The American Journal of Managed Care

Using Administrative Claims to Identify Children With Chronic Conditions in a Statewide Immunization Registry | Page 3

Published Online: May 20, 2014
Kevin J. Dombkowski, DrPH, MS; Lauren Costello, MSW; Shiming Dong, MS; and Sarah J. Clark, MPH
Missed opportunities for influenza vaccination were commonplace among children each season and varied substantially across age groups (Figure 1). Among all children in our sample, 71% remained unvaccinated for influenza during the 2008-2009 season, 68% remained unvaccinated during the 2009-2010 season, and 70% remained unvaccinated for H1N1 in the 2009-2010 season. Among those who remained unvaccinated, nearly twothirds (63%) of children during both the 2008-2009 and 2009-2010 seasons had at least 1 missed opportunity for seasonal influenza vaccination; 50% of children had a H1N1 missed opportunity in 2009-2010. Children aged 6 to 18 months were most likely to have at least 1 missed opportunity for H1N1 vaccination (81%) and seasonal vaccination in the 2008-2009 (90%) and 2009-2010 (88%) seasons. The proportion of children with chronic conditions having a missed opportunity decreased sharply among older children. Given their lower numbers of office visits, adolescents had the lowest rate of missed opportunities for the seasonal influenza vaccine during 2008-2009 (58%) and 2009-2010 (57%) and the H1N1 vaccine during 2009-2010 (43%). Importantly, Figure 1 also illustrates the population that was unvaccinated for influenza and had no office visit; ranging from a minority of unvaccinated children 18 months or younger (≤10%) to nearly 50% of adolescents.

We estimated maximum vaccination rates potentially achievable if missed opportunities were successfully converted into administered influenza doses for children with chronic conditions enrolled in the commercial health plans (Figure 2). By converting initial missed opportunities into influenza vaccination events, cumulative gains of 45% (2008-2009) and 44% (2009-2010) were estimated for seasonal influenza vaccinations and 35% for H1N1 influenza vaccinations. If missed opportunities were eliminated, the commercially insured children with chronic conditions could potentially have experienced seasonal influenza vaccination rates that were markedly higher than the observed vaccination rates. If all missed opportunities were converted to vaccination events, seasonal vaccination rates in February would have been 74% versus 29% (2008-2009) and 75% versus 32% (2009-2010). H1N1 vaccination rates could have reached 65% by the end of the influenza season in 2010, versus the rate of 30% that was observed at that time.

Seasonal and H1N1 influenza rates for the 2008-2009 and 2009-2010 seasons as reported in MCIR only were contrasted between our cohort of children with chronic conditions identified by the commercial health plans with 2 matched groups of non–chronic condition children. Less than one-third of the enrollees with chronic conditions identified by the commercial plans received the seasonal influenza vaccine in either the 2008-2009 (26%) or 2009-2010 (29%) influenza seasons; 31% of children received the H1N1 vaccination in 2009-2010. In contrast, children enrolled in Medicaid without a chronic condition had sharply lower vaccination rates for seasonal (17% during 2008-2009 and 19% during 2009-2010) and H1N1 (18%) vaccinations. Similarly, children never enrolled in Medicaid without a chronic condition indication in the MCIR had comparably low seasonal vaccination rates during both seasons (16% in 2008-2009 and 18% in 2009- 2010), and 20% for H1N1.


Our findings demonstrate the feasibility of using administrative claims data from commercial health plans to identify children with chronic conditions and subsequently match them within a statewide immunization registry to enable a high risk indicator. This study extends previous findings that document accuracy in using Medicaid administrative data to identify children with chronic conditions in a statewide IIS.18 To our knowledge, this is one of only 2 studies that link billing-based identification data with statewide immunization registries17; however, previous studies have utilized similar approaches to identify chronic conditions from administrative data,18,20-22 including variations of the Healthcare Effectiveness Data and Information Set (HEDIS) methodology.23-26

These findings have important implications for promoting vaccination among children with chronic conditions. Despite the progressive expansion of the influenza vaccination recommendations for all children younger than 18 years during the past decade,6 the ability to quickly identify children with chronic conditions remains important. Although universal influenza vaccination recommendations for children aged 6 months to 18 years have been adopted, this does not equate to universal vaccination. Influenza vaccination rates remain low for children with chronic conditions,9,10,14 even during times of pandemic.27 Integrating administrative claims with a statewide registry could enable a population-based mechanism for the identification of children with chronic conditions as priority cases either during pandemic events or supply shortages.

Although our study found a high degree of success in matching administrative claims with the statewide registry, ample opportunities to improve linkages exist. Establishing a common identifier unique to each child between systems would greatly improve methods of information exchange among registries and electronic health records (EHRs). In order to establish unambiguous linkages without a common identifier, a minimum set of demographic data on each child should be present prior to information sharing between systems as recommended by American Immunization Registry Association (AIRA), an organization that helps establish uniform standards to advance IIS and immunization programs.28

The ability to link administrative claims with statewide registries is only the first step in identification and prioritization of children with chronic conditions. Given the rapid adoption of EHRs by providers, mechanisms to identify individuals with chronic conditions on a population basis will likely continue to evolve. Current federal programs, including the Meaningful Use Incentive Program, will foster mechanisms to identify children with chronic conditions in EHRs. This program, which provides incentives for medical practices to establish EHRs, sets the stage for categorization of children with chronic conditions by tying funding to a practice’s ability to generate a list of patients by specific conditions using an EHR. Ongoing efforts to establish interoperability between EHR and statewide registries will expedite real-time reporting of influenza immunization doses administered by healthcare providers and could enable the exchange of information regarding chronic conditions, if allowed by the registry.29 Ultimately, improved interoperability with EHRs may introduce opportunities to identify chronic conditions from the source, with chronic condition lists being maintained by practices’ clinical and billing systems in conjunction with the Meaningful Use program objectives.

Our study also provides insight into the utility of a high risk indicator. Although the commercially insured children with chronic conditions were more likely to be vaccinated for seasonal influenza and H1N1 than their counterparts without a chronic condition, their observed influenza rates were low and missed opportunities were frequent. Similar to other studies, we found that only a minority of children with chronic conditions received the seasonal influenza or H1N1 vaccination30 and missed opportunities were commonplace among this group of high risk children.11 Low vaccination rates, combined with high rates of missed opportunities, suggest that multiple outreach strategies may be necessary to improve influenza vaccination rates among this group of children. Not surprisingly, adolescents had the lowest rate of vaccination among our sample and were the least likely to have been seen by a provider throughout both influenza seasons. Reminder/recall is one strategy to improve influenza vaccination among children with chronic conditions, where parents are notified by mail, telephone, or other mechanisms to serve as a prompt to vaccinate their children.30,31 For this group, vaccination reminders prompting parents of adolescents to schedule an appointment with vaccination providers, either public or private, may be an effective mechanism to increase office visits and influenza vaccination rates.

In contrast, reminder/recall may have limited impact on increasing vaccination rates among children experiencing missed opportunities since they, by definition, had 1 or more office visit during the flu season, yet remained unvaccinated throughout the season. We found that younger children had greater missed opportunities than older children, suggesting that outreach strategies could differ by age group. Most of the unvaccinated children younger than 3 years in our sample had at least 1 missed opportunity and were seen by a provider throughout the 2008-2009 and 2009-2010 influenza seasons. Consequently, parent reminders alone might not be effective in reducing missed opportunities for this group. Implementing provider-focused reminder systems in combination with mailed reminders for parents of younger children may be 1 strategy to convert missed opportunities to vaccination events.

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Issue: May 2014
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