1. 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

2. 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

3. 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.

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

5. 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%

6. 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

7. 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

8. 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

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

11. 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

12. 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

13. Conclusions
In the 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.

14. 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

15. 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

16. 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