1. 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

2. 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.

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

4. 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.

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

6. 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

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

8. 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)

9. 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

10. 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

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

12. 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

13. 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%

14. 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.

15. 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

16. 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.

17. 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