CHILDHOOD IMMUNIZATIONS

Identifying and Addressing Specific Barriers

Immunization of children during the first two years of life is effective in reducing the incidence of measles, mumps, rubella, polio, diphtheria, pertussis, tetanus and meningitis. Although vaccine preventable diseases are at their lowest rates ever among American children, immunization rates are still suboptimal. For example, in 1996 to 1997, only 81 percent of children 19 to 35 months of age had received all four doses of DTP vaccine, and only 26 percent of children had received varicella vaccine by their second birthday. [1]

This plan had long recognized the importance of immunizations. In 1993 and 1994, the plan was part of a statewide initiative in collaboration with the health department. Public service advertisements and billboards advertised the importance of getting immunized. Despite these efforts, the plan felt that its immunization rate still fell short, and that a more intensive and specific set of interventions was needed.

The plan used HEDIS 3.0 specifications to target the population of commercial members continuously enrolled for one year, and turning age 2 during the reporting year.

Performance was calculated for a random sample of the targeted population. The plan used the HEDIS 3.0 Combination One measure for pediatric immunizations:

• Children who had received four DTP or DtaP vaccinations, and
• Three OPV or IPV vaccinations, and
• One MMR vaccination, and
• Two hepatitis B vaccinations (with one between six months and two years of age), and
• One Hib vaccination (falling between the child's first and second birthdays)

A hybrid methodology was used to collect data from administrative and medical record sources.

Baseline performance, based on 1996 data, showed an immunization rate of 35 percent. Based on HEDIS measures of immunization back as far as 1994, the plan set a goal of 56.5 percent. By 1998, the plan used NCQA's Quality Compass to quote a benchmark of 63.5 percent from its geographic region.

A cross-functional team composed of staff representatives from member services, provider services and quality improvement identified possible barriers. Together with a statewide advisory committee made up of physicians, they brainstormed possible barriers to complete immunization.

Barriers considered included:

• Physicians miss opportunities to immunize during minor illness - either because they do not check immunization status, or because they withhold immunizations
• Physicians may not have access to shot records
• Vaccine inventory in doctors' offices may be inadequate
• Physicians may be unaware of the latest vaccination requirements
• Physicians are often not knowledgeable about the rate of immunization in their patient population

One factor contributing to the success of the initiative was getting clinician input early and often. At the beginning of this activity, the physicians' advisory committee suggested sending reminders early, to give parents lead time to schedule an appointment. This proved to be an important consideration. Acceptance of suggestions and feedback from clinicians was vital to achieving their buy-in.

The plan conducted a telephonic survey of 173 households with children age 0 to 2. They uncovered a number of additional barriers to care:

• Parents forget to bring immunization records to the doctor's office
• Parents refuse immunizations
• The child was sick during an office visit, and an immunization was not given
• Parents are unaware of the importance of immunizations
• Parents are unaware of the recommended immunization schedule

The plan chose interventions based on how well they addressed identified barriers.

In addition to distributing information on immunization guidelines to members via materials for new members, the member handbook, newborn packets and member newsletters, the plan instituted a bimonthly reminder card program. Reminders were timed to be received four weeks prior to an immunization due date. The cards encouraged parents to contact their pediatricians for recommended immunizations.

Articles in provider newsletters introduced the plan's efforts to improve immunization rates, gave pediatric immunization guidelines and communicated Healthy People 2000 goals.

Childhood immunizations were discussed at the plan's Peer Review Committee, and HEDIS results were distributed to network providers.

The first remeasurement, based on 1997 data, documented an immunization rate of 47.5 percent, a statistically significant improvement using a chi square test (p=.00002). However, the measure failed to meet the performance goal by nine percentage points.

In addition to previously identified barriers, the plan recognized that language barriers existed for some members.

It made two changes to the reminder card system. To address the identified language barrier, the card was made bilingual in English and Spanish. Also, based on the child's birth date, the card now included the specific immunization needed, along with its due date (the revised card is included in QP Tool ). The plan kept pediatricians informed by mailing them a copy of the new card.

NON-PARENT CAREGIVERS This health plan had a large senior population in its Medicare program. It took advantage of this by including an article on childhood immunizations designed for grandparents in its senior member newsletter. It addressed the fear of side effects, and encouraged grandparents to talk with their grandchild's pediatrician.

The plan continued member education with newsletter articles, telephonic "on hold" messages, and online resources about preventive health screenings and immunizations.

Physician newsletter articles and educational meetings stressed HEDIS and the childhood immunization initiative. Physicians were also informed of how to participate in a statewide immunization registry.

Physicians were mailed their practice-specific HEDIS result, and lists of patients due for specific immunizations. Practitioners were instructed to call and schedule appointments for members not making them on their own.

The plan surveyed physicians to obtain feed-back on the immunization effort and interventions. Practitioners were invited to give their input and opinions (A copy of the survey is included in QP Tool .)

The second remeasurement, based on 1998 data, showed an immunization rate of 50.1 percent. This increase was not statistically significant compared to 1997, but it represented a significant increase over 1996 baseline data. However, the plan had not yet met its goal.

The health plan continued its efforts during 1999. It added 29,000 pieces of health information to its interactive Web site. The plan added childhood immunizations to its quarterly provider profiles, and discussed immunization strategies and quality initiatives at educational forums and quarterly meetings with providers. In 1999, the plan reported an immunization rate of 49.3 percent.

In an effort to overcome barriers that have been resistant to improvement, the plan has taken a number of steps. It has implemented an automatic dialer system to make member reminder/education calls, and once again solicited feedback about the interventions from its providers. It has also surveyed parents of children with incomplete immunizations, asking them whether any of the following factors are acting as barriers:

• Not aware child needed immunizations
• Missed appointment
• Did not think immunizations were important
• Too difficult to get time off from work
• The doctor's office was not open at convenient times
• Transportation problems
• Wait was too long in the office
• Immunizations cost too much
• Worry about side effects
• Did not want child to get too many shots at once
• Not aware insurance covered shots

Based on the responses from parents and providers, the plan hopes to build on its experiences, and develop enhancements and new interventions to further improve immunization rates.

[1] - Humiston, SG, ''Immunization Challenges and Strategies for the New Millennium'' (presentation to National Managed Care Congress, 1995).