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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) .pdf icon

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 physicianís 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:

 
  1. Compare vaccination rates pre- and post-implementation of the standing orders.
    Or
  2. 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 patientís 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:

 
  1. Compare vaccination rates pre- and post-implementation of the computerized record reminder.
    Or
  2. 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) .pdf icon  
 
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 physicianís 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) .pdf icon 
 

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 physiciansí 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 physicianís 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:
 
  1. Compare vaccination rates pre- and post-implementation of the home visits.
    Or
  1. 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 patientís name and/or the doctorís signature and postcards with information regarding the importance of vaccination are more effective than generic postcards.

Measurement:

 
  1. Compare vaccination rates pre- and post-implementation of the mailed/telephoned reminders.
    Or
  1. 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

 
  1. reducing the distance from the setting to patients,
  2. increasing, or making more convenient, the hours during which vaccination services are provided,
  3. delivering vaccinations in settings previously not used, and/or
  4. 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:

 
  1. Compare vaccination rates pre- and post-implementation of the expanded access activity.
    Or  
  1. 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) .pdf icon 
 
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 patientís 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:

 
  • Staff time.
  • Handouts.
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:

 
  1. Compare vaccination rates pre- and post-implementation of the patient education materials.
    Or
  1. 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) .pdf icon 
 
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 physicianís 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:
 
  1. Compare vaccination rates pre- and post-implementation of the personal health record.
    Or
  2. 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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