Adult
Immunization: Strategies That Work
Strategies for Increasing
Adult Vaccination Rates
Including
links to examples
Contents:
The strategies/tools listed
below are low cost and easy to implement. For each strategy you
will find a definition, advantages and disadvantages, steps for
implementation, and studies documenting the effectiveness of the
strategy. Examples of materials that can be used with each strategy
are provided as well as a complete reference
list of the effectiveness studies.
Related
Documents
- These strategies were derived
from the work of the Task Force on Community Preventive Services
and are discussed further in the following articles:
Task Force on Community Preventive
Services. Introducing the Guide to Community Preventive Services:
methods, first recommendations and expert commentary. American
Journal of Preventive Medicine 2000;18(1, Supplement):1-142
.
Task Force on Community Preventive
Services. Vaccine-preventable diseases: improving vaccination
coverage in children, adolescents, and adults. A report on recommendations
of the Task Force on Community Preventive Services. Morbidity
and Mortality Weekly Report 1999;48(RR-8):1-15. http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr4808a1.htm
Standing Orders
|
Example:
|
|
Standing order (.pdf)
|
Definition:
|
|
A standing
order is a written order stipulating that
all persons meeting certain criteria (i.e.,
age or underlying medical condition) should
be vaccinated, thus eliminating the need
for individual physician’s orders for each
patient. |
Appropriate
settings for this strategy include:
|
|
Private
practice, managed care, hospitals including
ERs, and long-term care facilities. |
Advantages:
|
|
- The most consistently effective
method for increasing adult vaccination rates.
- Easy to implement.
|
Disadvantages:
|
|
Only reaches
patients already contacting the health
care system. |
Implementation:
|
|
- Decide what criteria will
be used to indicate patient eligibility for vaccination
and for specific vaccines.
- Physician writes standing
order.
- Physician meets with staff
to discuss implementation of the standing order.
- Monitor vaccination rates
(suggested).
|
Resources
needed: |
|
Standing
order. |
Effectiveness:
|
|
Standing orders are the most
consistently effective means for increasing vaccination rates.
One hospital study (Crouse, 1994) demonstrated that 40% of
inpatients were vaccinated against influenza in hospitals
using standing orders compared to 10% of patients in hospitals
utilizing physician education only.
When standing orders for influenza
and pneumococcal vaccination of persons 65 and older were
implemented in an emergency room, 50% of patients eligible
for influenza and 58% of persons eligible for pneumococcal
vaccines were vaccinated (Rodriguez, 1993). In nursing homes,
90% of patients in homes with standing orders were vaccinated
against influenza compared to 57% of patients in homes that
required a consent form for vaccination (Patriarca, 1985).
Margolis (1988) found that
use of standing orders in an outpatient clinic resulted in
81% of patients being offered influenza vaccine compared to
29% in a control group.
Another study (Klein, 1986)
in an outpatient setting resulted in 78% of eligible patients
being vaccinated against pneumococcal disease compared to
0% in a control group. |
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the standing orders.
Or
- Set a goal
(for example, 75% of persons 65 and older will receive influenza
vaccine) prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized
office, determine what proportion of persons on the list
were billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza,
the vaccination rate can be tabulated at the end of the
vaccination season.
In a very large
practice, a sampling method could be used to determine an
estimate of the proportion of at-risk persons vaccinated.
Enumerate number
of vaccinations given pre- and post-implementation.
|
Computerized
Record Reminder
|
Example:
|
|
|
Definition:
|
|
The computer can print a list
of possible reminders that appear on a patient’s record. The
software can be programmed to determine the dates that certain
preventive procedures are due or past due and then print computer_generated
reminder messages, usually overnight, for patients with visits
scheduled for the next day. |
Appropriate
settings for this strategy include: |
|
Private practice, managed care,
hospitals, and long-term care facilities. |
Advantages:
|
|
- Effective.
- Inexpensive once computerized
system is in place.
- Efficient.
|
Disadvantages:
|
|
- Only reaches patients with
office visits.
- May be less effective in
fee-for-service practices since cost to the patient may
be a barrier to vaccination in a fee-for-service practice.
|
Implementation: |
|
Design or identify a computerized
reminder system to use. Train professional staff in the use
of the computerized reminders. |
Resources needed:
|
|
- Computer program linked
to medical records or billing data to generate reminders.
