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We all know that vaccinating adolescents in accordance with the recommendations of the Advisory Committee on Immunization Practices is challenging. Adolescents do not always come in regularly or may be transitioning to other physicians, and immunizations may not be high on the family’s list of priorities. And while many physicians may think they’re doing a great job of immunizing their patients, several studies have shown that actual coverage numbers often don’t bear this out.1
Because of this, you might want to establish goals for your practice, such as achieving 90% or greater coverage rates for certain age ranges or certain vaccinations. In order to determine how well you are doing in vaccinating your patients, you’ll first need to develop and implement a plan for measuring the actual immunization rates in your practice. Here are a few tips to help your practice make that happen:

Participate in an immunization information system (IIS)

When it comes to measuring vaccination rates, accurate recordkeeping is key. Bear in mind that it’s not uncommon for an adolescent to have been vaccinated at more than one practice site. An IIS (or registry) can help with this because it collects and consolidates vaccination data from multiple health care sites within a particular geographic area.2 Also, the IIS can be used to generate the immunization records that are often required for school entry.1 In some cases, it may even be possible to link the IIS to your office’s electronic medical records software.1 Check with your state or local IIS staff to determine how this system can greatly facilitate your recordkeeping. For IIS staff contact information, please visit

Request assistance through the Assessment, Feedback, Incentives, and eXchange (AFIX) program

Many practices may not be aware that they can contact their state or regional health department to see if staff are available to provide complimentary assistance with immunization rate measurement through the AFIX program (, which is supported by the Centers for Disease Control and Prevention (CDC) in all 50 states. During an AFIX consultation, an immunization specialist will perform both a quantitative and qualitative assessment of the office’s patient records. Sometimes the quantitative evaluation may be performed entirely through an examination of IIS data for your office. The results of the assessment are then provided through feedback to the entire office staff in a written report or an in-person or webinar-conducted presentation, creating awareness of the vaccination coverage rates and immunization practices that are in need of improvement. The immunization specialist also may be able to help the practice determine next steps for improvement and provide incentives such as immunization resource materials. Finally, in the eXchange component of the program, the AFIX representative will follow up with the practice to discuss and document progress in the implementation of quality improvement strategies and to provide technical assistance.1,3,4

Use the CDC’s Comprehensive Clinic Assessment Software Application (CoCASA)

Originally designed for use in conjunction with the AFIX program, CoCASA provides immediate feedback and highlights areas requiring further follow-up. The application also offers possible explanations for suboptimal coverage, such as missed opportunities to vaccinate. In addition, CoCASA can be used to generate reports on specific subsets of patients. The tool can be obtained at no charge by visiting,4 Note that CoCASA will no longer be available after early 2019.5

Consider do-it-yourself chart review

If you prefer to measure your immunization rates without assistance from health department personnel, you can use one or more methods of chart review:

  • The consecutive survey method tends to be inexpensive, simple, and easy to implement. With this method, a practice zeroes in on a subgroup of patients and then analyzes vaccination data from the medical records of patients in that subgroup who have had consecutive office visits. Such a selection process may help ensure that the assessment includes data only for current patients, as opposed to those who have left the practice. However, it also runs the risk of overestimating the percentage of patients who are fully immunized because the method excludes patients who do not visit the practice regularly and are more likely to be undervaccinated.6
  • A second option is the random record method of measurement. Immunization data are collected from a random selection of medical records for all of a practice’s patients, regardless of how often they have sought care.6 To minimize the potential for underestimating the percentage of patients who are fully immunized, it may be best to restrict the random review to patients seen within the past year.7 Keep in mind, though, that the resources available within a typical office setting often do not allow for the use of the random record method, which is more ably implemented by health department staff.6

Health care professionals play a critical role in the protection of adolescents from vaccine-preventable diseases. Accordingly, it should be the goal of every practice to measure its immunization rates, as measurement provides the awareness needed for performance improvement.


1. Centers for Disease Control and Prevention (CDC). Immunization Strategies for Healthcare Practices and Providers. In: Hamborsky J, Kroger A, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington, DC: Public Health Foundation; 2015:33-46.

2. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR-2):1-61.

3. Gilkey MB, Dayton AM, Moss JL, et al. Increasing provision of adolescent vaccines in primary care: a randomized controlled trial. Pediatrics. 2014;134(2):e346-e353.

4. CDC. AFIX (Assessment, Feedback, Incentives, and eXchange). Accessed July 19, 2015.

5. Comprehensive Clinic Assessment Software Application Help Desk, CDC, personal communication, July 30, 2015.

6. Darden PM, Taylor JA, Brooks DA, et al. How should immunization rates be measured in the office setting? A study from PROS and NMA PedsNet. Clin Pediatr. 2008;47(3):252-260.

7. Morrow AL, Crews RC, Carretta HJ, Altaye M, Finch AB, Sinn JS. Effect of method of defining the active patient population on measured immunization rates in predominantly Medicaid and non-Medicaid practices. Pediatrics. 2000;106(1 Pt 2):171-176.

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