IMPROVING
IMMUNIZATION
RATES
LEARNING OBJECTIVES
 Enhance understanding of benefits of a recall system
for adolescent immunizations and well checks.
 Increase understanding of how many of your
adolescent patients are administered needed vaccines.
 Increase understanding of a multi-intervention
strategy to increase vaccination rates.
AUDIENCE SURVEY
 Is your practice part of CCNC?
 Does your practice use the NC Immunization Registry?
 Do you have an Electronic Health Record? Can you
actually get a report out of it without a PhD in
Computer Science and purchasing more software?
 Does your practice use a reminder/recall system for
anything?
2012 ACIP Recommended Vaccines
http://www.cdc.gov/vaccines/schedules/images/7-18yrs_chart_only.jpg
North Carolina 2012
VACCINE
NORTH CAROLINA
NATIONAL
≥ 2 MMR
89%
91%
Female complete HPV
66%
71%
Female ≥1 HPV
54%
53%
≥1 TdaP
78%
78%
≥1 MenACWY
66%
71%
≥3 Hep B
89%
92%
≥2 Var
63%
68%
≥1 Td/TdaP
84%
How can we improve?
 CDC Recommendations for Adolescent Immunizations,
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2011.
National Foundation for Infectious Diseases. Call to
action: Adolescent vaccination—Bridging from a strong
childhood foundation to a healthy adulthood. Bethesda,
MD, 2008.
Targeting Low Immunization Rates in Adolescents.
Council of State Governments Report, Summer 2006
AAFP, AAP
The Community Guide (The Community Services Task Force)
North Carolina Immunization Branch
Community Services Preventive
Task Force
Community Services Preventive
Task Force
Client Reminder and Recall Systems
 Recommended based on strong evidence of
effectiveness in improving vaccination coverage
 Initial review covering 42 studies (1980-1997) showed
median absolute increase of 12%
 Review covering 20 studies (1997-2007) less impressive
at median absolute increase of 6.1%
 In both reviews, combined interventions that included
Client Reminder and Recall Systems consistently
showed median absolute increases 1.5-2 times that of
the isolated reminder and recall system
Client Reminder and Recall Systems
 Suh et al. Pediatrics 2012 129(6) p e1437
Effectiveness and Net Cost of Reminder/Recall for
Adolescent Immunizations
4 private pediatric groups in Denver, each practice randomized 400 11-18
year olds who had not received 1 or more targeted vaccines
(Tdap,MenACWY, 1st HPV for females) to intervention (2 letters, 2
phone calls) or control. Baseline rates ranged from 33% to 54% for
having had all 3. “Post-intervention, the intervention group had
significantly higher proportions of receipt of at least 1 targeted vaccine
(47.1% vs. 34.6%, P<0.0001) and receipt of all targeted vaccines (36.2%
vs 25.2%, P<0.0001) compared with the control group.”
Immunization Information Systems
 “…confidential, population-based, computerized databases
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that record all immunizations doses administered by
participating providers to persons residing within a given
geopolitical area.”
194 papers
Client recall median absolute increase 5%
Provider assessment and feedback median absolute
increase 9%
Provider reminder system (one study) 14% increase
Sometimes hard to distinguish change from growth in use
and reporting; little cost data
CoCASA and NCIR are examples you can use
Provider Assessment and Feedback
 Assessment of providers coverage levels and
immunization practices, then feedback to provider
with recommended strategies to improve
 1980-1997 review (14 studies) showed median increase
of 16%
 1997-2007 median increase 9.4%
 When studied as part of a multi-intervention strategy
this seems to account for less of the increase seen, but
the overall increase in rates are higher in multiintervention studies
Provider Reminders
 Inform providers that particular patients are due for
specific vaccinations.
 1980-1997 median average increase of 16%
 1997-2007 median average increase of 10% (12% stand
alone, 10% as part of multi-intervention strategy)
Standing Orders
 1980-1997 review showed 27% median increase
 This review showed a much higher increase when
stand alone – small number of studies
 Larger number of studies in the 1997-2007 review
showed the opposite – 28% average median increase,
18% if stand alone, 32% as part of a multi-intervention
strategy
System-Based Combination
Interventions
 Recommend at least one intervention to increase
demand (client reminder and recall) with one or more
interventions aimed at providers/systems and one or
more interventions to increase access (year round
scheduling, expand hours, reduce copays, home visits,
school clinics).
What to do? Increase Demand
Recall/Reminder
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Use NCIR reporting system
Use CoCASA – CDC software program
Use your EHR if capable
Perhaps just a simple postcard you have patient fill out at
visit, you mail when appropriate
What to do?
Provider
Interventions
“How
Am
I
Doing?”
What to Do – Provider Interventions
 Provider Assessment and Feedback (you can use the data
from recall and reminder)
 Consider using AFIX – a quality improvement strategy,
developed by CDC, to raise coverage levels and improve
standards of practices at the provider level.
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Assessment
Feedback
Incentives
eXchange
Contact Amanda Dayton at NC Immunization Branch
PDSA
 Plan – Baseline rate, pick
Plan
Act
Do
Study
a strategy.
 Do – Implement the
strategy and observe.
 Study – Are we
improving? What
worked? Why?
 Act – Conclusions –
continue or change and
repeat cycle
Consider using AFIX!!
Resources & Links
 CDC
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf
http://www.cdc.gov/vaccines/who/teens/refs-pubs.html
 NFID NFID Call to action adolescentvacc.pdf
 CSG http://www.healthystates.csg.org/NR/rdonlyres/49419EBC-E9E7-4A9B-8F61CBD85DFE5018/0/TATargetingLowImmunizationRatesinAdol.pdf
 Community Guide http://www.thecommunityguide.org/vaccines/index.html
 AAFP
http://www.aafp.org/online/en/home/clinical/immunizationres.html?navid=immunizations
 AAP http://www2.aap.org/immunization/pediatricians/pdf/ReminderRecall.pdf
http://www.immunize.nc.gov/providers/ncir.htm
http://www.immunize.nc.gov/providers/providereducation.htm
http://www.immunize.nc.gov/providers/afix.htm