A.8
Prototype Indicator Set: Vaccine-Preventable Diseases

BACKGROUND

Each year in the United States, several thousand adults and smaller numbers of children develop infectious diseases that are highly preventable with the appropriate use of existing vaccines. Currently recommended childhood immunizations protect against measles, mumps, rubella, diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b (Hib), hepatitis B, and varicella. Vaccines for influenza and pneumococcal pneumonia are recommended primarily for older adults and younger people with special health risks.

Immunization targets set by Healthy People 2000 (USDHHS, 1991) call for 90 percent of 2-year-old children to have received all recommended vaccine doses and for 60 percent of persons aged 65 and over to have received a pneumococcal vaccination and an annual influenza vaccination. Estimates for 1994 indicate that 72 percent of 2-year-old children are fully immunized (CDC, 1996c). Among adults 65 years of age and older living in households in 1993, only 28 percent had received pneumococcal vaccine and 52 percent an annual influenza immunization (CDC, 1995a).

State laws requiring up-to-date immunization for school entry have led to nearly complete immunization coverage by the time children are 5 or 6 years of age. Most states have also adopted



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Improving Health in the Community: A Role for Performance Monitoring A.8 Prototype Indicator Set: Vaccine-Preventable Diseases BACKGROUND Each year in the United States, several thousand adults and smaller numbers of children develop infectious diseases that are highly preventable with the appropriate use of existing vaccines. Currently recommended childhood immunizations protect against measles, mumps, rubella, diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b (Hib), hepatitis B, and varicella. Vaccines for influenza and pneumococcal pneumonia are recommended primarily for older adults and younger people with special health risks. Immunization targets set by Healthy People 2000 (USDHHS, 1991) call for 90 percent of 2-year-old children to have received all recommended vaccine doses and for 60 percent of persons aged 65 and over to have received a pneumococcal vaccination and an annual influenza vaccination. Estimates for 1994 indicate that 72 percent of 2-year-old children are fully immunized (CDC, 1996c). Among adults 65 years of age and older living in households in 1993, only 28 percent had received pneumococcal vaccine and 52 percent an annual influenza immunization (CDC, 1995a). State laws requiring up-to-date immunization for school entry have led to nearly complete immunization coverage by the time children are 5 or 6 years of age. Most states have also adopted

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Improving Health in the Community: A Role for Performance Monitoring immunization requirements for participation in state-licensed day care and are adding requirements for measles and hepatitis B immunizations for adolescents. Colleges are also requiring evidence of up-to-date immunization. For most preschool children, adolescents, and older adults, however, no universal gateway comparable to school entry ensures that immunizations are up to date. Delayed immunization for preschool children and for adults has been linked to personal and family characteristics and to barriers and deficiencies in the health care delivery system (e.g., Orenstein et al., 1990; NVAC, 1991, 1994; Schulte et al., 1991; Freed et al., 1993; Szilagyi et al., 1993, 1994; IOM, 1994; CDC, 1995c; Frank et al., 1995; Wood et al., 1995). Family factors include lack of knowledge about immunization requirements, low socioeconomic status, low maternal education, and larger family size. In the health care system, providers may miss opportunities to immunize from practices such as not checking immunization status and not immunizing during minor illnesses. Barriers are created by requirements such as appointments for immunization and a comprehensive physical exam prior to immunization. The recognition that incomplete immunization poses an avoidable health risk has prompted a variety of efforts at national, state, and local levels to raise immunization rates. Activities include establishing collaborations that can promote responsibility and accountability for immunization, improving provider practices and communication with the public, and developing better information resources. Although the focus is generally on increasing immunization rates, communities also need to ensure that they can achieve their current levels of coverage for future cohorts. The committee included vaccine-preventable diseases among the health issues used to illustrate the development of performance indicators because of the high morbidity, mortality, and costs associated with these conditions and the availability of vaccines as an effective but underused preventive intervention. The incidence of illness and death is much higher among the elderly, but preventable morbidity or mortality among children should be unacceptable in a community. This is also an issue that touches many segments of a community, including children and their families, the elderly, health departments, private and public health care services, schools, and employers.

