November 2014 Bulletin

Communicating with Vaccine-Hesitant Parents

Doug Opel Bulletin

Dr. Douglas Opel, a general pediatrician and researcher at Seattle Children’s, addresses questions about his recently published study on communication with parents about vaccinations.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.

Q. What communication approach did you find was most effective for parents in general and for vaccine-hesitant parents in particular?

A. One particularly interesting communication practice was how the child’s provider started the vaccine discussion with the parent during well-child visits. Three-quarters of the providers in our sample used a presumptive format, which conveys the assumption that the parent will accept the recommended vaccines (e.g., “Well, we have to do some shots.”). The remaining providers used the opposite approach – a participatory format – in which parents are given more decision-making latitude (e.g., “What do you want to do about shots?”).

We found differences in outcomes depending on which initiation format was used. Parents were more likely to express initial verbal resistance to one or more vaccinations when providers used a participatory format compared to when providers used the presumptive format.

They were also more likely to refuse one or more recommended vaccines by the visit’s end when the provider began the vaccine discussion with a participatory format as compared to a presumptive format. This was true even after controlling for a parent’s vaccine-hesitancy status.

Another communication practice of interest was what providers did after a parent voiced initial resistance to vaccines during the vaccine discussion. When providers pursued a parent’s refusal to try to convince them to reconsider (e.g., “If he was my child, I would definitely go ahead.”), about half of parents who were initially resistant changed their mind. Among vaccine-hesitant parents, 27% changed their mind when the provider pursued the topic.

Q. Do you have any tips about communicating with vaccine-hesitant families?

  • Don’t be afraid to be presumptive, especially when you are talking with parents about vaccines for the first time. Start the vaccine discussion by telling parents what vaccines their child is due to receive. The large majority of parents have no issues with vaccines, so it’s OK to presume that the parent you are seeing will be one of the majority. You can even be presumptive and still give the parents an opportunity to express their own preference, such as, “Today, Johnny gets his MMR and varicella. Sound OK?”
  • If you prefer a participatory approach to start the vaccine discussion, commit to pursuing any refusals, concerns or questions. Even parents who seem to have a strong opinion might only need slight encouragement or reassurance to change their mind. Vaccine hesitancy appears to be a modifiable behavior.

Q. Does national data suggest we’re making progress getting children the vaccinations they need? Are families less hesitant today than they were five years ago?

A. In general, vaccination rates are very good and remain steady. One concerning trend, however, is the number of parents who opt out of school requirements for nonmedical reasons, which is a sort of surrogate metric of vaccine hesitancy. Nationally, nonmedical exemptions increased almost every year from 2006 to 2011.1 In Washington, however, we have seen a decline in exemptions since the new law went into effect in 2011.

Q. You published a study in 2011 about pediatricians’ attitudes toward alternative vaccine schedules. For example, most pediatricians are more comfortable waiting on Hep B vaccination than PCV. When we need to compromise, it seems like alternative schedules are our only choice. Do you have any updates since you published that study?

A. Alternative schedules are increasingly common in today’s practice, and certainly present a dilemma. There is no evidence for anything but the recommended schedule, so it is hard for providers to agree to them given our goal to protect the child from disease.

However, if you have thoroughly explored a parent’s reasons for wanting to delay or refuse and have been unable to convince them otherwise, I’d argue that alternative schedules that at least partially immunize the child are probably better than the alternative of requesting that the parent take their child elsewhere for pediatric care. If you have to prioritize, you would want to pick vaccines that cover diseases that are in active circulation, have severe sequelae or are highly contagious.

Currently, the consensus nationally is to follow a research agenda that promotes the continued testing of the safety and efficacy of the recommended schedule rather than putting resources toward a new agenda that seeks to test the safety and efficacy of alternative schedules. I imagine that might change if increasing numbers of parents continue to use alternative schedules.

Reference

  1. Omer SB, Richards JL, Ward M, Bednarczyk RA. Vaccination Policies and Rates of Exemption from Immunization, 2005–2011. New Engl J Med 2012;367:1170-1171.

Seattle Children’s Seeks to Partner with Primary Care Providers to Reduce 30-Day Readmission Rate

Seattle Children’s is now scheduling follow-up appointments with primary care providers for all general-medicine patients as part of an effort to reduce the 30-day readmission rate.

In addition, patients on six clinical pathways that have been the focus of improvement efforts will receive follow-up phone calls from nurse care coordinators within 72 hours of discharge. These pathways include asthma, croup, bronchiolitis, cellulitis, acute gastroenteritis and appendicitis.

These strategies are promoted by several state and national collaboratives for preventing avoidable readmissions, including Solutions for Patient Safety, a national collaborative with over 80 pediatric institutions participating in a variety of patient safety and quality activities.

“Families sometimes ask why they need to see their primary care provider, but we believe that transitions are a particularly vulnerable time for patients,” says Dr. Mark Del Beccaro, chief medical officer. “The follow-up visit provides an opportunity to identify any issues or complications that could lead to readmission, and supports continuity of care between the inpatient and primary care settings.”

