HIV/AIDS News & Information

A review of the literature strongly suggests that providers who administer vaccines will benefit from monitoring their performance through assessment, including physicians in private practice. For those who work in public clinics, all states now require clinics to measure immunization coverage of 2-year-old children and the Advisory Committee on Immunization Practices recommends routine assessment by all providers. In addition, managed care organizations have begun to use immunization assessment as an indicator of the quality of health care services. Report cards or the Health Plan Employer Data and Information Set (HEDIS) measurements are becoming more important to MCOs. HEDIS was developed by the National Committee for Quality Assurance, an accrediting organization for MCOs. Many physicians in private practice do participate in one or more MCOs through an independent practice association. As we change to a more managed health care delivery system, documentation of the quality of services and care will become common. While providers who work directly as an employee of a “staff model” MCO similar to Kaiser Permanente or Prudential will be required to measure quality of services, all other providers receiving capitation or other forms of payment from MCOs will soon feel the pressure to assist MCOs in documenting the provision of quality care.

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While we need to improve our immunization record, there is strong evidence that assessment of immunization coverage is an effective tool. In recent years, a few published studies have evaluated the effect of assessing immunization coverage on improving immunization levels; all have demonstrated improvement in coverage. One of the first studies was conducted in public health clinics in Georgia, where 70% of Georgian children received their immunizations. Annual assessments of coverage were conducted from 1987 to 1993 on nearly all of the 230 public clinics in Georgia. Immunization coverage and a diagnosis of the causes for suboptimal coverage were presented to the clinic staff and public health officials. Incentives were provided to encourage improvement in immunization rates. Information on coverage was shared between the clinics, strategies for improving immunization rates were shared at annual district and state meetings, and a peer-based incentive was created with peer pressure to improve coverage. This approach has been codenamed by the CDC as AFIX (Assessment, Feedback, Incentive, and Exchange). Improvement in coverage in Georgia public clinics was examined over a 7-year period. Coverage increased from less than 40% to 80% statewide with the incremental annual increases of 6%. During the same period, missed opportunities for immunization decreased from 18% to 0%.

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There are at least three principal reasons for assessing immunization coverage: (1) national objectives for preventing childhood vaccine-preventable diseases exist; (2) suboptimal immunization coverage is a reality; and (3) effectiveness of the assessment strategy has been demonstrated.

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To meet and then sustain our national health objectives for the year 2010 of eliminating most childhood vaccine-preventable diseases and of attaining 80%-90% immunization coverage of 2-year-old children, health care providers will have to improve the immunization rates of their patients. Based of the most recent scientific evidence, the Advisory Committee on Immunization Practices and the Task Force on Community Preventive Services have identified periodic assessment of immunization coverage of patients by a health care provider as a key strategy for improving immunization rates. Health care providers in private practice are critical to improving immunization coverage because they administer most of the vaccination in the United States. Of the 2-year-old children in the 1998 National Survey Provider Check Study, 62% has a private provider, 19% had a public health care provider, 8% had a hospital-based provider, and 6% had another, nonpublic health care provider. The objectives of this article are to review reasons why providers should assess immunization coverage, describe which providers will benefit from assessment, and discuss what assessment is and the role it has in optimizing the deliver of immunization services.

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In the past decade, the prevalence of excess body weight has reached epidemic levels throughout the US population, with the most rapidly increasing prevalence being seen in minority groups. Based on CDC statistics, between 1991 and 2000, the prevalence of obesity, defined as BMI >30, among African Americans rose by nearly 50%, increasing from 19.3% of this population group to 29.3%. Overweight and obesity are associated with 300,000 deaths each year in this country, and are directly linked to CVD, type 2 diabetes, IRS, certain types of cancer, and stroke, as well as a variety of respiratory, skeletal, and psychological disorders.

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Coronary heart disease is the single largest killer of American adults. Stroke, considered separately from other cardiovascular diseases, is the third leading cause of death in this country, behind heart diseases and cancer. For coronary heart disease and stroke, incidence and death rates are both significantly higher in African Americans than in other ethnic groups for women and for men. Hypertension, which is also highly more prevalent among African Americans, is a primary risk factor for each of these conditions. Based on the blood pressure reductions observed in the first DASH trial, it was estimated that population-wide adoption of the DASH diet could reduce coronary heart disease and stroke incidence by 15% and 27% respectively.

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As is commonly the case in dietary intervention studies, however, while many studies provided evidence that calcium intake influences blood pressure, others were unable to demonstrate a consistent effect, leaving in question calcium’s role in hypertension management. Heterogeneous blood pressure responses are intrinsic to single-nutrient interventions: while many individuals may exhibit a favorable blood pressure response with a specific treatment (e.g., increased calcium, reduced sodium), others may respond negatively, and still others, not at all. tleterogeneity has been observed repeatedly in nutrient intervention studies, and has been a major factor in the inconsistent and often contradictory results of clinical trials examining blood pressure effects of individ­ual dietary components.

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