One of the goals of Healthy People 2010 is to increase to 90 percent the proportion of children with up-to-date immunizations by age two. For multiple reasons, immunization rates are still below the target level. One reason is that health care providers have ineffective systems in place to assure that immunizations are given in a timely fashion. Provider feedback and reminder systems have been shown to increase immunization rates, but these interventions are time-intensive and retrospective in nature. Minkovitz and colleagues used this study to determine if provider prompting at an acute care visit could increase vaccination rates and decrease the incidence of missed vaccination opportunities.

Participants were three years of age or younger who used a pediatric clinic for primary care. A list of patients was generated from those who used this clinic before and after the intervention. The intervention consisted of triage nurses generating a computer printout for each child who visited the clinic in an acute-care visit over 14 months. A portion of the intervention included instructing health care providers about the need to review immunization records even during an acute care visit and to offer age-appropriate immunizations. In addition, immunization rates were reviewed with the staff and providers at regular meetings.

Up-to-date immunization was defined as having four diphtheria and tetanus toxoid and pertussis, three polio, one measles-mumps-rubella, three hepatitis B and three Haemophilus influenzae type b vaccines by 24 months of age. The up-to-date immunization rates increased substantially to 87 percent among children who were enrolled in the practice. Missed opportunity rates among children not up to date significantly dropped from 65 to 45 percent. Similar trends were also noted in infants 10 to 23 months of age.

The authors conclude that minor changes in the operation of the clinic resulted in an improvement in vaccination rates. This improvement was accomplished with no increase in funding and in a clinic environment where providers were faculty members, residents, medical students and nurse practitioners. In addition, the authors state that, in their setting, further improvements in vaccination rates may require efforts to ensure continuity of provider and plan assignment.

editor's note: Despite the fact that immunizations in the first two years of life have been found to be highly effective in preventing serious infections in this age group, repeated studies reveal that immunization rates continue to lag behind national goals. Studies have shown that despite the fact that the Centers for Disease Control and Prevention has established criteria for when immunizations should not be given, physicians continue to miss opportunities to bring children up to date. Minkovitz and colleagues did a simple intervention—establishing the immunization record of all children younger than age three who presented for an acute-care visit. This intervention required no increased funding and minimal staff effort. This process could be easily implemented into physicians' office practice to continue the process of improvement in immunization rates in children.—k.e.m.