Practitioner Policies and Beliefs and Practice Immunization Rates: A Study From Pediatric Research in Office Settings and the National Medical Association
Objective. To identify vaccination policies and beliefs associated with practice immunization rates (PIR) among office-based pediatricians.
Methods. Primary care pediatricians recruited from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics or the Pediatric Section of the National Medical Association abstracted immunization data from a consecutive sample of children who were 8 to 35 months old and seen in the office for any reason; 1 provider per practice collected this information. PIR were determined at 8 and 19 months of age by calculating the percentage of children in the sample who were fully immunized at that age. Before collecting the immunization data, all practitioners in each participating practice completed a questionnaire detailing his or her policies and beliefs regarding the administration of vaccines. Part of the questionnaire was a scenario involving a 4-month-old child who was due for a diphtheria-tetanus-acellular pertussis immunization at a health supervision visit. A list of 13 possible clinical conditions in this hypothetical patient were presented; practitioners were asked which of these were a contraindication to vaccination. One set of policies and beliefs was computed for each practice using a weighted average of the responses of each provider in a particular practice. Regression analyses were used to assess the association between each policy and belief and PIR at 8 and 19 months, after controlling for potentially confounding sociodemographic characteristics.
Results. Data were analyzed from 112 practices; median PIR at 8 and 19 months were 85% and 71%, respectively. The following policies and beliefs were not statistically associated with PIR at either 8 or 19 months: use of acute visits for vaccinations, conducting an immunization audit within the previous 12 months, perceived difficulties in implementing new vaccine recommendations or staying informed about new recommendations, conducting practice meetings to discuss immunization policies, perception of profitability of providing vaccinations, appointment reminders for scheduled visits, and specific tracking mechanisms for patients who are due for or behind in immunizations. After controlling for sociodemographic characteristics, recommending inactivated poliovirus vaccine and having fewer contraindications to vaccination were associated with statistically higher PIR at 8 months and 19 months. Increasing the maximum number of injections administered at 1 visit was associated with a higher PIR at 8 months but not 19 months of age.
Conclusion. Policies and beliefs linked to many official recommendations for increasing immunization rates were not associated with higher PIR. However, accepting fewer contraindications to vaccination, administering all vaccines for which an infant is eligible at each health supervision visit, and adopting recommended changes in immunization schedules may help providers fully vaccinate a higher percentage of their patients.
Recent evidence suggests that the majority of children in the United States receive their immunizations from office-based practitioners. In reviewing data from the National Immunization Survey, Santoli et al1 found that 58% of children received all of their vaccines in private practices, whereas 73% received all or some of their immunizations in a primary care medical home; only 14% of children were vaccinated exclusively in public health department clinics. The immunization status of children in different practices and clinics varies enormously. In a previous study, we found that among patients who were followed by 15 private practitioners in different states, the percentage in each practice who were fully immunized at 2 years of age ranged from 51% to 97%.2 Much of this variance was not related to geographic or patient/parent characteristics; a child’s individual provider was independently associated with the likelihood that he or she was fully immunized. The role of the practitioner has been cited as a crucial element in increasing the immunization rate of children in the United States.3
In an effort to provide guidelines for the provision of vaccinations, the Standards for Pediatric Immunization Practices were published in 1993.4 Although some of the 18 standards deal with educating parents, community approaches, and the administrative details of providing vaccines, many specific provider-based interventions designed to increase the immunization rate of the population served by a practice or clinic are recommended. These interventions include the use of all clinical encounters for vaccination, the simultaneous administration of all immunization doses for which a child is eligible at every visit, implementation of a tracking system for monitoring the immunization status of patients in the practice, conducting immunization audits, and a parsimonious approach to accepting contraindications to vaccination.
