Alan Hinman Alan Hinman vaccinate

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					                                                                    Outline of presentation
   Financing childhood immunizations
                   and                                       • Current status of vaccine-preventable
   Benefits of immunization registries                         diseases and childhood immunization in
                                                               the US and NJ
                                                             • How immunizations are financed in the US
            Alan R. Hinman, MD, MPH                          • Inequities in financing
    Vaccine Preventable Diseases Conference                     – Causes
                  July 26, 2010                                 – Possible solutions
                                                             • Current status of Immunization
                                                               Information Systems (IIS)
                                                                                                              2




Vaccines Routinely Recommended for Children and
                   Adolescents

      1985         1995             2009
      Measles       Measles         Measles
      Rubella       Rubella         Rubella
      Mumps         Mumps           Mumps
      Diphtheria    Diphtheria      Diphtheria
      Tetanus       Tetanus         Tetanus
      Pertussis     Pertussis       Pertussis
      Polio         Polio           Polio
                    Hib (infant)    Hib (infant)
                    HepB            Hepatitis B

   7
                    Varicella       Varicella
                                    Pneumococcal disease
                                    Influenza

                   10
                                    Meningococcal disease
                                    Hepatitis A
                                    Rotavirus
                                    HPV


                                   16                    3
                                                                                                          4




                                                     5                                                            6
  Comparison of 20th Century Typical                                 Increasing Vaccine-Specific Coverage
     and Current Morbidity, VPD                                      Rates Among Preschool-Aged Children
   Disease          Pre-vaccine era   2009(prov)     % change
   Diphtheria               21,053         0            100
   Hepatitis A             117,333*     1,849            98
                                                                            2010 Target
   Hepatitis B (acute)      66,232*     3,020            95                          DTP / DTaP(3+)†                                                  Hep B
   Hib <5                   20,000*        25           >99                                                                                           (3+)
                                                                                                                                                                            PCV 7
   Measles                 530,217         61           >99                                                                                                                 (3+)
                                                                           MMR(1+)
   Mumps                   162,344        962           >99                                                    Polio (3+)
   Pertussis               200,752     13,506            93
   Pneumo (invasive)        63,607*   41,550*            35
                                                                                                                              Hib (3+)
   Polio (paralytic         16,316          0           100
                                                                                                                                                    Varicella (1+)
   Rubella                  47,745          4           >99
        CRS                    152                  1
      >99
                                                                      † DTP(3+) is not a Healthy People 2010 objective. DTaP(4) is used to assess Healthy People 2010 objectives.
   Smallpox                 29,005         0            100           Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age.
   Tetanus                     580                 14                 Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS, and NIS (1994-2006), CDC, NIP and NCHS; No data from
                                                                 7    1986-1990 due to cancellation of USIS because of budget reductions.                                            8
      98




Vaccination coverage among children                                  Vaccination coverage among children
  19-35 months of age, 2008-2009                                       19-35 months of age, 2008-2009

 Vaccine                      USA           NJ                          Series                                                           USA                     NJ
 DTP/DTaP 4+                  84.9%        80.6%
 Polio     3+                 93.6%        89.1%                        4/3/1/3/3+ Hep B                                               75.0%                    73.1%
 MMR       1+                 91.5%        85.8%                        4/3/1/3/3/1+ Varicella                                         72.9%                    69.3%
 Hib       3+                 86.7%        88.4%                        4/3/1/3/3/1/4+PCV                                              65.7%                    62.4%
 Hep B     3+                 93.3%        90.5%
 Varicella 1+                 90.6%        84.1%
 PCV       4+                 80.6%        74.4%
 Hep A     2+                 44.1%        29.1%
                                                                 9                                                                                                                   9




   Vaccination coverage among
                                                                             Types of costs in immunization
adolescents aged 13-17 years, 2008
 Vaccine                      USA           NJ                                          • Vaccine purchase
 MMR 2+                       89.3%        91.8%                                        • Vaccine administration
 Hep B 3+                     87.9%        94.5%                                        • Non-vaccine costs
 Var 1+                       81.9%        86.2%
 Td/Tdap 1+                   40.8%        78.1%
 Tdap 1+                      40.8%        43.0%
 MCV4 1+                      41.8%        60.6%
 HPV 1+ (F)                   37.2%        43.0%
                                                                11                                                                                                                  12
                                                                                                                                                         Pediatric Vaccines Recommended for Children 0-6
                                                                                                                                                                           Years of Age
                    Sources of financing childhood                                                                                                             Doses Distributed by Funding Source
                           immunizations                                                                                                                                Calendar Year 2007

