Vaccination Programs: Health Care System-Based Interventions Implemented in Combination

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends using a combination of health care system-based interventions to increase vaccination rates in targeted populations.

Based on findings from 37 of the 64 included studies, the CPSTF further recommends a combination of interventions that include the following:

At least one intervention to increase client demand for vaccinations, such as:

One or more interventions that address either, or both, of the following strategies:

The full CPSTF Finding and Rationale Statement and supporting documents for Vaccination Programs: Health Care System-Based Interventions Implemented in Combination are available in The Community Guide Collection on CDC Stacks.

Intervention

Health care system-based interventions implemented in combination involve two or more coordinated interventions to increase vaccination rates within a targeted population. Interventions are used primarily in health care settings, although efforts may include additional activities within the community.

Specific interventions may include client reminder and recall systems; clinic-based client education; expanded access in health care settings; provider assessment and feedback; provider reminders; and standing orders. The selection and implementation of coordinated interventions may result from an overall quality-improvement effort in a health care setting.

About The Systematic Review

The CPSTF 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). It updates and replaces the 2010 finding for Health System-Based Interventions Implemented in Combination.

Study Characteristics

  • Studies conducted in urban (34 study arms), rural (1 study arm), and mixed settings (9 study arms)
  • Interventions targeted children (29 study arms), adolescents (2), adults (14), and older adults (22)
  • Studies evaluated the following vaccines:
    • Influenza child (5 study arms)
    • Influenza adult (27 study arms), child (1 study arm)
    • Pneumococcal adult (19 study arms)
    • Tetanus booster (4 study arms)
    • Vaccines recommended for children (24 study arms)
    • Vaccines recommended for adolescents (1 study arm)
  • Nearly one-third of studies evaluated interventions targeting populations with low socioeconomic status (22 study arms)

Summary of Results

Sixty-four studies with 76 study arms were included.

  • Overall change in vaccination rates from combination of at least two interventions: median increase of 9.0 percentage points (58 studies with 70 study arms)
    • Increases larger when implemented in settings with low baseline rates
  • Combination of at least one intervention from two or more strategies: median increase of 17.0 percentage points (37 studies with 44 study arms)

Summary of Economic Evidence

Five studies were included in the economic review. They assessed various combinations of provider reminders, standing orders, provider assessment and feedback, provider education, and provider incentives. Monetary values in 2012 U.S. dollars.

  • Median intervention cost per person per year: $4 (4 studies)
  • Mean cost per additional vaccinated person: $12 (3 studies)
  • One study with intensive intervention including home visits was considered an outlier and was not included in cost estimates

Applicability

Findings applicable to:

  • A range of clinical settings, communities, and client populations
  • Children ages 12 years and younger
  • Adults ages 18 to 65 years
  • Older adults ages 65 years and older
  • Urban settings
  • Different vaccines: childhood series, pneumococcal, influenza, tetanus booster

Evidence Gaps

  • How effective are interventions when applied to adolescents, or in rural settings?
  • What are the effects of long-term quality improvement efforts?

Implementation Considerations and Resources

CPSTF also recommends community-based interventions implemented in combination giving decision-makers a range of options to consider when selecting and coordinating interventions to meet local needs and resources.

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