Investigators have found that conscientious application of the entire set of standards within a clinic may increase the immunization rate of the children served. Pierce et al5 compared change in immunization rates between a public health clinic that implemented the Standards for Pediatric Immunization Practices and a control site in Albuquerque, New Mexico. The immunization rate of children at 12 months of age rose 22.9 percentage points in the intervention clinic, whereas there was virtually no change at the control site. Specific interventions such as use of immunization tracking systems,6 patient reminders,7–9 physician feedback and incentives,10,11 and attempts to reduce missed opportunities by using all clinical encounters for vaccination have been evaluated.12,13 Although the effectiveness of some of these interventions has been demonstrated, many studies have had mixed results. These studies have been conducted in specific geographic areas and/or in specialized populations of children. In addition, the costs of some techniques that have been shown to increase immunization rates have been high, limiting their widespread implementation.9,14 Finally, there has been limited acceptance by office-based practitioners of some of the recommended interventions to increase immunization rates,15,16 perhaps because of the paucity of relevant data on their efficacy.
We conducted a national study that compared the stated vaccination procedures of office-based practitioners with their practice immunization rates in an effort to identify specific policies and beliefs that were associated with high levels of fully immunized children. Many of the policies assessed were related to the Standards for Pediatric Immunization Practices. Our goal was to elucidate factors that were associated with high immunization rates and that could be implemented in other practices.
Data were collected for this study as part of a national project on the immunization status of young children conducted by the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics and the Pediatric Section of the National Medical Association (NMA). PROS is a practice-based research organization that consists of 1465 providers in 48 states, Puerto Rico, and Quebec. The NMA is primarily composed of black physicians who have traditionally provided care to disadvantaged populations.
The overall details of the study are described elsewhere.17 Briefly, data for this part of the project came from 3 sources. First, immunization information was abstracted from the medical records of a consecutive sample of children who were 8 to 35 months old and seen for any reason by 1 provider in the offices of participating practices. Up to 120 patients from a practice were enrolled in the study. At the time of an office visit, parents of study children completed a form that provided information on the age and race/ethnicity of their child and the educational level of the mother.
Before collecting the vaccination data, each provider in participating practices completed a practitioner survey. This survey included demographic information such as type of practice organization and the age of the provider. The practitioner was asked to indicate his or her policy on several issues regarding the administration of vaccinations in the practice. These policies included use of acute visits for needed immunizations; whether the practice had conducted an audit to assess the overall immunization rate of children in the practice during the preceding 12 months; whether providers hold meetings to discuss immunization policy; use of mail or telephone reminders for scheduled appointments; and use of a specific method for tracking the immunization status of children in the practice, such as an immunization registry, computerized tracking system, “tickler” file, or systematic chart reviews at times other than an office visit. There was a dichotomous response to each of these items. The practitioner was asked his or her policy on the type of poliovirus vaccine recommended (all inactivated poliovirus vaccine [IPV], IPV/oral poliovirus vaccine [OPV] sequential schedule, all OPV, or no specific policy). The practitioner also indicated the maximum number of injections that she or he would administer at 1 visit, with possible responses ranging from 1 to >5.
In addition to questions about policies, providers were asked about their perceptions on the profitability of providing immunizations in the office. Practitioners indicated whether they thought that they made money providing immunizations, broke even, lost money, or did not know whether administering vaccines was profitable. Practitioners also were queried about the difficulty of understanding and/or implementing new vaccine recommendations, with possible responses ranging from “very difficult” to “very easy.”
Finally, in the practitioner survey, providers were presented the scenario of a 4-month-old child who was due for a diphtheria-tetanus-acellular pertussis (DTaP) vaccine at a health supervision visit. Thirteen possible clinical conditions were listed; the respondent was asked to indicate which of these conditions was a reason to defer administering DTaP to this hypothetical patient in his or her practice. The list of possible clinical conditions included anaphylactic reaction to tetanus toxoid, gastroenteritis without dehydration, afebrile otitis media, a family history of a severe diphtheria-tetanus-pertussis (DTP) reaction, anaphylaxis to eggs, upper respiratory tract infection without fever, seizure disorder being treated with carbamazepine, bronchiolitis without fever, low-grade fever (<39°), fever between 39° and 40°, fever >40°, cerebral palsy, and congenital immunodeficiency.