                                • Government
                                   – Federal
                                   – State/local
                                • Insurance
                                   – Private
                                   – Public
                                • Out-of-pocket
                                                                                                                                                  Source: Biologics Surv eillance Data 2007. Represents a national summary of self-reported distribution data by the v accine manufacturers.
                                                                                                                                                  The data are an estimate of the annual national distribution and does not equal administration. Reported data may be incomplete and
                                                                                                                                                  include possible ov er-reporting or under-reporting of distribution data and may not reflect all v accines or manufacturers.
                                                                                                                                                  “Other” represents all purchases not on CDC contracts, including priv ate, health insurance, and gov ernment purchases through other
                                                                                                                                                  mechanisms.
                                                                                                                                        13                                                                                                                                             14
                                                                                                                                                  Data do not include influenza v accine doses.
                                                                                                                                                  Updated July 17, 2008




                                                                                                                                                   Cost to Vaccinate from Birth Through 18 Years of
                           Tdap, MCV4 & HPV Vaccine
                       Doses Distributed by Funding Source
                                                                                                                                                    Age with Vaccines Recommended Universally:
                               Calendar Year 2007                                                                                                                1990, 2000, and 2010
                                                                                                                                                                                                                                                                                    $1,483



                                                                                                                                                                                                                                                 $1,195




                                                                                                                                                                                                                $370



                                                                                                                                                                                $70

Source: Biologics Surv eillance Data 2007. Represents a national summary of self-reported distribution data by the v accine manufacturers.
The data are an estimate of the annual national distribution and does not equal administration. Reported data may be incomplete and
include possible ov er-reporting or under-reporting of distribution data and may not reflect all v accines or manufacturers.
“Other” represents all purchases not on CDC contracts, including priv ate, health insurance, and gov ernment purchases through other                   2010 represents minimum cost to vaccinate a child (birth through 18); exception is no preservative influenza vaccine, which is included for children 6-47 months of age.
mechanisms.                                                                                                                                  15                                                     HPV excluded for boys because it is not routinely recommended by the ACIP.
A significant but unknow n proportion of Tdap, MCV4, and HPV v accine distributed in the priv ate sector may be utilized in adults older than                                                    Federal contract prices as of February 1, 1990, September 27, 2000, and April 6, 2010.
                                                                                                                                                                                                                                                                                                                                  16
age 18 years.




                     317 Immunization Program

       317 grants support:

       • Purchase of vaccine for free
         administration at local health departments
       • Immunization delivery
       • Surveillance
       • Communication
       • Education

                                                                                                                                        17                                                                                                                                                                                        18
                                                             How Public Health Reaches
    Vaccines for Children Act                                  Children through VFC
• Provides entitlement to free vaccines                • VFC program has 45,000 provider sites
                                                          – 75% of sites are private providers
  specified by ACIP for
                                                          – 25% are public sector sites
   – Uninsured
   – Medicaid                                          • Collectively, VFC providers vaccinate 90% of
                                                         children
   – American Indian/Alaska Native                        – VFC vaccine for VFC-eligible children
   – Underinsured (FQHC only)                             – Private purchase vaccine for other children

• Allows States to buy off Federal Contract            • Improving VFC providers’ practices improves
  with their own funds                                   vaccinations for almost all children

