PEDIATRICS Vol. 107 No. 4 April 2001, p. e49

ELECTRONIC ARTICLE:
Variation in Clinician Recommendations for Multiple Injections During Adoption of Inactivated Polio Vaccine

Received Feb 1, 2000; accepted Aug 2, 2000.

Tracy A. Lieu^{*, §}, Robert L. Davis, Angela M. Capra^*, Loren K. Mell, Charles P. Quesenberry^*, Kathleen E. Martin^*, Ann Zavitkovsky, Steven B. Black^*, Henry R. Shinefield^*, Robert S. Thompson, and Lance E. Rodewald

From the ^* Division of Research and the Vaccine Study Center, Kaiser Permanente, Oakland, California;  Center for Health Studies, Group Health Cooperative, Seattle, Washington; ^§ Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts, Pediatric Clinical Effectiveness Program, Children's Hospital, Boston, Massachusetts, and Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts; and the  National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia.

Objectives.  To describe variation in clinician recommendations for multiple injections during the adoption of inactivated poliovirus vaccine (IPV) in 2 large health maintenance organizations (HMOs), and to test the hypothesis that variation in recommendations would be associated with variation in immunization coverage rates.

Design.  Cross-sectional study based on a survey of clinician practices 1 year after IPV was recommended and computerized immunization data from these clinicians' patients.

Study Settings.  Two large West Coast HMOs: Kaiser Permanente in Northern California and Group Health Cooperative of Puget Sound.

Outcome Measures.  Immunization status of 8-month-olds and 24-month-olds cared for by the clinicians during the study.

Results.  More clinicians at Group Health (82%), where a central guideline was issued, had adopted the IPV/oral poliovirus vaccine (OPV) sequential schedule than at Kaiser (65%), where no central guideline was issued. Clinicians at both HMOs said that if multiple injections fell due at a visit and they elected to defer some vaccines, they would be most likely to defer the hepatitis B vaccine (HBV) for infants (40%). At Kaiser, IPV users were more likely than OPV users to recommend the first HBV at birth (64% vs 28%) or if they did not, to defer the third HBV to 8 months or later (62% vs 39%). In multivariate analyses, patients whose clinicians used IPV were as likely to be fully immunized at 8 months old as those whose clinicians used all OPV. At Kaiser, where there was variability in the maximum number of injections clinicians recommended at infant visits, providers who routinely recommended 3 or 4 injections at a visit had similar immunization coverage rates as those who recommended 1 or 2. At both HMOs, clinicians who strongly recommended all possible injections at a visit had higher immunization coverage rates at 8 months than those who offered parents the choice of deferring some vaccines to a subsequent visit (at Kaiser, odds ratio [OR]: 1.2; 95% confidence interval [CI]: 1.0-1.5; at Group Health, OR: 1.8; 95% CI: 1.1-2.8).

Conclusions.  Neither IPV adoption nor the use of multiple injections at infant visits were associated with reductions in immunization coverage. However, at the HMO without centralized immunization guidelines, IPV adoption was associated with changes in the timing of the first and third HBV. Clinical policymakers should continue to monitor practice variation as future vaccines are added to the infant immunization schedule.  Key words:  immunizations, vaccines, provider practices, practice variation, inactivated polio vaccine.

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