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Using Administrative Claims to Identify Children With Chronic Conditions in a Statewide Immunization Registry | Page 4

Published Online: May 20, 2014
Kevin J. Dombkowski, DrPH, MS; Lauren Costello, MSW; Shiming Dong, MS; and Sarah J. Clark, MPH
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.

Our findings should be considered in light of several limitations. We were unable to evaluate the accuracy and completeness of the commercial healthcare claims data used to populate the high risk indicator in MCIR. Consequently, we were therefore unable to verify the accuracy of using the administrative claims data from the commercial health plans in identifying children with chronic conditions. Additionally, although this study examined missed opportunities among children with chronic conditions, we are unable to determine why missed opportunities occur. Furthermore, because our study intended to demonstrate the feasibility of using administrative data to identify children with chronic conditions, children were included in our sample if they had at least 1 claim for a chronic condition regardless of the number of provider encounters, severity, or duration of the condition. Future studies examining the accuracy, feasibility, and utility of using administrative claims data should also take into account the severity of chronic condition by subdividing children with chronic conditions into complexity groups. Finally, it should be noted that substantial time lags were encountered with respect to executing the data-use agreements required for this study. Such delays should be considered in future studies or applications of these methods to public health practice.

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Issue: May 2014
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