BOOKS OF RtfiDIfGS - PAHO/WHO

NUTTING ET AL.
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and the county clinic, it revealed that
neither location was taking advantage of its
opportunities to provide inmmunizations.
In discussing the results, both sites agreed
that it had assumed the other was responsible
for immunization, and both agreed to
begin immuniizing niore vigorously. An informal
follow-up study by one of the private
practitioners several months later
indicated that the encounter-based immunization
rate had increased three fold at
both locations.
One Service Unit (IHS-A) had a
population-based immunization rate of 86
per cent and an encounter-based rate of 46
per cent. When the encounter-based rate
was sorted by clinic, it was noted that the
MCH Clinic was performing well at85 per
cent, while the general clinic (34 per cent)
and the two field clinics (11 per cent) were
missing many opportunities to provide
immunization. Since most of the missed
opportunities occurred at the general
clinic, the Service Unit instituted a stalding
order for immunizations in the general
clinic.
In the second Service Unit (IHS-B), 56
per cent of the infant population was immunized
by 1 year of age. When the
encounter-based rate of 38 per cent was
sorted by provider discipline, it was noted
that the physicians werte providing immunizations
only 34 per cent of the time
and were commonly referring infants to the
physician extender for well baby care.
Also, 52 of the 316 infant visits made when
an immunization was due had been to the
pharmacist, who had recently begun a
program providing nonprescription medication
directly from the clinic pharmacy.
This result and the pattern apparent for
other functions led to the development of a
checklist of potential service needs for
prevention and chronic disease surveillance
for use by the pharmacist while dispensing
over-the-counter medications.
A contrasting pattern wa. seen in the
immunization indicators for the health
maintenance organization. Although the
providers were immunizing infants on 86
per cent of the visits when an immuniza-
NIEDICAL CARE
tion was due, only 58 per cent of the population
was being immunized. This pattern
suggested that patient contact was the
limiting factor in achieving higher immunization
rates in the infant community.
This was later confirmed by a study of the
utilization pattenl of the infants, which indicated
that many of the infants contacted
the provider system only when they were
ill.
The above experiences with immunization
illustrate several benefits of the assessment
method. It can focus attention on
a particular site or discipline; it can point to
areas where deficiencies are greatest; and
feedback of the results may, in some cases,
generate action. Several limitations are
also illustrated. The method does not identify
the causes of the deficiencies; it does
not uncover and analyze the many possible
remedial actions; nor does it evaluate remedial
actions during and after implementation
unless a separate study is
undertaken.
In several applications, treatment and
follow-up were examined by obtaining the
study cohorts from the laboratory logs of
each laboratory at every study site. For
iron-deficiency anemia the study cohort
included individuals with laboratory records
showing a hematocrit less than 33 vol
% and a hemoglobin less than 11 gm %. For
urinary tract infections the study cohort included
individuals with a urine culture resulting
in greater than 105 colonies per milliliter.
In order to examine the care for
routine and uncomplicated conditions
only, patients whose charts showed a noninutritional
cause for their anemia, or that
had a chronic urinary tract infection, urinary
tract anomaly or chronic pyelonephritis,
were eliminated from the studY
cohort.
Table 4 illustrates varying patterns of
performance in treatment and follow-up in
three IHS service units. The numbers in
the table are population-based indicators
that express the probability based on emipirical
data that a patient at a given point in
the process of care will pass successfully to
the next. Likewise, the probability that a;