Appendix E

Overview of Case Studies and Site Visits

The committee undertook eight state or locality-specific case studies in order to deepen the picture of local policy choices and performance of immunization programs and spending over the past decade. The state survey conducted for the committee by Dr. Gary Freed and associates provides a comprehensive view of the significant programmatic features and issues regarding immunization across the country (see Appendix D for a brief description of this survey). The individual case studies were designed to:

• trace program changes, development, and performance over time,
• collect detailed information on state- (and in the case of Los Angeles and San Diego, county-) level spending for immunization-related activities, and
• document the impact of federal policy directions and funding levels on state programs over the past decade.

The sampling of states and localities is far too small to be statistically representative, and the findings of the case studies cannot be used by themselves to make national generalizations, at least as regards state-level program models and policy choices. Nevertheless, the case studies and site visits allowed the committee to pursue questions about the implementation of national program and funding policies across an array of states. They also gave committee members, staff, and consultants the opportunity to communicate directly with state and local immunization and health program managers in a sustained fashion on several occasions, which provided much insight into the impact and importance of federal policies.

The sites chosen were Maine; New Jersey; North Carolina; Alabama; Michigan; Texas; Washington; and, in California, Los Angeles and San Diego Counties. These states and counties were selected because they vary demographically, and because their immunization policies and program structures reflect distinctive choices that convey a sense of the variety among all the states in immunization strategies, challenges, and achievements. Table E-1 displays notable demographic statistics for these states (California data are used for Los Angeles and San Diego Counties), Table E-2 shows immunization-related public policies and programmatic features; and Table E-3 displays Section 317, VFC, and state-source immunization spending for 1995 and 1998.

The framework for developing profiles of individual states and the data elements to be collected for all cases were designed by staff and reviewed by the committee. A subcommittee to oversee the conduct of the case studies was formed, and members of this subcommittee, as well as members of the committee at large, participated in site visits and were involved in both the written and oral presentation of findings to the rest of the committee.

Four site visits were conducted to large metropolitan areas known to have pockets of need and/or overall low immunization coverage rates:

• Detroit, Michigan;
• Newark, New Jersey;
• Houston, Texas; and
• Los Angeles and San Diego, California (a combined visit).

Interviews with and visits to operating programs included the following in each of the sites:

• county and municipal immunization program and health directors,
• managed care organizations serving Medicaid and SCHIP clients,
• persons using or developing immunization registries,
• WIC clinics or coordinators,
• private-practice physicians, and
• managers and practitioners in federally qualified health care centers.

The information gathered during the site visits was incorporated into each state's case study.

The case study reports were developed through interviews with state health department officials, including the immunization program directors, Medicaid agency staff, budget analysts, and CDC public health advisors to the state, among others. These interviews were, in most cases, coordinated with the initial telephone interview conducted by the research team for the state survey to minimize the imposition on the state respondent's time and avoid duplication. In addition to the interviews with key program managers, the case study sites were asked to provide detailed information on state spending from all revenue sources for immunization activities for the period 1992 through 1998:

• federal grants,
• state revenues (in the case of Los Angeles and San Diego, county revenues as well), and
• foundation grants.

Reconstruction of this historical information, broken out by category of spending (e.g., personnel, contracts, aid to counties) was extraordinarily difficult and labor-intensive for the state health departments, involving the efforts of their own budget analysts and sometimes state budget office staff. The cooperation the committee received from all of the studied states in retrieving and reporting this information was extraordinary as well. The detailed reports of spending on immunization activities comprise an essential element of the information base used by the committee in developing its findings and recommendations.

Finally, the respective state grant applications to CDC for Section 317 funds for 1992, 1995, 1999, and 2000 were reviewed, providing another source of information over time for the case studies.

BOX E-1 Case Study Summary The following authors prepared the eight case studies discussed in this report: Alabama--Roy Hogan, M.P.A., Consultant, Austin, Texas Maine--Kay Johnson, Ed.M., M.P.H., Johnson Group Consultants, Inc., Hinesburg, Vt. Michigan--Hanns Kuttner, M.A., School of Public Policy Studies, University of Chicago New Jersey--Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Paul Meissner, M.S.P.H., and Alana Balaban, B.Sc., Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City North Carolina--Wilhelmine Miller, M.S., Ph.D., Program Officer, Institute of Medicine Texas--Roy Hogan, M.P.A., Consultant, Austin, Texas Washington--Heather McPhillips, M.D., M.P.H., Department of Pediatrics, University of Washington, and E. Russell Alexander, M.D., M.P.H., Professor Emeritus, School of Public Health, University of Washington Comparison of Los Angeles and San Diego Counties, California--Gerry Fairbrother, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City, and Elka Munizaga, Division of Epidemiology and Social Medicine, Montefiore Medical Center, New York City The case studies are available on line at books.nap.edu/catalog/9836.html. A summary article of the case study findings appears in the American Journal of Preventive Medicine (Fairbrother et al., forthcoming).