                                              19                                                               20




 VFC and Section 317 Vaccine Funding               Two-Tiered State Vaccination Policies at
to Immunization Programs: 1990 - 2009                    Local Health Departments
                                                   • Traditionally, health department clinics vaccinated any
                                                     child brought for vaccination
                                                   • Underinsured children ineligible for VFC vaccine except at
                                                     FQHCs and RHCs (~3,000 clinics)
                                                      – VFC designated FQHCs and RHCs as safety-net
                                                        providers for underinsured children
                                                      – State and 317 funding used for underinsured
                                                      – Due to inadequate state/317 funding, many states
                                                        cannot purchase vaccine for underinsured children
                                                   • Result is a two-tiered policy
                                                      – Government purchased vaccine not available to
                                                        underinsured at health department clinics
                                                      – Access to new vaccines for some based on insurance
                                              21      – Ethical tension for public health officials and providers   22




                                                          Private insurance for childhood
                                                                   immunizations

                                                       • Approximately 53% of children <5 in 2003
                                                       • Approximately 10% considered uninsured
                                                       • Most insurers cover ACIP vaccines within
                                                         approximately 3 months
                                                       • Many require provider to purchase
                                                         vaccine – up-front costs for inventory
                                                       • Reimbursement may take some time and
                                                         may not cover true cost of purchase

                                              23                                                               24
  Public insurance for childhood                         Out-of-pocket expenses for
          immunizations                                   childhood immunizations

• Medicare                                         •   Primarily with underinsured children
• Medicaid                                         •   Providers may refer to health departments
• CHIP                                             •   Exacerbated by costs of newer vaccines
  – Medicaid enhancement                           •   May be further exacerbated by efforts to
  – S-CHIP                                             make HPV mandatory without assuring
                                                       that all children have access to vaccine in
                                                       public sector



                                              25                                                     26




 Inequities in vaccine purchase -                      Inequities in vaccine purchase –
              causes                                       some possible solutions
• Underinsurance                                   • Increase 317 appropriations
• Inability of 317 and state/local funds to        • Expand access to VFC for underinsured
  keep up with increasing vaccine costs            • Allow access to VFC for S-CHIP
• Burden on private providers to make              • Assure providers are fully reimbursed for
  large advance investments in purchasing            purchase costs
  new vaccines                                     • Allow delayed payments to vaccine
• Ethical dilemma at both state and                  manufacturers/distributors
  provider levels

                                              27                                                     28




     317 funding FY 2009-2011                               Vaccine administration

FY 2009                  $ 557 M                   • Studies indicate that it costs
FY 2010                  $ 559 M                     approximately $18-25/injection to
  + ARRA (2 yr)      $ 300M                          administer vaccines
FY 2011                  $ 576 M                   • VFC does not reimburse for vaccine
                                                     administration
                                                   • Widely varying rates of reimbursement
CDC estimate              $1,629 M                   from Medicaid and private insurers
317 Coalition ask         $ 803 M


                                              29                                                     30
                                                       Variation in provider vaccine purchase
                                                        prices and payer reimbursement* - 1
                                                        • Survey of 76 practices in 5 states
                                                        • Major variation (up to 3X) in minimum &
                                                          maximum purchase price for a given
                                                          vaccine
                                                        • Some practices got better prices than VFC
                                                        • Larger practices, those in MSAs, and
                                                          those participating in purchasing
                                                          cooperatives generally had lower prices

                                                  31
                                                             *Freed et al. Pediatrics 2008;122:1325-1331   32




Variation in provider vaccine purchase                 Variation in provider vaccine purchase
 prices and payer reimbursement - 2                     prices and payer reimbursement - 3
 • On average, practices had a positive net             • Vaccine administration fee
   yield on vaccine purchase, ranging from                reimbursement from most common payer
   $2.90 - $24.34 / dose for different vaccines            – First dose
 • However, for 15 / 21 vaccines studied, 2%                  • Mean    $16.62
   – 26% of practices lost money (up to                       • Range $ 3.87 - $26.55
   $29.31/dose)
                                                           – Subsequent doses
 • Larger practices, those in MSAs, and
   those participating in purchase                            • Mean    $11.63
   cooperatives generally had higher net                      • Range $ 3.36 - $37.20
   yield
                                                  33                                                       34




Variation in provider vaccine purchase                         Inequities in vaccine
 prices and payer reimbursement - 4                        administration reimbursement
 “There is a wide range of prices paid by               • Some possible solutions
   practices for the same vaccine product                 – Reimbursement from VFC
   and in the reimbursement for vaccines                  – Minimum/recommended
   and administration fees by payers. This                  reimbursement rate from CMS
   variation highlights the need for
   individual practices to understand their               – Negotiation with private insurers
   own costs and reimbursements and to
   seek opportunities to reduce costs and
   increase reimbursements.”