- Computerized medical records.
|
Effectiveness: |
|
Computerized chart reminders
can be very effective. In one practice, pneumococcal vaccination
rates of high risk persons increased from 29% before implementation
to 86% following implementation of computerized chart reminders
(Payne, 1995). |
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the computerized record
reminder.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be usedto determine an estimate
of the proportion of at-risk persons vaccinated.
Enumerate number of vaccinations
given pre- and post-implementation.
|
Chart
Reminder |
Example: |
|
Chart
reminder (.pdf)
|
Definition:
|
|
Chart reminders can be as simple
as a colorful sticker on the chart or can be a comprehensive
checklist of preventive services including vaccinations. Reminders
to physicians should be prominently placed in the chart. Reminders
that require some type of acknowledgment, even a simple checkmark
by the physician, are more effective. |
Appropriate
settings for this strategy include:
|
|
Private practice, managed care,
hospitals, and long-term care facilities. |
Advantages: |
|
Inexpensive. |
Efficient:
|
|
Reviewing health maintenance
inventories with patients requires less than 4 minutes with
the patients and quickly becomes part of the physician’s routine. |
Disadvantages:
|
|
- Only reaches patients with
office visits.
- Chart reminders may be more
effective in managed care organizations as compared with
fee-for-service practices since cost to the patient may
be a barrier to vaccination in a fee-for-service
practice.
|
Implementation:
|
|
- Design or identify a chart
reminder to use.
- Make copies to be inserted
into all appropriate patient records.
- Assign a staff person to
place the reminders in a prominent place in the chart.
|
Resources needed:
|
|
- Staff time.
- Chart reminders.
|
Effectiveness:
|
|
When tetanus and pneumococcal
vaccinations were included in a health maintenance inventory
sheet, 19.8% and 14.6% of adults were vaccinated against tetanus
and pneumococcal disease respectively, compared with 3.2% and
1.6% in the year preceding use of the health maintenance inventory
sheets (Rodney, 1983). In another study (Davidson, 1984), influenza
vaccination rates increased from 18% before use of a health
maintenance flow sheet to 40% with use of the health maintenance
flow sheet. |
Measurement:
|
|
Compare vaccination rates
pre- and post-implementation of the chart reminder.
Or
Set a goal (for example, 75%
of persons 65 and older will receive influenza vaccine) prior
to implementing the strategy and track vaccination rates resulting
from the intervention.
For the computerized office,
determine what proportion of persons on the list were billed
for the vaccine.
For the non-computerized office,
conduct a manual record review on a daily or weekly basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice, a
sampling method could be used to determine an estimate of
the proportion of at-risk persons vaccinated. |
Performance
Feedback
|
Example: |
|
Performance
feedback
(.pdf)
|
Definition: |
|
Provider
assessment and feedback involves retrospectively
evaluating the performance of providers
in delivering one or more vaccinations
to a client population and giving information
to providers.
An effective
incentive for many physicians is comparing
their vaccination rates for a particular
patient population to a goal or standard.
Such assessment provides feedback on
the physicians’ performance. Some practices
encourage friendly competition among
physicians which creates additional incentive
to increase vaccination rates.
One highly
effective method of performance feedback
uses posters to track the number of patients
vaccinated. |
Appropriate
settings for this strategy include:
|
|
Private
practice, managed care. |
Advantages:
|
|
- Competition
increases physician compliance with
vaccination recommendations.
- Immediate
feedback on each physician’s performance.
- Easy
to implement.
- Minimal
disruption of office activity.
- Each
doctor can use his own approach for
bringing patients into the office for
vaccination (e.g., telephone reminders,
informational brochures, personal encouragement).
- Motivating
to physicians.
- Evaluation
is built into this approach.
|
Disadvantages:
|
|
- Time
to train staff and implement strategy.
However, less time is needed for evaluation
since the poster is the actual evaluation
tool.
- Can
be difficult to continually track vaccination
rates.
|
Implementation:
|
|
- Enumerate
number of eligible patients (denominator).
- May
need to generate lists of patient names.