To determine 1 set of policies and beliefs for each participating practice, we computed a weighted average of all of the responses from each provider in the practice for every item on the survey. For the responses of the practitioner who collected the immunization data on a consecutive sample of patients seen by her or him, the weighting factor was based on the answer to the question, “What percentage of the parents of the children <3 years old that you see in your office on a typical day consider you their child’s primary doctor as opposed to 1 of your partners?” The percentage indicated was transformed to a decimal value, and this became the weighting factor for all of the responses of this practitioner. The responses of the other practitioners were then equally weighted such that the sum of all weighting factors for a practice was 1.0. For example, in a hypothetical 5-person practice, the provider who collects the immunization data indicates that 60% of the parents of patients <3 years old seen on a typical day consider her or him to be their child’s primary doctor. The responses of this practitioner have a weighting factor of 0.6. The weighting factor for the other 4 providers in the practice becomes 0.1 so that the sum of all weighting factors is 1.0.
For those items on the practitioner survey with a dichotomous response, answers of “no” were assigned a value of 0, and “yes” answers were assigned a value of 1. In addition, Likert scale responses and categorical variables were transformed to dichotomous variables. Thus, for the questions about difficulty in staying informed about vaccine recommendations and difficulty in implementing new immunization recommendations, responses of “difficult” or “very difficult” were assigned a value of 0, and a response of “easy” or “very easy” was assigned a value of 1. Similarly, for the item on the survey regarding the perception of profitability of providing immunizations, a response that the practitioner believed that he or she made money by administering vaccines was given a value of 1; all other responses were assigned a value of 0.
Each response by a practitioner was multiplied by the weighting factor for that provider, and resulting values for each item for every practitioner in a practice were summed to determine a single value for the practice; possible values for a policy with a dichotomous response thus ranged from 0 to 1. A similar procedure was performed for responses regarding the maximum number of injections recommended by the practitioners at 1 visit. For this item, possible values for a practice policy on the maximum number of injections ranged from 1 to 6 (with 6 corresponding to a response of “>5”). Finally, the number of clinical conditions that each practitioner considered to be a contraindication to administering a DTaP to a 4-month-old infant was determined. This value was multiplied by the weighting factor, and these products were summed for all of the providers in a practice to compute 1 value for the number of contraindications used by each practice. Possible values for this variable ranged from 0 to 13.
The main outcomes for the study were the practice immunization rate (PIR) at 8 and 19 months of age. The PIR at 8 months was defined as the percentage of enrolled study children from each practice who had received 3 DTP/DTaP/DT, 2 polio, ≥2 Haemophilus influenzae type b (Hib), and ≥2 hepatitis B vaccines before the age of 8 months. Similarly, the PIR at 19 months was defined as the percentage of enrolled patients from each practice who had received 4 DTP/DTaP/DT, 3 polio, ≥3 Hib, 3 hepatitis B, and 1 measles-mumps-rubella before the age of 19 months. Only children who were at least 19 months of age at the time that immunization data were collected were included in the calculation of PIR at 19 months.
Participating practices were included in the analyses only if immunization data on at least 80 eligible children had been collected. A total of 177 practices in PROS and the NMA contributed some immunization data to the entire project; however, 113 practices collected data on 80 or more children. Providers in 1 practice did not return any practitioner surveys; thus, immunization policies and beliefs were compared with PIR for 112 practices. These practices were located in 40 states.