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Improving Health in the Community: A Role for Performance Monitoring ''FIELD" SET OF PERFORMANCE MEASURES By using the domains of the field model, it is possible to identify many measures that might serve as performance indicators for a community's efforts to improve immunization levels and reduce the incidence of vaccine-preventable diseases. Disease Reducing as much as possible the cases and deaths attributable to vaccine-preventable diseases is the health outcome of primary interest. In the United States, from 20,000 to 40,000 influenza-associated deaths have occurred annually during recent epidemics (CDC, 1995b), and excess hospitalizations have been estimated to reach 172,000 during severe epidemics (Barker, 1986). Annual costs associated with epidemics have been estimated to exceed $12 billion (Nichol et al., 1994). Pneumococcal infections lead to another 40,000 deaths each year (CDC, 1989). Past successes in immunizing children have made the incidence of most "childhood" illnesses much lower, but they have not been eliminated. In a resurgence of measles from 1989 to 1991, approximately 55,000 cases were reported (CDC, 1993a). In 1994, nearly 4,600 cases of pertussis were reported, 2,500 of which occurred in children less than 5 years of age (CDC, 1996b). Although vaccines are effective in reducing the incidence of illness and the severity of cases that do occur, they cannot always prevent all cases. The vaccine for measles, mumps, and rubella, for example, is not usually given to children less than 12 months of age, which leaves younger children susceptible to these diseases. The effectiveness of influenza vaccine can vary from year to year, depending on how well the mix of antigens matches the circulating virus strains. Pneumococcal vaccine, which is usually administered only once, is formulated to protect against 23 (but not all) strains of pneumococcus. Estimates of the numbers of cases and deaths depend on the accuracy of diagnosis and the completeness of reporting. Because the incidence of most childhood illnesses is low, communities will probably have to monitor numbers of cases rather than incidence or mortality rates. Influenza and pneumococcal infections are more common. Death certificates can provide mortality data by cause of death, but pneumococcal pneumonia may be underreported because some deaths will be attributed to pneumonia without a specific diagnosis.

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Improving Health in the Community: A Role for Performance Monitoring Indicators that a community might consider monitoring include the following: Incidence (number of cases) of vaccine-preventable disease in children less than 5 years of age. This preschool population is the primary target of recent immunization improvement programs. The vaccine-preventable diseases are measles, mumps, rubella, polio, diphtheria, tetanus, pertussis, hepatitis B, Hib, and varicella. Incidence (number of cases) of hepatitis B among persons aged 15–29 years. Hepatitis B can be transmitted by sexual contact and exposure to blood and from pregnant mothers to their infants. Despite recommendations that preschool children and adolescents receive the hepatitis B vaccine, immunization rates are currently lower than for other vaccines (CDC, 1996b). Incidence of pneumonia and influenza. Pneumonia and influenza death rates for persons aged 65 years and older. Potential problems in obtaining accurate data for these indicators have been noted above. Genetic Endowment Genetic factors that impair the immune system can increase susceptibility to disease and limit the immune response generated by a vaccine. Such individuals would be among those in the community who are at higher risk for infection and, during disease outbreaks, might be the focus of special immunization efforts (for those vaccines that would be effective) or other forms of preventive care. An indicator for the influenza immunization rate among the population that is at higher risk is included in the following section. Individual Behavior, Social Environment, Health Care Because vaccines effectively prevent disease, immunization rates can seen as both a process measure and a meaningful proxy for health outcomes. As has been noted, many factors combine to influence whether immunizations are received at appropriate times. In terms of the field model, these factors include individual

