Achieving Success in Childhood Immunization
chieving complete and timely vaccine coverage for infants and young children can seem daunting, but the potential consequences of underimmunization are severe enough to support full compliance with the currently recommended early childhood vaccine schedule. Failure to achieve protective levels of antibodies and to maximize the immune response with the recommended number of doses—administered at the recommended times—can lead to reduced vaccine efficacy or even vaccine failure, depending upon the pathogen.1 Incomplete vaccine coverage affects not only the health of the individual child but also that of the child’s family and community, including teachers and other caregivers, other children who have not been fully vaccinated, and even the medical office staff. Practice- and parent-related challenges to achieving complete and timely immunization are numerous; however, effective strategies can be implemented to help keep children on schedule. Four representatives of pediatric practices in a variety of settings—large health care network, public clinic, and private practice—share their own strategies to help others achieve success in childhood immunization. (See Contributor Snapshots on page 11.)
Strategies for Achieving Success in Childhood Immunization
Dear Colleague: As I grow older and hopefully wiser in my pediatric career, now more than 2 decades into clinical practice, I become more and more humbly aware that the single most valuable thing that I do as a pediatrician is immunize my patients and their families. More lives are improved and/or saved through immunization than by any other single thing that I do. We are now at the beginning of a new era of medical care, one that recognizes that quality medical care can lead to better outcomes—and can even be costeffective. At the center of all of our Healthcare Effectiveness Data and Information Set (HEDIS) guidelines and quality measures are good old vaccines, the mainstay of preventive medicine for the foreseeable future. We pediatricians should be at the center of the quality care discussion. We are experts in delivery of preventive care, with our vaccine platform as the hallmark of that excellence. This monograph showcases some folks who do it beyond well. They are EXCELLENT immunizers, as we all should be. Nothing should be higher priority for us as we move into this era of quality of care and outcomes measures. In my own practice, an introductory letter—shared with every family when they meet with me and displayed prominently in each exam room—summarizes my immunization philosophy and policy. A notebook in each exam room contains articles on vaccines and all of the Vaccine Information Statements. A news board in the hall also holds vaccine articles. Our electronic health record (EHR) displays patients’ vaccine records on page 1 of their clinical desktop so that vaccine compliance is assessed at every point of contact. Electronic pursuit lists are constantly worked by staff to call patients back to update missing vaccines. A second computerized registry makes calls to those who are not up to date, asking them to call to schedule an appointment. We also participate in the Florida SHOTS™ (State Health Online Tracking System) registry to stay abreast of vaccines delivered elsewhere to our patients. Finally, my staff will immunize anyone, any time, no matter how busy we are: a must to avoid missed opportunities. It is my sincere hope that this monograph will assist you in ensuring that all of your patients are fully immunized according to the childhood vaccine schedule, so that we can attain our Healthy People 2020 goals. Sincerely,
Alix Casler, MD, FAAP Faculty Reviewer Alix Casler, MD, FAAP Medical Director, Department of Pediatrics, Physician Associates Orlando Health Assistant Professor of Pediatrics, University of Central Florida School of Medicine Orlando, Florida Clinical Assistant Professor, Florida State University College of Medicine Tallahassee, Florida 2 Summer 2013
Achieving Success in Childhood Immunization Immunization Success Strategy #1: Use Technology as a Tracking Tool for Vaccine Timeliness During the first 18 months of life, an infant is expected to receive more than 2 dozen vaccine doses (injections and oral) to protect against a variety of viral and bacterial infections, according to the 2013 immunization schedules recommended by the Advisory Committee on Immunization Practices (ACIP) and endorsed by the American Academy of Pediatrics (AAP). 2,3 Despite the complexity of the schedule, more than 90% of children in the US receive the recommended initial 1 to 3 doses of vaccines against diphtheria, tetanus, and pertussis (DTaP); measles, mumps, and rubella (MMR); pneumococcal disease (PCV); varicella; invasive disease due to Haemophilus influenzae type b (Hib); hepatitis B; and polio (IPV) before their third birthday.4 It should be noted that these doses are intended to be completed well before this, by the age of 15 months.2 Full and timely vaccine coverage dictates completion of the full primary series, the traditional 4:3:1:3:3:1:4,a by 2 years of age. This goal remains elusive, as a significantly smaller percentage of a 4:3:1:3:3:1:4 series, referred to as routine, includes ≥4 doses of DTaP/DT/DTP, ≥3 doses of IPV, ≥1 dose of MMR, 3 or 4 doses of Hib, depending on product type, ≥3 doses of hepatitis B, ≥1 dose of varicella vaccine, and ≥4 doses of PCV.
