1. California Department of Health Services Immunization Branch California VFC Office Evaluation Data: Using Quality Assurance Data to Evaluate Private Practices California Department of Health Services, Immunization Branch Howard Backer, MD, MPH Betty Tran, MPH

2. California Department of Health Services Immunization Branch Objectives Review descriptive data from CA VFC provider visits toReview descriptive data from CA VFC provider visits to  Explore VFC implications of office profiles  Compare LQA with CASA  Investigate methods of quantifying visit impact and provider improvement Use VFC data to guide program and policy emphasisUse VFC data to guide program and policy emphasis

3. California Department of Health Services Immunization Branch Private Provider Sites Using VFC Vaccines

4. California Department of Health Services Immunization Branch VFC Clinics*, by Type *3,963 active VFC Providers as of April 2004

5. California Department of Health Services Immunization Branch Specialty Type

6. California Department of Health Services Immunization Branch Number of Staff in Office* N=1139 *Blank responses and zeros not reported

7. California Department of Health Services Immunization Branch Penetration of VFC Program into Private Insurance Population Self-report by provider offices

8. California Department of Health Services Immunization Branch Number of Staff That are New Since Last Visit* *Blank responses and zeros not reported N=1139

9. California Department of Health Services Immunization Branch Type of Visit

10. California Department of Health Services Immunization Branch Typical Visit Quality Assurance Review Lot Quality Assurance Chart ReviewLot Quality Assurance Chart Review 30 charts 80% up-to-date threshold Average visit time: 2 hours, 6 minutes Standard Deviation: 40 minutes

11. California Department of Health Services Immunization Branch Type of Chart Assessment Type of Assessment FrequencyPercent Hybrid LQA 16114.2% Partial Assessment 71963.6% CASA (≥ 30 charts) 322.8% CASA (<30 charts) 373.3% No charts 18116.0% Total1130100%

12. California Department of Health Services Immunization Branch Comparison of Hybrid LQA and CASA Results *Minimum of 20 charts reviewed, mean=48 charts, SD=30

13. California Department of Health Services Immunization Branch Aggregated Results of Chart Reviews by Region Region Sample Size Mean95%CI2003-03 NIS Results† Bay200782.4% [80.7, 84.1] Central Valley 135683.7% [82.4, 86.2 ] Los Angeles 854981.4% [80.6, 82.2] 83.8 [78.3, 89.3] Northern Cal 124667.6% [65.0, 70.2] Southern Cal Excluding San Diego County 117686.5% [84.5, 88.5] San Diego County 11283.9% [77.1, 90.7] 72.8 [65.0,80.6] All Regions 1444681.4% [80.8, 82.0] 76.9 [72.5, 81.3] † July 2002 –July 2003, 4:3:1:3:3 series, children 19-35 months with VFC providers

14. California Department of Health Services Immunization Branch Aggregated Results of Chart Reviews by Region

15. California Department of Health Services Immunization Branch Vaccine Handling and Storage ItemDeficientN #% Monitors and records cold storage temps daily 16615.4%1081 Freezer temperature optimal for Varicella 17115.8%1084 Stores vaccines at appropriate refrigerator temperatures 15714.5%1086 Has written back up plan in case of power outage 34731.9%1087 Circuits marked with “do not unplug” 24722.9%1079 Records doses administered 21620.0%1081 Refrig/freezer marked with “do not unplug” 11710.7%1093

16. California Department of Health Services Immunization Branch Providers Meeting Criteria in Follow up Visit 2003 (Paired visits)* Storage and Handling *762 paired visits conducted between CY 2000 and 2003

17. California Department of Health Services Immunization Branch Key Measures to Improve IZ Registry, Reminder, Recall, and Tracking ItemDeficientN #% Utilizes effective tracking system for overdue patients 15415.2%1014 Utilizes reminders for next appointments 181.6%1108 Utilizes reminders for missed appointments 605.4%1108

18. California Department of Health Services Immunization Branch Providers Meeting Criteria in Follow up Visit (Paired Visits)* Key Measures to Improve IZ Rates *762 paired visits conducted between CY 2000 and 2003

19. California Department of Health Services Immunization Branch Tracking Recall System N=855

20. California Department of Health Services Immunization Branch Key Measures to Improve IZ Contraindications ItemDeficientN #% IZ when “low grade fever” 22320.1%1085 IZ when convalescing from acute illness 17115.8%1084 IZ when recently exposed to infectious illness 16615.4%1081 IZ when patient exhibits mild diarrhea 15714.5%1086 IZ when patient exhibits cold 12211.2%1086 Screens and IZ at sick child visits 948.8%1064

21. California Department of Health Services Immunization Branch Providers Meeting Criteria in Follow up Visit (Paired visits)* Inappropriate Contraindications *762 paired visits conducted between CY 2000 and 2003

22. California Department of Health Services Immunization Branch Providers Meeting Criteria in Follow up Visit (Paired Visits)* Documentation *762 paired visits conducted between CY 2000 and 2003

23. California Department of Health Services Immunization Branch Providers Meeting Criteria in Follow up Visit 2003 (Paired Visits)* Other Measures to Improve Immunization Practice *762 paired visits conducted between CY 2000 and 2003

24. California Department of Health Services Immunization Branch Maximal Number of Immunizations That Providers Will Give at Single Visit N=228

25. California Department of Health Services Immunization Branch Immunization Safety ItemDeficientN #% Provider is aware of responsibility to report to VAERS 978.9%1096 Provider knows know to report VAERS 1009.11094 91.8% of providers have NOT filed VAERS report in past 3 years (n=1089)

26. California Department of Health Services Immunization Branch Standard Value Immunization services free or minimal fee5 screens and immunizes at all encounters 10 questions about contraindications, informs risks and benefits 5 follows only true contraindications 12 administers simultaneously all vaccine doses due6 accurate and complete recording 12 walk-in IZ or IZ only visits without exam 4 reports adverse events 1 operates tracking system 15 proper vaccine management 12 semi-annual chart reviews4 maintains medical IZ protocols on-site 4 Vaccines administered by properly trained staff5 staff receives IZ education and training 5 Total100 Quantitative Quality Assurance Review

27. California Department of Health Services Immunization Branch CA VFC Office Evaluators and IZ Program Field Reps Lisa SlyLisa Sly June HoweJune Howe Sophia VourthisSophia Vourthis Beth McCarthyBeth McCarthy Karen TurnerKaren Turner Leslie BarberLeslie Barber Joey ChinJoey Chin Carol ConnellCarol Connell John ParasJohn Paras John ShiehJohn Shieh Judi CamachoJudi Camacho Nathan ChatmanNathan Chatman John HetskoJohn Hetsko Pat KirbyPat Kirby Claudia AguiluzClaudia Aguiluz Wendi CateWendi Cate David GambillDavid Gambill Denise RogersDenise Rogers Melissa Ely-MooreMelissa Ely-Moore