Regression analysis was used to determine the association between PIR and specific immunization policies and beliefs. Two procedures were performed for these analyses. First, the statistical associations between various sociodemographic characteristics of the practice and the PIR at 8 and 19 months of age were assessed. T tests were used for dichotomous practice-specific variables, such as practice organization (solo practitioner versus all other practice types), on the basis of the responses in the practitioner surveys. From the information recorded on the parental study forms, the percentage of mothers in each practice who were college graduates was determined, as was the percentage of black patients. The bivariate correlation coefficient between these percentages and PIR was calculated. Similarly, the correlations between the percentage of providers in each practice born before 1950 and PIR were computed. Sociodemographic characteristics that were statistically associated with PIR at either 8 or 19 months (P < .05) were considered to be potentially confounding variables and included in linear regression models. Separate analyses comparing each policy and belief to the PIR at 8 and 19 months of age after adjusting for the confounding variables were performed. In addition, to identify policies and beliefs that were independently associated with PIR, we analyzed regression models that included all of the potentially confounding sociodemographic characteristics and those policies and beliefs that were statistically associated with immunization rates at 8 and/or 19 months when assessed separately.
Study data were collected between March 1998 and January 2000. The project was approved by the American Academy of Pediatrics institutional review board.
The location and organization of the 112 participating practices are summarized in Table 1. The majority of the practices were located in suburban or rural locations; 64.3% were single specialty pediatric private practices. Participating practices had a median size of 4 practitioners, with a range of 1 to 13. The percentage of mothers of children in the practices who were college graduates ranged from 1% to 91%, with a median value of 29.2%. Among the 112 practices, the median PIR at 8 months was 85% (range: 21%–100%) and 71% at 19 months (range: 18%–96%).
To determine the potential for confounding, we assessed the association between these practice characteristics and PIR at 8 and 19 months. The results of these analyses are shown in Table 2. As can be seen in Table 2, the educational level of the mothers of children in the practice was significantly associated with PIR at both 8 and 19 months. The percentage of black children in the practice was associated with the PIR at 8 months, whereas the type of practice organization was statistically associated with the PIR at 19 months. Each of these variables was included in the models that assessed the relationship between policies and beliefs and immunization rates at 8 and 19 months.
As is presented in Table 3, after controlling for the appropriate confounding variables, there were no statistically significant associations between the majority of practice policies and beliefs that were assessed and PIR at either 8 or 19 months of age. A policy of recommending IPV (versus recommending OPV or some other poliovirus vaccine policy) was associated with a significantly higher PIR at 8 months (P = .008) and 19 months (P = .0001) of age. Similarly, practices that indicated that fewer of the 13 conditions presented were contraindications to administering a DTaP vaccine to a 4-month-old infant had significantly higher PIR at both 8 and 19 months of age than those practices that indicated that more of the conditions were contraindications to vaccination (P = .02 and P = .01, respectively). Finally, practices that, as a policy, administered a higher number of vaccine injections at 1 visit had a significantly higher PIR at 8 months than those that indicated that they gave fewer number of injections at 1 visit (P = .03).
Also shown in Table 3 are the coefficients and 95% confidence intervals for each variable in the regression models. These coefficients provide an estimate of the percentage point change in PIR associated with each policy or belief; 95% confidence intervals that include 0 are indicative of estimates that were not statistically associated with PIR. For those policies and beliefs that were statistically associated with PIR, the effect can be quantified. Thus, recommending IPV as opposed to another poliovirus vaccine policy was associated with a 8.9 percentage point increase in PIR at 8 months and a 15.1 percentage point increase in PIR at 19 months of age. Among the 112 participating practices, the median number of clinical conditions judged to be a contraindication to vaccination was 4.66 (out of a total of 13 possible), with a range of 2 to 11. For each clinical condition that was not judged to be a contraindication, the PIR at 8 months increased by 2.0 percentage points and by 2.6 percentage points at 19 months. Similarly, the median value for the maximum number of vaccine injections that would be administered at 1 visit was 4.17, with a range of 2 to 6. For each additional injection that would be given at 1 visit, the PIR at 8 months increased by 3.8 percentage points.