infants and toddlers completes the series, even by the age of 3 years. For example, in 2011, only 68% of children 19-35 months of age had received all of the recommended doses of DTaP, IPV, MMR, Hib, hepatitis B, varicella, and PCV, failing to meet the 85% to 90% targets of the national Healthy People 2020 initiative.4,5 Children often fall behind in their immunization timeliness between 7 and 16 months of age, when the booster dose or fourth dose in a vaccine series is crucial to achieving optimal protection.1,6 Parents of toddlers, in particular, may be less aware of the need for booster doses after the first year of life and therefore depend on reminders from their health care providers. All of the practices featured here take advantage of technology to increase immunization rates, utilizing it for more than appointment scheduling and record keeping. For both private practices— Happy & Healthy Pediatrics in Mineola, New York, and The Pediatric Group Summer 2013 3
Strategies for Achieving Success in Childhood Immunization
“Vaccines are always first on our minds. When we had paper charts, vaccines were listed on the first page. Now that we have electronic medical records they are still right there on the first page. We look to see if patients are up to date when they come in for checkups and also when they come in for sick visits and when they call. In fact, we even check to see if they are up to date when no contact has been made . . .” —Sally Smith, The Pediatric Group of Southern California
of Southern California in Tarzana and Agoura Hills—electronic medical records (EMRs) serve not only as a tracking system for current immunizations but also as a reminder system for pending doses. The Internet is another invaluable resource to improve immunization timeliness. The website for Happy & Healthy Pediatrics contains a password-protected patient portal for parents and guardians to determine when an appointment should be made. Parents of patients in The Pediatric Group of Southern California can access the ACIP-recommended immunization schedules for younger (birth through 6 years of age) and older (7 to 18 years of age) children, as well as the practice’s vaccination philosophy, through the practice’s website. Watts Health Care Corporation in Los Angeles, California, has found that the most eff icient method to set and confirm appointments with its patients is through its own automated calling system and personal telephone communication with the patient’s family. Watts Health Care also uses technology to track immunizations, through the California Immunization Registry (CAIR).7 The goal of CAIR, a collaboration of 10 regional registries, is to provide rapid access to complete and up-to-date immunization records, helping health 4 Summer 2013
care providers, schools, and other agencies track the delivery of immunizations and eliminating both missed opportunities to immunize and unnecessary duplicate immunizations. Health care organizations approved for CAIR include nonprofit community clinics such as Watts Health Care, private medical practices, hospitals, and state and local health departments’ clinics. All states have similar immunization registries in which health care providers may participate. Although the Lehigh Valley Health Network/Physician Group in northeastern Pennsylvania has not yet completed its conversion from paper charts to EMRs, it has devised several paper-, computer-, and web-based strategies to improve immunization timeliness. All 7 pediatric offices in the network follow the current ACIP immunization schedule and use computer-generated letters to remind parents to make vaccine appointments. During visits, physicians are prompted to assess the patient’s immunization status by an “immunization orders” section in individualized templates for each well-visit from newborn through teenager. To help ensure that vaccine doses are not missed, the Lehigh Valley Health Network has also trained its clinical and front office staff to recognize when a scheduled vaccine is not ordered or administered during a visit.