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Improving Health in the Community: A Role for Performance Monitoring behavior (e.g., seeking available services), the social environment (e.g., economic barriers to immunization services, insufficient information about the need for immunization), and health care services (e.g., missed opportunities for immunization during health care visits). Among children, underimmunization is also a marker for shortcomings in other forms of well child care, including screening for anemia, lead toxicity, and tuberculosis (Rodewald et al., 1995). Immunization rates can be used as community performance indicators, but they raise some conceptual and measurement issues. Rates of preschool immunization are usually presented as a composite of rates for at least four vaccines, three of which require multiple doses. With a summary rate such as this, a child who has missed a single dose of one vaccine is not distinguishable from a child who has received no vaccinations. In addition, focusing on immunization status at a particular age (e.g., 24 months) does not reveal the timeliness of immunizations at younger ages. Obtaining the data needed to calculate immunization rates—immunization status of individuals at specific ages and size of the population at those ages—may pose a challenge for communities. Retrospective rates can be calculated when children enter school, but these rates do not reflect current immunization levels among 2-year-olds. Many health plans can provide data on members, but the accuracy of the data will depend on their completeness. Missing information on immunizations received from other sources (e.g., a public clinic) will lead to underestimates. To obtain data on a community as a whole, a periodic survey or immunization registry may be needed, but the cost of these approaches may be a constraint. Indicators that might be used include the following: Immunization rate for children at 24 months of age. This is the broadest assessment of preschool immunization performance in the community. The measure is also included among the community profile indicators proposed by the committee. Immunization rate at 24 months of age for children enrolled in day care. The day care setting poses special risks for very young children because it increases the likelihood that they will be exposed to infectious agents. Up-to-date immunization improves protec-

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Improving Health in the Community: A Role for Performance Monitoring tion for the immunized child and can also reduce some infection risks for unimmunized children. Retrospective immunization rate at 24 months of age for grade school entrants. This measure can provide a 24-month immunization rate if no other data collection system is available. The limitation is that the rate is approximately three years old when it is calculated. Average number of underimmunized days per child for children 24 months of age. This measure can indicate whether there are extended periods of underimmunization, but the detailed information needed to construct it may not be available in communities that do not have an immunization registry. Percentage of children under 24 months of age with up-to-date immunization status. This measure could be used to monitor adherence to the immunization schedule over the first two years of life. It might be operationalized as immunization rates for children at specific ages (e.g., 6 months, 12 months). It would require data most easily produced by an immunization registry. Immunization rate for adolescents at 13 years of age. The current immunization schedule (CDC, 1996a) calls for administering four vaccines at 11–12 years of age if all recommended doses have not yet been received. These vaccines are hepatitis B, tetanus-diphtheria, measles-mumps-rubella (MMR), and varicella. Proposed as an indicator for HEDIS 3.0 (NCQA, 1996) is the percentage of enrolled 13-year-olds who received a second dose of MMR by age 13. Influenza immunization rate for all persons. Percentage of Medicare enrollees who received an influenza immunization during the previous calendar year; percentage who have ever received a pneumococcal pneumonia immunization. Even though Medicare benefits include coverage for both of the above immunizations, immunization rates remain low. Medicare claims files might be a source of data for this indicator, but they will not reflect immunizations provided in settings in which fee-for-service claims are not generally submitted (e.g., hospitals,

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Improving Health in the Community: A Role for Performance Monitoring public health clinics, managed care organizations). The immunization rate for the Medicare population is included in the community health profile proposed by the committee. Influenza immunization rate for persons at high risk living in the community (the "noninstitutionalized" population). Influenza immunization rate for persons in nursing homes. Influenza can pose an especially high risk of serious illness and death in both of these populations. Determining the size of a community's population at high risk (the denominator needed for the rate in item 9) may prove difficult, however. Social Environment Factors in the social environment can affect both risk of illness and immunization rates. Language and other cultural differences may hinder access to all forms of health care or may have a specific impact on willingness to accept immunization. Low socio-economic status is frequently associated with inadequate health care, including delays in receiving immunizations. Low-income families often have not had a regular source of care, which can make it difficult to maintain accurate immunization records. Programs serving these families (e.g., WIC), can be a base for interventions targeting immunization. Lack of health insurance can create economic barriers to immunization, but similar barriers may exist with health insurance policies that do not cover the cost of preventive services such as immunization. Medicare coverage for influenza immunizations was not available until 1993. Lack of easy access to current information on the immunization status of children in a community has spurred interest in state or local immunization registry systems. Such systems promise health care providers easy access to up-to-date immunization records. Communities (through health departments, health plans, or other means) could use registry information to identify categories of children whose immunization rates are low or to inform families of specific children who are due for immunizations. Registries will benefit a community most if all children are included and all providers contribute immunization records, but the cost of creating and maintaining a registry should not be overlooked. Indicators that a community might want to monitor include the following:

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Improving Health in the Community: A Role for Performance Monitoring Immunization rate at 24 months of age for children currently enrolled in Medicaid. Immunization rate at 24 months of age for children enrolled in WIC. Children enrolled in Medicaid or WIC are an identifiable population that generally is at higher risk for underimmunization. Because enrollment in Medicaid is often not continuous, the numerator and denominator for the Medicaid rate would require clear definition. Some children enrolled at 24 months of age may not have been enrolled at ages when immunizations were due, and other children not currently enrolled might have been enrolled at those ages. Among children with commercial health insurance coverage, percentage with full coverage for childhood immunizations. The cost of vaccines and the fees charged to administer them have contributed to delayed immunization even for children who have health insurance. Full coverage ensures that immunizations will be paid for by the insurer whether or not a deductible requirement has been met. In some states, this indicator will be less relevant because free vaccines are available to all children, regardless of health insurance status. Number and percentage of health insurance policies that cover influenza immunizations for persons at high risk. The population at high risk must be defined clearly, and criteria for counting health insurance policies would be required. Policies that provide full coverage should be distinguished from those that require payment of a deductible. Existence in the community of a computerized immunization registry that provides automated appointment reminders; if a registry exists, percentage of children in the community included. At present, few communities have registries. This indicator should become more useful in the future as registry development proceeds. If a statewide registry is developed, a community would still want to know what proportion of its children were included. Existence in the community of an active childhood immunization coalition involving health service providers, the lo

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Improving Health in the Community: A Role for Performance Monitoring cal health department, parents, and interested community organizations. A community may benefit from the creation of a coalition that brings together individuals and groups interested in improving immunization rates. A coalition can help coordinate separate activities that may be under way and provide leadership for activities that may be needed to reach parts of the community not being served by independent efforts (Hubbert and Peck, 1993). Physical Environment The physical environment influences vaccine-preventable disease and immunization rates primarily through the problems that long distances and lack of transportation pose for access to immunization services. These factors may be a special concern in rural areas. In urban areas, transportation problems might be considered a function of the socioeconomic rather than the physical environment. No performance indicators related to this domain are suggested. Health Care Because immunization is a health care service, the practices of individual and institutional health care providers (health plans, hospitals, clinics, etc.) play a large part in determining immunization rates in a community. Missed opportunities to administer immunizations could be reduced by steps such as reviewing immunization status at all visits, giving all scheduled vaccines during a visit, and vaccinating during visits for mild illnesses. Adoption of the Standards for Pediatric Immunization Practices (CDC, 1993b), which are aimed at reducing missed opportunities and other provider-based barriers to immunization, has recently been shown to improve immunization rates in a public health clinic (Pierce et al., 1996). Increasingly, health plans are applying continuous quality improvement tools to assess immunization practices, identify missed opportunities and incomplete immunization records, and guide the development of new policies and procedures (e.g., Leatherman et al., 1995; Carlin et al., 1996). Community-level performance indicators that might be monitored include the following: Immunization rate at 24 months of age for children enrolled in managed care organizations.

