MOC IV Learning CollaborativeSession V

September 12, 2012

IMPROVINGIMMUNIZATION

RATES

LEARNING OBJECTIVESEnhance 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 SURVEYIs 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

HPV66% 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, 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, AAPThe 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 SystemsRecommended 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 SystemsSuh 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 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% increaseSometimes hard to distinguish change from growth in

use and reporting; little cost dataCoCASA and NCIR are examples you can use

Provider Assessment and FeedbackAssessment 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 multi-intervention studies

Provider RemindersInform 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 Orders1980-1997 review showed 27% median

increaseThis review showed a much higher increase

when stand alone – small number of studiesLarger 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 DemandRecall/Reminder

Use NCIR reporting systemUse CoCASA – CDC software programUse your EHR if capablePerhaps just a simple postcard you have patient fill

out at visit, you mail when appropriate

What to do? Provider

Interventions

“How AmI

Doing?”

What to Do – Provider InterventionsProvider 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.

Assessment Feedback Incentives eXchange

Contact Amanda Dayton at NC Immunization Branch

PDSA

Plan

Do

Study

Act

Plan – Baseline rate, pick 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 & LinksCDC

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.pdfCSG

http://www.healthystates.csg.org/NR/rdonlyres/49419EBC-E9E7-4A9B-8F61-CBD85DFE5018/0/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