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Immunization Registries: Improving Health and Health
Care
*Indicates AKC I project, ** indicates AKC II project
ARIZONA*/**
The immunization rate doubled to 90% in 1999 for 700 low-income children at five Phoenix, Ariz., child care centers and two charter schools
when the organizations' nurse acquired a computer and access to the Arizona registry's database. By identifying under-immunized children and administering the missing shots, cases of measles,
pertussis, and
varicella at those institutions were reduced to zero, despite county-wide outbreaks of those diseases during the same timeframe. In addition, children's school attendance increased and parents' lost time at work
decreased. (Source: Margaret McChesney, Health Links, Phoenix, Ariz.,at the Every Child By Two presentation at the Western Governors Association meeting, June 1999.)
By eliminating manual chart pulls, state Medicaid agencies connecting to registries realize considerable savings.
In 1999, the Arizona Health Care Cost Containment System (AHCCCS), the state Medicaid provider, reached an agreement with the state immunization registry to allow batch inquiries of the registry central database. AHCCCS has spent over $100,000 per year on pulling charts in providers' offices in order to audit the immunization rates of Medicaid-enrolled children. A test of the system showed that immunization records for one-third of the children currently could be accessed by connecting to the registry a $33,000 annual savings. Savings will grow as more children are added to the state registry database. (Source:
Terry Hughes, Scientific Technology Corporation, Inc., June 1999.)
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ARKANSAS**
The Arkansas immunization registry has helped detect errors in vaccine administration and recall children to
ensure they are adequately immunized. In 1996, 133 children received the wrong dosage of HepB at birth. When the hospital submitted forms to the health department for entry into the registry, the dosage error was
discovered and the hospital was assisted in notifying each family that a repeat dose was needed. In 1998, a similar situation occurred with 180 children given the wrong dose at birth. A registry-generated list again
helped the hospital inform parents.
In 1999, the Arkansas registry identified 139 children as receiving possible invalid doses of DtaP and Hib that had been incorrectly combined to
prevent two injections. The registry was able to determine that of the 139 children, 81 had actually received an invalid dose. An additional 49 children were identified as needing other vaccines. Recall letters were
sent to parents. Also in 1999, the registry identified 51 children who had received vaccine from expired lot numbers and helped to recall them. (Source: Karen Fowler, Arkansas Immunization Registry, November
1999.)
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CALIFORNIA
When a lot of Tripedia vaccine was recalled by its manufacturer, Southern California Kaiser Permanente registry determined that over 15,000 of its
enrolled children had received DTaP during the time period that the vaccine was available. However, the registry also was able to determine that only four children had received an immunization from the recalled
vaccine lot. By identifying the children who had received the vaccine, the registry saved the children and their parents time and pain by preventing unnecessary immunization
.
In addition, the health plan realized a substantial savings by not having to re-immunize the 15,000 children. (Source: John Fontanesi, University of
California at San Diego, presentation at CDC, March 1999.)
An in-depth study of costs and benefits associated with three California registries showed a 30% to 50%
increase in staff productivity
when an immunization registry was instituted in a practice. At the same time, the study showed that immunization rates can be increased through appropriate use of the registry and alteration of immunization practices by the provider. (Source:
John Fontanesi, UC San Diego, National Immunization Conference presentation, June 1999.)
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CALIFORNIA--SAN BERNARDINO COUNTY*/**
Children are receiving their shots on time in San Bernardino Co., Calif., as a result of implementing the registry with its reminder/recall function. The San Bernardino registry conducted a study on the average age in months for
children completing either selected immunizations or series completion before and after implementation of their registry. The registry has had a major impact on the average age at which a child receives the MMR
vaccine, which is a one-dose shot due at 12-15 months of age. In 1992, the average age for receiving an MMR vaccine was 33 months. In 1999, after the implementation of the registry and the reminder/recall
function, which returns children to their providers for immunizations (and most likely other well-child services), the average age was 13 months. (Source: Sarah Mack, San Bernardino Co. Department of Health,
February 2000.)
A 1997 study of the immunization histories of more than 75,000 children in the San Bernardino County, Calif., registry database showed that almost
2,000 children (2.5%) of the children had received at least one unneeded dose of vaccine. At the time the immunizations were given, the children's providers did not have access to accurate information about the
children's past immunizations. Registry staff estimated that $15,000-$36,000 in vaccine costs could have been saved if accurate information about the children's immunizations
had been available to their providers. More than half of San Bernardino County's providers now participate in the county registry, with access to immunization records of over 116,000 children. (Source:
Sarah Mack, San Bernardino County Department of Health, June 1999.)
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MINNESOTA
At HealthPartners, a large Minnesota HMO, the immunization registry resulted in significant improvement in
immunization coverage.
HealthPartners has 300,000 patients who receive care in staff model clinics, and 800,000 patients who receive care in affiliated clinics. A study compared coverage of 2-year-olds in a staff model clinic (with a registry) and affiliated clinics (without a registry). In 1996, 4:3:1:1: rates for the staff model and affiliated clinics were similar: 88.2% and 85.1%. When the registry was implemented in the staff model clinics in 1997, the rate rose to 95.7% but remained essentially unchanged (83.9%) for the affiliated clinics. Similarly, the 1996 4:3:1:1:2 rate for the staff model clinics was 60.6%, and for the affiliated clinics, 70.2%. In 1997, the rate rose to 87.8% for the staff model clinics, but only to 73.7% for the affiliated clinics. (Source:
James Nordin, HealthPartners, Minneapolis, Minn., at the All Kids Count Conference, April 1999.)