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Improving Health in the Community: A Role for Performance Monitoring Immunization rates for influenza and pneumococcal disease for persons aged 65 and older who are enrolled in managed care organizations. In much of the country, managed care organizations (MCOs) are serving an increasing proportion of the population, including Medicare enrollees. Their membership is a defined subpopulation served primarily by a defined set of providers. Many MCOs have or are developing information systems that can generate data on immunization status. To give an accurate measure, MCO records must include information on immunizations that a member receives from other sources. Percentage of health care providers who have a policy to give immunizations to children seen at a visit for minor illness or injury. Percentage of health care providers who have a policy to give simultaneous vaccinations. Percentage (or number) of hospitals that have a policy to immunize children who are seen in emergency rooms for minor illnesses or injuries. Percentage of health care providers who have a policy to screen the medical chart for immunization history whenever a child is seen. Adoption of these four policies would address leading reasons for missed opportunities to vaccinate. Policies must, however, be put into practice to have an impact on immunization rates. Obtaining data would probably require a survey of providers in the community. Companion measures might be created to reflect the proportion of a community's children served by providers with such policies. Percentage of health care providers who do regular, sample chart audits to determine the immunization status of pediatric or adult patients. Currently, many providers lack automated information systems that can generate information on the immunization status of their patients. Regular chart audits are one way to identify patients whose immunizations are not up to date. Percentage of health care providers who refer patients to public clinics for immunizations. Referring patients to another location such as a public clinic

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Improving Health in the Community: A Role for Performance Monitoring delays the immunization process and can make it more burden-some for families. Health and Function The vaccines for pneumonia and influenza are recommended primarily for older adults, but both illnesses also occur among working-age adults and result in time lost from work or other usual activities. A community might want to monitor lost work time as an indicator of the impact of these conditions on overall health status. Number of work days missed due to pneumonia or influenza. A means of obtaining this information would have to be developed. Employers might be able to report on short-term disability claims. SAMPLE INDICATOR SET From the preceding list of potential indicators, eight are proposed as the primary set that a community might use to monitor community-level performance. The proposed set is a mix of structure, process, and outcome measures reflecting the collective contribution of multiple entities that a community might expect to be accountable. Their selection reflects the committee's best judgment, but individual communities must consider available resources, including the availability of data. Comments are included on other uses of the measure (e.g., as a Healthy People 2000 objective), data and measurement issues, and suggestions as to where accountability for performance might lie. Five of the eight proposed indicators are probably measured most easily through a community or state computerized immunization registry. Immunization registries are expensive, but other than periodic chart review on a community-wide basis, they are the only way to make the regular assessments of current immunization status that can inform efforts to improve immunization rates and health status. One of the indicators may require cooperation from employers to obtain necessary data. If a community does not have the resources for a registry or if employer involvement is limited, other indicators for which data may be more readily available should be considered (e.g., reported disease rates, death rates, health care provider policies). Small

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Improving Health in the Community: A Role for Performance Monitoring numbers of cases will, however, limit the usefulness of morbidity and mortality rates. Indicators based on policies are capacity measures that do not give a direct assessment of process and may not be sensitive to changes in health status. A community is advised to use the most appropriate indicators within the resources available to the stakeholders involved in the performance monitoring process. Starting with some indicators and developing additional ones over time is better than waiting until data can be collected on the ideal indicator. Immunization rate for children at 24 months of age. High community immunization rates can promote further reductions in morbidity and mortality from several vaccine-preventable diseases. As noted, Healthy People 2000 has set a target for 90 percent of 24-month-old children to have all age-appropriate immunizations. To use this measure, it will be necessary to specify what combination of immunizations will constitute a "complete series" at that age. As the immunization schedule changes, the composition of a complete series will change. Data may be available from a computerized immunization registry or could be obtained from a community survey or review of a sample of public and private medical records (which would require linking records for those children who received immunizations from more than one source). Retrospective rates can be calculated by reviewing immunization records of children entering school. This approach is inexpensive, but it does not produce information on the current immunization status of preschool children. Consideration should be given to calculating rates for any subpopulations in the community that are a focus of concern. This indicator reflects the overall ability, and accountability, of the community to ensure that children receive appropriate immunizations. Immunization rate at 24 months of age for children currently enrolled in managed care organizations. This indicator provides accountability for a specific segment of the health care sector. To compare data over time or across MCOs, however, consistent data collection methods and definitions of the population included in the denominator of the rate must be used. The current draft of HEDIS 3.0, which would apply to both Medicaid and commercial enrollees, specifies that the denominator includes children reaching 2 years of age during the reporting period who have been continuously enrolled for the 12 months preceding that birthday (NCQA, 1996). The numerator includes

