Provider characteristics and behaviors as predictors of immunization coverage

doi:10.1016/S0749-3797(01)00373-7

American Journal of Preventive Medicine

Volume 21, Issue 4, November 2001, Pages 250-255

https://doi.org/10.1016/S0749-3797(01)00373-7 Get rights and content

Abstract

Background: Most studies of immunization behaviors measure adherence to standard immunization practices, relying on surveys without linking reported behaviors to objectively measured immunization rates. This study attempts to close that gap.

Methods: In 1997, pediatric, family, and general providers in Pennsylvania serving children aged <36 months (N=251) completed immunization behavior surveys. We linked these responses to patient chart audits for practice-level immunization rates.

Results: Immunization rates for our sample fell short of national goals (average up-to-date immunization status at 12 months=69%). They were significantly higher for pediatricians than for family/general practitioners (78% vs 58%, p<0.001) and for practices treating ≥100 children in the past 30 working days than for those treating <100 children (77% vs 62%, p<0.001). Behaviors with significant associations to higher immunization coverage were: (1) appropriately giving diptheria, tetanus toxoids, and pertussis immunization under false contraindications versus withholding it (73% vs 66%, p<0.05); (2) willingness to give at least four injections at one visit versus fewer injections (74% vs 65%, p<0.01); and (3) holding immunization in-service training versus no training (71% vs 65%, p<0.05). However, multivariate analysis showed that only provider specialty remained a significant predictor of coverage.

Conclusions: Pediatricians have higher coverage rates than family/general practitioners. Although pediatricians see more children, the number of immunization-delayed children at 12 months is approximately the same for both provider groups. Therefore, efforts to improve coverage should continue to be directed toward both groups.

Introduction

Recent studies have shown that immunization rates are falling short of the 90% goal by age 2 years set by Healthy People 2010,1 particularly for disadvantaged population subgroups.2, 3 This paper focuses on physicians’ characteristics and how these characteristics are related to practice-level immunization rates. Understanding the characteristics of physicians related to immunization rates allows better targeting of physician-based interventions. This study was conducted for the Pennsylvania Chapter of the American Academy of Pediatrics’ (PA-AAP) Immunization Education Program (IEP).

Interventions are often directed at physician practices because missed opportunities have been shown to account for an appreciable proportion of immunization delay.4 A missed opportunity occurs when a child sees a provider but does not receive a needed immunization. It has been estimated that in urban settings, missed opportunities account for between 1 and 4 months of immunization delay in the first year of life.2 Moreover, it has been estimated that elimination of all missed opportunities could increase age-specific immunization rates by >15%.5

In an effort to reduce missed opportunities and to raise immunization rates, standard provider behaviors have been recommended, including adhering to proper contraindications, screening for immunization status at all visits, and administering all needed immunizations during a single visit.6, 7 Other standards have been developed to increase practice-based immunization rates, including routine audits of immunization levels and regular in-service education for all practice employees.6 Routine audits of immunization levels have been shown to be effective in public settings.8, 9

Interventions to promote these standards would benefit by being able to identify and target physician practices most at risk for lower immunization levels. This study assesses whether self-reported behavior and other characteristics are useful for identifying such practices. It also seeks to identify physician practice characteristics associated with immunization rates to improve targeting.

A considerable number of provider surveys have assessed adherence to immunization standards.10, 11, 12, 13, 14, 15, 16 However, little research has directly linked provider behaviors and characteristics with practice-level immunization rates. The few studies that have done so are based on small sample sizes, which greatly limit their power and ability to generalize.14, 17, 18 he present study examined practice-level immunization rates and used both background characteristics and provider behaviors as predictors of coverage within a sample of 251 practices, including records for >14,000 children.

