CHILDHOOD IMMUNIZATIONS

Building on an Automated System

What is the return on investment for quality improvement? When it comes to immunizing our children, the return is exceptional. Having already invested significant resources in an automated immunization tracking system, this health plan leveraged its investment by improving its immunization rate. Over the course of the activity, the plan emphasized not only education and outreach but also changed fundamental systems related to care and services.

A basic method for prevention of serious illness is immunization. Childhood immunizations help prevent serious diseases, such as polio, tetanus, hepatitis, and meningitis. Furthermore, the prevention of disease may prevent lost school and workdays, and save millions of dollars.

The Children's Defense Fund estimates that providing immunizations yields a 10:1 economic return on investment in terms of reduced medical expenditures. While schools require immunizations for entry, much preventable disease occurs in the preschool years. This prompted the development of a HEDIS 2.0 measure that looked at the immunization rate of two-year-olds.

Besides the automated tracking system, this plan already distributed immunization guidelines to all new parents. Its quality improvement activity would build on work already done.

This plan used HEDIS 2.5 (and 3.0) methodology throughout the activity. The target population was composed of two-year-olds who had been continuously enrolled in the plan since age six weeks. The HEDIS measure used was the percentage of children who had received all recommended vaccinations.

The hybrid method (a combination of chart review and administrative data) was used to calculate the immunization rate of a representative sample. Baseline data from 1994 showed that 70.5% of the plan's two-year-olds had received all their recommended vaccines by their second birthday. A benchmark of 90% was identified from the Healthy People 2000 goal.

As its performance goal, the plan's quality improvement committee chose a rate of 90% compliance, meeting the established benchmark.

The plan performed a barrier analysis to help design its interventions. Staff believed that a large percent of noncompliant cases was late by less than one month. An analysis of claims data found that 48% of the noncompliant cases had received the required immunizations within one week of the child's second birthday. Moreover, nearly two thirds of the noncompliant cases had received immunizations within two weeks of their second birthday.

Other factors identified as contributing to noncompliant cases:

• Lack of knowledge by staff regarding immunization schedules and revisions
• Lack of knowledge by members regarding immunization schedule
• Variability of reminder systems for routine immunizations
• Variability in updating and following immunization schedules
• Variability of recording immunization information

The plan did a further analysis of its performance by service area. Tracking of service-area-specific performance allowed for the identification of specific regional barriers and actions.

The plan devoted its first full year's interventions to procedural systems, member education, and outreach.

Monthly profiles with immunization rates were distributed to each primary care physician. Pediatric immunizations were included in physician incentive programs; this incentive program linked center performance to annual physician salary awards.

The plan implemented a new procedure, designed to require an assessment of immunization status at all visits. At check-in, receptionists attached the child's immunization record to all encounters. The medical assistant or nurse reviewed the record and identified opportunities to immunize. An end-of-visit discharge process provided an opportunity to educate and perform a final status review of immunizations. A scheduling system enhancement enabled the plan and provider offices to establish the next visit date based on a child's age.

PRACTICE-BASED IMPROVEMENT Real improvement fundamentally improves the way care is delivered. Because it managed the actual delivery system, this plan was able to change procedures for appointment making, patient check-in, and rooming. For IPA model plans, this activity provides a model for collaborative efforts based at the medical group or practitioner level.

Staff developed a new pamphlet around a child's schedule of visits as a member education effort. This was given to all parents during well-child visits. Immunization education was added to prenatal classes.

The plan applied another resource-intensive intervention in order to meet its performance goal. It compiled a list of members who did not make or keep an appointment for an immunization. Staff called these parents to stress the importance of immunizations.

Remeasurement, based on 1995 data, showed a dramatic increase in the immunization rate to 91.8%, already above the plan's goal.

PRIORITIZATION Once immunization levels are above 90%, further efforts to improve rates yields diminishing returns. If immunizations remain a priority, attention should be given to maintaining gains, updating systems for new vaccines, and streamlining existing processes to improve efficiency.

Pleased by these results, the plan decided to dig deeper and determine additional barriers that might keep it from achieving 100% compliance.

Identified issues included:

• Resistance to automation
• Lack of staff knowledge regarding computers
• Continued lack of knowledge by members
• Variability in improvement among different group model centers

The plan examined immunization rates for each service area and revised action plans as needed. New interventions implemented in some service areas were:

• Revised practitioner evaluations, to include immunization notes
• Reporting rates at departmental meetings
• Registered nurse chart review at every visit, with standing orders to immunize

The plan's 24-hour nurse advice line added a message about the need for childhood immunizations that played when callers were on hold. Healthwise Handbook, a popular commercial self-help book, was customized and distributed to all members with children.

To address concerns about the automated system, the plan conducted medical record reviews to verify accuracy of the computerized information.

Data from 1996 indicated that the 90.5% rate of immunizations was statistically unchanged.

Barrier analysis showed:

• Continued lack of member knowledge about immunization schedules
• Variability in the correct use of the automated tracking system
• Variability among providers in recommended immunization schedules

The plan decided to concentrate on new members, parents of children who still had not received immunizations. Guidelines were sent to all such members, and outreach phone calls or letters were initiated to them.

In addition, the call center staff was trained to review immunization with parents during their calls for appointment, and the plan added immunization schedules to its nursing staff certification program.

In 1997, the plan modified its method for calculating immunization rates to comply with the HEDIS 3.0 specifications. Using this methodology the plan measured its immunization rate, which declined to 78.5%. This was believed to be due in part to the change in measurement specifications. After adjusting for the change in specifications, the plan reported a rate of 84%, which does not demonstrate a significant change.

In 1998, the health plan initiated several additional interventions.

The chief of pediatrics revised the existing guidelines to include new immunization recommendations from the Center for Disease Control and Prevention and the American Academy of Pediatrics. The plan created a communications plan to distribute the new guidelines to providers.

The plan conducted member focus groups to determine preferences for format, frequency, location, and media for education on the new guidelines. In addition, a member incentive program was created to bring in old immunization records.

The automated system continues to improve. Changes to the system allow it to record a parent's refusal of an immunization. It also was modified to print automatic reminders for all late immunizations.