Rates of immunization for 5,598 children who were moved from fee-for-service care to a newly implemented primary care case management managed care program were reviewed in 1995 as part of the Quality Assessment and Improvement Project for Medicaid Managed Care in Virginia. Managed care was implemented for Virginia’s Medicaid population through a staged geographic approach. This project studied managed care as implemented in the first geographic area to be included in Medicaid managed care. The managed care program assigned each Medicaid recipient to a primary care physician (PCP) who, in exchange for a monthly per-patient management fee, was responsible for preventive services and functioned as a gatekeeper for access to medical care.

We identified all children who turned two years old during a one-year period (July 1, 1993, to June 30, 1994) and who were enrolled in the Medicaid primary care case management program for a period of at least six months. In primary care case management, the Medicaid recipient is assigned to a designated primary care provider for management of health care. Although some information on immunizations was available through the administrative database of the Medicaid agency, we surveyed providers for additional information regarding the immunization status of each child. The administrative database was deemed inadequate on its own to answer the research question because a) providers sometimes immunize without billing, b) some of the patients may have received their immunizations before they came on to the Medicaid program, either from the same provider or another provider, and c) some patients may obtain their immunization from their local public health departments. buy generic cialis

We informed all primary care providers in the primary care case management program about the purpose and scope of the immunization study, and sent them a survey about the immunization status of each child. Included with the survey were letters of endorsement from the state medical society and the state chapter of the American Academy of Pediatrics. To reduce the burden of data collection, we first combined immunization information from the state Medicaid claims and the state health department databases and gave it to each PCP using a customized data collection instrument. The PCP was then asked to complete the immunization assessment through abstraction from his/her own patient records.

For all immunizations, state Medicaid records accounted for 36% of received immunizations, state Health Department records accounted for 10%, and providers documented another 24% of the required immunizations; thus 70% of the immunizations were accounted for with this method. There was no documentation of completion for the remainder (30%) of the required immunizations. At the time of the study, the American Academy of Pediatrics and the American Academy of Family Practice recommended 16 vaccinations at specific intervals by the age of 18 months. We used this database to study predictors of children having received the 4:3:1 immunization series (4 vaccinations with diphtheria, pertussis, tetanus; 3 polio vaccinations; and one measles, mumps, rubella vaccination). Up-to-date immunization (UTD) was defined as receipt of all recommended vaccinations by 18 months of age, even though the child may not have received individual shots at the age-appropriate interval. Age appropriate immunization (AAI) was defined as receipt of appropriate vaccinations at no more than 30 days past the recommended age for the vaccination in the immunization series. For example, a child was considered to have received age appropriate immunizations at two months if the appropriate shots were received by 90 days post-partum. By definition, AAI children were a subset of the group of UTD children.
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DEMOGRAPHIC VARIABLES AND ANALYSES

Race was defined from the administrative data as African-American, white or other; there were insufficient numbers of children of Latino, Asian or Native American origin to analyze separately. Race was self-reported at time of application for Medicaid. Mother’s age was classified as either young (<20 years of age) or older (20 years of age and above); for 9% of the children, mother’s age was not available and was coded as unknown. Urban status was defined as residence in a Standard Metropolitan Statistical Area. Assigned primary care providers in this Medicaid managed care program were classified as public providers (health departments and community health centers) or private providers (family practice, pediatrics, and other specialties).

Chi-square analysis was used in unadjusted analyses of UTD status and AAI status. Two logistic regression models were used to estimate relative odds of being immunized versus not immunized after adjustment for gender, race, provider type, mother’s age, and rural/urban residence. The first model estimated the relative odds of the child having UTD immunization status at 18 months of age. The second model estimated the relative odds of AAI status among UTD children. All analyses used SAS. trusted online pharmacy