                                                  35                                                       36
                                                     Inequities in non-vaccine costs -
            Non-vaccine costs                                     causes

  • Include costs of                                • 317 can support HD costs
     – Acquiring vaccine                            • VFC supports infrastructure and program
                                                      costs; administration fees, in theory,
     – Storing vaccine
                                                      include non-vaccine costs
     – Handling vaccine                                – However, Medicaid establishes
     – Loss of vaccines                                  reimbursement rate
     – Infrastructure                               • Private insurers typically do not include
     – Insurance                                      non-vaccine costs in calculating
                                                      reimbursement rates

                                             37                                                        38




   Inequities in non-vaccine costs –              PCP perspectives on reimbursement for
       some possible solutions                        childhood immunizations* - 1
  • CMS establishes minimum or                      • National survey of 1280 pediatricians and
    recommended reimbursement rate                    family physicians
  • Private insurers encouraged to include          • Response rate 70% for pediatricians;
    non-vaccine costs in reimbursement                60% for family physicians
    calculations                                    • 49% reported delaying purchase of
                                                      specific vaccines for financial reasons
                                                    • 53% reported decreased profit margin
                                                      from immunizations in previous 3 years

                                             39          *Freed et al. Pediatrics 2008;122:1319-1324   40




PCP perspectives on reimbursement for             PCP perspectives on reimbursement for
     childhood immunizations - 2                       childhood immunizations - 3
  • Decreased profit margin from                    • Extent to which practice has seriously
    immunizations                                     considered whether to stop providing all
     – Mod/significant decrease 41.4%                 vaccines to privately insured patients
     – No/small decrease         22.6%                 – Seriously considered        11%
     – Don’t know                36.0%                 – Considered not seriously 23%
                                                       – Never considered            66%




                                             41                                                        42
PCP perspectives on reimbursement for                Selected NVAC recommendations
     childhood immunizations - 4                       on vaccine financing, 2008 - 1
  “Physicians who provide vaccines to                • Extend VFC underinsured access to
    children and adolescents report                    public health departments, not just
    dissatisfaction with reimbursement levels          FQHC/RHC
    and increasing financial strain from             • Expand VFC by reimbursing for vaccine
    immunizations. Although large-scale                administration
    withdrawal of immunization providers             • Reduce financial burden for initial &
    does not seem to be imminent, efforts to           ongoing vaccine inventories
    address root causes of financial
    pressures should be undertaken.”                 • Professional organizations should
                                                       provide Technical Assistance to members
                                                43
                                                       on efficient business practices              44




  Selected NVAC recommendations                      Selected NVAC recommendations
    on vaccine financing, 2008 - 2                     on vaccine financing, 2008 - 3
  • Providers should participate in                  • Government & professional organizations
    purchasing pools                                   should encourage participation in VFC
  • Insurance plans should provide first-            • Ensure funding to cover all costs arising
    dollar coverage with no deductible or co-          from assuring compliance with school
    pays for all ACIP-recommended vaccines             immunization requirements
  • NVPO should calculate marginal increase          • Promote public/private sector approaches
    in insurance premiums if plans were to             to help fund school-based and other
    cover all ACIP-recommended vaccines                complementary-venue child & adolescent
                                                       immunization efforts
                                                45                                                  46




                Conclusions                           National Objective for Registries
  • Private-public partnership has improved
    childhood immunization rates
     – VFC has been a major factor                     Increase to 95% the proportion of children
                                                       aged <6 years who participate in fully
  • Increasing number and costs of vaccines
                                                       operational immunization registries
    have put strains on system resulting in
    inequities
  • Unless resolved, these inequities may              (Healthy People 2010, objective 14.26)
    undermine our current successes
  • Dealing with adolescents and adults adds
    complexity
                                                47                                                  48
                                                                                                                                      Percentage of children aged < 6 years participating in a grantee
                                                                                                                           immunization information system -- United States, six cities§, and eight Territories† , 2008


