the NUTD
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children. PDPH and outreach staff verified through provider records that 225 children had moved from Philadelphia, 19 had died, and 16 had medical or religious immunization exemptions. They could not locate or find additional information on 1 167 of the children in spite of searching provider records and contacting available phone numbers and addresses (Figure 1). Of the 5 610 remaining children, providers verified that 3 612 (64%) were actually UTD by the time they had reached 10 months of age but that the vaccinations had not been entered into the IIS. Of these UTD children, 2 203 (61%) continued to receive vaccinations at the recommended ages so that they were also UTD at 19 months (Figure 1). Outreach staff contacted the parents or guardians of the 1 998 (36%) children truly NUTD at 10 months according to provider records and the IIS. Of these children, 118 (6%) parents or guardians refused to discuss their child’s vaccination status with outreach staff. By 13 months of age, 999 (50%) of the NUTD children had been taken to a vaccination provider and received the vaccinations that had been overdue at 10 months of age. At 19 months of age, 1 537 (77%) of the children NUTD at 10 months of age were NUTD for recommended vaccinations due by 19 months of age.
FIGURE 1 ● Immunization Status of Childrena Eligible for Outreachb
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a Living in areas served by target outreach organization A and B. b NUTD for immunizations due at age 6 months: three doses of DTaP vaccine, two IPV vaccine, two doses of Hib vaccine and two doses of HepB vaccine. c UTD for immunizations due at age 6 months: three doses of DTaP vaccine, two doses of IPV vaccine, two doses of Hib vaccine and two doses of HepB vaccine. d UTD for immunizations due at age 19 months: four doses of DTaP vaccine, three doses of IPV vaccine, three doses of Hib vaccine, two doses of HepB vaccine, one dose of
MMR vaccine and one dose of Var vaccine. NUTD, Not up-to-date for immunizations; UTD, up-to-date for immunizations; IIS, Immunization Information System; DTaP, diphtheria tetanus and acellular pertussis vaccine; IPV, inactivated polio virus vaccine; Hib, haemophilus influenzae type b vaccine; Hep b, hepatitis b vaccine; MMR, measles, mumps and rubella vaccine; Var, varicella vaccine.
462 ❘ Journal of Public Health Management and Practice Multiple outreach efforts between ages 10 and 19 months were recorded for 480 (24%) of the 1 998 children truly NUTD at 10 months. Of the 480 children with multiple outreach efforts, 151 (31%) were UTD for all recommended vaccinations at 19 months of age. Of the 1 508 children who received one outreach effort, 310 were UTD at 19 months (21%). The difference in coverage for children with multiple versus single outreach efforts was significant (P < .05).
● Discussion Although the IIS indicated that a large portion (73%) of 10-month-old children were NUTD for immunizations due by 6 months of age, a majority of children thought to be NUTD were actually UTD. This indicates that providers are not transferring immunization information to the IIS in a timely fashion. As a result, unnecessary effort is spent by outreach staff in contacting providers and parents of UTD children and in entering their individual records into the IIS. With these children, outreach efforts were primarily useful in updating the information in the IIS. Efficiency of health department, outreach and provider staff could be improved if immunization providers input complete immunization information into the IIS in a timely manner.14,15 Other studies have shown that input of electronic medical records and electronic billing data into an IIS promotes data completeness in the IIS.11,12 IIS completeness could also be improved if birthing hospitals routinely entered administration of the birth dose of hep B vaccine into the IIS. The large proportion of children whose records are not complete in the IIS limits the usefulness of the recall function of the IIS. Recall involves contacting parents of NUTD children and has been shown to increase coverage.1 However, because many administered immunizations are not recorded in the registry, use of the IIS to recall parents of children who appear NUTD would create confusion among parents whose children actually were UTD but whose records were incomplete in the IIS. Therefore, until data completeness is improved, the IIS in Philadelphia is primarily useful for reminding parents of cohorts of children that ageappropriate immunizations are coming due. In this study, many children living in areas not served by community outreach organizations are NUTD at 10 months of age according to the IIS. These children may be truly NUTD or may simply need their IIS records updated to reflect all immunizations received. As a result of this evaluation, the PDPH is currently contacting the last immunization provider for these children and, if the child is still NUTD, attempting to locate and contact the child’s parents.
Among children referred to outreach, nearly one in five children (17%) could not be located through telephone calls, postcards, and home visits on the basis of the information in the IIS and in the provider records. In spite of the relatively short time period between birth and these outreach efforts, many children appear to have relocated, highlighting the mobility of this population. While some of these children likely have moved out of Philadelphia and are receiving immunizations from providers outside of the city, it is also likely that some of the children have remained in the city but are not receiving needed immunizations. Some children might also still be at the residence recorded in the IIS, but their parents may have opted not to vaccinate their child or respond to outreach efforts. More strategies need to be developed to locate children NUTD for immunizations and educate their parents about the need to obtain recommended immunizations for their child. Children who are truly NUTD at 10 months appear likely to also be NUTD at 13 and 19 months in spite of receiving outreach. Only half of NUTD 10-monthold children had received vaccines due at 6 months of age by 13 months of age. Furthermore, even if they did catch up by 13 months of age, most were again NUTD for age-appropriate vaccinations at 19 months. Multiple outreach efforts were somewhat more effective in ensuring that children were UTD at 19 months than a single outreach effort. Therefore, it might be prudent to provide continued outreach for children behind in their vaccinations through 19 months of age, at which time most childhood vaccinations are scheduled to be complete until 4 years of age, or until children are brought UTD. This evaluation is limited to the city of Philadelphia with its IIS and outreach program. The findings therefore cannot be generalized to other areas, other IIS, or other outreach systems. However, the methods used to evaluate this outreach program might be modified to evaluate the effectiveness of other such programs. In addition, we likely underestimate UTD coverage at 19 months because it is based on the information in the IIS, which may be incomplete. Underestimation of coverage is likely more common among children who were UTD at 10 months of age because these children received no chart audits or outreach, which assist in updating IIS records. In summary, this evaluation provides evidence that provider chart audits and outreach to parents may be beneficial to improving IIS completeness and childhood immunization coverage. More efficient use of health department funds could be made if providers submitted complete data on administered immunizations to the IIS in a timely manner. More effort needs to be made to identify strategies to assist providers in this effort. Outreach to parents likely helped some children become
Provider Chart Audits and Outreach to Parents
UTD by 13 months of age. However, outreach efforts for children NUTD at 10 months need to be continued at least through 19 months or when the early childhood immunization schedule is complete. In addition, in spite of outreach, many children were not brought UTD by 13 or 19 months, so new strategies need to be developed to motivate the parents of these children to obtain recommended vaccinations and to ensure that missed opportunities for vaccination do not occur. Finally, more strategies need to be identified to locate children whose providers have not updated their immunization records and whose last contact information is not valid. Although these children may be receiving care from providers outside of the IIS, they also may not be receiving healthcare and may be in need of immunizations.
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