Elsevier

Vaccine

Volume 24, Issue 6, 6 February 2006, Pages 803-818
Vaccine

Determining indications for adult vaccination: Patient self-assessment, medical record, or both?

https://doi.org/10.1016/j.vaccine.2005.07.093Get rights and content

Abstract

Context

Eight or more vaccines may be indicated for adults in the United States. Determining if any vaccines are needed requires integrating information on the patient's demographic and behavioral risk factors and health status, the health status of the patient's close contacts, and the patient's immunization history. This process can be time consuming for providers and their staff. We used patient self-assessment as a method of determining which vaccines are indicated for a patient and whether indicated vaccines had been received.

Design, setting, and participants

Cross-sectional convenience sample of 300 adults in three family practice settings. Participants completed a self-assessment tool to determine if influenza, pneumococcal, measles, mumps, and rubella (MMR), tetanus, hepatitis A and hepatitis B vaccines were indicated and previously received. A chart audit was then performed to obtain similar information.

Main outcome measures

Agreement (kappa statistic [<0.00: poor agreement; 0.00–0.20: slight; 0.21–0.40: fair; 0.41–0.60: moderate; 0.61–0.80: substantial; 0.81–1.00: almost perfect]) between the self-assessment tool and the audit for (1) indicated vaccines and (2) previous receipt of indicated vaccines indicated according to both the assessment form and the audit.

Results

Agreement between the self-assessment tool and chart review was substantial or better only for pneumococcal and MMR vaccines (kappa = 0.65 and 0.85, respectively). For influenza vaccine, agreement improved (from kappa = 0.56 to kappa = 0.74) when indications attributable to health conditions of family members were excluded. Agreement regarding receipt of vaccines was highest for influenza vaccine (kappa = 0.70). Only 57% of patients correctly recalled tetanus vaccination that were documented in the medical record (kappa = −0.04). Kappa statistics were unreliable for hepatitis A and B vaccines because so few vaccinations had been received.

Conclusions

Discrepancies in agreement regarding indications for vaccines appeared to result from absence of information in the medical record regarding high risk behaviors and family contacts. Lack of agreement regarding vaccines that had been previously been received appeared due to both poor recall and lack of documentation. Combining medical record audit with self-assessment may be the most complete assessment of vaccination status of adults, but requires reconciling disagreements. Electronic medical records and registries that contain information about risk factors and previously administered vaccines may be necessary to overcome some these problems.

Introduction

Most American adults should be evaluated for eight different vaccines [1]. To determine which of these vaccines should be administered, it is necessary to know whether or not the vaccine is indicated and if it has already been received. Determining if a vaccine is indicated for a specific patient can be complex and time consuming since it requires knowledge about the patient's demographics (age, sex, race, ethnicity, fertility status, residence), health conditions, occupation, avocations, travel plans, behaviors (e.g. sexual preferences, number of sexual partners, and street-drug use), as well as the age and health condition of family members [2]. The provider must also determine if the patient has already received the correct number of doses at the appropriate intervals.

Interventions to increase immunization coverage in adults usually include only indications based on one or two easily assessed factors such as the patient's age [3] or a specific disease (e.g. diabetes) [3], [4], and rarely include comprehensive assessment of health-based or behavioral and occupational risk factors [2]. Adult immunization interventions most often concentrate on influenza and pneumococcal vaccine, rarely including vaccines such as hepatitis B, which is primarily indicated for behavioral and occupational exposures. The difficulty of assessing adults under age 65 is reflected in a recent review of evaluations of interventions to increase vaccination in this age group [5], [6], [7], [8], [9], [10], [11]. Most involved only one or two adult vaccines, and no study included more than three of the eight recommended vaccines. To our knowledge there are no reports of attempts to increase the coverage for all indicated vaccines. To facilitate such an intervention, we developed and validated a patient-administered self-assessment tool that assists providers in determining whether any of these vaccines are indicated.

Section snippets

Methods

This study was approved by the institutional review boards of the Centers for Disease Control and Prevention and Louisiana State University Health Science Center. The study sites which did not have their own institutional review boards, obtained federal wide assurance numbers and completed an authorization agreement saying that they would rely on the Centers for Disease Control's institutional review board for review of the protocol.

Results

The mean age of the 300 patients was 48.2 (range 18–94) years. Most (70.2%) were female. According to information on the self-assessment form 41.5% were white, 36.5% were black or African American, and 4% were American Indian or Alaska Native. The remainder (16%) did not specify their race or indicated it as other. Ethnicity was reported as Hispanic by 17.7% of the patients. One site did not provide race/ethnicity data.

Discussion

While the medical record is the “gold standard” for the immunization status of children [15], we have shown that there are many limitations to relying on the medical record alone to determine the immunization needs of adults. In determining if a patient was in a target group and if the patient had received the indicated vaccine, patient- and medical record-provided information often disagreed. More indications were consistently found on self-assessment. Even when we limited analysis to vaccines

Acknowledgements

The authors thank the staff of the clinics where the studies were conducted: Michael Baron, Kathie Guthrie, Vicki Duke, Maxine Small, Lloyd White, Veronica Nwadeyi, Brenda Swann, Linda Franklin, Holley Galland, Jullie Assercq, Toan Hau, John Howe, Sharon Werner, Yihong Zheng, Phyllis Saucier, Helen Funderburk, Alan Firestone, Geoff Steffens, Nancy Guinn, Carmen Rodriguez, Darri Harrison, Josh Firestone, Celina Padilla and the staff of El Pueblo Health Services. We also thank Glenn Jones, Mary

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  • Cited by (0)

    This study was approved by the Institutional Review Boards of the Centers for Disease Control and Prevention and Louisiana State University. The other two clinics did not have their own IRBs so the CDC IRB served in this capacity.

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