Strategy
Developing and implementing a public health detailing program to share practice-level IIS coverage data; driving change at the practice level to improve immunization service delivery.
Challenge
Colorado continues to rank at the bottom of kindergarten vaccination rates in the U.S. For the 2022-23 school year, Colorado ranked 45th in the country in kindergarten coverage rates for measles, mumps and rubella (MMR) at 86.8%, well below the 92-94% community immunity threshold needed for measles. In the CDC analysis of kindergarten vaccination data reported by states for the 2022-2023 school year, Colorado’s rankings all worsened by at most 5 places (DTaP) and at least 1 place (varicella) compared to the 2021-2022 school year. Colorado’s rates fell below 90% and below the national estimate for all vaccines: DTaP: 87.2% (CO) vs. 92.7% (US); MMR: 87% (CO) vs. 93.1% (US); poliovirus: 87% (CO) vs. 93.1% (US); varicella: 85.9% (CO) vs. 92.9% (US). The percentage of kindergartners with any exemption on file was 4.3%, compared to a 3% national estimate. The COVID-19 pandemic initially disrupted the delivery of routine vaccines, with varying levels of impact to certain age groups. Since that time, coverage for most vaccines and most age groups as measured by the Colorado Immunization Information System (CIIS) has improved and risen above pre-COVID baselines. The continued decreases in kindergarten vaccination coverage as measured through annual data collection from Colorado schools seem exceptional. Internal CIIS data analysis measuring estimated vaccine hesitancy has not changed significantly over time. With noncompliance rates also increasing with the kindergarten population, there may be issues with vaccine access and/or enforcement of school immunization law in the kindergarten population. Pockets of undervaccinated children within larger areas of high vaccination coverage can lead to outbreaks of vaccine-preventable disease. The continued and significant decreases in MMR kindergarten vaccination coverage rates are especially concerning given the fact that measles outbreaks are occurring both globally and within the U.S. kindergarten coverage rates are not included in typical IQIP provider visits and have not been a focus of past provider outreach efforts in Colorado. Most, if not all, of Colorado providers have no sense of what vaccination coverage for their kindergarten-aged patients looks like. This public health detailing program was created to: (1) share practice-level IIS coverage data, and (2) drive change at the practice level to improve immunization service delivery.
Solution
A public health detailing approach is a provider outreach initiative focused on increasing the uptake of best practices in support of public health priorities. Colorado had initially begun the development of an immunization public health detailing program in early 2020, prior to the COVID-19 pandemic vaccine response. Upon the end of the COVID-19 public health emergency, Colorado sought to reinitiate the development and implementation of a public health detailing program to support immunization providers’ efforts toward increasing immunization coverage in under-vaccinated pediatric populations across Colorado, specifically among kindergarten-aged children. The short-term goals of this project were to enroll providers to participate in the public health detailing program, increase awareness of provider, school and community level kindergarten vaccination rates, increase collaboration between public health and primary care providers, and to drive change at the practice level to improve immunization service delivery, specifically among kindergarten-aged children. By engaging with providers using public health detailing, we aimed to decrease missed opportunities in provider offices, increase adherence to ACIP’s childhood immunization schedule, increase compliance with Colorado school immunization law, and increase the number of providers implementing best practices in immunization service delivery for their kindergarten-aged patients. The overall goal of the project is to increase kindergarten vaccination coverage and reduce the incidence of vaccine-preventable disease.
The overall strategies for this project included:
- Developing and implementing the public health detailing program to train primary care providers in the importance of immunization best practices.
- Using the IIS to identify and prioritize practices with the highest number of kindergarten-aged children with the lowest MMR and DTaP vaccination rates (i.e., >50 kindergarten-aged patients, < 80% MMR and DTaP vaccination rates).
- Receiving approval from CDC for adding kindergarten coverage assessment as an optional IQIP strategy.
- Performing outreach and recruitment of practices for the program.
- Conducting four brief detailing visits with prioritized practices enrolled in the program.
- Leveraging data within the IIS to generate customized vaccination coverage assessments for participating practices’ kindergarten-aged patient populations.
- Implementing IIS-based reminder/recall in partnership with participating practices.
- Evaluating the impact of the public health detailing program on increasing practice-level kindergarten vaccination rates within the IIS.
The public health detailing program directly impacted the immunization service delivery of participating practices, with the main affected population being their kindergarten-aged patients.
The Immunization Branch leveraged the expertise and experience of colleagues within the CDPHE STI/HIV Branch who had conducted public health detailing related to increasing providers’ prescription of PrEP for those at higher risk for HIV. For the rollout of the program, IQIP and data unit staff were also involved.
The program was launched in July of 2023, and was originally slated to end June 30, 2024. CDPHE received an extension of the funding that will allow Colorado to continue this work through June 30, 2025.
Outcome
The program was implemented within the Immunization Branch. The contracted and permanent staff working on this project completed virtual visits with providers, using the Immunization Quality Improvement for Providers (IQIP) process as a model for implementation. 153 practices voluntarily participated in the first year of Public Health Detailing across 27 counties.
CDPHE hired a full-time contracted nurse consultant to implement the public health detailing program in October of 2023, and the work will continue through June of 2025. Additionally, CDPHE staff contributed to the development and implementation, with two nurse consultants contributing 20-25% of their time (520 and 625 hours) to program and resource development. Members of CDPHE’s data and IIS teams contributed 5-10% of their time to pull immunization rate data and assist with provider level reminder and recall (105 and 210 hours).
CDPHE applied for and was awarded supplemental AA1 component funding from the CDC to develop and implement the public health detailing program. The total amount requested to fund the program was $311,365, which covered contracted staff time, immunization program staff time, supplies, and travel.
The public health detailing program can reach many providers with at least an initial visit. The level of provider engagement varies significantly across providers, staff turnover in the clinics affects the effectiveness and impact of the detailing program on the clinic, as it interrupts the process and results in repeated steps and provider education. Clinics lack baseline knowledge of using the IIS for data and reports, requiring a large amount of focus on one area of the program. During the implementation of the program, many clinics expressed interest in better understanding school immunization law and required data reporting. These elements were added to the program after implementation.
Supplemental Materials
- Colorado’s Public Health Detailing Program presentation
- Colorado’s Public Health Detailing Program Staff Spotlight