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Provider Quality Improvement Activities (CASA/AFIX)
|
Year |
DTaP4 |
IPV3 |
MMR1 |
HepB3 |
HIB3 |
Varicella1 |
2007 |
82.2% |
91.3% |
89.8% |
88.5% |
89.8% |
83.8% |
County Immunization Rates
County rates for the 2007 CASA year are shown on the linked map. Rates for individual counties varied from 33% to 90%, but it should be noted that in some sparsely populated counties only 1 or 2 providers were sampled. Thus, in some counties with small populations, the county rate noted may be based on the immunization status of just a few children.
Provider Attributes Affecting Coverage Rates
Because un-weighted rates are lower in New Mexico than weighted rates, we have an indication that larger practices on the whole have better rates than smaller practices. Also, pediatric providers have had consistently higher rates than family practice clinics.
The table below gives coverage data from the past four years by provider type. Excellent progress has been made over this period by I.H.S. clinics and Federally Qualified Health Centers. In the private sector, several large pediatric practices have consistently maintained high levels of coverage.
Provider Type |
CASA Year |
4:3:1:3:3 Average Rate |
Federally Qualified Health Centers, Community Health Centers |
2003-04 |
61.7% |
2004-05 |
71.7% |
|
2005-06 |
81.0% |
|
2007 |
78.1% |
|
Indian Health Service |
2003-04 |
64.6% |
2004-05 |
84.8% |
|
2005-06 |
80.2% |
|
2007 |
86.3% |
|
Private |
2003-04 |
64.1% |
2004-05 |
73.4% |
|
2005-06 |
74.6% |
|
2007 |
75.2% |
Activities that significantly raised immunization coverage rates were: 1) review of patients' immunization status at every encounter, 2) effective use of New Mexico's Done by One shortened schedule, 3) a policy of vaccinating children with mild illness (colds), 4) availability of walk-in services, and 5) flagging of patients needing immunizations.
As part of the 2007 survey, provider staffers were also asked what would most help them achieve higher immunization rates for the patients. The most cited factors were improved parental compliance and improvements to NMSIIS. Others factors included improved reminder/recall, better patient transportation, and a better ability to deal with transient populations and communication barriers.
The effect of NMSIIS on Coverage Rates
CASA reviewers were asked to check the NMSIIS records of children who were not up-to-date whenever possible. Additional shots were found in NMSIIS for 36% (74 of the 206) of the providers surveyed, and raised rates for these providers an average of about 7-8%. For some small providers, the additional shots found in NMSIIS raised the provider's coverage rates by over 30%. We estimate that shots recorded in NMSIIS but not in patients' charts could account for an increase of up to a few percentage points in New Mexico's overall state rates.
The Medically Homeless and Immunization Coverage
To be included in a provider's CASA survey, an individual two-year old had to meet 'medical home' criteria of 3 lifetime visits and 2 visits in the past year to that provider. In 2007, the Immunization Program attempted to define the extent of patients without a 'medical home' and their effect on coverage rates by doing complete NMSIIS look-ups on the groups of children who did not meet visit criteria for selected provider CASAs. The NMSIIS database proved too incomplete to provide reliable immunization histories on these groups. This small study did suggest, however, that one-year olds were much less likely than two-year olds to meet the 'medically homeless' criteria, suggesting that rather than being truly medically homeless, many children may simply visit a physician less frequently as two-year olds than as one-year olds.
To better evaluate all children missing immunizations during site visits, all charts of one-year olds will be included in 2008 CASA surveys. Visit criteria will be retained for two-year olds to maintain data comparability.
What are the implications of VFC site visit and CASA data for raising rates?
- As in the past, reviewers found that many smaller providers had problems with vaccination quality and coverage. Achieving higher coverage statewide will depend partly on our success in reaching children who receive care at smaller and non-specialist providers.
- Reconsider the role of Public Health Offices as potential 'medical homes', and make public health nurses available to regularly follow-up on children needing immunizations.
- Promote physician buy-in of strategies to increase coverage. In many offices, immunizations are considered the domain of nursing staff and medical assistants. More physician oversight of policies could give immunizations a higher profile in the overall clinic setting.
- Provide targeted assistance to follow up on children who are found to be incompletely immunized during CASA surveys. Charts of these children represent a ready pool of children needing reminder/recall. If the surveyed office is unable to do effective reminder/recall, give Immunization Consultant or public health nurse assistance to bring these kids up-to-date.
- Work with umbrella health systems to reach multiple providers belonging to the same system.
- Attempt to better define the extent of the medically homeless and better determine their primary care needs.
- Encourage providers to focus on strategies that give the best coverage results, including screening for immunization status at every visit, use of the Done by One schedule and other proven policies.
- Encourage providers to pay more attention to the delivery of the 4th dose of DTaP and the first Varicella dose, which continue to hold coverage rates down.
- Continue to assist providers in improving the quality of their services though CHILI trainings and the Immunization Consultant program.
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