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The American Journal of Managed Care May 2014
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Using Administrative Claims to Identify Children With Chronic Conditions in a Statewide Immunization Registry
Kevin J. Dombkowski, DrPH, MS; Lauren Costello, MSW; Shiming Dong, MS; and Sarah J. Clark, MPH

Using Administrative Claims to Identify Children With Chronic Conditions in a Statewide Immunization Registry

Kevin J. Dombkowski, DrPH, MS; Lauren Costello, MSW; Shiming Dong, MS; and Sarah J. Clark, MPH
This study examines the feasibility and utility of using administrative claims from commercial health plans to identify children with chronic conditions in a statewide registry.
Objectives

To demonstrate the feasibility and utility of using administrative claims data from commercial health plans to establish a high-risk indicator in a statewide immunization registry for enrollees with chronic conditions.

Study Design

Retrospective cohort analysis.

Methods

Administrative data were used to identify children with 1 or more chronic conditions enrolled in 2 commercial health plans during the 2008-2009 and 2009-2010 influenza seasons and matched with a statewide immunization registry. The proportion of cases that successfully matched and historical health services utilization, including influenza vaccinations and missed opportunities, were assessed.

Results

A total of 93% of children with chronic conditions identified through administrative claims were successfully matched with the statewide registry. Less than one-third of children received the seasonal influenza vaccine in either the 2008-2009 (29%) or 2009-2010 (32%) seasons; 30% of children received the H1N1 vaccination in 2009-2010. Most children in the 2008-2009 (63%) and 2009-2010 (63%) seasons had at least 1 missed opportunity for seasonal influenza vaccination. Younger children had the highest percentage of missed opportunities while adolescents had the lowest rate of missed opportunities for vaccination. Conclusions It is feasible to identify children with chronic conditions using administrative data and to link them with a statewide immunization registry. Low influenza vaccination rates and high occurrences of missed opportunities among children with chronic conditions suggest the utility of integrating administrative claims data with statewide registries to support various outreach mechanisms, including physician-focused and parent-targeted reminder/recall, based on target age to improve vaccination rates.

Am J Manag Care. 2014;20(5):e166-e174
Administrative data from commercial health plans can be used to identify children with chronic conditions in a statewide immunization registry. Low influenza vaccination rates and high occurrences of missed opportunities among children with chronic conditions in our sample suggest the utility of integrating administrative claims data with statewide registries. This integration can:
  • Enable a population-based mechanism for identification of children with chronic conditions as priority cases during pandemic events or supply shortages.

  • Support various outreach strategies to improve influenza vaccination rates, including physician-focused and parent-targeted reminder/recall.
Children with chronic conditions are especially vulnerable to complications from influenza.1-5 Annual influenza vaccinations have long been recommended for this group of children.6,7 More recently, the Advisory Committee on Immunization Practices (ACIP) adopted a universal recommendation of yearly influenza vaccination for healthy children aged 6 months to 18 years.6,8 Despite this recommendation, vaccination rates for seasonal influenza remain low for children with chronic conditions.9-15 Missed opportunities, where eligible children are seen by a practitioner but no vaccination dose is administered, have been documented among this population and may contribute to low vaccination rates.9,11

Immunization registries, also known as immunization information systems (IISs), are well established in the United States and provide reminder/recall functions that are effective in increasing vaccination rates.16 However, IISs are not typically designed to track clinical information in addition to vaccinations and consequently cannot target reminder recall notices specifically to those with chronic conditions. Enhancing immunization registries with a high risk indicator may be a mechanism to promote increased vaccination rates among this population through the use of registry-based reminder/ recall capability. In 2006, Michigan’s IIS, known as the Michigan Care Improvement Registry (MCIR), was enhanced with a high risk indicator based on Medicaid administrative data to bolster vaccination rates among children with chronic conditions. This indicator has been demonstrated as being an effective mechanism to target reminder/ recall notices,17 although the benefits of that system have initially been limited to children enrolled in Medicaid.18,19

With that in mind, the objective of this study was to build on the success of the Medicaid-based MCIR high risk indicator by expanding it to include administrative data from 2 commercial health plans. First, we sought to demonstrate the feasibility of using administrative claims data from commercial health plans to establish a high risk indicator in astatewide immunization registry for enrollees with an influenza-sensitive chronic condition (hereafter referred to as a “chronic condition”). We also sought evaluate the potential utility of this expansion of the MCIR high risk indicator by assessing historical influenza vaccination experiences among children with chronic conditions.

METHODS

We assessed the feasibility and utility of using commercial health insurance administrative data to identify children with chronic conditions in the MCIR statewide IIS. Administrative data were obtained from 2 Michiganbased commercial health plans and were matched with corresponding information in the MCIR. This study was approved by the University of Michigan institutional review board.

Study Population

The commercial health plan identified 48,936 children younger than 18 years who were enrolled in either health plan (health plan 1 or health plan 2) for calendar years 2008 and 2009 and had 1 or more claim for at least 1 chronic condition during this period. Chronic conditions were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (primary or secondary) reported on claims for conditions indicated as placing individuals at increased risk for influenza disease in the ACIP annual influenza vaccination recommendations.8 Diagnosis codes for the specified conditions were assigned using the same methods as those employed in prior studies (Appendix A).17,18 From this initial cohort, we excluded children who were younger than 6 months, had other insurance, or were not continuously enrolled (8246 [17%] in the 2008-2009 season; 7465 [15%] in the 2009-2010 season). Health plan enrollment and health services utilization were obtained for each subject for the period of 2008 to 2010; information was obtained for demographic characteristics and plan enrollment as well as claims for all outpatient office visits, including vaccine administrations.