Section snippets

Methods

In 1996, the Pennsylvania Department of Health (DOH) contracted with the PA-AAP to develop and implement an immunization education program for physicians and office staff to increase immunization rates and decrease missed opportunities. The Educating Physicians in their Communities (EPIC) Immunization Education Program (IEP) developed a curriculum and trained teams to provide office-based education and traditional continuing medical education (CME) lectures. The teams consisted of a primary

Results

Table 2 illustrates the distributions of the reported predictor variables. Most of the providers studied had >10 years of experience and came from larger pediatric practices serving many children aged <3 years. Most had stable patient populations, and about half served an appreciable proportion of low-income patients. A total of 75% participated in the VFC program, which was new at the time. We found considerable variation in reported provider immunization behavior. About half the respondents

Discussion

Our linkage of provider background characteristics, reported behaviors, and immunization coverage shows that provider specialty is the strongest predictor of immunization coverage. Pediatricians had the highest coverage levels regardless of other practice characteristics or reported behaviors. When we used the same variables (except provider specialty) to predict UTD12 coverage within specialty, none of the relationships between the predictors and coverage rates was significant. This finding

Acknowledgements

We thank Jerold Aronson, MD; Lois Kohrt; Amy Wishner, MSN; Allan M. Arbeter, MD; Susan Zimicki, PhD; Barbara Gault, PhD; and Sarah Wilcox, MA, for their contributions to this research. The Pennsylvania Chapter of the American Academy of Pediatrics and the Pennsylvania Department of Health funded this study. The results and conclusions represented herein do not reflect the position of the Health Care Financing Administration.

