1. Kevin Dombkowski, DrPH, MS March 7, 2007
CHEAR Unit, Division of General Pediatrics, University of Michigan
Taking a Statewide Immunization Information System to the Next Level: Identifying Children with High-Risk Conditions
Kevin Dombkowski, DrPH, MS
March 7, 2007

2. Identifying Children with High-Risk Conditions
Today’s illustration:
focuses on children with conditions placing them at high-risk for influenza complications
builds on existing reminder capabilities of the Michigan Care Improvement Registry (MCIR)
integrates patient-level data derived from Medicaid administrative claims
The examples I’ll share with you this afternoon are based on our recent work in Michigan
We’ll focus on influenza vaccination among children with high-risk conditions
We’ll build on the existing reminder capabilities of the Michigan Care Improvement Registry
And further leverage those features by integrating information obtained from Medicaid administrative claims data

3. Influenza Vaccination
Burden of influenza is great:
can affect 20-30% of children during typical year; higher during epidemics
commonly considered self-limiting
in some cases may lead to serious complications:
office visits
prescription use
hospitalizations
death
So just a brief bit of background about influenza
We know that influenza affects upward of 30% of children in a typical flu season and higher in epidemic periods
While flu is commonly self limiting, it may lead to serious complications requiring increased office visits and medication use
And can in some cases lead to hospitalizations and even death

4. Influenza Vaccination
Flu vaccination has long been recommended for persons high-risk conditions, yet low vaccination rates are commonplace
Prior studies suggest very low vaccination rates among children with asthma (10-25%)
How are kids in Michigan with asthma doing?
Now we know that vaccination is the first line of defense against influenza
And flu vaccination has long been recommended for persons with high-risk medical conditions
Despite those recommendations vaccinations rates have been consistently reported to be very low among children with asthma – the most prevalent of these high-risk conditions
Rates have been reported below 25% in numerous studies;
We were interested in how this looked in Michigan

5. Influenza Vaccination
Influenza vaccination missed opportunities were a concern
Missed opportunities: office visits at which a child is eligible for influenza vaccination, but not administered
High rates of missed opportunities previously reported among children with asthma ( %)
And in particular, we were concerned that missed opportunities may be a barrier
By missed opportunities we mean office visits at which a child is eligible for influenza vaccine, but it is not administered
We know from earlier studies in other settings that missed opportunities are commonplace among kids with asthma, ranging between 38=-62%

6. Influenza Vaccination Missed Opportunities
Influenza vaccination rates among children with asthma in Michigan
4,358 children, 5-18 yrs.
2 consecutive seasons ( , )
rates ranged 17% – 22%
10% were vaccinated in consecutive seasons
So we looked at a group of children in the Michigan Medicaid program with asthma
Our study group was just over 4,300 kids between 5-18 years of age with persistent asthma
We not only found low vaccination rates, we observed that they occur consistently from one flu season to the next
In fact, only 10% of kids were consistently vaccinated in both seasons.
_______________
*** Dombkowski KJ, Davis MM, Cohn LM, Clark SJ. Effect of missed opportunities on influenza vaccination rates among children with asthma. Arch Pediatr Adolesc Med. Sep 2006;160(9):

7. Influenza Vaccination Missed Opportunities
Missed opportunities for flu vaccination are more common than vaccination:
70% of unvaccinated children had at least 1 missed opportunity during flu season
40% had missed opportunities in successive flu seasons
When we looked at missed opportunities, we found them to be very common;
The vast majority of kids – over 70% had at least one missed opportunity during flu season
And in fact, the most common outcome was having missed opportunities in both seasons – 40% of our study subjects.
So, before I go on, I’d like to underscore the fact that getting the kids into the physician office does NOT seem to be the issue
It’s the fact that most kids are standing in a physician office during the flu season, yet they remain unvaccinated.
WHY?
_______________
*** Dombkowski KJ, Davis MM, Cohn LM, Clark SJ. Effect of missed opportunities on influenza vaccination rates among children with asthma. Arch Pediatr Adolesc Med. Sep 2006;160(9):

11. I just want to point out the potential impact these missed opportunities have on influenza vaccination rates
Here we see the potential rates that could be achieved if we reduced missed opportunities by
25%
50%
Or eliminated them altogether; Obviously they make a big difference.