“Vaccinating children according to the routine schedule is one of the best ways to help protect them from serious—and sometimes deadly—diseases. We make it a priority in our practice to educate parents on the multitude of immunization benefits and to dispel the destructive myths.” —Debra Carter, MD, Lehigh Valley Health Network/Physician Group
Immunization Success Strategy #2: Proactively Address Parental Concerns About Vaccine Safety Parents may be reluctant to vaccinate or even refuse entirely to vaccinate their children for a variety of reasons.8 Oncecommon childhood illnesses—measles, tetanus, and bacterial meningitis, for example—are less prevalent nowadays, leaving younger parents to question the need for protection against them. In recent years, increased concern over vaccine safety and side effects, regardless of parental immunization philosophy, has been a common reason for vaccination delay or refusal.8 One recent survey found, however, that many parents change their minds about vaccination delay or refusal if provided information or assurance from their child’s health care provider. 8 In fact, parents are more likely to trust their child’s physician “a lot” as a source of vaccine-safety information than they are to trust other health care providers (76% vs 26%), government vaccine experts (23%), or family members and friends (15%).9 Even so, a substantial number of parents (26%) put at least some trust in nonhealth professionals, particularly celebrities, for their vaccine safety information and thus risk acting on misinformation.9 (See also Immunization Success Strategy #3: Make Parental Education and Communication a Priority.)
State vaccination requirements for day care and school attendance can also have a strong inf luence on parents’ decisions to immunize, although many of the same states allow nonmedical exemptions to immunization.8 The pediatric practices we spoke with employed a number of effective strategies for dealing with parents whose attitudes toward vaccination differ from the practice’s own immunization policy—that all children should be vaccinated in full and on time. All 4 practices strongly discourage alternative immunization schedules. In their collective experience, however, few parents actually refuse childhood immunizations entirely. In The Pediatric Group of Southern California, parents who refuse to immunize are not discharged from the practice but must sign a waiver indicating their refusal. (See, for example, the Refusal to Vaccinate Form available from the website of AAP: http://www.aap.org/ i m mu n i z a t ion /p e d i a t r ic i a n s/p d f / RefusaltoVaccinate.pdf.) On the other hand, the Lehigh Valley Health Network provides its written immunization policy to parents early in the provider-patient relationship—even at prenatal visits—and suggests that parents who are firmly opposed to immunization may be more comfortable with a pediatric practice that shares a similar philosophy. Summer 2013 5
Strategies for Achieving Success in Childhood Immunization
Happy & Healthy Pediatrics takes a different approach by maintaining a separate waiting room and examination room for unimmunized families and restricting their appointment hours to reduce the risk of exposing other patients to vaccine-preventable diseases. Furthermore, the practice has a policy of not providing written exemptions for school admission of unimmunized children. Watts Health Care has found that many parents who initially refuse immunizations can be persuaded during office visits via brief, informative discussions to have their children receive at least the basic vaccine series. Furthermore, Watts Health Care ensures that its entire pediatric staff has a thorough knowledge of the science of immunization and use of specific vaccines, so they are prepared to provide accurate information to parents.
Table 1. Selected Standards for Pediatric Immunization Practice of the National Vaccine Advisory Committee 11 • Providers educate parents and guardians about immunization in general terms. • Providers utilize all clinical encounters to screen and, when indicated, immunize children. • Providers co-schedule immunization appointments in conjunction with appointments for other child health services. • Providers administer simultaneously all vaccine doses for which a child is eligible at the time of each visit.
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Immunization Success Strategy #3: Make Parental Education and Communication a Priority Ongoing communication with and education of parents can help to maintain an open and positive relationship, which in turn can help enhance immunization rates.10 One of the National Vaccine Advisory Committee (NVAC) standards on pediatric immunization is that providers educate parents and guardians about immunization in a culturally appropriate manner and language that is easy to understand (Table 1).11 Clinicians should discuss immunization with parents early and often, perhaps citing personal experiences with vaccinating their own children. Parents also should be well informed regarding the dangers of the diseases that vaccines help prevent. Happy & Healthy Pediatrics uses a variety of communication and education strategies to improve immunization compliance for the entire family, not just their pediatric patients. Discussions about childhood immunizations and protection against inf luenza, for example, begin early—often with expectant parents at their “Meet the Pediatrician” visit—and continue at each infant visit. In addition, new parents are themselves offered pertussis vaccine at the first newborn visit and are provided a manual of newborn care that emphasizes immunization of all adult contacts against inf luenza and pertussis. For ongoing education, Happy & Healthy Pediatrics writes and distributes a semi-monthly email newsletter for parents, to alert them to immunization updates and local disease outbreaks. One newsletter included a link to a video
“The only way to really protect the children is to protect the entire family.” —Elissa Rubin, MD, Happy & Healthy Pediatrics
showing a child suffering the violent cough of pertussis, to bring increased attention to the need for vaccination. The practice also hosts weekend “shot clinics” for anyone in frequent contact with children—including stepparents, grandparents, nannies, and babysitters. The Pediatric Group of Southern California prides itself on its “cuttingedge technology” to communicate with and educate parents. The practice uses its website, the “Smile Reminder” software patient messaging system, a Facebook page, and tweets from its Twitter account to alert parents to practice updates and information, including scheduled appointments, new school immunization requirements, educational lectures, and
availability of seasonal vaccines. Monthly newsletters, written by one of the pediatricians and distributed quickly and easily via the patient messaging system, offer articles on topics that are both relevant and timely to the community. These might include healthy New Year’s resolutions for preschoolers, elementary school children, and teenagers, as well as links to up-to-date information on the websites of the AAP and Centers for Disease Control and Prevention. In addition, The Pediatric Group of Southern California offers a quarterly parent education lecture series in the office. Previous lectures have included, for example, 1 of the group’s pediatricians speaking on immunization updates and controversies.
