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Holly Groom David Hopkins Jennifer Murphy

The Effectiveness of Immunization Information Systems (IIS) Preliminary Results of a Systematic Review for the Task Force on Community Preventive Services. Holly Groom David Hopkins Jennifer Murphy. Agenda. Background Research questions Evidence on IIS capabilities

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Holly Groom David Hopkins Jennifer Murphy

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  1. The Effectiveness of Immunization Information Systems (IIS)Preliminary Results of a Systematic Review for the Task Force on Community Preventive Services Holly Groom David Hopkins Jennifer Murphy

  2. Agenda • Background • Research questions • Evidence on IIS capabilities • Summary of findings & Research gaps • Draft Task Force findings statement • Discussion

  3. Task Force on Community Preventive Services An independent, nonfederal, volunteer body of public health and prevention experts, whose members are appointed by the Director of CDC. The role of the Task Force is to: • Oversee systematic reviews led by CDC scientists • Carefully consider and summarize review results • Make evidence-based recommendations for interventions that promote population health • Identify areas within the reviewed topics that need more research

  4. Goal To conduct a systematic review of the literature to answer the following questions: • Are IIS effective in increasing appropriate vaccinations, or reducing vaccine preventable disease in the population? • Do IIS “effectively” support other important public health activities or interventions?

  5. VPD Coordination Team CDC Partners Peter Briss (CCEHIP) Abigail Shefer (NCIRD) Lance Rodewald (NCIRD) Faruque Ahmed (NCIRD) External Partner Alan Hinman (Task Force for Global Health; former TF member) Staff Team David Hopkins Jennifer Murphy Carolyn Beeker Adesola Pitan Holly Groom (NCIRD) Gail Bang (MLIS) Task Force Member John Clymer Liaison Members Kathy Green (DOD) Kevin Fajardo (USAF)

  6. Academic Research Kevin Dombkowski (UM) Health Systems Sue Scholz (Aurora - WI) Health Departments Rebecca Coyle (Idaho) Mary Beth Kurilo (OR) CG Task Force Ned Calonge CG Liaisons Joe Hagan (AAP) CDC Field Staff Amy Groom (IHS) Jane Zucker (NYC) PascaleWortley (ISD) CDC IIS Branch Staff Diana Bartlett Bobby Rasulnia CDC PH Systems Research Timothy Van Wave Our IIS Review Consultation Team

  7. IIS Uses Reported in Program Surveys Data source: Annual immunization progress report for CY2009, CDC ** Task Force Recommended Interventions (updated 2009)

  8. Diagram of IIS Operation, Uses, and Effects Immunization Information System Monitoring Vaccine Safety Surveillance Monitoring Vaccine Supply/ Distribution Assessing Vaccination Coverage Client Reminder/ Recall Provider Reminders Health Depts (Imm. Programs). Provider Assessment Feedback Access to Entire Client Immunization History Response Vaccination Providers (Practitioners; Schools; WIC; Health departments) Change in Knowledge /Motivation Shortage Response Coverage Response* Outbreak Response & PH Emerg. Additional Interventions Change in Vaccination Interactions Population Clients of Provider Integrated Child Health Information Systems Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations * Within Coverage Response: Targeting Geographic Pockets of Need Assessing Vaccine Effectiveness Targeting High-Risk Populations Tracking Age- Appropriate Rates or Missed Opportunities Monitoring Changes in Extra / Over Vaccinations Monitoring Changes in Vaccination Documentation Monitoring Uptake of New Vaccines 8

  9. Papers Included in this Review Mapped to IIS Functions of Interest 2 1 Immunization Information System 1 Published - Grey Monitoring Vaccine Safety Surveillance 12 6 1 8 31 Monitoring Vaccine Supply/ Distribution Assessing Vaccination Coverage Client Reminder/ Recall 1 23 Provider Reminders Health Depts (Imm. Programs). Provider Assessment Feedback Access to Entire Client Immunization History 10 2 Response Vaccination Providers 1 6 (Practitioners; Schools; WIC; Health departments) 3 1 Change in Knowledge /Motivation 3 Shortage Response Coverage Response* Outbreak Response & PH Emerg. 12 Additional Interventions 4 2 Change in Vaccination Interactions Population Clients of Provider Integrated Child Health Information Systems Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations * Within Coverage Response: 5 5 8 12 1 7 7 0 4 1 Targeting Geographic Pockets of Need Assessing Vaccine Effectiveness Targeting High-Risk Populations Tracking Age- Appropriate Rates or Missed Opportunities Monitoring Changes in Extra / Over Vaccinations Monitoring Changes in Vaccination Documentation 9 Monitoring Uptake of New Vaccines 9 4