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The utilization of the Papanicolaou (Pap) test and the human papillomavirus (HPV) vaccine has significantly decreased rates of cervical cancer and related mortality. Disparities in receiving these preventive screenings are scarcely studied in Muslim females. Our study explores primary care providers’ (PCP) approaches to cervical cancer screening in Muslim females. We created a cross-sectional Qualtrics survey using convenience sampling of PCPs who perform Pap tests in central Ohio. Recruitment emails were disseminated via departmental email listservs. We had 200 analyzable responses and 78% of respondents reported having Muslim patients. Bivariate analysis was used to identify predictors of providers’ approaches. Providers younger than 35 years obtained a sexual history from Muslim females less frequently, family medicine providers were more likely to obtain a sexual history from Muslim females, and gynecologists were more likely to offer the HPV vaccine to Muslim females. Providers who counseled patients about Pap tests (P<0.001) and HPV modes of transmission (P<0.004) were more likely to offer cervical cancer screening for Muslim females. Our findings suggested that providers’ age and specialty may be predictors of proactive cervical cancer screening and prevention in Muslim females and that there is a gap between current guidelines and preventive clinical practices regarding the HPV vaccine and transmission counseling.
Pediatric primary care immunization policies in New York State
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This is in alignment with related studies, as pediatricians have higher up-to-date immunization rates [30] and higher influenza vaccination rates. [31] Earlier research indicates a greater tendency for pediatricians to provide opportunities for vaccination and adhere to immunization guidelines in general when compared with family medicine physicians. [32–34] Further research should be conducted to examine why pediatric practices are more likely to have publicly-available immunization policies.
Practice immunization policies may reflect how their physicians and nurses approach vaccine hesitant parents. This study utilized New York State primary care practices’ websites to locate immunization policies for pediatric patients and collect practice-level data.
For this cross-sectional study, we extracted website data in February/March of 2019. We first conducted a qualitative content analysis using the policy text and developed definitions of practice policy types (i.e., formal, informal, or no policy). Two authors independently reviewed and coded the text, and employed consensus meetings and feedback from the third author to finalize the content analysis. We then examined associations between practice-level characteristics and immunization policy presence through categorical data analysis.
Of the 254 practice websites identified, 36 referred to formal immunization policies that may include consequences (e.g., dismissal) for refusing to vaccinate or not fully vaccinating, and 64 referred to informal policy statements supporting immunization. Most (89%) policies included appeals to scientific and/or professional authority. Almost all (92%) contained language tailored to potential reasons for parents’ vaccine hesitancy. Our categorical analyses indicate that majority-pediatrician practices are associated with the presence of either formal or informal immunization policies (p < 0.001). Our results also suggest regional variation in the presence of such policies across New York state, although statistical significance is not achieved.
Vaccine hesitancy in the pediatric population has become a global concern due to infectious disease outbreaks, most recently the COVID-19 pandemic. Future studies may examine whether practice-level policies are effective in improving local immunization rates.
A method for measuring the effect of certified electronic health record technology on childhood immunization status scores among Medicaid managed care network providers
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This study has some limitations: (1) As with all studies that utilize PSM to develop comparison groups, this study assumes non-ignorability or selection-on-observables to define covariates for propensity score matching. The authors attempted to mitigate this weakness by using data supported by immunization research [20]. The finding of an odds close to one of change in the immunization measure could have been due to unwarranted controlling of confounding variables.
To provide a methodology for estimating the effect of U.S.-based Certified Electronic Health Records Technology (CEHRT) implemented by primary care physicians (PCPs) on a Healthcare Effectiveness Data and Information Set (HEDIS) measure for childhood immunization delivery.
This study integrates multiple health care administrative data sources from 2010 through 2014, analyzed through an interrupted time series design and a hierarchical Bayesian model. We compared managed care physicians using CEHRT to propensity-score matched comparisons from network physicians who did not adopt CEHRT. Inclusion criteria for physicians using CEHRT included attesting to the Childhood Immunization Status clinical quality measure in addition to meeting “Meaningful Use” (MU) during calendar year 2013. We used a first-presence patient attribution approach to develop provider-specific immunization scores.
We evaluated 147 providers using CEHRT, with 147 propensity-score matched providers selected from a pool of 1253 PCPs practicing in Maryland. The estimate for change in odds of increasing immunization rates due to CEHRT was 1.2 (95% credible set, 0.88–1.73).
We created a method for estimating immunization quality scores using Bayesian modeling. Our approach required linking separate administrative data sets, constructing a propensity-score matched cohort, and using first-presence, claims-based childhood visit information for patient attribution. In the absence of integrated data sets and precise and accurate patient attribution, this is a reusable method for researchers and health system administrators to estimate the impact of health information technology on individual, provider-level, process-based, though outcomes-focused, quality measures.
This research has provided evidence for using Bayesian analysis of propensity-score matched provider populations to estimate the impact of CEHRT on outcomes-based quality measures such as childhood immunization delivery.
Choice of measures of vaccination and estimates of risk of pediatric pertussis
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One frequently used measure is being up-to-date (UTD) on vaccinations, which implies all recommended doses of a vaccine have been administered by a specific age [1–4]. UTD may include the nuanced timing of a dose, or whether the dose fell within the vaccine schedule recommendations, and therefore studies employing this measure may be examining different phenomenon from studies that examine UTD without considering dose timing [5–8]. When the timing of a dose is considered, the metric is often referred to as delayed or age-appropriate vaccination.