Message in a Cup: The Wake County, North Carolina, Sippy Cup Project The Sippy Cup Project has reached more than 1000 children and pregnant and postpartum women in urban and rural regions of Wake County, North Carolina, thanks to the efforts of its Human Services Division of Public Health. This clever method of promoting immunization compliance was created after streamlined local health care budgets left little funding for vaccination incentive programs. Wake County Public Health Educators developed the Sippy Cup incentive—infant vaccination timetables printed in English and in Spanish on a bright yellow cup—and were awarded Aid-to-County funding from the NC Immunization Program. A total of 1100 cups were distributed to the Prenatal, Women’s Health, Child Health, and Immunization Clinics; and the Women, Infants, and Children (WIC) Program at the Wake County Public Health Center in downtown Raleigh; as well as to regional health centers in the towns of Fuquay-Varina, Wake Forest, and Zebulon. Wake County Human Services, in collaboration with the County Health Department, continues to support the efforts of private practice, nonprofit agencies, and hospitals to provide timely and accessible immunization services. Photo courtesy of Wake County Human Services Division of Public Health.
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Strategies for Achieving Success in Childhood Immunization
Table 2. Combination Childhood Vaccines Approved by the US Food and Drug Administration 13 Trade name (year licensed)
Comvax® Vaccine (1996)
6 weeks – 71 months of age
3-dose schedule at 2, 4, and 12-15 months of age
Pediarix® Vaccine (2002)
6 weeks – 6 years of age
3-dose series at 2, 4, and 6 months of age
ProQuad® Vaccine (2005)
12 months – 12 years of age
2 doses: first at 12-15 months of age, second at 4-6 years of age
Kinrix® Vaccine (2008)
4 – 6 years of age
5th dose of DTaP and 4th dose of IPV
Pentacel® Vaccine (2008)
6 weeks – 4 years of age
4-dose schedule at 2, 4, 6, and 15-18 months of age
Routinely recommended timing
a A dash ( - ) between vaccine products indicates that the products are supplied in their final form by the manufacturer
and do not require mixing or reconstitution by the user. A slash ( / ) indicates that the products must be mixed or reconstituted by the user. b Hib = Haemophilus influenzae type b; HepB = hepatitis B; DTaP = diphtheria and tetanus toxoids and acellular pertussis; IPV = inactivated poliovirus; MMRV = measles, mumps, rubella, and varicella. Adapted from the Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR-2):1-64.
At times, parents themselves may drive immunization compliance. Parents may seek vaccines at higher rates as they hear in the media about disease outbreaks, such as the pertussis outbreaks occurring in a number of states, including Minnesota and Wisconsin, and the pertussis epidemic in Washington State in 2012.12 The early and widespread 2012-2013 influenza epidemic led many who “never get flu shots” to seek them out. Medical practices must be equipped to respond to this type of increased demand for vaccine by ensuring adequate supply and staffing. Unlike parents in some other practices, many parents and guardians of patients in the Watts Health Care pediatric community have limited access to electronic sources of information, and the practice therefore relies primarily on oral com8 Summer 2013
munication. Parental education is structured to explain the vaccine mechanisms of disease prevention, the severity and consequences of the illnesses that vaccines help prevent, and the essential safety of vaccines. When dealing with negative views of immunization, Watts providers listen respectfully to parents’ opinions and acknowledge their concerns, misperceptions, and beliefs. Education becomes the tool to dispel those concerns, and the providers have found that often only a brief conversation is needed.
