Strategies for Increasing Adult Vaccination Rates
Including Links to Examples

WhatWorks! -- Increasing Adult Vaccination Rates

NOTE: The WhatWorks! interactive training program offers the same content as listed below but in a learning setting. It is for primary care practitioners who want to focus on strategies to increase adult vaccination rates.

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 [PDF 14KB - 2 pages] of the effectiveness studies.

Example:

Standing order [PDF 40KB - 1 page]

Additional examples of standing orders are provided on the Immunization Action Coalition website.

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 physician’s 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 healthcare system.

Implementation Steps:

The physician:

1. Decides on the criteria that will be used to indicate patient eligibility for vaccination and for specific vaccines.
2. Writes the standing order (see example).
3. Meets with staff to discuss implementation of the standing order strategy.
4. Monitors vaccination rates.

Measurement:

The measurement for Standing Orders is the same as those many other strategies.

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.

Sample:

Computerized record reminder  [13KB - 1 page]

Definition:

The computer can print a list of possible reminders that appear on a patient’s 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:

Computerized record reminders can be effective, efficient, and inexpensive once the computerized system is in place. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.

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 Steps:

1. Design or identify a computerized reminder system that meets the needs of the practice (see sample).
2. Train professional staff on how to use computerized reminders.

Measurement:

The measurement for Computerized Record Reminders is the same as those many other strategies.

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).

Sample:

• Chart reminder [83KB - 2 pages]

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 that patient vaccinations are due or overdue 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:

Chart reminders are inexpensive and efficient. Reviewing health maintenance inventories with patients requires less than 4 minutes and can become part of the physician’s routine. Provider reminder strategies are so effective they have been demonstrated to improve rates both alone and in combination with other strategies.

Efficient:

Reviewing health maintenance inventories with patients requires less than 4 minutes with the patients and quickly becomes part of the physician’s 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 Steps:

1. Design or identify a chart reminder to use (see sample).
2. Make copies to be inserted into all appropriate patient records.
3. Assign a staff person to place the reminders in a prominent place in the chart.
   

Measurement:

The measurement for Chart Reminders is the same as those many other strategies.

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.

Sample:

• Performance feedback [9KB - 1 page]

Definition:

Provider assessment and feedback involves retrospectively evaluating the performance of providers in delivering one or more vaccinations to a client population and then reviewing their assessment data with providers.

Performance feedback as used in this program focuses on benchmarking, i.e., comparing performance to a goal or standard and is usually implemented in private practice or managed care settings. But keep in mind, assessment of vaccination coverage and feedback to providers in hospitals and long-term care facilities has been shown to be effective in improving vaccination coverage rates in those institutions.

Incentives/benchmarking: 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 physicians’ performance. Some practices encourage friendly competition among physicians, which creates an additional incentive to increase vaccination rates.

One highly effective method of performance feedback uses posters to track the number of patients vaccinated. (See sample.)

Appropriate settings for this strategy include:

Private practice, managed care.

Advantages:

• Competition increases physician compliance with vaccination recommendations.
• Immediate feedback on each physician’s 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 Steps:

1. Enumerate number of eligible patients (denominator).
2. Generate lists of patient names if necessary.
3. Create or adopt target-based poster on which to track number of patients vaccinated (see sample).
4. Hold meetings with staff and doctors to explain the graphic, i.e., a denominator-based tracking system.
5. At the end of each week, physicians and their staff should record all vaccinations being tracked (for example, all influenza vaccinations given to at-risk patients), tabulate the cumulative weekly total, and calculate the percentage of the target population vaccinated.
6. Graph this percentage on the poster. (Reports of vaccinations received outside the office should not be included unless the patient has documentation.)

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. For example, at the end of the influenza vaccination season, the percent of patients vaccinated is the measure of success.

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.

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.

Example:

• Home visits sample  [6KB - 1 page]

Definition:

Home visits involve providing face-to-face services to clients in their homes. These services can include education about vaccine-preventable diseases and vaccines, assessment of need for or referral to vaccination services, and delivery of vaccinations. Home-visiting interventions can also involve telephone or mail reminders.

Appropriate settings for this strategy include:

Private practice, managed care.

Advantages:

• Efficient, if using existing home healthcare 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 Steps:

1. Determine if your practice has a relationship with home health services for your clients.
2. Meet with home health staff to discuss implementation of strategies to improve vaccination.
3. Develop appropriate protocols for home visit vaccination services.
4. Implement vaccination protocols.
5. Monitor increased vaccination rates.

Measurement:

The measurement for Home Visits is the same as those many other strategies.

Effectiveness:

Home visits have been found to modestly increase vaccination and counseling for vaccination. Nicholson et al. (1987) documented a higher influenza vaccination rate of 20.4% among older persons immobile at home with a specific vaccination program, compared to similar persons with no specified vaccination program, in the United Kingdom.

Black et al. (1993) demonstrated an increased rate of offering influenza vaccine with a targeted influenza vaccine promotion in homebound patients (42.2% vs. 18.2%). However, vaccination rates were similar (56%) in the intervention and control groups.