                      Participation in IIS – 2008

                                                                            US              NJ
                                                                                                                                                                                                                                        No Report
                                                                                                                                                                                                                                        In
      Children <6 (2+ doses)                                              75%              64%                                                                                                                                          Transition*
                                                                                                                                                                                                                                        0-33%
                                                                                                                                                                                                                                        34-66%
      Children 11-18 (2+ doses)                                           65%              27%                                                                                                                                          67-94%

      Adults >19 (enrolled)                                               24%               1%                                                                                                                                          95-100%


                                                                                                                                                                                                               † American Samoa (No Report);
      Public provider sites                                               75%              64%                                                                                                                 Marshall Islands (67%-94%);
                                                                                                                                                                                                               Federated States of Micronesia (95% -
      Private provider sites                                              37%              37%                                                                            § Chicago, IL (34%-66%);             100%);
                                                                                                                                                                          District of Columbia                 Guam (No Report);
                                                                                                                                                                          (95%–100%);
                                                                                                                                                                                                               N. Mariana Islands (No Report);
                                                                                                                                                                          Houston, TX (34%–66%);
                                                                                                                         National Coverage: 75% (excluding Territories)                                        Palau (No Report);
                                                                                                                         Source: CY2008 IISAR                             New York City, NY
                                                                                                                                                                          (95%–100%);                          Puerto Rico (67%-94%);
                                                                                                                         * In transition is defined as a grantee
                                                                                                                    49                                                                                         Virgin Islands (No Report).          50
                                                                                                                         implementing a new IIS product.                  Philadelphia, PA (95%–100%);




             Percentage of public provider sites actively participating in a grantee                                                   Percentage of private provider sites actively participating in a grantee
     immunization information system - United States, six cities§ , and eight Territories † , 2008                              immunization information system-- United States, six cities§, and eight Territories† ,
                                                                                                                                                                                 2008




                                                                                                        No report
                                                                                                        In
                                                                                                                                                                                                                                       No report
                                                                                                        Transition*
                                                                                                        0-33%                                                                                                                          In
                                                                                                        34-66%                                                                                                                         Transition*
                                                                                                                                                                                                                                       0-33%
                                                                                                        67-94%                                                                                                                         34-66%
                                                                                                        95-100%                                                                                                                        67-94%
                                                                                                                                                                                                                                       95-100%


                                                                                  † American Samoa (No Report);
                                                                                                                                                                                                                  † American Samoa (No Report);
                                                                                  Guam (No Report);
                                                 § Chicago, IL (34%-66%);                                                                                                                                         Guam (No Report);
                                                                                  Marshall Islands (95%-100%);
                                                 District of Columbia                                                                                                                                             Marshall Islands (0%-33%);
                                                                                  Federated States of Micronesia (95%-                                                          § Chicago, IL (0%-33%);
                                                 (95%–100%);                      100%);                                                                                                                          Federated States of Micronesia (0%-
                                                                                                                                                                                District of Columbia
                                                 Houston, TX (67%–94%);                                                                                                                                           33%);
                                                                                  N. Mariana Islands (No Report);                                                               (95%–100%);
National Coverage: 74% (excluding Territories)   New York City, NY                                                                                                                                                N. Mariana Islands (No Report);
                                                                                  Palau (No Report);                                                                            Houston, TX (0%–33%);
Source: CY2008 IISAR                             (67%–94%);                                                              National Coverage: 37% (excluding Territories)                                           Palau (No Report);
* In transition is defined as a grantee                                           Puerto Rico (34%-66%);                                                                        New York City, NY (67%–94%);
                                                 Philadelphia, PA (67%–94%);                                             Source: CY2008 IISAR                                                                     Puerto Rico (0%-33%);
implementing a new IIS product.                                                   Virgin Islands (No Report).       51   * In transition is defined as a grantee                Philadelphia, PA (67%–94%);                                         52
                                                 San Antonio, TX (95%–100%).                                             implementing a new IIS product.                                                          Virgin Islands (No Report).
                                                                                                                                                                                San Antonio TX (0% 33%)




