CHILDHOOD IMMUNIZATIONS

Stressing Education and Documentation

Sometimes an opportunity for improvement isn't evident from a simple measurement. This health plan measured immunization rates that didn't appear dramatically low. But when it compared its results with those of other plans, it became obvious that there was room for improvement. A basic approach not only improved the plan's immunization rates, it also raised the skill level of the plan's staff in quality improvement techniques. When a new immunization requirement was added, it became another opportunity, rather than an obstacle, for further improvement.

A well-defined schedule of immunizations for children from birth to two years of age has been endorsed by the Centers for Disease Control and Prevention (CDC), the US Preventive Services Task Force, and the American Academy of Pediatrics. Childhood immunization has also been one of the standard effectiveness-of-care measures in HEDIS since its inception.

This plan was one of 21 that participated in the NCQA Report Card Pilot Project. When it discovered that its immunization rate was 20% less than for the project's highest performer, it chose to concentrate its efforts on a quality initiative for childhood immunization. When hepatitis B immunization was added to the HEDIS measurement set, the plan set into motion specific efforts to increase the numbers of its members protected against this sometimes chronic and deadly disease.

The plan used HEDIS 2.0 (and 2.5 and 3.0) methodology throughout this activity. The target population comprised 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. In addition, the plan measured the rate of each recommended immunization:

• Diptheria-tetanus-pertussis (DTP)
• Oral polio vaccine (OPV)
• Measles-mumps-rubella (MMR)
• Haemopbilus influenzae type B (HB)

Throughout this activity, the plan used medical records to determine the immunization rate for a representative sample of its population. Baseline data from 1993 showed that the plan's overall immunization rate was 70%. The 1993 results by vaccines are listed in Table 1.

The plan chose an overall immunization rate of 91%, the highest rate reported by a plan in the NCQA Report Card Pilot Project, as its benchmark. (Benchmarks were not established for individual vaccines.) The plan set an overall immunization rate of 90% as its performance goal.

At the start of the initiative, the plan limited its analysis to an assessment of data integrity. There was concern that the compliance rate could be understated, since medical records might not reflect the use of the other sources of immunization that were available in the community.

Although formal root cause analysis was performed, a lack of parental knowledge about immunization requirements was perceived as a possible barrier that intervention might solve.

ANALYTIC ABILITY A lack of experience in quality improvement was perhaps the plan's biggest obstacle. Plan staff was inexperienced in data extraction/analysis as well as root cause and barrier analysis. The plan's staff worked closely with corporate and local IS departments to address data issues. They received training in the use of continuous quality improvement methods such as fishbone diagrams and Pareto charts. These working relationships and skills were subsequently used for other quality initiatives.

The plan worked to improve its childhood immunization rates through two main activities: (1) member and provider education, and (2) regular reminders to parents and their children's primary care physicians (PCPs).

First, the plan concentrated on educational interventions for parents. A blank immunization record was mailed to all parents, with the suggestion that they complete one for each child. An article about childhood immunizations was published in the member newsletter.

Next, the plan employed regular reminders to parents and PCPs. In August 1994, a postcard that stressed the importance of immunizations was mailed to all households with children aged two and younger.

Meanwhile, physician education focused on PCPs. The plan included an article on immunizations in the physician newsletter. It began to distribute posters from the CDC that touted the need for the complete immunization of children.

Remeasurement, using 1994 data, revealed an overall immunization rate of 80%, a statistically significant improvement. Results by vaccine are listed in Table 2.

Although pleased with the increase in immunization rates, the plan did not feel that all of the improvement was due to its interventions. Plan personnel theorized that the emphasis on the importance of childhood immunizations might have led to more careful documentation and record-keeping by providers. Better documentation, in part, accounted for the higher reported immunization rates. In order to sustain meaningful improvement, the plan felt a need to expand and intensify its relatively passive interventions.

The plan felt that its interventions would be more effective and sustainable if they occurred as part of a defined program of health promotion and parental education. The resulting program was launched in 1995 and continued throughout the initiative. It provided parents with information on nutrition, safety, immunizations, and other care elements for infants and toddlers. These were mailed at birth, six months, and 12 months; the mailings also served as immunization reminders. This educational endeavor was supplemented by information in the member newsletter.

In order to strengthen their analytic activities, the plan hired a statistician in 1995.

The second remeasurement, using 1995 data, showed that the overall immunization rate was unchanged from the prior year at 80%, sustaining the prior year's improvement. With the exception of MMR, the plan's compliance rates for each vaccine increased significantly between 1993 and 1995. Results by vaccine using HEDIS 2.5 are listed in Table 3.

An analysis of the data revealed two important facts:

• the greatest deficiency occurred for vaccines required between the ages of 12 and 24 months
there were three large-volume practices with especially low immunization compliance rates

DATA ANALYSIS It's often difficult to discover barriers or opportunities for improvement without some breakdown of performance results. This plan analyzed its data by age and medical group. This type of analysis can be key to identifying large areas for interventions.

Guided by their analysis, the plan implemented new interventions.

Face-to-face meetings were held with the three high-volume, low-compliance practices to develop a plan for improvement. An incentive program for parents also was developed. It featured a monthly prize drawing for parents whose children had completed all required immunizations.

The critical population of 12- to 24-month-olds was targeted with a reminder letter to parents of 18-month-olds. This was added to the mailings that were already scheduled as part of the health promotion and parental education program.

The third remeasurement, using 1996 data, was performed using HEDIS 3.0 methodology. A change in enrollment specifications and the addition of the hepatitis B vaccine made the new specifications more demanding. Nevertheless, the overall immunization rate rose to 82%, and all of the individual vaccine rates increased. The result of the measurement of the complete immunization against hepatitis B was 92%. All the results are listed in Table 4.

This plan made significant improvements over the course of this quality initiative. It has concluded that health education for parents is essential to improving childhood immunization compliance. Frequent, ongoing reminders to parents were an effective mechanism for achieving and maintaining improvement.

However, while the incentive program was successful in its first year of operation, the number of entries per month has slowed substantially over time. The plan has concluded that it is important to regularly develop new promotional initiatives to maintain parental interest.

As a result of its targeted interventions, the plan was happy to note that all three large-volume groups showed improvements in overall immunization compliance rates.

This initiative laid the groundwork for the development and implementation of a comprehensive health promotion program for children. This activity not only had an impact on the plan's members, it also had a significant impact on the plan's staff and operations.