  10. The Task Force considered the evidence in 4 sections IIS-generated interventions Clinical decision support Public health action Public health decision support Methods: Organization and Presentation of Results

  11. Section 1: IIS Generated Interventions (TF recommended interventions) Immunization Information System Published - Grey 12 8 Client Reminder/ Recall Provider Reminders Health Depts (Imm. Programs). Provider Assessment Feedback 1 10 2 Vaccination Providers (Practitioners; Schools; WIC; Health departments) Population Clients of Provider Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations 11

  12. Changes in Vaccination Rates Reported in Studies Evaluating IIS-Generated Client reminder/recall (n=13 study arms from 10 studies) Study (baseline%) Hambidge 04 (71) Kempe 05 (58) p=0.05 Beaudrault 09 (57) Irigoyen 06-1 (48) Irigoyen 06-2 (48) Median change: + 5 pct pts (IQI 3.6, 6) LeBaron 04-1 (44) LeBaron 04-2 (44) Dombkowski 10 (40) Hambidge 09 (33) Daley 02 (20) Dombkowski 10-1 (20) Favors Intervention Dombkowski 10-2 (20) Stockwell 10 (13) Absolute percent change in vaccination rates 12 Published studies are underlined

  13. Changes in Vaccination Rates Reported in Studies Evaluating IIS-Supported Provider Assessment and feedback (n=5 measurements from 5 studies) Study (baseline%) Hambidge 04 (71) Median change: + 9 pct pts (Range of values: 5,15) Harris 08 (69) Fernandez 08 (59) Scholz 08 (58) Mickle-Hope 09 (33) Favors Intervention Absolute percent change in vaccination rates

  14. Changes in Vaccination Rates Reported in Studies Evaluating IIS-Generated Provider Reminders (n=1 measurement from 1 study) Study (baseline%) Childhood series + PCV7 (4313313) Fu 2009 (74%) Favors Intervention Absolute percent change in Up-to-Date vaccination rates 14

  15. Section 1: IIS-Generated Interventions Included Evidence: • Client reminder/recall (IIS-CRR) 20 papers • Provider assessment and feedback (IIS-PAF) 11 papers • IIS-generated Provider reminders (IIS-PR) 1 paper • Task Force Assessment: Evidence demonstrates capability of IIS to conduct or support 3 Task Force recommended interventions to increase vaccination rates -US IIS-CRR have been evaluated in several regions with evidence of effectiveness in increasing vaccination rates -US IIS have been demonstrated to support state-wide provider assessment and feedback interventions under the AFIX program -US IIS have built-in provider reminder capabilities, with one study demonstrating effectiveness in increasing childhood vaccination rates

  16. Section 2: IIS in Clinical Decision Support Immunization Information System Published - Grey Health Depts (Imm. Programs). Access to Entire Client Immunization History 1 Vaccination Providers 6 (Practitioners; Schools; WIC; Health departments) Change in Knowledge /Motivation Change in Vaccination Interactions Population Clients of Provider Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations * Within Coverage Response: 16

  17. Section 2: IIS in Clinical Decision Support Task Force Assessment • This review was unable to quantify the use of IIS in daily clinical decision support among vaccination providers (0 papers) • Identified studies demonstrate other decision support capabilities for important vaccination providers • Schools (US) empowered to enter vaccination histories of students rapidly enhanced content of IIS (3 papers) • Schools employing the IIS for vaccination requirement/waiver documentation (1 paper) • Health systems (US) adopting the IIS for the documentation of vaccinations (for use in HEDIS and/or incentive pay) • (3 papers)

