title: Operational conditions affecting the vaccination of older adults.
abstract: BACKGROUND
  The content and context of the process of vaccinating older adults against influenza in outpatient settings has not been adequately described. Failure to appreciate the causal antecedents or precursors to the act of provider recommendation may explain why so many efficacious interventions identified by the U.S. Task Force on Community Preventive Services fail to be routinely implemented and why influenza immunization rates have remained static over the past decade.
  
  
  METHODS
  This study used critical path analysis from data collected during standardized workflow observations of patients more than 50 years of age from a convenience sample of 16 ambulatory care settings in San Diego, California; Rochester, New York; and Albuquerque, New Mexico. Observations were made from October 23, 2001 to January 31, 2002.
  
  
  RESULTS
  In this study, 62% (151/243) of patients observed during scheduled extended visits received influenza vaccinations. When operational, temporal, and clinical factors are examined altogether through critical path analysis, a model of seven critical organizational support, temporal, and clinical activities emerges that is able to predict 93% of the immunizations. Variation from the model predicts 73% of the missed opportunities.
  
  
  CONCLUSIONS
  Vaccination of adults should not be seen as simply an incremental activity added to the general health encounter. Assuring a high rate of vaccination requires adequate time and operational support. Provider-patient discussion is more productively viewed as the culmination of the immunization process, not the beginning. Finally, this study indicates the potential need to identify and compare processes of care associated with other specific preventive services.
authors.affiliation: University of California, San Diego, Division of Community Pediatrics, La Jolla, CA 92092, USA. jfontanesi@ucsd.edu
authors.forename: John
authors.initials: J
authors.lastname: Fontanesi
authors.forename: Abigail M
authors.initials: AM
authors.lastname: Shefer
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Fishbein
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Bennett
authors.forename: Michelle
authors.initials: M
authors.lastname: De Guire
authors.forename: David
authors.initials: D
authors.lastname: Kopald
authors.forename: Kathy
authors.initials: K
authors.lastname: Holcomb
authors.forename: David W
authors.initials: DW
authors.lastname: Stryker
authors.forename: Margaret S
authors.initials: MS
authors.lastname: Coleman
mesh_terms: D000368:Aged; D003625:Data Collection; D005260:Female; D006801:Humans; D007252:Influenza Vaccines / Q000008:administration & dosage*; D007251:Influenza, Human / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009819:Office Visits; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D017064:Process Assessment, Health Care; D012044:Regression Analysis; D014481:United States
chemical_list: D007252:Influenza Vaccines