12. Why Do Missed Opportunities Occur?
Mailed survey to 600 office-based pediatric primary care physicians in Michigan
Focused on attitudes and experiences regarding influenza vaccination
among children with asthma
during the influenza season
To understand this, we conducted a survey of pediatric primary care physicians across the state of Michigan
We mailed a survey to 600 pediatricians and family physicians that assessed their attitudes and experiences with flu vaccination among kids with asthma during the 05/06 flu season
We wanted to better understand several things;

13. Why Do Missed Opportunities Occur?
Explored physician attitudes regarding:
recommendation variations based on severity of asthma
estimated vaccination rates
reasons for not administering
attitudes toward a high-risk indicator in MCIR as a flu vaccination reminder
We had hypothesized that there may be variability in recommendations for flu vaccine based upon the severity level of asthma
We asked physicians about the flu vaccination rate for their patients with asthma
And importantly, we asked them to detail reasons why kids with asthma may not receive flu vaccine in their practice
We also asked about their attitudes regarding the MCIR and its potential use to remind physicians regarding flu vaccination for high-risk patients.

14. Physician Survey Results
96% routinely recommended influenza vaccine to children with persistent asthma:
PD=99%, FP=92% (p=0.001)
82% routinely recommended influenza vaccine for children with intermittent asthma:
PD=91%, FP=70% (p<0.0001)
A few of our key findings:
Nearly all – 96% of physicians indicated that they recommend flu vaccination for kids with persistent asthma
In contrast, only 82% indicated that they routinely recommend flu vaccination for kids with intermittent asthma

15. Physician Survey Results
Most physicians (51%) reported >50% of children with asthma in their practice received flu vaccine:
PD=64%, FP=36% (p<0.0001)
Physicians that rarely recommended flu vaccine for intermittent asthma:
2.3 times more likely to report flu vaccine rates ≤25%
When we asked physicians about flu vaccination among their patients with asthma, most estimated that over half were vaccinated – this was significantly higher among pediatricians
Looking at the other end of the spectrum, we found that among those physicians who RARELY recommend flu vaccination for kids with intermittent asthma,
Those physicians were 2.3 times more likely to report the lowest vaccination levels, < 25%.

16. Reasons Children Were Not Vaccinated
Physicians that always recommend influenza vaccination for intermittent asthma:
Vaccine not available: 51%
Patient already vaccinated: 48%
Parent / patient refused: 41%
Physicians who always recommend flu vaccination for children with intermittent asthma noted the following reasons most often for children NOT being vaccinated:

17. Reasons Children Were Not Vaccinated
Physicians that rarely recommend influenza vaccination for intermittent asthma:
Asthma not severe enough: 51%
Vaccination overlooked: 50%
Not identified as eligible: 41%
Each of these reasons was significantly more likely to be identified compared to those who always recommend influenza vaccination for intermittent asthma (p <.0001)
In contrast, physicians who rarely recommend flu vaccination for children with intermittent asthma noted the following reasons most often for children NOT being vaccinated:
Each of these 3 reasons was significantly more likely to be identified by physicians that RARELY recommend flu vaccination for kids with intermittent asthma, compared to those who ALWAYS recommend

18. Physician Survey Results
High MCIR participation: 91%
Most typically had MCIR information available during office visits: 66%
Most considered the high-risk indicator to be helpful / very helpful: 75%
Some concerns noted:
completeness of MCIR data (18%)
use of Medicaid claims (24%)
Briefly, a few findings related to MCIR use:

19. Meeting the Challenge Reminders can target:
U.S Task Force on Clinical Preventive Services indicates that reminder and recall notices are very effective
Reminders can target:
Patients
Providers
Can we use reminders to improve influenza vaccination rates among children with high-risk conditions?
With those results in mind, we know that the best available evidence suggests that reminders / recall notices are very effective at improving vaccination rates
It’s important to note that reminder notices can be focused on patients / parents or providers
The question remains: can we use reminders to improve influenza vaccination rates among children with high-risk conditions

20. Meeting the Challenge Daley, et al, 2004: Key findings:
4 practices in Denver, CO
mailed reminders for influenza vaccination
children with high-risk conditions
6-72 months old
Key findings:
claims linkages feasible, accurate
increased flu vaccination rates
reduced missed opportunities
If we look at some work from a prior study conducted by Matt Daley & colleagues in the Denver area, we find some promising results
In this study they sent mailed reminder notices to children with high risk conditions between the ages of 6-72 months
They identified kids with high-risk conditions based upon diagnosis codes in the billing systems at these practices and then integrated this information into their immunization registry
Some important findings:
Feasible, an the high-risk indication is accurate
Increased flu vaccination rates
Reduced missed opportunties
_______________
Daley MF, Barrow J, Pearson K, et al. Identification and recall of children with chronic medical conditions for influenza vaccination. Pediatrics. 2004;113(1 Pt 1):e26-33.