Example:

• Mailed reminder and telephone script  [178KB - 2 pages]

Definition:

To implement this reminder/recall strategy, medical staff either call the patient or send a postcard/letter reminding the patient that a vaccination is due (reminder) or overdue (recall) and offer the patient the opportunity 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.
• Regular use helps to increase vaccination rates.
• Mailed reminders works well for literate patients; telephone reminders may be more effective for less literate patients.

Disadvantages:

• Both reminder type 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 Steps:

1. Determine selection criteria (i.e., age and/or diagnosis).
2. Generate a list of patients to be reminded (manually or via computerized billing or medical records).
3. 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.
4. Develop reminder (see sample).
5. Send reminders or place calls (6 calls a day, 5 days a week for eight weeks = 240 patients contacted).
6. Schedule appointments.

Measurement:

The measurement for Mailed/Telephoned Reminders is the same as those many other strategies.

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 patient’s name and/or the doctor’s signature and postcards with information regarding the importance of vaccination are more effective than generic postcards.

Example:

• Expanding Access sample [223KB - 1 page]

Definition:

Expanding access can include

• reducing the distance patients must travel to receive vaccination services
• increasing, or making more convenient, the hours during which vaccination services are provided
• delivering vaccinations in settings previously not used
• 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 notices, and is strongly recommended as part of a multicomponent intervention.

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 Steps:

1. Determine which access barriers are the most important for your patients.
2. Meet with staff to discuss implementation of strategies to improve access.
3. Develop appropriate materials to advertise the clinic’s expanded access activity. For example, advertising can be done through mailings, posters, or a health care plan’s newsletter.
4. Implement strategies.
5. Monitor increased vaccination rates in comparison to resources expended.

Measurement:

The measurement for Expanding Access in Clinical Settings is the same as those many other strategies.

Effectiveness:

Expanding access is effective in increasing vaccination levels in adults. Nicholson et al. (1987) found that special immunization clinics increased influenza vaccination rates from 18.5% to 25.6% in older persons in the United Kingdom.

Lukasik et al. (1987) demonstrated that availability of influenza vaccination anytime during usual office hours, in combination with a telephone reminder, increased the vaccination rate to 50.8%, compared to a 26.8% rate of informing patients about the vaccine who were already in the office.

Sample:

• Influenza Vaccine Information Statement [52KB - 2 pages]

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 patient’s 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 healthcare providers.
• Written materials are not as useful in practices serving those with low literacy levels; however, video and audio resources can sometimes be used.
• For minority populations, may need bilingual information sheets.

Implementation Steps:

1. Create or identify an appropriate patient information sheet or use the Vaccine Information Statement (VIS). (See sample).

2. Assign a staff person to distribute the information sheet or VIS.

Measurement:

The measurement for Patient Education is the same as those many other strategies.

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).

Example:

• Personal health record sample [16KB - 1 page]
• To view a wallet card

Definition:

Personal health records (PHRs) 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 healthcare.
• 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 are available (e.g., one-page sheet or wallet-size card).
• Patient has a record of preventive services received should they move or change providers.

Disadvantages:

• Requires patient to take initiative (schedule and keep appointments) and remember to bring PHR with them.
• Requires acceptance, promotion, 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 Steps:

1. Create or adapt a personal health record.
2. Decide on a distribution plan (mail or distribute in the office).
3. If distributing in the office, appoint a person (receptionist, nurse, doctor) to distribute the PHR to patients and explain its use. If mailing, generate a list of eligible patients (usually based on age) from computerized medical records, computerized billing records, or manually from medical records.

Measurement:

The measurement for Personal Health Records is the same as those many other strategies.

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 physician’s 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.

Related article on child rates and vaccination records:

Are Patient-Held Vaccination Records Associated With Improved Vaccination Coverage Rates? Pediatrics, Vol. 125, No. 3, March 2010, pp. e467-e472.

Because the measuring and tracking rates are the same for most strategies, the information was only listed once on this page.

Use these links to return to the sections above.
Standing Orders | Computerized Record Reminders | Chart Reminders | Home Visits | Mailed/Telephoned Reminders | Expanding Access in Clinical Settings | Patient Education | Personal Health Records

To measure the effectiveness of the strategy, you can use either of these two approaches:

1. Compare vaccination rates pre- and post-implementation of the strategy.
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.
   

Methods for tracking rates include:

• For the computerized office, determine what proportion of persons on the list were billed for the vaccine. Or access the Comprehensive Clinic Assessment Software Application (CoCASA) program developed to assess adult immunization rates.
• For the non-computerized office, conducting a manual record review on a daily or weekly basis. For guidelines, see Conducting a Baseline Assessment [PDF 38KB - 3 pages].
• 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.

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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 January 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.

Latest Reports on Increasing Adult Vaccination Rates

1. AAP Policy Statement: Increasing Immunization Coverage
   Pediatrics published online May 31, 2010; Vol. 125 No. 6 June 2010, pp. 1295-1304 (doi:10.1542/peds.2010-0743) NEW June 2010
   
   
2. The February 2010 report, Adult Immunization: Shots to Save Lives, released by the Trust for America's Health (TFAH), the Infectious Diseases Society of America (IDSA), and the Robert Wood Johnson Foundation (RWJF) outlines a number of policy recommendations to increase rates of adult vaccinations.

2. Doctors Role in Increasing Immunization Uptake in Adults
   AAFP News Now (03/08/10) Mitchell, David