Immunization Success Strategy #4: Avoid Missed Opportunities To improve immunization coverage and timeliness, clinicians need to avail themselves of every opportunity to assess
“Health care providers must look at the responsibility to immunize as their own.” —Oliver Brooks, MD, Watts Health Care Corporation
immunization status and to vaccinate as scheduled.11 Both well and sick visits provide opportunities, since vaccines can be administered safely to most children with mild illness. 6,11 Furthermore, although parents and providers alike often express concern over multiple injections given at 1 time, leading to deferred doses,14,15 all eligible vaccines should be administered simultaneously (Table 1).11 Studies have found that deferring even some doses in the first year of life is strongly associated with a substantially lower vaccine completion rate by 25 months of age.15 The availability of combination vaccines (Table 2) can lead to fewer deferred doses and improved immunization compliance and timeliness.16 By allowing for the administration of multiple antigens in a single injection, combination vaccines help reduce patient and parent distress, leave fewer children unprotected against communicable diseases, simplify record keeping, and improve practice eff iciency.13,16,17 For example, at The Pediatric Group of Southern California, the use of combination vaccines has led to nearly 80% on-time immunization with DTaP, IPV, MMR, Hib, hepatitis B, varicella, and PCV for their patients 19 to 35 months of age—well above the 2011 combined vaccination rate of 68%.4 In addition, parents in their practice have expressed how pleased they are to be able to reduce the number of shots their children receive at a visit. All of the featured practices emphasized their implementation of robust immunization policies and NVAC stan-
dards (Table 1), as well as their favorable view of combination vaccines. Watts Health Care views each clinic visit as an opportunity to immunize; therefore, the pediatric immunization schedule is incorporated into all routine assessments to achieve optimal protection. Happy & Healthy Pediatrics and The Pediatric Group of Southern California maximize opportunities to vaccinate not only by reviewing immunization records at every visit but also during parent telephone calls. Lehigh Valley Health Network has continually revised its wellvisit documentation sheets to incorporate new combination vaccines as they are approved. Furthermore, all 4 practices— private, public, and network—offer additional access to health care and opportunities for immunization through afterhours and weekend clinics. The immunization strategies shared by these practices have led to high pediatric immunization rates. Most patients in the Lehigh Valley Health Network and at Watts Health Care Corporation are immunized fully and on time at regularly scheduled well visits; it is very rare for children not to receive all doses of the recommended vaccines. At Happy & Healthy Pediatrics, Dr. Elissa Rubin, 1 of the partners, has structured the practice around preventive medicine, including vaccines for children (and their caregivers), and she has achieved high rates of immunization compliance. More than 90% of parents of newborns entering Dr. Rubin’s practice receive vaccines against tetanus, diphtheria, and pertussis, Summer 2013 9
Strategies for Achieving Success in Childhood Immunization
and many grandparents and other family members also choose to be immunized there. At The Pediatric Group of Southern California, nearly 80% of patients 19-35 months of age are current with their immunizations. The relatively few families in these practices who refuse childhood vaccinations entirely are a reflection of the dedication of practice staff, their efforts to communicate and educate, and their innovative approaches to ensure that their pediatric patients are adequately protected against vaccine-preventable diseases. Whether treating infants and children in a private practice in a suburban community, a regional health care network, or an inner-city public clinic, these practices have developed individualized strategies to help them reach Healthy People 2020 immunization goals. They have identified barriers to complete and timely vaccination coverage—not only for their pediatric patients but also for their parents and caregivers—and they have addressed those barriers using specific practice-centered approaches that emphasize documentation, communication, and education. Whether their strategies focus on up-to-date technologic tools or tried-and-true written and oral means, these practices continue to maximize opportunities for childhood immunizations while increasing parents’ knowledge and satisfaction. 10 Summer 2013
