Provider Counseling for Immunizations in Primary Care Settings Presenter: Linda Hill, MD, MPH Co-authors: John Fontanesi, PhD; Jill Rybar, MPH; David Kopald, BS;Mary Rose Mueller, PhD; Abby Shefer, MD; Richard Schieber, MD, MPH; Mark Messonnier, PhD, MS University of California, San Diego University of San Diego Centers for Disease Control and Prevention

Putting Prevention into Practice: Harder Than it Looks Multiple clinical practice guidelines have been published There is variable uptake of CPGs by clinicians IOM Report highlighted the Quality Chasm created by the lack of uptake of CPGs

Tobacco Counseling, For Example Tobacco CBGs are widely distributed However, ‘ever advice’ for smoking cessation by a physician ranges from 21-66% by smokers self report ETS counseling at well child and acute care pediatric visits is even lower. Only 1.5% of pediatric ambulatory care visits included tobacco cessation counseling, including only 4.4% of illness visits for asthma.

Immunization Services CGBs well documented for immunizations Guidelines take two forms: immunization schedule and ‘Standards’ Influenza vaccine and Pneumovax are recommended for adults 18-50 who have chronic diseases such as: COPD; DM; HIV; renal disease; RAD; Splenectomy

High Risk Adults 18-49: how are we doing? Healthy People 2010 Goal: 60% coverage for influenza and pneumococcus Levels of coverage: Influenza vaccine: 20% Pneumovax: 8%

Reasons For Not Providing Preventive Services Competing demands on provider time and attention Patient characteristics (health conditions, patient expectations) Cost Quality of the clinical practice guidelines

Purpose of this analysis Determine the amount of time physicians spend discussing, with high risk adults, the need for immunizations Determine the amount of time spent on other preventive services Develop strategies for physicians that promote to discussing and prescribing appropriate immunizations

Methods Primary care visits in a variety of ambulatory care settings were audio taped Taped sessions were coded by two of the investigators (both licensed HP), using the Davis Code, developed at UCD

Preliminary Results 37 visits evaluated 4 sites used: 3 CHCs and 1 private practice Patients: 20-50 y.o. with chronic diseases Included eligible patients enrolling from 9/03 to 1/05

Time spent discussing immunizations Of all 24 visits when immunizations are discussed, 9% of the visit is used (about 1.1 minutes) Of the visits when immunizations are discussed AND the patient got a shot .4 minutes is spent discussing immunizations When immunizations were discussed, NO time was spent on other prevention

What took most of the time? The majority of the visit (8 of the 13 minutes) was spent on the history and planning treatment The majority of that interaction was spent discussing medications: clarifying their list, reviewing need for refills, patient assistance for medicine and writing the prescriptions

Conclusions In the 12-14 minutes physicians had to spend with high risk adults there were multiple competing priorities; When immunizations were discussed, other discussions were reduced, including other prevention; Vaccination of these high risk adults is unlikely to occur without discussion.

Putting in Context Other Price studies have shown 1. Physician advice is the greatest predictor of receipt of immunizations (as opposed to age, ethnicity or other patient characteristics) 2. that physician immunization advice is most likely to occur when: At least 1:4 ratio of physician to other staff Chart present at the time the patient is seen Provider time: total visit time ratio no less than 1:2

Recommendations Increase physician support: Have efficient systems in place: chart, ratio of staff, reducing waiting times Systematize preventive services Review medications prior to the seeing the physician to increase time for other priorities Obtain immunization history prior to seeing the physician to increase efficiency and prompt physicians

Future Studies Complete coding of all study interviews and revise the analysis Coding the quality of the advice Relating the quality with immunization outcomes Relating the quality with patient satisfaction as recorded in exit interviews