Improving Immunization Rates in Your Practice

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• Improving Immunization Rates in Your Practice

William L. Atkinson, MD, MPH National Center for
Immunization and Respiratory Diseases
May 2008
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20th Century Annual and Current Morbidity of
Vaccine-Preventable Diseases
Percent Decrease
20th Century Annual Morbidity
2006
Disease
Diphtheria Measles Mumps Pertussis Polio
(paralytic) Rubella Congenital Rubella
Syndrome Tetanus H. influenzae, type b and
unknown (lt5 yrs)
175,885 503,282 152,209 147,271 16,316 47,745 823
1,314 20,000
0 55 6584 15,632 0 11 1 41 208
100 99.9 95.7 89.4 100 99.9 99.9 96.9 99.
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Sources CDC. MMWR 1999 48242-264. MMWR
200756853-63. Data are estimated. at
or near record lows in 2005. Includes serotype
b (9) and unknown serotype (217)
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Immunization Coverage Among 19-35 Month Old
Children, 2006-2007
U.S. Coverage 85 92 93 89 90 80
NY Coverage 91 95 95 92 91 86
Vaccine DTaP4 MMR Hepatitis B3
PCV3 Varicella 43133
National Immunization Survey, July 2006-June
2007. Source http//www.cdc.gov/vaccines/stats-s
urv/imz-coverage.htmnis
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Measles Resurgence -United States, 1989-1991

• Cases 55,622
• Age group affected Children lt5 yrs
• most unvaccinated
• Hospitalizations gt11,000
• Deaths 123
• Resulted from low measles vaccination levels
  among preschool-aged children

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MeaslesUnited States, 2008

• 64 cases reported from 9 states
• 84 imported or linked to an imported case
• 22 younger than 12 months of age
• Only 1 case had documentation of vaccination (2
  doses)
• many unvaccinated because of religious or
  personal beliefs
• 39 exposed in a healthcare setting

MMWR 200857. Early release, May 1, 2008
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• PertussisUnited States, 1980-2007

Tdap approved
Year
2007 provisional total
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Preview

• Why bother?
• Measuring your rates
• How to increase rates
• Increase demand
• Enhance access
• Address provider barriers

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Why Bother?

• Immunization prevents disease
• Increasing immunization rates often increases
  other preventive services (e.g., lead screening)
• Immunizations are a measure of office system
  quality

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MD-Estimated vs Measured Performance of 45
Practices
One of the key barriers to improvement is that
clinicians believe coverage in their offices is
higher than it actually is.
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How To Measure Your Office Rates

• Use the NYS immunization registry
• Have a free PBII evaluation (contact your county
  immunization program)
• Simply check 10 charts

PBII Provider Based Immunization Initiative
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Task Force on Community Preventive Services
How to Increase Vaccination Levels

• 1. Increase demand
• 2. Enhance access
• 3. Address provider barriers

MMWR 199948(RR-8)1.
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Increase Demand

• Use client reminder/recall systems
• Recommend the vaccine
• Use multifaceted programs including education
• Support regulations (eg, school entry
  requirements)

MMWR 199948(RR-8)1.
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Client Reminder and Recall Systems

• Reminder vs Recall
• Reminder - sent before appointment
• Recall - sent after patient missed appointment
  (more efficient because families who were going
  to remember without any effort from you already
  did)
• Forms - mail, phone and text messages

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Use the NYS Immunization Information System (IIS)
to Generate Letters

• New legislation will require participation in the
  NYS IIS as of January 1, 2008
• Use this system to generate letters

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Put systems in place to follow up on no shows
and cancellations (kids deserve your help)
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Systems for Follow-Up

• Check address and phone number at every visit
• Families should leave with an appointment
• For pts who cannot receive all the vaccines they
  need in a single visit (because of intervals) use
  -
• Shot only visits
• School based health centers for adolescents

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Provider Recommendation Overcomes Negative
Attitudes
J Gen Intern Med. 199611673.
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Examples of Multifaceted Programs

• Display posters and brochures about childhood
  immunization in waiting rooms/ reception areas
• Post the schedule in waiting rooms in a simple,
  understandable format
• Provide shot record for parents

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Examples of Multifaceted Programs

• Discuss changes in the schedule and the
  importance of keeping children up to date on
  their immunizations
• Encourage parents to know their childs
  immunization status, to keep the child's record
  up to date and in a safe place, and to bring it
  to every visit

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Enhance Access

• Reduce cost
• Provide VFC vaccine
• Expand access
• Extend office hours
• Host special weekend or evening clinic hours
  (especially important for influenza)
• Provide walk-in immunization services (no
  appointment required)
• Provide info on transportation services
• Couple with other programs (e.g., WIC settings)

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Address provider barriers - Start by clarifying
the immunization schedule
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Clarifying the Schedule

• Get all providers to use a single current
  immunization schedule
• Post the schedule in exam and medication rooms
  and at the scheduling desk
• Everyone should carry a laminated pocket copy of
  the schedule

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Common Schedule Errors

• COMVAX
• 3rd dose before age 12 mos
• MMR and varicella
• First dose before age 12 mos
• DTaP
• 4th dose before age 12 mos or lt6 mos since 3rd
  dose

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Address provider barriers - Rid your office of
missed opportunities
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Missed Opportunities - Some Causes and Solutions

• Vaccinates only at well care visits
• Gives only 2 shots/ visit
• Uses invalid contraindications
• (minor illness, antibiotic use, etc)
• Doesnt know what shots are due at the time of
  the visit (immunization record problems)
• Forgets or makes an error!

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Dont trust your memory -use standing orders
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Standing orders are among the most effective
strategies!

• What nonphysicians offer and administer vaccines
  without direct MD involvement
• How established through policies and protocols
• Where clinics, hospitals, nursing homes

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Dont trust your memory -use provider reminders
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Provider Reminders

• What A systematic way to remind providers to
  order the correct vaccines
• How paper inserted in chart, stamp in record,
  EMR
• Potential problems
• They have to be put on chart, etc.
• They have to be right
• Providers start to ignore them

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CDC Vaccines and ImmunizationContact Information

• Telephone 800.CDC.INFO
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/nip
• Vaccine Safety
• www.cdc.gov/od/science/iso/