1. Pichichero ME. Booster vaccinations: Can immunologic memory outpace disease pathogens? Pediatrics. 2009;124(6):1633-1641. 2. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older—United States, 2013. MMWR. 2013;62(Suppl 1):1-19. 3. American Academy of Pediatrics. Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules—United States, 2013. Pediatrics. 2013;131(2):397-403. 4. CDC. National, state, and local area vaccination coverage among children aged 19-35 months—United States, 2011. MMWR. 2012;61(35):689-696. 5. US Department of Health and Human Services. Healthy People 2020. http://www.healthypeople. gov/2020/topicsobjectives2020/objectiveslist. aspx?topicId=23. Accessed January 28, 2013. 6. Luman ET, Chu SY. When and why children fall behind with vaccinations: missed visits and missed opportunities at milestone ages. Am J Prev Med. 2009;36(2):105-111. 7. California Immunization Registry (CAIR). http:// cairweb.org. Accessed January 28, 2013. 8. Gust DA, Darling N, Kennedy A, Schwartz B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics. 2008;122(4):718-725. 9. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Sources and perceived credibility of vaccine-safety information for parents. Pediatrics. 2011;127 (Suppl 1):S107-S112. 10. Diekema DS. Improving childhood vaccination rates. N Engl J Med. 2012;366(5):391-393. 11. The National Vaccine Advisory Committee (NVAC): the standards for pediatric immunization practice. http://www.hhs.gov/nvpo/nvac/standar.html. Accessed January 28, 2013. 12. CDC. Pertussis (Whooping cough). Outbreaks. http:// www.cdc.gov/pertussis/outbreaks.html. Accessed January 28, 2013. 13. CDC. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60 (RR-2):1-64. 14. Meyerhoff A, Jacobs RJ, Greenberg DP, Yagoda B, Castles CG. Clinician satisfaction with vaccination visits and the role of multiple injections, results from the COVISE Study (Combination Vaccines Impact on Satisfaction and Epidemiology). Clin Pediatr (Phila). 2004;43(1):87-93. 15. Meyerhoff AS, Jacobs RJ. Do too many shots due lead to missed vaccination opportunities? Does it matter? Prev Med. 2005;41(2):540-544. 16. Kalies H, Grote V, Verstraeten T, Hessel L, Schmitt HJ, von Kries R. The use of combination vaccines has improved timeliness of vaccination in children. Pediatr Infect Dis J. 2006;25(6):507-512. 17. Marshall GS, Happe LE, Lunacsek OE, et al. Use of combination vaccines is associated with improved coverage rates. Pediatr Infect Dis J. 2007;26(6): 496-500.
CONTRIBUTOR SNAPSHOTS Public Clinic Oliver Brooks, MD, is a pediatrician affiliated with Watts Health Care Corporation, a public, multispecialty, not-for-profit organization in Los Angeles. Watts Health Care was established following the riots in South Central Los Angeles in 1965 in response to the lack of health care access in the Watts neighborhood. Dr. Brooksâ€™ practice includes 4 physicians and 4 nurses who treat 15,000 patients per year.
Health Care Network Debra Carter, MD, is Assistant Medical Director of General Pediatrics and Pediatric Specialties at the multispecialty Lehigh Valley Health Network/Physician Group in northeastern Pennsylvania, which encompasses 2 full-service hospitals and 9 community health centers with 400 employed physicians. Dr. Carter oversees 7 general pediatric offices staffed by 26 pediatricians and 3 nurse practitioners who together see 32,000 patients, also overseeing all the pediatric specialties. The network also operates a stand-alone outpatient pediatric clinic for approximately 12,000 Medicaid and uninsured children.
Private Practice Elissa Rubin, MD, is a partner in the 3-pediatrician group Happy & Healthy Pediatrics, a private practice in Mineola, New York, with more than 4000 patients. This comprehensive wellness center addresses physical health, including care and prevention of illnesses, as well as psychological well-being, nutrition, behavioral issues, growth and development, and school progress.
Private Practice Sally Smith is the administrative assistant for The Pediatric Group of Southern California, a private practice in Tarzana and Agoura Hills, with 4 physicians and 2 nurse practitioners who treat nearly 3000 patients. The practice creates a caring environment for families and takes a developmental approach to pediatric care while using advanced technology for communication and education. Summer 2013 11
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