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Systematic Review
This report aimed to determine whether health care system-based interventions implemented in combination increase vaccination rates in targeted client populations.
The authors state:
The Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. Of the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (interquartile interval [IQI]: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.
The included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:
• Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client or family incentives, client-held paper immunization records, case management, and manual outreach and tracking)
• Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client out-of-pocket costs, and home visits)
• Interventions directed at vaccination providers (provider reminder systems, standing orders, provider assessment and feedback, provider education, and provider incentives)
The most common individual interventions implemented in a combined approach were client reminder and recall systems (34 study arms) and provider reminders (31 study arms). Thirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points). Nine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results. Evidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.
The economic review identified 5 studies (search period 1980-2012). Monetary values are in 2012 U.S. dollars. Two studies evaluated pneumococcal vaccination, and one study each examined Tdap, tetanus, and childhood series. The median size of the intervention group was 20,000 (IQI: 567 to 212,500, 5 studies). The median cost of implementation per person per year was $4 (IQI: $0.84 to $13, 4 studies). Based on three studies, the mean cost per additional person vaccinated was $12 and ranged from a minimum of $6 to a maximum of $21.
The authors state:
The Community Preventive Services Task Force recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.
Based on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following.
At least one intervention to increase client demand for vaccinations, such as:
• Client reminder and recall systems
• Clinic-based client education
• Manual outreach and tracking
And one or more interventions that address either, or both, of the following strategies:
• Interventions to enhance access to vaccinations: expanded access in health care settings; reduced client out-of-pocket costs; home visits
• Interventions directed at vaccination providers or systems: provider reminders; standing orders; provider assessment and feedback.
Interventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.