Recommendations of the Advisory Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Rates --
Assessment and Feedback
of Provider-Based Vaccination Coverage Information
This statement by the Advisory Committee on Immunization
Practices
(ACIP) presents programmatic strategies to increase vaccination
rates. This
is the first statement to recommend the use of routine assessment
and
feedback of provider-based vaccination coverage information.
Routine assessment and feedback of vaccination rates obtained
at the
provider site is one of the most effective strategies for achieving
high,
sustainable vaccine coverage. For example, in 1986, the
Immunization
Program of the Division of Public Health, Georgia Department of
Human
Resources, initiated a program to assess annually the vaccination
records
of children enrolled in public health clinics to determine progress
toward
achieving the national goal of 90% series-complete coverage by age
2 years.
During 1986-1994, series-complete vaccination rates at age 2 years
among
children in public health clinics increased from less than 40% to
approximately 80% -- an increase attributed to assessment and
feedback,
which motivated providers to develop and implement targeted
interventions
(1,2;CDC, unpublished data, 1996).
Assessment and feedback also has resulted in substantial
increases in
vaccination rates in public health clinics in Colorado, Illinois,
Iowa,
Kansas, and South Carolina (3-5;CDC, unpublished data, 1996).
Assessments
in private and managed-care provider settings in Arizona,
Massachusetts,
New York, and Washington suggest that this strategy also can
improve rates
in these settings (4,6-8). Beginning in 1995, all states receiving
federal
funds for vaccination programs have been required to conduct annual
assessments of vaccination rates in public health clinics. *
Managed-care
organizations also have begun assessing vaccination rates by using
data
from the Health Plan Employer Data and Information Set (HEDIS) (9).
Similarly, the Bureau of Primary Health Care, Health Resources and
Services
Administration, is introducing assessment and feedback of pediatric
vaccination rates as part of quality improvement in community and
migrant
health centers.
CDC developed the Clinic Assessment Software Application
(CASA) to
assist in measuring vaccination rates in vaccination practices
(10). Only
documented antigen-specific vaccine doses and dates of vaccination
are used
in CASA (or computer vaccination-registry systems with CASA-like
functions
{11}) to determine provider vaccination rates for all routinely
recommended
vaccines. Reports produced by CASA also indicate the extent to
which
vaccination rates can be improved by administering multiple
vaccines
simultaneously, using accelerated vaccination schedules,
encouraging
parents to initiate the vaccination series on time, and contacting
parents
when children are due for or have missed vaccinations. Providers
and clinic
staff can receive feedback as soon as all vaccination data are
entered into
CASA. Effective assessment requires complete documentation of
antigen-specific doses and dates of vaccination from current and
previous
providers' records.
A goal of CDC is that vaccination coverage assessments be
conducted at
all provider sites (public and private) at regular intervals.
Assessments
provide data about vaccine-delivery practices and vaccine coverage
that
motivate and assist providers in developing and implementing
practices to
achieve optimal vaccination rates. Although the cost-effectiveness
of
vaccinations is well documented, assessment as a specific
intervention has
not been subjected to such analyses. However, implementation of
regular
assessments is expected to result in higher vaccination rates and,
therefore, be cost-effective.
The ACIP recommends the regular assessment of vaccination
rates for
individual clinics or providers, including feedback about
vaccine-delivery
practices, to motivate providers and staff to improve vaccination
practices. Implementation of these recommendations can contribute
substantially to improving vaccination rates and sustaining high
rates in
all vaccine-provider sites.
References
CDC. Evaluation of vaccination strategies in public clinics --
Georgia,
1985-1993. MMWR 1995;44:323-5.
Dini EF, Chaney M, Moolenaar RL, LeBaron CW. Information as
intervention: how Georgia used vaccination coverage data to
double public
sector vaccination in seven years. Journal of Public Health
Management
and Practice 1996;2:45-9.
Galati RV. Assessments and incentives in the public sector:
Illinois and
Colorado. In: Proceedings of the 29th National Immunization
Conference.
Atlanta, Georgia: US Department of Health and Human Services,
Public
Health Service, CDC, 1996 (in press).
Houts C, Warming J. Assessments with public and private
providers. In:
Proceedings of the 29th National Immunization Conference.
Atlanta,
Georgia: US Department of Health and Human Services, Public
Health
Service, CDC, 1996 (in press).
Greene JE. Assessments using an immunization registry. In:
Proceedings
of the 29th National Immunization Conference. Atlanta, Georgia:
US
Department of Health and Human Services, Public Health Service,
CDC,
1996 (in press).
Thompson RS, Taplin SH, McAfee TA, et al. Primary and secondary
prevention services in clinical practice: 20 years' experience
in
development, implementation, and evaluation. JAMA
1995;273:1130-5.
Bushnell C. Practice-based immunization assessments: the
measures of
change. In: Proceedings of the 29th National Immunization
Conference.
Atlanta, Georgia: US Department of Health and Human Services,
Public
Health Service, CDC, 1996 (in press).
Morrow RW, Gooding AD, Clark C. Improving physicians'
preventive health
care behavior through peer review and financial incentives.
Archives of
Family Medicine 1995;4:165-9.
CDC. Use of a data-based approach by a health maintenance
organization
to identify and address physician barriers to pediatric
vaccination --
California, 1995. MMWR 1996;45:188-93.
CDC. Clinic Assessment Software Application (CASA): user's
guide.
Atlanta, Georgia: US Department of Health and Human Services,
Public
Health Service, CDC, 1994.
Frame PS. Computerized health maintenance tracking systems: a
clinician's guide to necessary and optimal features: a report
from the
American Cancer Society Advisory Group on Preventive Health
Care
Reminder Systems. J Am Board Fam Pract 1995;8:221-9.
Public Law 103-333.
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