Improving Immunizations in Children: A Clinical Break-even Analysis.

Immunizations are an important public health and primary care priority, leading to billions of dollars in savings to society and over 100 million infectious cases prevented in the United States alone.1,2 Accordingly, Healthy People 2010 and 2020 have made increasing the percentage of those immunized a priority, with a stated national goal of 80% of children aged 19–35 months having received all of their recommended immunizations.3 Two of the main causes of poor immunization rates in a medical practice are missed opportunities by clinicians for immunization, and patients not coming in for appointments.4 Many approaches have been taken to address low immunization rates from these causes. Audit and feedback mechanisms, whereby clinicians are given constant information regarding the immunization rates of their patients, along with electronic medical record (EMR) reminders and templates, clinic-wide standing orders, and vaccine delivery protocols have all been shown to improve immunizations through decreased missed opportunities.5–7 Use of patient registries, automated patient reminders, reminder-recall systems, and home visits have shown to be effective at immunizing those who do not consistently seek medical care.8–10 Telephone calls and home visits have proven to be the most effective but are also the most costly.11,12 Multiple studies have evaluated cost-effective ratios on multicomponent interventions for childhood immunizations,13,14 but none were found that provided a break-even cost analysis for the clinic to implement such quality improvement measures. Physician leadership in continuous quality improvement (CQI) is fundamental in the success of these interventions,15 underscoring the importance of training resident physicians in CQI principles.16,17 The University of Utah Family Medicine Residency Program has implemented a novel experiential CQI curriculum for residents, which includes each 3rd year resident leading a team of providers and staff from the two residency clinics.18 The curriculum also includes protected time for CQI teams to meet monthly, and didactic training for the 3rd year residents in the CQI FOCUS-PDSA methodology.19 One of the resident-led CQI projects performed during academic year 2011–12 at the Madsen Family Health Center (MHC) showed a significant improvement in the number of children under 2 years of age receiving recommended immunizations through a decrease in missed opportunities by distributing immunization records of all scheduled pediatric patients to provider-medical assistant (MA) teamlets.20 A second residency clinic, the Sugarhouse Family Health Center (SHC), was not included in the initial intervention in 2011–12. Despite this intervention, many patients were still not receiving care at recommended intervals and were thus falling behind on immunizations; these patients would thus not be impacted by the point-of-care intervention to decrease missed opportunities. The rates of recommended immunizations for children under 3 years of age at MHC and SHC in November 2012 were 75.1% (n=133) and 79.6% (n= 223), respectively. This is compared to the national rate of 68.4% and Utah rate of 73% during the same time period.21 The objective of this project was to further improve vaccination rates of children under 3 years of age by expanding the point-of-care intervention to a second clinic, as well as adding an outreach component to impact patients not seeking medical care. A break-even analysis will be performed to evaluate how many patients need to be immunized to provide a financial benefit to the clinic. The goal of 90% of children receiving recommended vaccinations for their age was established by the CQI team. The age range was chosen to coincide with Healthy People 2020 goals.