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Improving Health in the Community: A Role for Performance Monitoring children with at least four doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of MMR vaccine between the first and second birthday, one dose of Hib vaccine between the first and second birthday, and two doses of hepatitis B vaccine. The 1997 reporting year will add an indicator for administration of the varicella vaccine, but this will not be included in the combined measure. A community may want to consider whether the continuous enrollment provisions and the specified vaccine doses are appropriate, but changes in the measure would add to an MCO's reporting burden. Immunization rate at 24 months of age for children currently enrolled in Medicaid. The Medicaid population can be one of a community's most vulnerable groups. For this population, facilitating access to immunization and other health services is particularly important. Although Medicaid removes financial barriers to health care, other barriers may be created by transportation, cultural differences, limited education, and provider access. Because many states have moved, or are planning to move, their Medicaid population to managed care plans, many children should be served by providers who can support this indicator through their HEDIS reporting. Primary accountability may rest jointly with Medicaid providers and the local public health agency. A broader measure, which would require more diverse data collection, might examine the immunization status of children who were enrolled in Medicaid at any time up to their second birthday. In that case, responsibility and accountability for up-to-date immunization might extend to additional health care providers. Existence in the community of a computerized immunization registry that provides automated appointment reminders; if a registry exists, the percentage of children in the community included. Public and private funding is encouraging states and local areas to create computerized immunization registries that can generate appointment reminders (Faherty et al., 1996). Because they are intended to provide information on all children and all immunizations received, registries should be a valuable tool to support efforts to increase immunization rates and have the potential to support other health services for children. To produce accurate data, they will have to update on a continuing basis information on the child population (births and children moving into or out of

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Improving Health in the Community: A Role for Performance Monitoring the registry area) and on immunizations administered by all providers. As a new approach to improving immunization rates, registries should be evaluated for their effectiveness (and cost-effectiveness), so that communities can make informed choices in allocating available resources. In terms of accountability, this indicator reflects the cooperation that is necessary among health departments, public and private health care providers, and others to develop, implement, and maintain a registry. Among children with commercial health insurance coverage, percentage with full coverage for childhood immunizations. This indicator was chosen because the cost associated with childhood immunizations has created a barrier for some families. In communities with a substantial capitated MCO presence, this indicator may be less appropriate because coverage for preventive services such as immunizations is usually included. In addition, state programs that offer free vaccine to all children make specific terms of health insurance coverage less influential. The information required for this indicator may not be readily available in a community. Some information may be available from the state insurance licensing authority on provisions of policies offered in the state, but the licensing authority will not have information on self-insured companies and probably will not have community-specific data on numbers of children covered. It may be necessary to contact the employers that employ and insure the largest number of community residents or to obtain information through a community survey. Information provided by this indicator can be used to establish accountability by employers and insurers for reducing financial barriers to immunization. Percentage of Medicare enrollees who received an influenza immunization during the previous calendar year; percentage who have ever received a pneumococcal pneumonia immunization. This indicator corresponds to Objective 20.11 in Healthy People 2000 , which calls for 60 percent immunization rates for older persons living in the community. Data should be available from Medicare claims files for fee-for-service patients requiring vaccine in an outpatient setting. These data may understate immunization rates if a large percentage of Medicare enrollees in the community are enrolled in capitated managed care plans that do not file claims for the individual services provided or are vaccinated as

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Improving Health in the Community: A Role for Performance Monitoring inpatients. The proposed inclusion in HEDIS 3.0 of a measure on influenza immunization for Medicare members would help overcome these limitations. Hospitals and other public and private health care providers that give immunizations share responsibility for the rates in the community. Pneumonia and influenza death rates for persons age 65 and older. Healthy People 2000 has targeted reducing the epidemic-related death rates in the older population. Immunization is an important tool for reducing these rates, but as noted, the available vaccines are effective against only a portion of the infectious agents that cause these diseases. Data on cause of death are obtainable from death certificates. The number of deaths in a single year may be small for some communities, so calculation of stable rates may require aggregating data over multiple years. Where numbers of deaths are small, caution is required in comparing data over time or with other communities. Existence in the community of an active childhood immunization coalition, involving health service providers, the local health department, parents, and interested community organizations. Such a coalition may be able to provide the leadership needed to organize and coordinate the actions of health service providers, health departments, and other groups in the community to reach out to families with young children who need immunizations, ensure that immunization services are available and accessible, and—in conjunction with a immunization registry—see that children get the immunizations they need. It may also be able to advocate for better provider practices and insurance coverage. The effectiveness of such coalitions should be tested to ensure that the mechanism can achieve its intended aims. In addition, an issue-specific coalition should be closely linked to any broader health coalition in the community. The proposed indicator set is intended to support a community effort to reduce morbidity and mortality from vaccine-preventable diseases. The indicators include measures of health outcomes (pneumonia and influenza deaths), risk factors (immunization coverage rates for all children, children in managed care organizations, Medicaid children, Medicare enrollees), and community actions that can help to improve immunization coverage