Outcomes Measured

Feasibility. Among the commercially insured children 18 years or older who were identified as having 1 or more chronic condition (40,690 in the 2008-2009 season, 41,471 in the 2009-2010 season), we calculated the proportion of cases that could be successfully matched with their corresponding record in the MCIR. A common unique identifier was not available for linking the health plan members with the MCIR, requiring that matching be achieved using the child’s name (first/last), date of birth, and gender. Health services utilization was then evaluated among eligible children who were matched successfully with the MCIR data to determine past influenza vaccination experiences as well as missed opportunities for influenza vaccination.

Utility. Three outcomes were measured for the 2008- 2009 and 2009-2010 influenza seasons, defined to be September to February of each season: (1) primary care office visits (either ≥1 or ≥2 office visits); (2) vaccination for either seasonal or H1N1 influenza; and (3) missed opportunities for either seasonal or H1N1 influenza vaccinations. Primary care office visits were identified based on Current Procedural Terminology (CPT) procedural codes and/or ICD-9-CM diagnosis codes. Office encounters with a physician in a family practice, general practice, internal medicine, or pediatric setting were classified as a primary care visit. Immunization visits and other visits during each influenza season were identified using CPT procedure codes, and well child visits were classified using CPT procedure codes and ICD-9-CM diagnosis codes (Appendix B).

Vaccination records for children with chronic conditions that could be matched with the MCIR were obtained for influenza seasons 2008-2009 and 2009-2010. Healthcare providers are required by Michigan law to input in the MCIR all vaccination doses administered to persons younger than 20 years of age. Seasonal and H1N1 influenza vaccination rates were classified as the receipt of a dose as recorded in the MCIR or through administrative claims. In cases where more than 1 seasonal or H1N1 vaccination dose was administered during an influenza season, we considered the first date of influenza vaccination (from either administrative claims or MCIR data) as the vaccination date for our analysis. Missed opportunities for seasonal influenza vaccination were classified as the initial office visit occurring during the influenza season (September-February) among children who remained unvaccinated throughout the entire influenza season. Since H1N1 influenza vaccine supply was limited from September to October 2009, missed opportunities for H1N1 influenza vaccination were classified as the initial office visit occurring from November 2009 through February 2010 among children who remained unvaccinated throughout the entire influenza season. Subsequent missed opportunities were not counted. The date of the missed opportunity was classified as the date of the initial office visit occurring between September and February for seasonal influenza vaccination and between November and February for H1N1 influenza vaccination in which the child remained unvaccinated. We calculated estimated seasonal and H1N1 influenza vaccination rates that could potentially be achieved if missed opportunities were successfully converted into influenza vaccination events. Seasonal and H1N1 influenza rates for the 2008-2009 and 2009-2010 seasons were contrasted between our cohort of children with a chronic condition identified by the commercial health plan with a matched group not having a chronic condition. We used the MCIR to identify children who were not designated with the system’s high risk indicator as the basis for our comparison group. However, at the time of our study, the MCIR high risk indicator process was limited to children with chronic conditions who were, or had previously been, enrolled in Medicaid. Children with only commercial insurance would not have chronic conditions identified through claims. As a result, the high risk status of children who were commercially insured in plans other than the 2 health plans used in this study was not known with certainty in the MCIR. To control for potential misclassification, we further categorized our comparison group of children without a MCIR high risk indicator into 2 subgroups: (1) children currently enrolled in Medicaid, not identified in the MCIR as having a chronic condition (since these children are or were previously enrolled in Medicaid, their claims were subject to queries to identify chronic conditions and therefore, absence of a high risk indicator in the MCIR is reflective of not having a chronic condition); and (2) children never enrolled in Medicaid, whose status in the MCIR was indicated as not high risk. While this group likely contains primarily children who did not have a chronic condition, it is possible that some may have had a chronic condition that was not detected in claims data queries, since this group had never been enrolled in Medicaid. Using this process, 1 comparison child was randomly selected for each commercially insured high-risk case, matching on birth month and year, gender, and Michigan county of residence. This resulted in a 1:1 matched set of comparison children for each high risk case. Claims data were not available for children who had never been enrolled in Medicaid; as such, seasonal and H1N1 influenza doses were compared in this subanalysis across the 3 groups using doses reported in the MCIR.

Data Analysis

To assess feasibility, we summarized the proportion of cases in the commercial health plans that were successfully matched within MCIR. Primary outcomes measured for the utility of using administrative claims were the receipt of seasonal and H1N1 vaccination and either at least 1 or at least 2 office visits. Health utilization was compared between 1 health plans (health plan 1 and health plan 2) by child characteristics, including age, gender, and rural/urban designation (US Census Metropolitan Statistical Area classification). The proportion of children with a missed opportunity was assessed and compared by influenza season (2008-2009 and 2009-2010) by each child’s age group. In addition, observed rates of seasonal and H1N1 influenza vaccinations as reported in MCIR were calculated and compared among the commercially insured high risk group and the 2 comparison groups described above. Estimated influenza vaccination rates were determined by classifying each child with a missed opportunity as a potential influenza vaccination event, and compared across seasons for the commercially insured children with chronic conditions. All analyses were conducted using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina).

RESULTS

 
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