         IIS Uses Reported in Program Surveys                                                                                                          IIS Progress: 2000-2009
    Use Reported by IIS Program                                                  2007                  2009
    Reminder/Recall for Clients**                                                68%                   89%                     Capability                                                        2000           2007                2009
    AFIX (Provider Assessment and Feedback)**                                    77%                   86%                     Lifespan IIS                                                          NR          77%                   84%
    Forecasting algorithm (Provider Reminders**)                                  -                    84%
                                                                                                                               Child participation (2+ iz) *                                     18%             71%                   78%
    UTD assessments (ind)/Coverage (pop)                                       82%/84%          89%/86%
    Routine surveillance (look-up vaccine hx)                                    80%                   75%                     Adolescent participation 11–12 yrs                                    NR          70%                42%**
                                                                                                                               (2+ iz)
    Outbreak management                                                          66%                   79%
                                                                                                                               Adult participation (2+ iz)                                           NR          21%                14%**
    New vaccine uptake                                                           75%                   82%
    Track doses administered                                                     79%                   82%                     Public provider participation                                     38%             73%                   89%
    Pockets of need                                                              71%                   71%                     Private provider participation                                    19%             53%                   71%
    Emergency preparedness                                                       55%                   86%
                                                                                                                               % of doses reported w/in 30 days                                      NR          70%                   70%
    Track adverse events                                                         43%                   54%
   Data source: Annual immunization progress report for CY2009, CDC                                                                Data source: Annual immunization progress report for CY2009, CDC
                                                                                                                                     * HP 2010 Objective; iz=immunization
           ** TF Recommended Interventions                                                                          53
                                                                                                                                       ** Excluded seasonal flu vaccinations in 2009                                                                54
           Results: Overall Coordination Team Findings                                                                                                       Results: Search Yield (Published and Grey)
      •     Evidence is limited for a direct assessment of IIS
            effectiveness in increasing vaccination rates                                                                                                    Database Searches (Published) Grey Literature Search
             – One study provides a before-after comparison from Australia                                                                                        Potentially relevant articles from
                                                                                                                                                                                                                        Potentially relevant abstracts from
                                                                                                                                                                  electronic databases and review of                    selected conferences (2002–May
      •     Multiple studies demonstrate the capabilities of IIS to                                                                                               reference lists (1966–Nov 2009)                       2010) IIS-specific
            implement 3 Task Force recommended interventions                                                                                                      All intervention reviews         (47,042)                                    201 abstracts
             – Client reminder/recall
             – Provider assessment and feedback
                                                                                                                                                                  Ordered for detailed review        (2752)
             – Provider reminders (if the IIS is incorporated into provider
               practice)                                                                                                                                                                  Articles not found    0
                                                                                                                                                                                                                                               Abstracts
      •     Multiple studies demonstrate the capabilities of IIS directly to                                                                                      Number of papers identified for this                                         excluded
            support public health responses to vaccine-preventable                                                                                                intervention                         123                                     68
            disease outbreaks and other public health emergencies
                                                                                                                                                                                           Articles excluded   52

      •     Studies demonstrate the capabilities of IIS in the management                                                                                         Studies that met inclusion criteria     71            Number of abstracts included 123
            of vaccine supply and distribution

      •     Multiple studies demonstrate the utility of IIS in support of                                                                                         Published studies included in analysis                Number of abstracts included
            clinical and public health decisions                                                                                                                                                       71           +
                                                                                                                                                                                                                        123                                56
                                                                                                                                                  55




