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Overview of AFIX

What is AFIX?

The AFIX approach used by awardees incorporates four key strategies proven reliable to improve providers’ immunization service delivery and raise vaccination coverage levels

Assessment of the healthcare provider's vaccination coverage levels and immunization practices.

Feedback of results to the provider along with recommended strategies to improve processes, immunization practices, and coverage levels.

Incentives to recognize and reward improved performance.

eXchange of information which is also known as follow up with providers to monitor and support progress towards implementing quality improvement strategies and improving vaccination coverage levels.

The purpose of AFIX is to assist and support health care personnel by identifying low immunization rates, opportunities for improving immunization delivery practices, and ensuring that providers are;

  1. Aware of and knowledgeable about their immunization rates and missed opportunities to vaccinate
  2. Motivated to incorporate changes to their current practices
  3. Ready to try new immunization service strategies
  4. Capable of sustaining these new behaviors.

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Data and Methods Used

The Assessment and Feedback portions of the process are data-driven. The data is assessed through an Immunization Information System (IIS) or the Comprehensive Clinic Assessment Software Application (CoCASA) along with the use of a site visit questionnaire to assess the immunization improvement strategies present at provider offices, all of which help determine provider performance and act as a catalyst to improve and maintain coverage levels. Assessment of performance enables providers to determine how well they are doing through systematic, routine examination of client records. The data collected through these Assessments can then be used to diagnose potential problems relating to service delivery and office policies.

Presenting and discussing the Assessment information is known as Feedback. How Feedback is done is key to the success of the process. Using the Assessment data during the Feedback session will help target practice areas that need to be improved. Strategies for improvement will then be specific to the practice, and their effectiveness can be measured during subsequent Assessments and the eXchange of Information or follow up phase.

The Incentives phase  of the AFIX process may include methods that stimulate competition among provider sites, encourage provider participation and mutual support, recognize successful solutions, and promote improved immunization services and delivery.

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History of AFIX

In order to raise coverage levels to achieve national immunization goals, the Georgia Department of Public Health implemented a statewide program in 1986 that consisted of annual Assessments of immunization records at its public health clinics. Information was fed back to clinic providers and their staff who, in turn, developed their own solutions to improve coverage. Incentives included rank order listings of clinics by coverage level, awards for sites with the highest levels, and presentations by successful clinics at annual immunization meetings. Other successful strategies included coordinating with WIC, conducting reminder/recall phone activities, and providing performance Feedback to nursing staff. As a result of these efforts, immunization coverage levels in Georgia public clinics increased from 40% to 91% between 1986 and 2001. This intervention has become a national model program to improve immunization rates.

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Effectiveness of AFIX

AFIX is widely supported as an effective and recommended strategy for improving immunization rates and practices in both public and private provider settings. In 2008, the Task Force on Community Preventive Services updated their original 1999 literature review on the topic and reaffirmed their earlier recommendation of Assessment and Feedback “based on strong evidence of its effectiveness across a range of settings and populations.” This same review is cited in the CDC’s Advisory Committee for Immunization Practices (ACIP) 2011 General Recommendations in their endorsement of Assessment and Feedback.

AFIX is also incorporated in Healthy People 2020’s objectives and goals as objective number IID-17 (provider IIS assessment) with the following definition and targets:

IID-17: Increase the proportion of providers who have had vaccination coverage levels among children in their practice population measured within the past year.

  • IID-17.1 Target is 50% of public health providers
  • IID-17.2 Target is 50% of private providers

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The Need for AFIX

Although vaccine-preventable diseases are at their lowest point ever, variations in coverage levels exist in all age groups; "pockets" of under-immunized populations can be found in many urban and rural areas, particularly in those below the poverty level. Consult the National Immunization Survey for coverage levels by year. Since nearly 98% of American-born infants begin well-child care in the U.S., it makes sense for public health to focus on providers. Provider-based strategies, such as AFIX, focus on sustainable improvements in service delivery. One provider who sees many clients can effect long lasting improvements in immunization practice. In addition, it has been said that only those who provide care can, in the end, change care. Thus, it is vital to direct interventions to improve service delivery towards health care providers.


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