1. IMPROVING IMMUNIZATION RATES

2. 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.

3. 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?

4. 2012 ACIP Recommended Vaccines http://www.cdc.gov/vaccines/schedules/images/7-18yrs_chart_only.jpg

5. North Carolina 2012 VACCINENORTH CAROLINANATIONAL ≥ 2 MMR89%91% Female complete HPV66%71% Female ≥1 HPV54%53% ≥1 TdaP78% ≥1 MenACWY66%71% ≥3 Hep B89%92% ≥2 Var63%68% ≥1 Td/TdaP84%

7. 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, AAP The Community Guide (The Community Services Task Force) North Carolina Immunization Branch

8. Community Services Preventive Task Force

10. 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

11. 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, 1 st 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.”

12. 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% increase Sometimes hard to distinguish change from growth in use and reporting; little cost data CoCASA and NCIR are examples you can use

13. 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 multi- intervention studies

15. 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)

16. 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

18. 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).

19. What to do? Increase Demand Recall/Reminder 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

20. What to do? Provider Interventions “How Am I Doing?”

21. 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. Assessment Feedback Incentives eXchange Contact Amanda Dayton at NC Immunization Branch

22. PDSA PlanDoStudyAct 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!!

23. Resources & Links CDC http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf http://www.cdc.gov/vaccines/who/teens/refs-pubs.html 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 NFID Call to action adolescentvacc.pdf CSG http://www.healthystates.csg.org/NR/rdonlyres/49419EBC-E9E7-4A9B-8F61- CBD85DFE5018/0/TATargetingLowImmunizationRatesinAdol.pdf http://www.healthystates.csg.org/NR/rdonlyres/49419EBC-E9E7-4A9B-8F61- CBD85DFE5018/0/TATargetingLowImmunizationRatesinAdol.pdf Community Guide http://www.thecommunityguide.org/vaccines/index.html http://www.thecommunityguide.org/vaccines/index.html AAFP http://www.aafp.org/online/en/home/clinical/immunizationres.html?navid=immunizations http://www.aafp.org/online/en/home/clinical/immunizationres.html?navid=immunizations AAP http://www2.aap.org/immunization/pediatricians/pdf/ReminderRecall.pdf http://www2.aap.org/immunization/pediatricians/pdf/ReminderRecall.pdf

24. http://www.immunize.nc.gov/providers/ncir.htm

25. http:// www.immunize.nc.gov/providers/providereducation.htm

26. http://www.immunize.nc.gov/providers/afix.htm