Regression models that included all policies and beliefs found to be associated with PIR at either 8 or 19 months and the potentially confounding sociodemographic variables were analyzed. Both limiting the number of contraindications (P = .047) and recommending IPV (P = .030) were found to be independently associated with higher PIR at 8 months. Similarly, limiting contraindications and recommending IPV were also independently associated with higher PIR at 19 months (P = .008 and P = .0001, respectively). However, after controlling for these policies, increasing the maximum number of injections administered at 1 visit was not independently related to PIR at either 8 months (P = .343) or 19 months (P = .273).
The results of this study were disappointing in that we were unable to find supporting evidence for many of the interventions that have been proposed to increase PIR. Among those assessed, the policy that had the greatest positive association with PIR, recommending IPV, may largely be a reflection of intrinsic practitioner beliefs and thus difficult to replicate in other providers. On a more positive note, accepting fewer contraindications to vaccinations and increasing the maximum number of injections administered at 1 visit were found to be associated with higher PIR. These policies, both of which are components of the Standards for Pediatric Immunization Practices,4 could be immediately instituted without cost in all practices in the United States.
Our result that accepting more contraindications to vaccination is associated with lower PIR is consistent with findings in a previous PROS project on immunizations in private practices.2 In that study, practitioners who indicated that 4 or more clinical conditions (out of 7) were contraindications to administering a DTP to a 4-month-old had PIR at 24 months that were 15.3 percentage points lower than those who accepted 3 or fewer of the conditions as contraindications. In the present study, among the 13 clinical conditions presented to the practitioners, only anaphylaxis to tetanus toxoid is an absolute contraindication to administering a DTaP vaccine to a 4-month-old infant.18 Bronchiolitis, if part of a significant illness, could constitute a “precaution” to providing the immunization. Similarly, although fever by itself is not a contraindication, temperatures of 38° to 39°, 39° to 40°, or above 40° could be part of a moderate or severe illness and thus also considered to be a “precaution” to administering vaccines.17 Thus, our finding of a median value of 4.66 for the number of contraindications to vaccination accepted by practices is consistent with these recommendations. Although accepting a single additional contraindication had only a modest negative effect on PIR, the cumulative effect of accepting more contraindications was substantial. On the basis of our models, a practice that indicated that 11 of the 13 conditions presented were contraindications might be expected to increase their PIR by 12 percentage points at 8 months and by 15.6 percentage points at 19 months if they reduced the number of contraindications to 5 of the 13 conditions.
Our finding that a policy of administering a higher maximum number of injections given at 1 visit may be related to higher PIR at 8 months of age is consistent with the standard that calls for providers to give all vaccines for which a child is eligible at every visit.4 Other investigators have reported a similar trend. Lieu et al19, in reviewing reasons for underimmunization among 4691 children who were 15 to 24 months of age, found that the simultaneous administration of all possible vaccines would have resulted in 30% of these patients being fully immunized. However, in our study, the effect on the PIR at 8 months was modest; after controlling for the policy of recommending IPV and accepting fewer contraindications to vaccination, the policy of increasing the maximum number of injections was not statistically associated with immunization rates. It is also interesting that this policy was not related to increased PIR at 19 months, suggesting that practitioners who may delay some immunizations to limit the number of injections at each visit use the period between 8 and 19 months of age in their patients to “catch up” on these vaccines.
The finding that a policy of recommending IPV was associated with higher PIR should be interpreted in the proper context. The practitioner surveys in this study were completed during a time of transition from an all-OPV schedule, recommended until 1997, to the currently recommended all-IPV schedule.17,20 Subsequently, the availability of OPV has been drastically reduced and the choice of type of vaccine mostly eliminated.20 We believe that the results on the association between a policy of recommending IPV and PIR is not specific for poliovirus vaccine but rather a marker, identifying practitioners who are “early adopters” of new vaccine recommendations.