      Papers Included in this Review Mapped to IIS Functions of Interest
                                                                     2 1                                                                                           Changes in Vaccination Rates Reported in Studies Evaluating IIS-
  -   Published                                    1                                                                                                              Generated Client reminder/recall (n=13 study arms from 10 studies)
                         Grey                                                Surveillance                                                  Monitoring
                                       Immunization                                                                                         Vaccine
                                    Information System                                               6
                                                                                                                                             Safety
             8 12                                                                            1
                                                                                                                                                             Study (baseline%)
                    Client                                                                    Monitoring          Assessing       31
                   Reminder/                                                                Vaccine Supply/       Vaccination
                                                                     1                                                                                           Hambidge 04 (71)
                    Recall                                                                    Distribution         Cov erage      23
    Health                      Prov ider               Prov ider                                                                                                  Kempe 05 (58)
                               Assessment              Reminders
    Depts
                                Feedback                                                                                                                        Beaudrault 09 (57)                                                 p=0.05
    (Imm.
  Programs).                                                             Access to Entire
                               2       10                                    Client                                                                              Irigoyen 06-1 (48)
                                                                          Immunization
                                                                             History                                                                             Irigoyen 06-2 (48)
                                   Vaccination            1                                              Response
                                    Providers                                                                                                                    LeBaron 04-1 (44)        Median
                               (Practitioners; Schools;       6            Change in          3     1                                                                                     change:
                                     WIC; Health
                                                                          Know ledge /
                                                                                                                                                                LeBaron 04-2 (44)
                                    departments)
                                                                           Motiv ation                                    Outbreak    3                                                   + 5 pct pts
                                                                                              Shortage    Cov erage
                                                                                                                         Response &                               Dombkowski 10
                                                                                              Response    Response*
                                                                                                                         PH Emerg.    12                                     (40)         (IQI 3.6, 6)
                                   Additional                                                                                                                    Hambidge 09 (33)
                                 Interv entions
                                                     4        2             Change in                                                                                Daley 02 (20)
                                                                           Vaccination
            Clients of
            Prov ider
                                                 Integrated Child          Interactions                                                                      Dombkowski 10-1 (20)
                                                Health Information                                                                         Reduced                                                                                            Favors
                                                     Systems                               Increase in             Reduced                                   Dombkowski 10-2 (20)                                                             Intervention
          Population                                                                                                                       Morbidity
                                                                                           Appropriate             Vaccine-
                                                                                                                                             And                 Stockwell 10 (13)
                                   * Within Coverage Response:                            Vaccinations            Preventable
                                                                                                                                           Mortality
                                                                                                                   Disease
  0 4                    1                  8     12                 5       5               7 7              1
                                                                                                          Monitoring        Monitoring
   Targeting         Assessing             Targeting             Tracking Age-             Monitoring
                                                                                                         Changes in         Changes in       9
  Geographic           Vaccine             High-Risk          Appropriate Rates or          Uptake of
                                                                                                         Extra / Ov er      Vaccination                                                    Absolute percent change in vaccination rates
Pockets of Need     Effectiv eness        Populations         Missed Opportunities        New Vaccines
                                                                                                         Vaccinations      Documentation      4         57
                                                                                                                                                               Published studies are
                                                                                                                                                                                                                                                             58

                                                                                                                                                               underlined




                                     Information on Barriers to                                                                                                       Other Reviews and Recommendations
                                          Implementation
                                                                                                                                                                    • We identified no relevant systematic reviews on
               IIS have already been implemented in most US                                                                                                           Immunization Information Systems
               jurisdictions
                                                                                                                                                                    • Recommendations of other groups
               The major barriers are…
                                                                                                                                                                         – HP 2010 goal: 95% participation of children <6 years
                  – Provider participation (time/effort/requirements)
                  – Client participation                                                                                                                                 – National Vaccine Advisory Committee (2007): “IIS have
                  – Achieving point-of-care use among vaccination providers                                                                                                demonstrated their effectiveness in improving
                                                                                                                                                                           immunization services and immunization coverage.”
                             • Confidence in completeness and timeliness of the data
                             • Simplicity in access, use, and reporting                                                                                                  – ACIP (2006) “IIS are a critical tool…”

