Missed Opportunities for Childhood Vaccinations in Office Practices and the Effect on Vaccination Status
1 From the Division of General Pediatrics, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
2 From the Division of General Pediatrics, Department of Emergency Medicine, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
3 From the Department of Emergency Medicine, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
4 From the Department of Biostatistics, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
5 From the School of Nursing, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
6 From the Infectious Disease Division of the Department of Pediatrics, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, Rochester, NY.
To determine the rate of childhood undervaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever >60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness. The impact of MOs was twice as great for children having Medicaid or no health insurance as for children covered by private insurance. Missed opportunities contributed 13% of the total undervaccination time in the suburban practice, 27% in the clinic, and more than 40% in the other practices. It is concluded that missed opportunities for vaccination occur frequently and contribute significantly to the undervaccination of preschool children. The effect of MOs is greatest in practices serving impoverished children. Reducing MOs would substantially improve the vaccination levels of preschool-age children.
Key Words: preschool children • vaccination • immunization
Submitted on May 8, 1992
Accepted on July 20, 1992
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