Division of General Pediatrics

Adrienne Randolph, MD, MSc — an intensivist at Boston Children's and lead author on that flu vaccine study — believes care coordination and communication are key to solving the problem. "Many chronically ill children lack a 'medical home' [a single medical resource that coordinates and tracks all aspects of care] because there are so many subspecialists involved in their care," she says.

That lack of home can fuel a lack of clarity as to who should vaccinate and under what circumstances, leading to missed opportunities. For instance, if a child is an inpatient, her provider may prefer to wait to vaccinate until she is healthy, but the vaccine may not be offered as part of her discharge process. She may have an appointment with a specialty clinic, but that clinic may not offer seasonal vaccination to its patients. And her primary care provider (PCP) may think that vaccination is too risky, given her chronic condition.

Gregory Young, MD, president and CEO of the Pediatric Physicians' Organization at Boston Children's and a primary care provider at Longwood Pediatrics in Boston, notes that while ultimately flu vaccination should be a medical home function, a chronically ill patient's medical home doesn't necessarily have to live with her PCP.

"For patients on kidney dialysis, those actively being treated for cancer or those with cystic fibrosis, the medical home is often based in the specialty setting," he explains. "But for children with high complexity and vulnerability that doesn't necessarily boil down to a single condition, it should be the primary care setting."

Instead of only asking why these children don't get the vaccine in the medical home, Young says, we should instead ask what needs to be done to ensure that no opportunity is ever missed. In his mind, all of the providers involved in a child's care should feel accountable for vaccinating.

"If a child is my patient, and I see her once or twice a year, but she sees the cardiologist four times a year, then I believe what should happen is if the child visits the cardiologist in September, and she hasn't received the vaccine yet, she should be vaccinated. The cardiologist's office should tell the family to let my practice know and include the shot documentation in their cardiology visit note."

Randolph agrees that every medical interaction during the time leading up to flu season should be seen as an opportunity to vaccinate. She cites recent efforts by Boston Children's Benderson Family Heart Center, intensive care units (ICUs), and Emergency Department to offer seasonal flu vaccination to all patients seen in the fall. "Specialty clinics should be encouraged to immunize children during their visits," she adds.

Both point to the need for systems that support the medical home role, ones capable of flagging patients who haven't been vaccinated, communicating out to a patient's entire care team—specialists and PCP—if the vaccine has been provided and noting if the child should receive a second dose (as is necessary for children up to 8 years old during their initial season of vaccination).

Young highlights the need for clinics and practices to start measuring their flu vaccine coverage rates for their chronically ill patients. "You can't manage what you don't measure. Most practices don’t know what the immunization rate is for vulnerable children.

"It's only when you start measuring these things that people can start thinking critically about the systems that are in place," he continues. "We all want to do the right thing, but we need to have the information available."

Randolph points out that there are larger systematic benefits beyond the clear health benefits to solving this problem and making sure chronically ill patients get the flu vaccine, but that the system needs to change to make sure vaccination happens. "The cost and effort of vaccinating are very low compared to those of an ICU admission for flu-related critical illness. The time it takes to prevent that outcome is worth it."