HealthPartner's registry also includes adults. During the fall flu immunization drive, unimmunized adults were identified through the registry, and
subsequently, influenza and pneumococcal immunization rates for enrollees aged 65+ increased from 64% to 82% and 65% to 85%, respectively. The health plan saved $4 in direct medical costs for every $1 spent on
increasing influenza coverage rates; a similar savings is expected for pneumococcal disease. Registry staff note that the inclusion of all ages in the registry has had a major impact on overall cost effectiveness. (Source:
James Nordin, Health Partners, Minneapolis, Minn., at the All Kids Count Conference, April 1999.)
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MINNESOTA--SOUTHWEST**
The Southwestern Minnesota Immunization Information System (SIIS) was instrumental in controlling a pertussis outbreak
at a public school in a small rural community. Registry information helped to identify those children at risk (including children in families with philosophical exemptions for immunizations or whose last
immunization was more than three years previous), thereby controlling the size of the outbreak and preventing disease. (Source: Gloria Tobias, Countryside Public Health, Madison, Minn., at the All Kids Count
Immunization Registry Conference, April 1999.)
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NEW JERSEY*
In Camden County, a combination of recall and outreach resulted in a 22% increase in up-to-date children over
three years. The Camden County Immunization Program (CCIP), a free walk-in immunization clinic that has used the New Jersey Immunization Information System (NHIIS) since 1996, takes responsibility
for approximately 15,000 children whose providers are not yet using NJIIS. CCIP sends letters generated from the NJIIS to parents indicating when a child is due for immunizations and urging them to return to
their primary provider for the shots. They also generate 3 separate recall letters to families whose children are 30, 60 and 90 days past due for the recommended immunizations. Approximately 300 such letters are
generated each month. Approximately 50% of these notices result in a phone call to the clinic, indicating the shot has been received. Additional records are received directly from health care providers and updated
in the NJIIS. If there is no response 30 days after the 90-day letter, a phone call is made to the parent/guardian or physician. For those residents without phones, or those who don't respond to the phone call, a
home visit is conducted. Approximately 200 phone calls and 75 home visits are made each month.
A CASA (Clinical Assessment Software Application) assessment of 2-year-olds conducted at CCIP in 1999 showed a 74% compliance rate for 4:3:1, a 22%
increase from a similar assessment in 1996. Staff credit the increase to outreach efforts.(Source: Camden Co. Immunization Program, November 1999.)
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OKLAHOMA**
In 1999, the Oklahoma immunization registry, OSIIS, helped shape the Advisory Committee on Immunization
Practices (ACIP) recommendation on the use of inactivated polio vaccine (IPV) and is helping to evaluate the impact of the AAP/HHS Joint Statement on Thimerosal Exposure on HepB
vaccination
practices. OSIIS data include a large set of immunization providers and a large proportion of the population (458 facilities reporting; 78,444 children born from Jan. 1, 1996 to June 30, 1998 with immunization
records in the registry; one-third of children from private providers, representing approximately 70% of the population in the birth cohort). OSIIS was able to set up data queries to allow the analysis of the
percentage of birth cohort receiving IPV versus OPV as first and second polio dose. The data demonstrated that providers rapidly adopted the IPV as the first polio dose and ameliorated the implementation of the ACIP
recommendation might lead to deferral of other vaccines, and thereby decrease coverage for other recommended vaccines. Data from the registry showed no delays and, in fact, demonstrated that children who received
IPV as their first polio dose were more likely to be up to date. The analysis was instrumental in shaping the decision to adopt an all-IPV recommendation.
OSIIS is also being used to monitor trends in doses of HepB vaccines to determine if birth doses of HepB declined following the Joint Statement on
Thimerosal (e.g., postpone the first dose), and to monitor birth doses levels once thimerosal-free HepB vaccine is generally available. OSIIS also will target automated recall-reminder efforts to children who did
not receive birth doses of HepB. (Source: Don Blose, OSIIS, November 1999.)
In 1999, OSIIS helped increase the state's immunization rates for 2-year-olds by 6%, from 72% to 78%
. (CDC National Immunization Survey and the OSIIS state survey). OSIIS mails approximately 14,000 reminder postcards each month to the parents of children who are behind on their shots. In addition,
the registry coordinates a campaign of an estimated 4,000 greeting cards sent each month with a message from the Governor and his spouse encouraging new parents to vaccinate their children. These registry
activities, combined with local partnerships, have brought Oklahoma's two-year-old coverage rates from a ranking of 49th to 31st.
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OREGON */**
Health plans and Medicaid managed care immunization rates in Oregon have increased as much as 32% and 36% respectively
as a result of having more accurate, up-to-date immunization data.
The Oregon state immunization registry, ALERT, is one of the most developed registries in the country, with data from 94% of county health
departments, 85% of private providers, three of Oregon's largest health plans, electronic birth records, and school districts. Approximately 95% of children from birth through age 5 have immunization records in
ALERT. As a result, registry data are complete, and health plans and Medicaid are now able to accurately report immunization rates. ALERT provides immunization data to Oregon's four managed care plans for HEDIS
purposes. In 1999, the plans reported increases in immunization rates ranging from 11% to 32%.
Similarly, Oregon's Medicaid is using the registry to document immunization rates for Medicaid children. Medicaid managed care plan data showed a rate
of 22%; the registry showed a rate of 58% for the same children an increase of 36 percentage points. (Source: Barbara Canavan, ALERT, February, 1999.)
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