- Create
or adopt target-based poster on which
to track number of patients vaccinated.
- Hold
meetings with staff and doctors to
explain the graphic denominator-based
tracking system.
- At
the end of each week, physicians and
their staff should record, for example,
all influenza vaccinations given to
at-risk patients, tabulate the cumulative
weekly total, and calculate the percentage
of the target population vaccinated.
They should then graph this percentage
on the poster. (Reports of vaccinations
received outside the office should
not be included unless the patient
has documentation.)
|
Resources
needed:
|
|
- Staff
time.
- Poster
to track vaccinations given.
|
Effectiveness:
|
|
In one
study (Buffington, 1991), the percentage
of eligible patients vaccinated against
influenza at that practice office was
50%, compared to 34% in a control group
that did not used the target- based approach.
An additional 16% were vaccinated in
public clinics, bringing the total percent
of patients vaccinated to 66% among patients
whose physicians used the target-based
approach (6% higher than the Healthy
People 2000 goal) compared with 50% among
control physicians. One physician in
this study vaccinated 79% of his patients.
Another
study (Kouides, 1993) offered small financial
incentives for physicians vaccinating
70% and 85% of their eligible patients.
Physicians in the incentive group vaccinated
73% of their eligible patients compared
to 56% of eligible patients in a control
practice. |
Measurement:
|
|
The
poster itself is an ongoing evaluation
tool. At the end of the vaccination season
(for example, December 31st
), the percent of patients vaccinated
is the measure of success.
|
Another
highly effective method of performance
feedback |
|
To
help you improve immunization coverage
rates in your practice, CDC now offers
Comprehensive Clinic Assessment
Software Application (CoCASA),
which is used to analyze coverage
rates in your practice and identify
those who need vaccination. This program
is part of the Assessment, Feedback,
Incentives, and Exchange (AFIX)
methodology for improving standards
of healthcare delivery in your practice.
Learn how you can use these programs
to improve standards in your practice. |
Home Visits
|
Example: |
|
|
Definition: |
|
These involve providing face-to-face
services to clients in their homes. Services can include education,
assessment of need, referral, and provision of vaccinations.
Home-visiting interventions also can involve telephone or mail
reminders. |
Appropriate
settings for this strategy include: |
|
Private practice, managed care. |
Advantages:
|
|
- Efficient, if using existing
home health care delivery services.
- May help access lower income
and other disadvantaged persons.
|
Disadvantages:
|
|
- Increased staff time, expense,
and possible training requirements, particularly if implemented
solely for vaccination services
- Clients may lack records,
or recall, of previous immunizations
|
Implementation:
|
|
- Determine if your clinical
setting has a relationship with home health services for
your clients.
- Meet with home health staff
to discuss implementation of strategies to improve vaccination.
- Develop appropriate protocols
for home visit vaccination services.
- Implement vaccination protocols.
- Monitor increased vaccination
rates.
|
Resources needed:
|
|
- Staff time.
- Cost, particularly if home
visits are implemented solely for vaccination services.
|
Effectiveness:
|
|
Nicholson et al (1987) found
a 10% increase in influenza vaccination among persons who
had a protocol to include vaccination on existing home visits.
Black et al. documented a significant
increase in the proportion of homebound patients who reported
speaking with a nurse about influenza vaccination, but no
net change in vaccination levels, compared to a control group
of homebound patients.
|
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the home visits.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be used to determine an estimate
of the proportion of at-risk persons vaccinated.
Enumerate number of vaccinations
given pre- and post-implementation.
|
Mailed/Telephoned
Reminders
|
Example: |
|
|
Definition: |
|
Medical staff place a call
to the patient or send a postcard/letter reminding the patient
that a vaccination is due and offer the opportunity for the
patient to schedule an appointment. |
Appropriate
settings for this strategy include: |
|
Private practice and managed
care. |
Advantages:
|
|
- Phone contact ensures that
the message is understood and provides the opportunity to
schedule an appointment.
- Reaches patients who may
otherwise not have scheduled visits.
- Easy to implement, requiring
minimal staff time.
|
Disadvantages:
|
|
- Relies on patient to schedule
and keep appointments.