In addition to not administering all immunizations for which a child is eligible at a health supervision visit, failure to use acute visits for needed vaccines has been cited as a “missed opportunity.” Reducing missed opportunities for vaccination has been proposed as a key ingredient in increasing immunization rates.21 However, there is no evidence in our study to support the contention that a policy of providing vaccines during acute visits actually increased PIR. Szilagyi et al22 reported a similar finding among pediatricians and family physicians in Rochester, New York: a policy of immunizing during acute visits was correlated with lower PIR. This same group of investigators conducted a randomized controlled trial that assessed the efficacy of interventions designed to reduce missed opportunities for vaccination.13 The interventions were not associated with significantly higher PIR. It is possible that practitioners who use acute visits for vaccination do so with the knowledge that it is difficult to adequately immunize their patient populations. This tends to bias investigations on the efficacy of this policy toward finding no efficacy or a negative effect on PIR. However, on the basis of the lack of positive effect found in our study and by other researchers, as well as the failure of a randomized trial of an intervention to reduce missed opportunities, perhaps the policy of providing immunizations during acute visits should not be so strongly endorsed.
In this study, we compared the stated vaccination policies of practitioners and their PIR. Because there are, undoubtedly, differences between stated and actual policies, our results should be interpreted cautiously. In addition, although a wide variety of practices distributed throughout the United States contributed data to the project, providers who participated may not be representative of all practitioners who administer immunizations. Finally, because of the assessment of multiple variables, it is possible that some statistically significant associations between various policies and beliefs and PIR would be found merely by chance. Furthermore, given the large amount of data collected, numerous regression analysis techniques were possible. Those policies that we reported as associated with PIR were found to be statistically related to immunization rates in virtually every analysis performed. Conversely, regardless of the technique used, the other policies and beliefs evaluated were consistently not associated with PIR. On the basis of the sample size of pediatric practices, we had a power of 0.8 to detect differences of 7.5 to 10 percentage points in PIR associated with a specific policy or belief. It is possible that smaller but statistically significant associations between a policy or belief and PIR might have been missed.
It was not our intent to validate or invalidate any of the individual Standards for Pediatric Immunization Practices or other recommended interventions designed to increase PIR. Rather, our purpose in conducting this study was to generate hypotheses regarding the efficacy of these various interventions. On the basis of our findings, we hope that more definitive trials will be performed on individual policies. In the meantime, our results suggest that practitioners may substantially increase their PIR by focusing on strictly limiting contraindications to vaccinations during health supervision visits, by maximizing the number of immunizations given at each visit, and by following recommended changes in the immunization schedule.
LILLY’S XIGRIS DRUG TO TREAT INFECTION HAS FDA APPROVAL
“The Food and Drug Administration approved Eli Lilly & Co’s’s drug Xigris to treat septic infections…FDA approval was expected, since Xigris is the first new drug in years to reduce deaths from sepsis, an infection that causes massive blood clotting and the shutdown of internal organs…Xigris, in a large clinical study, reduced deaths from severe sepsis by nearly 20%…Xigris is expected to carry a hefty price tag… of about $6800… A separate study of pediatric patients will need to be conducted. Xigris, which acts to prevent excess blood clotting, did cause an increase in bleeding events, including intracranial hemorrhage…Xigris is a recombinant, or genetically engineered, form of a naturally occurring protein in the blood called activated protein C. Lilly and other scientists had observed that many sepsis patients have low levels of activated protein C, which tends to regulate the body’s clot formation.”
Burton TM. Wall Street Journal. November 23, 2001
Noted by JFL, MD
This study was funded by the Centers for Disease Control and Prevention, National Immunization Program, and the Health Resources and Services Administration, Maternal and Child Health Bureau.