21. Meeting the Challenge
Use Michigan’s statewide immunization registries to provide influenza vaccination reminders for high-risk children
…. So we wondered why not use the Michigan immunization registry infrastructure as a platform to implement a reminder system for influenza vaccination for children with high risk conditions
Given the excellent features and capabilities, we thought those would serve as an excellent starting point….

22. MCIR High-Risk Condition Indicator
Use Michigan Medicaid administrative claims to identify high-risk children
Integrate high-risk indicator into MCIR
Use automated reminders to prompt physicians using to:
assess eligibility
administer flu vaccine
Our thought was to use Michigan Medicaid claims data to identify the children with high-risk conditions,
But we also wanted to include cases identified from the Michigan CSHCS program’s qualifying diagnosis files
We envisioned integrating this information into MCIR, then build on existing capabilities to prompt physicians to assess eligibility and administer the flu vaccine.

23. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule

24. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule

25. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule

26. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule

27. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule

28. Multiple stakeholders:
Agreement on concept
Resolve concerns
Clarify responsibilities
Develop schedule
It should be pointed out that numerous stakeholders were involved with this process – something to think about as you consider similar approach in your jurisdiction

29. ………. So when we pulled it all together………

30. MCIR High-Risk Condition Indicator
Identified high-risk conditions using diagnosis codes reported in:
Medicaid claims
CSHCS (Title V) qualifying diagnoses
Classified cases based on CDC list of conditions at increased risk for flu complications***
Developed a child-level file with identifiers for those with high-risk conditions
We were able to successfully identify children with high-risk conditions in both the Medicaid claims data as well as the CSHCS qualifying diagnosis files.
We classified cases based on the conditions listed in the MMWR, assigning diagnosis codes to the various conditions listed.
The objective of this process was to develop a list – a file with each child’s Medicaid ID for whom one or more high risk condition was identified.
_______________
*** Centers for Disease Control and Prevention. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2005;54(RR08):9

31. To illustrate this process, imagine a file with over 2
To illustrate this process, imagine a file with over 2.5 million claims…..

32. Search diagnosis codes to find claims for children with high-risk conditions
We use computers to do what the do so well – find things.
In this case, the example on the screen shows a set of claims for a child with asthma – one of the high-risk conditions
We add that child’s Medicaid ID to a list………

33. Which looks something like this………
A file tracking the Medicaid ID and other identifiers necessary to link to MCIR for each child with one or more high-risk condtion.
Summarize identifiers for each child found in administrative data files

34. MCIR High-Risk Condition Indicator
Identified 59,000 children with high-risk conditions using administrative data
Integrated the child identifiers into MCIR – not the specific condition
Implemented the physician reminder notification in October 2006
When we had completed the process, we ended up with over 59,000 children with a high-risk condition
The list of identifiers was integrated into MCIR – but NOT the condition information
The high risk indicator reminder notification system was implemented in October of 2006.

36. 04/17/2003 XXXXXXX XXXXXXX Citizen Mary Jane 123456789 Smith

37. 04/17/2003 XXXXXXX XXXXXXX Citizen Mary Jane 123456789 Smith

38. MCIR High-Risk Condition Indicator
Administration of influenza vaccine dose disables the indicator / message for the remainder of the flu season
Providers may remove the high-risk designation for a child if they feel it is in error

39. MCIR High-Risk Condition Indicator
Other opportunities:
evaluate pilot implementation of high-risk indicator
integrate high-risk indicator into printed reports and patient rosters generated by MCIR
generate mailed reminder notices
expand beyond Medicaid and CSHCS enrollees

40. Acknowledgements Many thanks to my collaborators at: Funding sources:
University of Michigan
Michigan Dept. of Community Health
Funding sources:
Blue Cross Blue Shield of Michigan Foundation

41. Think Spring !