- Not useful in practices
with high patient turnover or with a population that changes
residences frequently.
- May need bilingual reminders.
- Generating the list of patients
who should receive reminders may be difficult in some practices
(e.g., for those without computerized records).
- If baseline vaccination
rates are high, the incremental increase in vaccination
rate attained may not be worth the time and effort invested.
|
Implementation:
|
|
- Determine selection criteria
(i.e., age and/or diagnosis).
- Generate a list of patients
to be reminded (manually or via computerized billing or
medical records).
- Review list to remove the
names of patients who have died, transferred their care
to another provider, entered a long-term care facility,
left the practice/area, or received vaccinations.
- Develop reminder.
- Send reminders or place
calls (6 calls a day, 5 days a week for eight weeks = 240
patients contacted).
- Schedule appointments.
|
Resources needed:
|
|
- Staff time.
- Telephone script or postcards.
|
Effectiveness:
|
|
Mailed and telephoned reminders
are similar in effectiveness (McDowell, 1986; Brimberry, 1988);
effectiveness of both decreases as baseline vaccination rates
increase.
McDowell (1986) found that
telephoned reminders resulted in 37% of persons receiving
influenza vaccine compared with 9.8% in a randomized control
group.
Mailed reminders have resulted
in a 20% increase in pneumococcal vaccination rates. Postcards
personalized with the patient’s name and/or the doctor’s signature
and postcards with information regarding the importance of
vaccination are more effective than generic postcards.
|
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the mailed/telephoned reminders.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be used to determine an estimate
of the proportion of at-risk persons vaccinated.
|
Expanding
Access in Clinical Settings |
Example:
|
|
|
Definition:
|
|
Expanding
access can include |
|
- reducing the distance from
the setting to patients,
- increasing, or making more
convenient, the hours during which vaccination services
are provided,
- delivering vaccinations
in settings previously not used, and/or
- reducing administrative
barriers to vaccination (e.g., "drop-in" clinics
or "express lane" vaccination services). This
group of strategies has been very effective in increasing
immunization rates when combined with other strategies,
such as patient reminder/recall (and are strongly recommended
to be used in combination with them), less clearly so when
used alone.
|
Appropriate
settings for this strategy include: |
|
Private practice, managed care,
and hospitals. |
Advantages:
|
|
- Efficient.
- May help access lower income
and other disadvantaged persons.
- Increase access to those
not already in the system.
- Clearly effective when combined
with other strategies.
|
Disadvantages:
|
|
- Increased staff time and
expense.
- New clients may lack records,
or recall, of previous immunizations.
|
Implementation:
|
|
- Determine which access barriers
are the most important for your setting and your patients.
- Meet with staff to discuss
implementation of strategies to improve access.
- Implement strategies.
- Monitor increased vaccination
rates, in comparison to resources expended.
|
Resources
needed:
|
|
- Staff time.
- Cost, if new clinical setting
established to increase access.
|
Effectiveness:
|
|
Hutchison and Shannon (1991)
found that implementing "drop-in" clinics in combination
with mailed reminders increased influenza vaccination levels
35% compared to no intervention.
Nichol (1991) documented that
79% of inpatients received influenza vaccine, when it was
offered them in conjunction with a standing orders program.
Lukasik and Pratt (1987) demonstrated
that increased access plus patient reminders increased influenza
vaccination at least 22% compared to no intervention, or interventions
without these two elements. |
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the expanded access activity.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be used to determine an estimate
of the proportion of at-risk persons vaccinated.
Enumerate number of vaccinations
given pre- and post-implementation.
|
Patient
Education |
Example:
|
|
Influenza
V accine Information Statement
(.pdf)
|
Definition:
|
|
Patients coming in for a scheduled appointment are handed
an information sheet to review in the practice waiting room,
prior to hospital discharge, or upon admission to a long-term
care facility.
For instance, during influenza
season, the receptionist would give all patients an information
sheet on the need for influenza and pneumococcal vaccines
in certain persons. The patient could be instructed to mark
whether they fall into any of the risk groups, read the information,
and then check whether or not they wish to receive the vaccines.
The physician could then quickly
review the handout, answer any questions, and administer (or
have the nurse administer) the indicated vaccines.