The following pediatric practices or individual practitioners completed this study: (listed by AAP chapter):
Alabama: Drs. Heilpern & Reynolds, PC (Birmingham), Stephen Brandt, MD (Ozark); Alaska: Anchorage Pediatric Group (Anchorage); Arizona: Orange Grove Pediatrics (Tucson), Cigna HealthCare (Tucson); California-1: Castro Valley Pediatrics (Castro Valley), Drs. Anita Tolentino-Macaraeg, MD, and Arminda Tolentino, MD (Hollister), Shasta Community Health Center (Redding), Cantor, Giedt, & Kamachi (Salinas); California-4: Edinger Medical Group, Inc (Fountain Valley); Colorado: Cherry Creek Pediatrics (Denver), Julie Brockway, MD (Ft. Collins), Gino Figlio, MD (Lamar); Connecticut: Jeff Cersonsky, MD (Southbury); Delaware: DuPont Pediatrics (Middletown); Florida: Rose Joseph, MD (Fort Lauderdale); Georgia: Victor Lui, MD (Chamblee), The Pediatric Center (Stone Mountain); Hawaii: Jeffrey Lim, MD (Honolulu); Illinois: Southwest Pediatrics (Palos Park); Indiana: Northpoint Pediatrics (Indianapolis), Georgetown Medical Care (Indianapolis), Jeffersonville Pediatrics (Jeffersonville); Iowa: Integra Health Pediatrics (Cedar Rapids), Asha Madia, MD (Des Moines); Kansas: Ashley Clinic (Chanute); Kentucky: Michael Simon, MD, and Jennifer Crane, MD (Lexington); Maryland: O’Donovan & Ahluwalia, MD, PA (Baltimore), Children’s Medical Group (Cumberland), Shore Pediatrics (Denton), Shore Pediatrics (Easton), Clinical Associates, PA (Towson); Massachusetts: Garden City Pediatrics (Beverly), Pediatric Associates of Norwood (Norwood), Worcester Pediatric Associates (Worcester); Michigan: Susan Hendrickson, MD (Bay City), Children’s Hospital of Michigan (Detroit), MiddleBelt Pediatrics HCA (Farmington Hills), Downriver Pediatric Associates, PC (Lincoln Park), Pediatric & Family Care of Rochester Hills, Mackinac Straits Primary Care (St. Ignace), Orchard Pediatrics (West Bloomfield); Minnesota: Brainerd Medical Center (Brainerd), South Lake Clinic (Minnetonka); Missouri: Edith Colbert, MD (Chesterfield), Children’s Mercy Hospital (Kansas City), Northland Pediatric Associates (North Kansas City); Montana: Stevensville Pediatrics (Stevensville); New Hampshire: Exeter Pediatric Associates (Exeter), Pediatric & Adolescent Medicine (Kingston), Laconia Clinic (Laconia); New Jersey: Delaware Valley Pediatric Associates, PA (Lawrenceville); New Mexico: Presbyterian Family Health care -Rio Bravo (Albuquerque); New York-1, Pediatric Associates (Camillus), Panorama Pediatric Group (Rochester), Genesee Health Service (Rochester), Edward Lewis, MD (Rochester); New York-2, Andrea J. Leeds, MD, PC (Bellmore), Sonia Vinas, MD (Brooklyn), Huntington Medical Group, PC (Huntington Station); North Carolina: Eastover Pediatrics (Charlotte), Hendersonville Pediatrics (Fletcher); North Dakota: Altru Clinic (Grand Forks), Medical Arts Clinic (Minot); Ohio: Bryan Medical Group (Bryan), North Central Ohio Family Care (Galion), Drs Harris and Rhodes (Lancaster), Comprehensive Pediatrics (Westlake), Wooster Clinic (Wooster), St. Elizabeth Health Center (Youngstown); Oklahoma: Shawnee Medical Center Clinic (Shawnee), Pediatric & Adolescent Care, LLP (Tulsa); Oregon: NBMC (Coos Bay); Pennsylvania, Ches Penn Health Services (Chester), Erdenheim Pediatrics, PC (Flourtown), Plum Pediatrics (Pittsburgh), Pennridge Pediatric Associates (Sellersville), Reading Pediatrics, Inc (Wyomissing); Rhode Island: Marvin Wasser, MD (Cranston); South Carolina, Cheraw Pediatrics (Cheraw), Palmetto Pediatrics (Columbia), Grand Strand Pediatrics (Surfside Beach); Texas: White Rock