               FERPA requirements                                                                                                                                        – AAP (2006) statement in support of IIS development,
                  – Schools and healthcare providers                                                                                                                       implementation, and evaluation (fiscal influences on
                                                                                                                                                                           practice, costs and benefits, and areas for future
                                                                                                                                                                           improvement)
                                                                                                                                                  59                                                                                                         60
           Limitations Across the Included                                 IIS Effectiveness in Increasing Vaccination
                      Evidence                                                                Rates
 • Most evidence reflects internal comparisons or                          • Included studies: 1 (Before-after on IIS-linked
   efficiencies                                                              incentives)
    – No studies provide concurrent comparisons on
      presence/absence of an IIS                                           • Impact on change in vaccination rates:
                                                                                  • Meaningful ?                                       Yes
 • IIS evaluations were based on IIS data                                         • Consistent across the body of evidence?                (1 study)
    – Changes in participation/reporting are potential confounders
      on assessments of change in vaccination rates                        • Modification based on additional analyses or
      (effectiveness)                                                        information? Yes (Applicability of Australia’s incentive-linked ACIR
                                                                             to the US)
 • Trends over time are difficult to untangle
    – Increased reporting/participation over time                          • Overall Team assessment:
    – Increased reporting/participation associated with more                 Australia’s IIS, with participation tied to incentive
      complete data (and greater utility for decision-makers)
    – Older studies probably do not reflect current capabilities             payments for both clients and vaccination providers,
                                                                             has been effective in increasing vaccination rates
 • Evidence likely reflects programs with
   accomplishments (reporting bias)                                   61                                                                               62




   Section 2: IIS-Generated Interventions                                     Section 3: IIS in Clinical Decision Support
                                                                              Team Assessment
Included Evidence                                                               This review was unable to quantify the use of IIS in daily
   Client reminder/recall (IIS-CRR)                       20 papers             clinical decision support among vaccination providers
   Provider assessment and feedback (IIS-PAF)             11 papers             (0 papers)
   IIS-generated Provider reminders (IIS-PR)               1 paper
                                                                                 The conceptual argument is strong…
  Overall Team assessment:                                                           For practitioners who consistently utilize the IIS as the
                                                                                     primary vaccination database for their client population
  Evidence demonstrates capability of IIS to conduct or support 3                    For practitioners who utilize the IIS in advance of the provider-
  Task Force recommended interventions to increase vaccination                       client interaction (IIS has built-in provider reminder functions)
  rates
                                                                                 Identified studies demonstrate other decision support
  -US IIS-CRR have been evaluated in several regions with
                                                                                 capabilities for important vaccination providers
  evidence of effectiveness in increasing vaccination rates
                                                                                     Schools (US) empowered to enter vaccination histories of
  -US IIS have been demonstrated to support state-wide provider                      students rapidly enhanced content of IIS     (3 papers)
  assessment and feedback interventions under the AFIX program                       Schools employing the IIS for vaccination requirement/waiver
                                                                                     documentation                                (1 paper)
  -US IIS have built-in provider reminder capabilities, with one                     Health systems (US) adopting the IIS for the documentation of
  study demonstrating effectiveness in increasing childhood                          vaccinations (for use in HEDIS and/or incentive pay) (3
  vaccination rates                                                                  papers)
                                                                      63                                                                               64




     Section 4: IIS in Public Health Action                                    Section 5. IIS in Public Health Decision
                                                                                                Support
  Evidence indicates a role for IIS in responding to
  outbreaks of vaccine-preventable diseases and other
  public health emergencies                                                  Team Assessments
  (15 papers)                                                                  IIS provide opportunities for timely,
  -Measles outbreaks: IIS in targeted recall (2 papers)                        efficient analyses of vaccination rates and
                                                                               trends      (Multiple papers)
  Evidence indicates an increasing role of IIS in vaccine
  dose accountability, including the Vaccines for
  Children Program
                                                                                Although in this regard IIS are not direct
                                              (7 papers)                        interventions to increase vaccination
Overall Team assessment                                                         rates, the capabilities of IIS provide
                                                                                information to guide current and future
-IIS have a role in current and future vaccine preventable                      public health action
   disease outbreak responses (targeted recall)

-IIS involvement in VFC is likely to increase, contributing
   to increases in provider and client participation                  65                                                                               66
 Overall Coordination Team Assessment
A large body of evidence describe IIS                Task Force Recommendation
capabilities..
   To generate or support recommended Task        • The Task Force on Community Preventive
   Force interventions                              Services recommends immunization
   In school documentation of student               information systems on the basis of
   vaccination status                               strong evidence of effectiveness in
   In outbreak response                             increasing vaccination rates.
   In vaccine accountability
   In expanding and enhancing program
   surveillance and investigation                               June 16, 2010



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