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Recommendations of the Advisory Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Rates -- Assessment and Feedback of Provider-Based Vaccination Coverage Information

This statement by the Advisory Committee on Immunization Practices (ACIP) presents programmatic strategies to increase vaccination rates. This is the first statement to recommend the use of routine assessment and feedback of provider-based vaccination coverage information.

Routine assessment and feedback of vaccination rates obtained at the provider site is one of the most effective strategies for achieving high, sustainable vaccine coverage. For example, in 1986, the Immunization Program of the Division of Public Health, Georgia Department of Human Resources, initiated a program to assess annually the vaccination records of children enrolled in public health clinics to determine progress toward achieving the national goal of 90% series-complete coverage by age 2 years. During 1986-1994, series-complete vaccination rates at age 2 years among children in public health clinics increased from less than 40% to approximately 80% -- an increase attributed to assessment and feedback, which motivated providers to develop and implement targeted interventions (1,2;CDC, unpublished data, 1996).

Assessment and feedback also has resulted in substantial increases in vaccination rates in public health clinics in Colorado, Illinois, Iowa, Kansas, and South Carolina (3-5;CDC, unpublished data, 1996). Assessments in private and managed-care provider settings in Arizona, Massachusetts, New York, and Washington suggest that this strategy also can improve rates in these settings (4,6-8). Beginning in 1995, all states receiving federal funds for vaccination programs have been required to conduct annual assessments of vaccination rates in public health clinics. * Managed-care organizations also have begun assessing vaccination rates by using data from the Health Plan Employer Data and Information Set (HEDIS) (9). Similarly, the Bureau of Primary Health Care, Health Resources and Services Administration, is introducing assessment and feedback of pediatric vaccination rates as part of quality improvement in community and migrant health centers.

CDC developed the Clinic Assessment Software Application (CASA) to assist in measuring vaccination rates in vaccination practices (10). Only documented antigen-specific vaccine doses and dates of vaccination are used in CASA (or computer vaccination-registry systems with CASA-like functions {11}) to determine provider vaccination rates for all routinely recommended vaccines. Reports produced by CASA also indicate the extent to which vaccination rates can be improved by administering multiple vaccines simultaneously, using accelerated vaccination schedules, encouraging parents to initiate the vaccination series on time, and contacting parents when children are due for or have missed vaccinations. Providers and clinic staff can receive feedback as soon as all vaccination data are entered into CASA. Effective assessment requires complete documentation of antigen-specific doses and dates of vaccination from current and previous providers' records.

A goal of CDC is that vaccination coverage assessments be conducted at all provider sites (public and private) at regular intervals. Assessments provide data about vaccine-delivery practices and vaccine coverage that motivate and assist providers in developing and implementing practices to achieve optimal vaccination rates. Although the cost-effectiveness of vaccinations is well documented, assessment as a specific intervention has not been subjected to such analyses. However, implementation of regular assessments is expected to result in higher vaccination rates and, therefore, be cost-effective.

The ACIP recommends the regular assessment of vaccination rates for individual clinics or providers, including feedback about vaccine-delivery practices, to motivate providers and staff to improve vaccination practices. Implementation of these recommendations can contribute substantially to improving vaccination rates and sustaining high rates in all vaccine-provider sites.


  1. CDC. Evaluation of vaccination strategies in public clinics -- Georgia, 1985-1993. MMWR 1995;44:323-5.

  2. Dini EF, Chaney M, Moolenaar RL, LeBaron CW. Information as intervention: how Georgia used vaccination coverage data to double public sector vaccination in seven years. Journal of Public Health Management and Practice 1996;2:45-9.

  3. Galati RV. Assessments and incentives in the public sector: Illinois and Colorado. In: Proceedings of the 29th National Immunization Conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1996 (in press).

  4. Houts C, Warming J. Assessments with public and private providers. In: Proceedings of the 29th National Immunization Conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1996 (in press).

  5. Greene JE. Assessments using an immunization registry. In: Proceedings of the 29th National Immunization Conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1996 (in press).

  6. Thompson RS, Taplin SH, McAfee TA, et al. Primary and secondary prevention services in clinical practice: 20 years' experience in development, implementation, and evaluation. JAMA 1995;273:1130-5.

  7. Bushnell C. Practice-based immunization assessments: the measures of change. In: Proceedings of the 29th National Immunization Conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1996 (in press).

  8. Morrow RW, Gooding AD, Clark C. Improving physicians' preventive health care behavior through peer review and financial incentives. Archives of Family Medicine 1995;4:165-9.

  9. CDC. Use of a data-based approach by a health maintenance organization to identify and address physician barriers to pediatric vaccination -- California, 1995. MMWR 1996;45:188-93.

  10. CDC. Clinic Assessment Software Application (CASA): user's guide. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1994.

  11. Frame PS. Computerized health maintenance tracking systems: a clinician's guide to necessary and optimal features: a report from the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems. J Am Board Fam Pract 1995;8:221-9.

    • Public Law 103-333.

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