Pediatrics, PA (Dallas), Sarah Helfand, MD (Dallas), Winnsboro Pediatrics (Winnsboro); Utah: Gordon Glade, MD (American Fork), John Weipert, MD (American Fork), Alpine Pediatrics (American Fork), University of Utah Health Sciences Center (Salt Lake City); Vermont: Judy Orton, MD (Bennington), CHP Brattleboro Pediatrics (Brattleboro), University Pediatrics (Burlington), Rebecca Collman, MD (Colchester), Mousetrap Pediatrics (Milton), Practitioners of Ped Medicine (South Burlington), CHP Timber Lane Pediatrics (South Burlington), Drs Joseph Hagan, Jr, MD, George Brown, MD, and Jill Rinehart, MD (South Burlington), St Johnsbury Pediatrics (St Johnsbury), University Pediatrics (Williston); Virginia: Drs Casey, Goldman, Lischwe, Garrett, and Kim (Arlington), Fishing Bay Family Practice (Deltaville), Pediatric Associates of Richmond, Inc (Richmond), South Richmond Health Center (Richmond); Washington: Jemima Tso, MD (Chehalis), Columbia Basin Health Association (Othello), Redmond Pediatrics (Redmond), Rockwood Clinic (Spokane), Yakima Neighborhood Health Services, Inc (Yakima); West Virginia: Grant Memorial Pediatrics (Petersburg); Wisconsin: Beloit Clinic, SC (Beloit).
- Received February 26, 2001.
- Accepted July 5, 2001.
- Address correspondence to James A. Taylor, MD, Child Health Institute, 146 N Canal St, Ste 300, Seattle, WA 98103. E-mail:
- ↵Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children program, United States, 1997. Pediatrics.1999;104(2) . Available at: http://www.pediatrics.org/cgi/content/full/104/2/e15
- ↵Taylor JA, Darden PM, Slora E, Hasemeier CM, Asmussen L, Wasserman RC. The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from Pediatric Research in Office Settings (PROS). Pediatrics.1997;99 :209– 215
- ↵Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RT. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics.1999;103 :31– 35
- Alemi F, Alemagno SA, Goldhagen J, et al. Computer reminders improve on-time immunization rates. Med Care.1996;34 (10 suppl) :OS45– OS51
- ↵Lieu TA, Capra AM, Makol J, Black SB, Shinefield HR. Effectiveness and cost-effectiveness of letters, automated telephone messages, or both for underimmunized children in a health maintenance organization. Pediatrics.1998;101(4) . Available at: http://www.pediatrics.org/cgi/content/full/101/4/e3
- ↵Hillman AL, Ripley K, Goldfarb N, Weiner J, Nuamah I, Lusk E. The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care. Pediatrics.1999;104 :931– 935
- ↵Askew GL, Finelli L, Lutz J, DeGraaf J, Siegel B, Spitalny K. Beliefs and practices regarding childhood vaccinations among urban pediatric providers in New Jersey. Pediatrics.1995;69 :889– 892
- ↵Taylor JA, Darden PM, Brooks DA, et al. The impact of the change to IPV on the immunization status of young children in the United States: a study from PROS and the National Medical Association. Pediatrics.2001;107 (6) . Available at: http://www.pediatrics.org/cgi/content/full/107/6/e90
- ↵American Academy of Pediatrics. Guide to contraindications and precautions to immunizations, January. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics;2000:755– 758
- ↵Lieu TA, Black SB, Sorel ME, Ray P, Shinefield HR. Would better adherence to guidelines improve childhood immunization rates? Pediatrics.1996;98 :1062– 1068
- ↵American Academy of Pediatrics, Committee on Infectious Diseases. Prevention of poliomyelitis: recommendations for use of only inactivated poliovirus vaccine for routine immunization. Pediatrics.1999;104 :1404– 1406
- Copyright © 2002 by the American Academy of Pediatrics