Seattle Children’s has recently worked to improve the timeliness of delivery of discharge summaries to primary care providers.

“We know that timely information is essential to make the most of the follow-up visit in the primary care office,” says Del Beccaro. “If you have any concerns or if there is anything we can do to improve the transition process, please let me know.”

During the follow-up phone call, the nurse care coordinators will ensure patients understand discharge instructions and the follow-up plan, as well as addressing any questions. If the nurse care coordinators become aware of any concerns that should be discussed with a primary care provider, they will instruct the family to contact their provider.

For questions about the work supporting this goal, contact Dr. Mark Del Beccaro.


Preparing for Ebola at Seattle Children’s

Seattle Children’s has been preparing for the possibility of a patient with Ebola for more than three months following guidance from the Centers for Disease Control and Prevention (CDC), World Health Organization and Public Health – Seattle & King County. Seattle Children’s is training staff about appropriate isolation and patient management, using simulations to test and improve the systems in place.

All patients in all settings are being screened for fever and travel. A patient with suspected Ebola would then be managed according to an algorithm based on CDC recommendations with additional precautions.

If you have a febrile patient who has traveled recently to West Africa, contact Public Health – Seattle & King County immediately at 206-296-4774 for guidance and assistance transporting the patient to the nearest appropriate facility if necessary. At this time, there is no single designated healthcare facility for Ebola cases in King County.

For more information, see the Oct. 7 advisory or the Ebola facts and resources page on the Public Health – Seattle & King County website.


Upcoming CME – Common Orthopedic Trauma: Exam Demo and Case-Based Diagnosis and Management

L.T. Staheli Pediatric Orthopedic Symposium

Saturday, Jan. 10, 2015, at Seattle Children’s Hospital (main campus)

Please join us for this one-day, highly practical course designed to provide the most current information on common orthopedic trauma seen in primary care. The format is unique this year, with exam demonstrations and cases, and an interactive discussion of best practices for diagnosis and management.

View the brochure (PDF) and register online.


Grand Rounds for November 2014 (CME Credit Available)

Upcoming Grand Rounds

  • Type 1 Diabetes in Youth: Where Have We Come from, Where Are We Now and a Path to a Cure, Nov. 13
  • The Interface of Pediatrics and Pathology: The Legacy of Ron Lemire, Nov. 20
  • Nov. 27 – No Grand Rounds due to Thanksgiving
  • See all upcoming grand rounds.

Watch Past Grand Rounds Online

  • What Is Pediatric Oral and Maxillofacial Surgery? A Brief Review of Common and Not-So-Common Pediatric Oral Disease and Pathology
  • What Mechanisms Sustain HIV Infection During Antiretroviral Treatment?
  • Working with the Latino Community to Address Youth Violence
  • Practice Points of Ophthalmology Every Pediatrician Should Know
  • See all online grand rounds.

New Medical Staff and Allied Health Professionals, November 2014

New Medical Staff

  • Andrew Amata, MB, BS, Seattle Children’s, Anesthesiology and Pain Medicine
  • Amber Anderson, MD, Pediatric Associates, Pediatrics
  • Bryan Balmadrid, MD, University of Washington, Gastroenterology and Hepatology
  • Rose Cipres-Jaucian, MD, St. Joseph Medical Center, Neonatology
  • Kavita Dedhia, MD, University of Washington, Otolaryngology
  • Erin Dillon-Naftolin, MD, Seattle Children’s, Psychiatry and Behavioral Medicine
  • Corrie Fletcher, DO, Seattle Children’s, Hospital Medicine
  • Janet Friday, MD, Seattle Children’s, Emergency Medicine
  • Emily Gallagher, MD, MPH, Seattle Children’s, Craniofacial Medicine
  • Devon Haydon, MD, University of Washington, Neurosurgery
  • Mali Hetmaniuk, MD, Seattle Children’s, Anesthesiology and Pain Medicine
  • Fuki Hisama, MD, University of Washington, Neurology
  • Borah Hong, MD, Seattle Children’s, Cardiology
  • Rebecca Kruse-Jarres, MD, Puget Sound Blood Center, Hematology-Oncology
  • Lina Merjaneh, MD, Seattle Children’s, Endocrinology
  • Katie Nielsen, MD, MPH, Seattle Children’s, Critical Care Medicine
  • Aya Reiss, MD, MSc, Seattle Children’s, Emergency Medicine
  • Frederick Walters, MD, Bainbridge Pediatrics, Pediatrics
  • Mark Zobel, MD, Overlake Imaging Associates, Radiology

New Allied Health Professionals

  • Malika Bean, CRNA, Seattle Children’s, Anesthesiology and Pain Medicine
  • Leyla Khastou, ARNP, Seattle Children’s, Emergency Medicine
  • Milla Muller, CRNA, Seattle Children’s, Anesthesiology and Pain Medicine