Vaccination uptake at the individual level can be assessed in a variety of ways, including traditional measures of being up-to-date (UTD), measures of UTD that consider dose timing, like age-appropriate vaccination, and risk reduction from individual doses. This analysis compared methods of operationalizing vaccination uptake and corresponding risk of pertussis infection.
City-wide case-control study of children in Philadelphia aged 3 months through 6 years, between 2001 and 2013. Multiple logistic regression was used to isolate the independent effects of each measure of vaccination uptake and the corresponding relative odds of pertussis.
Being UTD on vaccinations was associated with a 52% reduction in risk of pertussis (OR 0.48, 95% CI: 0.34, 0.69). Evaluation of delayed receipt of vaccine versus on-time UTD yielded similar results. There was a decrease in risk of pertussis for each additional dose received with the greatest reduction in pertussis infection observed from the first (OR 0.48, 95% CI: 0.28, 0.83) and second dose (OR 0.17, 95% CI: 0.08, 0.34). Additional doses conferred minimal additional protection in this age group.
Examining vaccination status by individual doses may offer improved predictive capacity for identifying children at risk for pertussis infection compared to the traditional UTD measure.
Physicians' human papillomavirus vaccine recommendations, 2009 and 2011
2014, American Journal of Preventive Medicine
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Mirroring recommendations for other vaccines,9–13 pediatricians were more likely than FPs to recommend HPV vaccination. Although reasons for differences in HPV vaccine recommendations by physician specialty are largely underexplored, research on other vaccines suggests a need to further examine the potential impact of financial barriers,9,14 importance of immunizations in the practice,15 and concerns about vaccine safety16 on FPs’ HPV vaccine recommendation practices. Physicians aged 40–49 years (vs 50–65 years) were more likely to “always” recommend vaccination in 2009, whereas younger physicians (aged 25–39 years) were more likely to recommend in 2011.
Physician recommendation is a key predictor of human papillomavirus (HPV) vaccine uptake. Understanding factors associated with recommendation is important for efforts to increase current suboptimal vaccine uptake.
This study aimed to examine physician recommendations to vaccinate female patients aged 11–26 years, in 2009 and 2011, at 3 and 5 years postvaccine licensure, respectively. A second aim was to identify trends in factors associated with vaccine recommendation for ages 11 and 12 years.
Nationally representative samples of physicians practicing family medicine, pediatrics, and obstetrics and gynecology were randomly selected from the American Medical Association Physician Masterfile (n=1538 in 2009, n=1541 in 2011). A mailed survey asked physicians about patient and clinical practice characteristics; immunization support; and frequency of HPV vaccine recommendation (“always” ≥75% of the time vs other). Analyses were conducted in 2012.
Completed surveys were received from 1013 eligible physicians (68% response rate) in 2009 and 928 (63%) in 2011. The proportion of physicians who reported always recommending HPV vaccine increased significantly from 2009 to 2011 for patients aged 11 or 12 years (35% vs 40%, respectively; p=0.03), but not for patients aged 13–17 years (53% vs 55%; p=0.28) or 18–26 years (50% vs 52%; p=0.52). Physician specialty, age, and perceived issues/barriers to vaccination were associated with vaccine recommendation for patients aged 11 or 12 in both years.
Results suggest a modest increase in recommendations for HPV vaccination of girls aged 11 or 12 years over a 2-year period; however, recommendations remain suboptimal for all age groups despite national recommendations for universal immunization.
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Similarly, Riedesel et al11 found that endorsements from colleagues and national organizations showed a greater intention to immunize against HPV. Historically, physicians have relied on state endorsements to support a variety of vaccines6,22,23; however, ultimately the institution must integrate these endorsements into standard practice policies and procedures for widespread uptake. The third HPV vaccine-related theme that emerged reflected physicians' personal views, which ranged from concerns about the vaccine's safety and efficacy to its overall acceptability.
The current study presents findings from a qualitative examination of free text comments from a national survey of U.S. physicians on human papillomavirus vaccine recommendation beliefs and practices. Qualitative analyses of free text physician responses may offer a more complete and physician-driven description of influences on human papillomavirus vaccine recommendation.
In 2009, a survey assessing physicians' knowledge, attitudes, and human papillomavirus vaccination practices was conducted among a national sample of U.S. physicians practicing Family Medicine, Pediatrics, or Obstetrics/Gynecology (response rate 67.8%). Qualitative comments were analyzed using a Grounded Theory approach.
Of 1008 completed surveys, 112 participants provided comments, which were organized into three primary HPV vaccine-related themes: (a) comments about cost of the vaccine, (b) comments about institutional policies and procedures, and (c) physicians' personal views and one secondary theme related to survey methodology: the parent study's use of an upfront cash incentive. Many comments pertained to issues that were queried in the closed-end survey items; however, some comments provided insight into understudied areas (e.g., physician attitudes regarding survey methodology).
Physician respondents used the free text space to reemphasize issues that were most important to them and to offer insight about aspects of the vaccine and the survey process.

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¹: Dr. Koepke is currently affiliated with the Centers for Medicare and Medicaid Services.

²: Dr. Vogel is currently affiliated with Mathematica Policy Research.

View full text

Provider characteristics and behaviors as predictors of immunization coverage

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

Missed opportunities for childhood vaccinations in office practices and the effect on immunization status

Pediatrics

Interaction of SES and provider practices as predictors of immunization coverage in Virginia children

Pediatrics

The contribution of missed opportunities to childhood under immunization in Baltimore

Pediatrics

Potential impact on vaccination coverage levels by administering vaccines simultaneously and reducing dropout rates

Arch Pediatr Adolesc Med

Standards for pediatric immunization practices

The critical role of provider practices in undervaccination

Pediatrics

Information as interventionhow Georgia used vaccination coverage data to double public sector vaccination coverage in seven years

J Public Health Manag Pract

Impact of measurement and feedback on vaccination coverage in public clinics, 1998–1994

JAMA

A national survey to understand why physicians defer childhood immunizations

Arch Pediatr Adolesc Med

Beliefs and practices regarding childhood vaccination among urban pediatric providers in New Jersey

Pediatrics