Adrienne D. Mims M.D. MPH Kaiser Permanente, Georgia Reasons For Not Obtaining Pneumococcal Vaccination In A Managed Care Population Adrienne D. Mims M.D. MPH Kaiser Permanente, Georgia

Acknowledgements Carla A Winston, PhD - CDC Kecia Leatherwood, MSPH Pascale Wortley, MD, MPH - CDC Michael Blue, MSHA Latoya Cochran, BS This study was funded by the CDC and took place at Kaiser Permanente, Georgia. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency.

Overview Pneumococcal vaccine is recommended for age >65 and younger persons with chronic medical conditions. According to 2000-2001 National Health Interview Survey (NHIS) 57% of Whites compared to 33% Blacks report having had a pneumococcal vaccine.

Background When comparing fee-for-service insurance with managed care, there is a decrease in racial disparities in immunization coverage However, racial disparities in immunization rates persist within managed care.

Objective To determine the reasons for non-vaccination among patients in a managed care population.

Prior Initiatives to Increase Pneumococcal Immunization Rates Patient Centered: Outreach letters during fall influenza campaign Newsletter articles Prevention guideline posters in exam rooms Pneumococcal posters in clinic triage station

Prior Initiatives to Increase Pneumococcal Immunization Rates Clinician Centered: Published Guidelines on website, pocket guide and email Mandatory CME tests Lime green chart flags in targeted member’s medical record Departmental & individual quality measure

Methods: Population Patients from: 3 predominantly Caucasian 2 predominantly African American clinics 3,711 patients age 18+ with diabetes, congestive heart failure and/or coronary artery disease (Chronic). 2,395 patients age 65+ (Elderly)

Methods: Intervention Randomized patients to intervention call or usual care Intervention was a telephone call from trained managed care nurses Calls occurred over a 6 week period, in summer of 2004

Intervention – Telephone call Confirmed vaccination status Described importance of vaccine Recorded reasons for non-vaccination Provided counseling tailored to patient’s reason for non-vaccination Offered to schedule a visit for vaccination

Methods: Analysis of Telephone Calls Determination of true frequency of non-vaccination Compare reasons for non-vaccination by: age race educational level gender

Prior Vaccinations Reported by Patients Who Were Reached by Calls Chronic Group n=1039 Previously vaccinated 234 (22.5%) Never vaccinated 809 Elderly Group n=850 Previously vaccinated 375 (44.1%) Never vaccinated 475

Results Primary reasons for non-vaccination: Response Chronic 809 Elderly 475 “I did not know I needed the shot” 56.0% 41.0% “I don’t want to get a shot” 10.5% 13.9% “I am concerned the shot will make me sick” 7.9% 14.1% Other – transportation, cost, childcare, illness, etc. 25.6% 31.0%

Among Chronic group patients reached by phone who reported: “I did not know I needed the shot” Demographic N Percent P value White 88 of 156 Whites who answered reasons said did not know 56.4% p=.21 Black 252 of 455 Blacks 55.4% <HS 35 of 75 46.7% p=.17 HS or GED 98 of 164 59.8% > HS 232 of 414 56.0% Female 175 of 353 49.6% P=0.001 Male 197 of 318 62.0% percents in this slide reflect percent who gave as a reason “ did not know needed” versus all other reasons. Note that of 809 unvaccinated patients, only 671 answered the reasons why not, and of those some were missing race or education, so only the gender comparison contains all respondents. If all one does is compare “did not know” versus all other reasons, the difference between chronic group males and females is significant. We had previously examined whether the overall distribution of reasons differed by race, gender, or education; and subsequently looked at whether the top 4 reasons differed overall by race, gender, or education. These were the data – restricted to the top four reasons – which were requested by Adrienne and shared on 3/15/05.

Among Elderly group patients reached by phone who reported: “I did not know I needed the shot” Demographic N Percent P value White 59 of 140 Whites who answered reasons said did not know 42.1% p=.72 Black 80 of 199 Blacks 40.2% < HS 41 of 96 42.7% p=.35 HS or GED 39 of 106 36.8% > HS 67 0f 146 45.9% Female 90 of 235 38.0% p=.19 Male 62 of 137 45.3% Note that of 475 unvaccinated people, only 372 answered reasons for non-vaccination, and some did not reply to race or education, so only the gender questions contains all responders

the shot” did not differ by age, race, education or gender. Conclusion The primary reason for not having received the Pneumococcal vaccination, “I did not know I needed the shot” did not differ by age, race, education or gender.

Recommendations To increase vaccination rates, Managed care programs need to: Ensure systems are in place that enhance patient awareness Facilitate methods to increase frequency of practitioner recommendations for the vaccine Address patient’s perceived access issues