Strategies for Improving Vaccine Delivery: A Cluster-Randomized Trial.

OBJECTIVE: New emphasis on and requirements for demonstrating health care quality have increased the need for evidence-based methods to disseminate practice guidelines. With regard to impact on pediatric immunization coverage, we aimed to compare a financial incentive program (pay-for-performance [P4P]) and a virtual quality improvement technical support (QITS) learning collaborative. METHODS: This single-blinded (to outcomes assessor), cluster-randomized trial was conducted among unaffiliated pediatric practices across the United States from June 2013 to June 2014. Practices received either the P4P or QITS intervention. All practices received a Vaccinator Toolkit. P4P practices participated in a tiered financial incentives program for immunization coverage improvement. QITS practices participated in a virtual learning collaborative. Primary outcome was percentage of all needed vaccines received (PANVR). We also assessed immunization up-to-date (UTD) status. RESULTS: Data were analyzed from 3,147 patient records from 32 practices. Practices in the study arms reported similar QI activities (∼6 to 7 activities). We found no difference in PANVR between P4P and QITS (mean ± SE, 90.7% ± 1.1% vs 86.1% ± 1.3%, P = 0.46). Likewise, there was no difference in odds of being UTD between study arms (adjusted odds ratio 1.02, 95% confidence interval 0.68 to 1.52, P = .93). In within-group analysis, patients in both arms experienced nonsignificant increases in PANVR. Similarly, the change in adjusted odds of UTD over time was modest and nonsignificant for P4P but reached significance in the QITS arm (adjusted odds ratio 1.28, 95% confidence interval 1.02 to 1.60, P = .03). CONCLUSIONS: Participation in either a financial incentives program or a virtual learning collaborative led to self-reported improvements in immunization practices but minimal change in objectively measured immunization coverage.

Context Matters: Practitioner Perspectives on Immunization Delivery Quality Improvement Efforts.

Uneven adherence to immunization guidelines might leave some communities vulnerable to outbreaks of vaccine-preventable diseases. To examine factors related to implementation of immunization delivery best practices, we analyzed responses to monthly surveys and debriefing interviews from 16 diverse pediatric practices engaged in a year-long virtual learning collaborative. The collaborative provided a toolkit, online learning sessions, performance feedback, and conference calls with a quality improvement coach. Participants used iterative plan-do-study-act cycles to implement self-selected changes in immunization practices. Descriptive statistics were applied to quantitative data; qualitative data were analyzed using a framework approach. Impediments to implementing guidelines included difficulties with electronic record systems, rigid management structures, competing priorities, and parental resistance. Facilitators included linkage with regional immunization registries, positive social interactions, and performance feedback. Findings suggest that improving immunization delivery requires not only awareness of recommendations and training in improvement methods but also efforts to ameliorate contextual factors that impede immunization delivery.

Frequent vaccination missed opportunities at primary care encounters contribute to underimmunization.

OBJECTIVE: To examine missed opportunities to administer an eligible vaccination (MOs) and their contribution to underimmunization in contemporary pediatric practices. STUDY DESIGN: This study was a retrospective analysis from 42 diverse pediatric practices located throughout the US. Medical records of 50 randomly selected children 3-18 months of age per practice were reviewed in Spring 2013. Immunization status for age and MOs were assessed as of each encounter and as of March 1, 2013. RESULTS: Of 2076 eligible patients, 72.7% (95% CI 67.6-77.9) were up-to-date with receipt of standard vaccines. Most children (82.4%; 95% CI 78.3-85.9) had at least 1 MO, and 37.8% (95% CI 30.0-46.2) had at least one MO to administer an overdue vaccination. After adjustment, risk of underimmunization was 3.5 times greater for patients who had ever experienced an MO for an overdue vaccination compared with those who had not (adjusted relative risk = 3.5; 95% CI 2.8-4.3). If all age-appropriate vaccinations had been administered at the last recorded encounter, 45.5% (95% CI 36.8-54.5) of the underimmunized patients would have been up to date at the time of assessment. CONCLUSION: MOs were common and contributed substantially to underimmunization in this contemporary sample of diverse primary care practice settings.

Excess screen time in US children: association with family rules and alternative activities.

We describe the association of screen time in excess of American Academy of Pediatrics recommendations (≤2 h/d) with family television-use policies and regular nonscreen activities among US school-aged children. Data from the 2007 National Survey of Children's Health were used. The sum of minutes spent on television, videos, video games, and recreational computer use was calculated for children 6 to 17 years old. Bivariate and multivariate logistic regression models were used to calculate relative odds of exceeding American Academy of Pediatrics guidelines and of heavy screen use (>4 h/d) for varying family media-use policies and frequency of alternative activities (physical activity and family meals). In all, 49% of school-aged children had screen time >2 h/d and 16% had screen time >4 h/d. Lower frequency of family meals, presence of TV in the bedroom, absence of rules about TV viewing, and less physical activity were associated with both >2 and >4 hours per day of screen time.