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Improving Health in the Community: A Role for Performance Monitoring in the long run (registries, health insurance coverage, immunization coalitions). Only one direct health outcome measure is included (influenza and pneumonia death rates). Thanks largely to the success of immunization programs, vaccine-preventable diseases are rare in children. The small numbers of cases are unreliable indicators of the effectiveness of childhood immunization efforts. On the other hand, deaths from pneumonia and influenza remain common in older people, and data are readily available from vital statistics. Because immunization is a proven effective means for preventing a number of diseases, most of the proposed indicators focus on immunization coverage rates (indicators 1, 2, 3, and 6) as measures of health risk. In terms of performance, the indicator for immunization coverage rates for all children covers the community as a whole. Three other measures (children in managed care organizations, Medicaid children, Medicare enrollees) address the performance of specific health care delivery sectors. The inclusion of an indicator for immunization rates for children in managed care organizations, as opposed to other health care providers, primarily reflects the greater availability of data from MCOs. In practice, all providers serving children in the community share responsibility for ensuring that those children are immunized. Comparing the overall immunization rate with the rates for MCOs or Medicaid gives an indirect indication of rates among children not included in either of the two specific systems. The residual group includes children both with and without health insurance coverage. Two measures (registries and immunization coalitions) are indicators of a community's willingness and ability to organize itself to overcome barriers to immunization (due, perhaps, to factors based in domains of the field model other than health services). These indicators do not measure the performance of specific entities in the community because the community as a whole must make them happen. Coalitions, in particular, however, do provide an opportunity for community entities (such as health departments) to play leadership roles. Thus, the presence of a coalition suggests that some entity in the community is performing well in this regard.