It is also effective to include
in the handout a statement that vaccination will be administered
as part of the patient’s routine care that day, unless the
patient signs the sheet to indicate refusal. |
Appropriate
settings for this strategy include: |
|
Private practice, managed care,
hospitals, and long-term care facilities. |
Advantages:
|
|
- Inexpensive and easy to
implement, requiring minimal staff time.
- Patients can ask questions
and receive feedback.
- Does not require generating
a patient list.
|
Disadvantages:
|
|
- Only reaches patients already
in contact with health care providers.
- Not useful in practices
with low literacy levels.
- For minority populations,
may need bilingual information sheets.
|
Implementation:
|
|
- Create or identify appropriate
patient information sheet or use the Vaccine Information
Statement (VIS).
- Assign a staff person to
distribute information sheet or VIS.
|
Resources needed:
|
|
|
Effectiveness:
|
|
When implemented as a pre-discharge
measure in a hospital, pneumococcal and influenza vaccination
rates were 75% and 78% respectively, compared to 0% of patients
not given an informational
handout (Bloom, 1988). This method has also been used to effectively
increase tetanus toxoid administration (Cates, 1990). |
Measurement:
|
|
- Compare vaccination rates
pre- and post-implementation of the patient education materials.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be used to determine an estimate
of the proportion of at-risk persons vaccinated.
Enumerate the number of
vaccines given and compare to historical data.
|
Personal
Health Records
|
Example:
|
|
Personal
health record sample
(.pdf)
|
Definition:
|
|
Personal health records (PHR)
are issued to patients (either given to patients at the time
of a visit or mailed) and contain a preventive care schedule,
including recommended times to receive vaccinations. |
Appropriate
settings for this strategy include: |
|
Private practice and managed
care. |
Advantages:
|
|
- Empowers patients and encourages
them to be proactive in their own health care.
- Simple and inexpensive.
- Can and should be combined
with other preventive health measures, such as cancer screening,
to most efficiently use the advantages of the PHR.
- Several models are available.
- Patient has a record of
preventive services received should they move or change
providers.
|
Disadvantages:
|
|
- Requires patient to take
initiative (schedule and keep appointments).
- Requires acceptance and
reinforcement of method by provider.
- Requires moderate level
of literacy from patient.
- For minority populations,
may need to translate card into another language.
- Not useful in populations
with historically low compliance rates.
- If vaccination rates are
already relatively high in this practice, the incremental
increase in vaccination rate attained may not be worth the
time and effort invested.
|
Implementation:
|
|
- Create or adopt a PHR.
- Decide on a distribution
plan (mail or distribute in office).
- If distributing in office,
appoint a person (receptionist, nurse, doctor) to distribute
it to patients and explain its use. If mailing, a list of
eligible patients, probably based on age, should be generated
from computerized medical records, computerized billing
records, or manually from medical records.
|
Resources needed:
|
|
- Staff time.
- Personal health records.
|
Effectiveness:
|
|
In one study (Dickey and
Petitti, 1992), pneumococcal vaccination rates increased to
20.5% among patients with PHRs compared to 4.8% of patients
not given a PHR. Td rates were 12.5% among patients with PHRs
compared to 5% in the control group.
The effectiveness may hinge
on the physician’s attitude toward the PHR and receptiveness
to patient-initiated care. Effectiveness will be maximized
when physicians encourage the patients to take initiative,
and physicians are willing and able to provide the requested
services. |
Measurement: |
|
- Compare vaccination rates
pre- and post-implementation of the personal health record.
Or
- Set a goal (for example,
75% of persons 65 and older will receive influenza vaccine)
prior to implementing the strategy and track vaccination
rates resulting from the intervention.
For the computerized office,
determine what proportion of persons on the list were
billed for the vaccine.
For the non-computerized
office, conduct a manual record review on a daily or weekly
basis.
For influenza, the vaccination
rate can be tabulated at the end of the vaccination season.
In a very large practice,
a sampling method could be used to determine an estimate
of the proportion of at-risk persons vaccinated.
The number of vaccinations
administered can be tracked using billing records to determine
if more vaccinations are administered after implementing
the PHRs as compared with the number of vaccinations before
the PHRs were used.
|
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