ASSESSING IMMUNIZATION COVERAGE IN PRIVATE PRACTICE: EFFECTIVENESS OF ASSESSMENT
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%.
A number of other states have used AFIX in publie clinics: Colorado, Illinois, Indiana, Iowa, and South Carolina. Although not all of these states have duplicated the AFIX model exactly, one or more of the AFIX components were used. Illinois increased coverage 12% in 3 years, from 44% in 1993 to 56% in 1995; Iowa increased coverage 27% in public clinics in 3 years, from 50% in 1993 to 77% in 1995; and South Carolina increased coverage 15% in 3 years, from 69% to 84% (Table l). Subsequently, the AFEX-like strategy has been extended to other states. buy antibiotics canada
Assessment has also been used by managed care organizations (MCOs) to improve immunization coverage. For instance, Group Health of Puget Sound increased coverage 27% in nearly 2 years, from 62% in the first quarter of 1993 to 89% in the third quarter of 1994 (Table 2). In four states belonging to US Health Care, measles, mumps, rubella (MMR) vaccine coverage increased 18% in 3 years (CDC, unpublished data). Other MCOs, including Harvard Pilgrim Health Plan, Health Partners in Minnesota, and Cigna in Phoenix have increased coverage rates using continuous quality management techniques, which are also heavily data-driven. In addition, among 418 private physician offices in Pennsylvania, New Jersey, New York, and Connecticut, in an independent practice association managed care organization, Morrow found a nearly 20% improvement in measles-mumps-rubella immunization coverage among providers who followed the MMR standards 1 year after an intervention began of peer review, feedback, and financial incentives.
AFIX components used in private practice settings also have demonstrated an improvement in immunization coverage. In a large group practice in Massachusetts with 10 pediatricians among 1400 2-year-old children surveyed, coverage increased 18% (from 54% to 72%) at the end of the first year of the intervention (CDC, unpublished data). The practice introduced a combination of assessment and feedback of vaccination status of patients at every encounter and recall and reminder systems for patients who were late or due for vaccinations. More recently, in a statewide study of 231 private physician offices in Maine from 1994 through 1996, assessment and feedback improved the median up-to-date immunization coverage at 24 months to 9% above baseline coverage 1 year after the intervention began. By 1997, nearly all states have reported assessment and feedbackamong private physicians. buy antibiotics amoxicillin
Besides the quasiexperimental studies, a number of randomized controlled trials have also demonstrated the effectiveness of the assessment and feedback strategy in improving immunization practice. Buffington and Bennett found in private physicians offices in an academic organization a 16% improvement in influenza coverage over the control group among elderly persons 65 years of age or older after continuous assessment and feedback was provided weekly. Assessment included the provision of weekly number of immunized patients and the cumulative percentage of the target population that had been immunized. In addition, Fairbrother et al. found a feedback and financial bonus intervention that improved the percentage of up-to-date children for vaccination by 25% because of better documentation of immunization records. In only one of the three randomized controlled trials identified was assessment and feedback found to be ineffective. Carey et al. examined compliance with standards by an annual audit of the organization and delivery of preventive services (e.g. influenza vaccination) in 37 rural community health centers in North Carolina. The mean influenza vaccination rate in 1987 of 59% was higher than the rate 2 years later in 1989 (48%), while all other preventive practices showed improvement. Perhaps infrequent assessment, feedback and the use of the mean and not the median influenza vaccination rate may explain the lack of improvement in immunization coverage. Mean rates are influenced more by extreme variation in rates. kamagra soft tablets