  18. Section 3: IIS in Public Health Action Immunization Information System Published - Grey Surveillance 6 1 Monitoring Vaccine Supply/ Distribution Assessing Vaccination Coverage Response 3 Coverage Response* Outbreak Response & PH Emerg. 12 Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations

  19. IIS used to identify practices located in geographic area of measles outbreak • IIS used to assess vaccination status of patients in those practices and recall 7,312 unvaccinated children <5 yrs

  20. Section 3: IIS in Public Health Action • Task Force Assessment • Evidence indicates a role for IIS in responding to outbreaks of vaccine-preventable diseases and other public health emergencies (15 papers) -Measles outbreaks: IIS in targeted recall (2 papers) • Evidence indicates an increasing role of IIS in vaccine dose accountability, including the Vaccines for Children Program (7 papers)

  21. Section 4. IIS in Public Health Decision Support 2 1 Immunization Information System Published - Grey Monitoring Vaccine Safety Surveillance 31 Assessing Vaccination Coverage 23 Response 3 1 Shortage Response Coverage Response* 4 2 Integrated Child Health Information Systems Reduced Morbidity And Mortality Reduced Vaccine- Preventable Disease Increase in Appropriate Vaccinations 5 5 8 12 1 7 7 0 4 1 Targeting Geographic Pockets of Need Assessing Vaccine Effectiveness Targeting High-Risk Populations Tracking Age- Appropriate Rates or Missed Opportunities Monitoring Changes in Extra / Over Vaccinations Monitoring Changes in Vaccination Documentation 9 Monitoring Uptake of New Vaccines 21 4

  22. Section 4. IIS in Public Health Decision Support Task Force Assessments • IIS provide opportunities for timely, efficient analyses of vaccination rates and trends (Numerous papers) • Surveillance capabilities of IIS provide information to guide current and future public health action on a local and national scale

  23. Task Force Findings • A large body of evidence describe IIS capabilities.. • To generate or support recommended Task Force interventions • In school documentation of student vaccination status • In outbreak response • In vaccine accountability • In expanding and enhancing program surveillance and investigation • Overall Task Force Conclusion Recommend based on strong evidence of effectiveness

  24. Research Gaps • Quantify the daily/regular use of IIS • Quantify coverage for IIS-generated interventions • Proportion of client population involved (CRR) • Proportion of vaccination providers involved • Quantify provider use of IIS as a clinical decision support tool • Investigate the “threshold” for provider and client participation for the purposes of • Provider confidence in the IIS as CDST • Program confidence in data (trends) • Economic evaluations including both the operation costs and the savings from efficiencies

  25. Draft Task Force Findings (June, 2010) The Task Force on Community Preventive Services recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates. Evidence was considered strong based on the findings from 71 published papers and 123 conference abstracts which demonstrate that IIS have the following capabilities directly related to increasing vaccination rates and reducing vaccine-preventable disease; 1) generation of, or support for, effective interventions such as client reminder/recall, provider assessment and feedback, and provider reminders, 2) generation and evaluation of public health responses to outbreaks of vaccine preventable disease, 3) vaccine management and accountability, 4) determinations of client vaccination status for decisions made by clinicians, health departments, and schools, and 5) surveillance and investigations on vaccination rates, missed vaccination opportunities, invalid dose administration and disparities in vaccination coverage. In addition, there are many studies assessing IIS data quality for use by decision-makers in clinical settings, communities, states, and the nation. 25

  26. Discussion

  27. Additional slides

  28. IIS Progress: 2000-2009 Data source: Annual immunization progress report for CY2009, CDC * HP 2010 Objective; iz=immunization ** Excluded seasonal flu vaccinations in 2009

  29. Results: Search Yield (Published and Grey) Grey Literature Searches Database Searches (Published) Potentially relevant articles from electronic databases and review of reference lists (1966–Nov 2009) All intervention reviews (47,042) Potentially relevant abstracts from selected conferences (2002–May 2010) IIS-specific 201 abstracts Ordered for detailed review (2752) Articles not found0 Abstracts excluded 68 Number of papers identified for this intervention 123 Articles excluded 52 Number of abstracts included 123 Studies that met inclusion criteria 71 Number of abstracts included 123 Published studies included in analysis 71 + 29

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