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Improving Health in the Community: A Role for Performance Monitoring REFERENCES Barker, W.H. 1986. Excess Pneumonia and Influenza Associated Hospitalization During Influenza Epidemics in the United States. American Journal of Public Health 76:761–765. Carlin, E., Carlson, R., and Nordin, J. 1996. Using Continuous Quality Improvement Tools to Improve Pediatric Immunization Rates. Joint Commission Journal on Quality Improvement 22:277–288. CDC (Centers for Disease Control and Prevention). 1989. Pneumococcal Polysaccharide Vaccine: Recommendations of the Immunization Practices Advisory Committee (ACIP). Morbidity and Mortality Weekly Report 38:64–68, 73–76. CDC. 1993a. Measles—United States, 1992. Morbidity and Mortality Weekly Report 42:378–381. CDC. 1993b. Standards for Pediatric Immunization Practices. Morbidity and Mortality Weekly Report 42(RR-5):1–13. CDC. 1995a. Influenza and Pneumococcal Vaccination Coverage Levels Among Persons Aged 65 Years—United States, 1973–1993. Morbidity and Mortality Weekly Report 44:506–507, 513–515. CDC. 1995b. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report 44(RR-3). CDC. 1995c. Increasing Pneumococcal Vaccination Rates Among Patients of a National Health-Care Alliance—United States, 1993. Morbidity and Mortality Weekly Report 44:741–744. CDC. 1996a. Immunization Schedule—United States, January–June 1996. Morbidity and Mortality Weekly Report 44:940–943. CDC. 1996b. Monthly Immunization Table. Morbidity and Mortality Weekly Report 45:99. CDC. 1996c. National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19–35 Months—United States. Morbidity and Mortality Weekly Report 45:145–150. Faherty, K.M., Waller, C.J., DeFriese, G.H., et al. 1996. Prospects for Childhood Immunization Registries in Public Health Assessment and Assurance: Initial Observations from the All Kids Count Initiative Projects. Journal of Public Health Management and Practice 2(1):1–11. Frank, R.G., Dewa, C.S., Holt, E., Hughart, H., Stobino, D., and Guyer, B. 1995. The Demand for Childhood Immunizations: Results from the Baltimore Immunization Study. Inquiry 32(2):164–173. Freed, G.L., Bordley, W.C., and DeFriese, G.H. 1993. Childhood Immunization Programs: An Analysis of Policy Issues. Milbank Quarterly 71:65–96. Hubbert, E.D., and Peck, M.G. 1993. What Works II: 1992 Urban MCH Programs. Omaha, Neb.: CityMatCH at the University of Nebraska Medical Center. IOM (Institute of Medicine). 1994. Overcoming Barriers to Immunization: A Workshop Summary. J.S. Durch, ed. Washington, D.C.: National Academy Press. Leatherman, S., Venus, P., Smalley, M.A., Hunt, G., McCarthy, D., and Peterson, E. 1995. Population Health Surveillance in a Managed Care Setting: A Continuous Quality Improvement Project to Increase Pediatric Immunization Rates Using Administrative Claims and Survey Data. Minneapolis: United Healthcare Corporation, Center for Health Care Policy and Evaluation. Draft. NCQA (National Committee for Quality Assurance). 1996. HEDIS 3.0 Draft for Public Comment. Washington, D.C.: NCQA.

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Improving Health in the Community: A Role for Performance Monitoring TABLE A.8-1 Field Model Mapping for Sample Indicator Set: Vaccine-Preventable Diseases Field Model Domain Construct Sample Indicators Data Sources Stakeholders Disease Eliminate vaccine-preventable diseases Pneumonia and influenza death rates for persons age 65 and older Death certificates Health care providers Health care plans State health agencies Local health agencies Business, industry Community organizations Special health risk groups General public Individual Response Ensure that Medicare enrollees are immunized appropriately Percentage of Medicare enrollees who received an influenza immunization during the previous year; percentage who have ever received a pneumococcal pneumonia immunization Immunization registry or medical charts Health care providers Health care plans State health agencies Local health agencies Community organizations Special health risk groups General public   Ensure that children are immunized appropriately Immunization rate for children at 24 months of age     Social Environment Ensure that populations with special health risks are immunized appropriately Immunization rate at 24 months of age for children currently enrolled in Medicaid Immunization registry or medical charts Health care providers State health agencies Local health agencies Special health risk groups

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Improving Health in the Community: A Role for Performance Monitoring   Reduce financial barriers to immunization Among children with commercial health insurance, percentage with full coverage for immunization Employers, insurance licensing authority Health care plans Local government Business, industry General public   Provide leadership for immunization efforts Existence in the community of an active childhood immunization coalition   Health care providers Health care plans State health agencies Local health agencies Local government Business, industry Education agencies and institutions Community organizations Special health risk groups General public Health Care Ensure that the health care system is organized to provide high immunization rates Immunization rate for children at 24 months of age Immunization registry or medical charts Health care providers Health care plans State health agencies Local health agencies Business and industry Community organizations Special health risk groups General public     Immunization rate at 24 months of age for children currently enrolled in managed care organizations Immunization registry or medical charts Health care providers Health care plans Business and industry General public

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Improving Health in the Community: A Role for Performance Monitoring Field Model Domain Construct Sample Indicators Data Sources Stakeholders Health Care   Existence in the community of a computerized immunization registry; if available, percentage of children in the community included Immunization registry, birth records Health care providers Health care plans State health agencies Local health agencies General public   Ensure that Medicare enrollees are immunized appropriately Percentage of Medicare enrollees who received an influenza immunization during the previous year; percentage who have ever received a pneumococcal pneumonia immunization