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BACKGROUND Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization. METHODS We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model. RESULTS Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians’ perceived lack of skills to effectively communicate with vaccine-hesitant parents. CONCLUSIONS Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

OBJECTIVES: To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS: We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS: Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference −0.3; 95% confidence interval: −1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (−4.6; 95% confidence interval: −7.5 to −1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS: We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians “do more” for hospitalized children who are not UTD.

OBJECTIVES:To assess (1) the accuracy of child immunization status documented by providers at hospital presentation for acute respiratory illness and (2) the association of provider-documented up-to-date (UTD) status with immunization receipt during and after hospitalization.METHODS:We conducted a retrospective cohort analysis of children ≤16 years old treated for asthma, croup, bronchiolitis, or pneumonia at a children’s hospital between July 2014 and June 2016. Demographics, clinical characteristics, and provider-documented UTD immunization status (yes or no) at presentation were obtained from the medical record. We compared provider-documented UTD status to the gold standard: the child’s UTD status as documented in the Washington State Immunization Information System (WAIIS). The sensitivity, specificity, and positive predictive value of provider-documented UTD status were calculated. We assessed the association of provider-documented UTD status and immunization during and within 30 days posthospitalization using multivariable logistic regression.RESULTS:Among 478 eligible children, 450 (94%) had provider-documented UTD status at hospital presentation and an active WAIIS record. Overall, 92% and 42% were UTD by provider documentation and WAIIS records, respectively, with provider-documented UTD status having 98.4% sensitivity (95% confidence interval [CI]: 95.4%–99.7%), 12.2% specificity (95% CI: 8.5%–16.8%), and 44.6% positive predictive value (95% CI: 39.7%–49.5%). Per WAIIS records, 20% and 44% of children who were due for vaccines received a vaccine during or within 30 days posthospitalization, respectively. There was no significant association between provider-documented UTD status and immunization during or after hospitalization.CONCLUSIONS:Provider-documented UTD immunization status at hospital presentation for children with respiratory illnesses overestimates UTD status, creating missed opportunities for immunization during and after hospitalization.

OBJECTIVES: Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations. METHODS: This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0–100 scale) were dichotomized into scores of ≥50 (hesitant) and RESULTS: Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5–16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting “vaccine concern” or “vaccine unnecessary.” CONCLUSIONS: Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.

Risk is implicit in all clinical decision-making. Whether a clinician refrains from ordering a head computed tomography scan for a patient with a headache or decides to obtain blood work on a child with a fever, each decision involves a balance between accepting and limiting risk. Ideally, clinicians strive to achieve this balance. Clinicians accept some risk (eg, the risk of missing a rare disease) to avoid placing undue burden on the patient and the health care system with invasive, expensive, and/or potentially unnecessary testing. Yet, clinicians also strive not to assume too much risk so that timely diagnoses are made and morbidity and mortality prevented.1 Achieving this balance is difficult for a number of reasons. First, clinicians often lack precise estimates of the risks and harms for a given clinical scenario. There is simply an absence of or paucity of data to help quantify many of the risks, benefits, and outcomes associated with different possible therapeutic options. This confounds the ability to know whether pursuing 1 particular option corresponds to accepting too much or too little risk. As a result, decision-making is often intrinsically imperfect. Second, even if precise estimates of the involved risks are known, determining the threshold constituting acceptable risk (ie, the level above which too much risk would be assumed) is largely subjective. The issue of acceptable risk is inherently a matter of values, which, in pediatrics, includes not only the clinician’s values but also those of the parent and sometimes the child. Although there is general agreement that it is unacceptable for a parent to assume high levels of preventable risk and harm on behalf of his or her child, what constitutes a high level of risk and harm? Is it a 1 in 100 or 1 in 100 000 risk of the child …