RJ Jacobs AS Meyerhoff Capitol Outcomes Research, Inc. Effect of Middle-School Entry Requirements on Adolescent Hepatitis B Immunization Rates RJ Jacobs AS Meyerhoff Capitol Outcomes Research, Inc.

Background Adolescent HB Immunization Recommended since 1995 No HB middle-school (MS) entry requirements in 19 states What are the arguments against? Poor use of resources Not needed IZ Coverage Data Young Children - well studied through NIS Older Children - limited data (mainly ad hoc)

Adolescent HB Vaccination Coverage NHIS data – 1997 vs. 1998 (Stokley, 2001) HB Series completion among 13-15 year olds Parent recall 57% to 69% With written documentation 15% to 27% HMO data – 1996 vs. 1998 (Gonzalez, et al,2002) HB Series completion among 13 year olds HMO A: 26% to 43% HMO B: 50% to 66% HMO C: 6% to 26% Gonzalez, et al – these are 1998 data California mandate 1999 Oregon mandate 2000 Washington no mandate

Middle-School Mandate Evaluations Florida (MMWR, 1998) >62% coverage within months after 9/97 mandate No pre-mandate data available California (MMWR, 2000 & 2001) Pre-mandate: 16% (verified) and 44% parent recall Immediately post-mandate: 69% (verified) One-year post-mandate: 73% (verified)

Middle-School Mandates: Remaining Questions Are other statewide mandates effective? Are the effects of mandates durable? Whose coverage rates are being improved? Do mandates affect (positively or negatively) the rate of routine adolescent health care visits?

Methods - Overview Records Review of: 982 children ages 11-15 years 53 private pediatrics & general care centers 23 states Outcomes Measures: Initiation & Completion of HB vaccine series Occurrence of a well care visit after 11th birthday Comparisons: State mandate status Other State, Center and Adolescent Characteristics Review of IZ records of 982 children from 23 states Identified states with and without middle-school mandates Selected centers with access to IZ records Selected adolescents visiting these centers Recorded IZ records and well-care visit history Center response rate 10% Center participation rate 70%

Methods - Sample Selection Selection of States ES mandate since 1999 or earlier & no pending MS mandate MS mandate since 1999 vs. no MS mandate Selection of Centers Pediatricians and general/family practice Random samples - AMA Master file Selection of Adolescents Index month = month prior to agreement Consecutive 11-15 year olds seen for any reason (up to 20) Review of IZ records of 982 children from 23 states Identified states with and without middle-school mandates Selected centers with access to IZ records Selected adolescents visiting these centers Recorded IZ records and well-care visit history Center response rate 10% Center participation rate 70%

Methods – Recording Response / Analysis Record Review Dates of 1st, 2nd, 3rd HB Vaccine Dose Date of Most Recent Well-Care Visit Center: Specialty, VFC Participation, Staffing Levels Adolescent: Race, Age, Gender, Health Insurance Analysis Crude Odds Ratios Adjusted Odds Ratios / Logistic Regression Center response rate 10% Center participation rate 70%

Mandate vs. No-Mandate States / Centers MS Mandate States CA, CO, DE, DC, FL, HI, MA, MO, OK, OR, SC, WI, WY 30% of US population No MS Mandate States GA, IN, IA, LA, MS, NH, OH, TN, UT, WA 18% of US population No differences between states: Peds, FPs, GPs per capita early childhood HB coverage No differences between centers: VFC participation Specialty Practice Size Nurse-to-Physician Ratio Person administering vaccines

Differences by Mandate Status All significant at p<.001 Completion among those starting also higher (83% vs 63%, p<.001 All differences p<.001

Center Factors Associated with HB Coverage Completed HB Series P < Specialty Pediatrics GP / FP 65% 51% <.001 VFC Participation Yes No 64% 36% Nurse-to-Physician Ratio GT 1-to 1 LE 1-to-1 62% 53% <.01

Adolescent Factors Associated with HB Coverage Completed HB Series P < Race Asian / Pacific Islander African American Non-Hispanic White 91% 58% 54% <.001 Health Insurance Private MCO Private FFS Government 66% 51% 57% Race similar to data reported by Wang at 2002 NIC (California) 93% Asian, 84% Blacks, 81% Whites

Where Does Mandate Have Greatest Effects? Difference in Rate of HB Series Completion GT 1 nurse per physician LE 1 nurse per physician +24% +50% VFC Providers Non-VFC Providers +31% +43% Pediatrics GP / FP +33% +38% Private MCO FFS / Government +34% +49%

Logistic Regression Model Results Adjusted Odds Ratio (95% CI) Series Completion Well Care Visit Mandate Presence Universal State VFC Provider Pediatrics Specialty GT 1 nurse per physician Asian / Pacific Islander Private MCO 4.3 (3.1-6.0) 1.7 (1.1-2.7) 1.6 (1.1-2.4) 1.6 (1.1-2.3) 1.5 (1.1-2.0) 3.4 (1.3-8.9) NS 1.5 (1.1-2.2) 3.1 (1.2-8.2) 2.2 (1.1-4.6)

Study Limitations Cross-Sectional Design Differences may be due to factors other than mandate status Longitudinal study preferred (longer follow up from FL/CA) Method of Patient Identification Sample size OK for patients, but small for centers Identification of patients (like NIS) preferred, but costly 100% had access and showed willingness to seek care Only 6% were uninsured Centers with high coverage may have disproportionately participated

Conclusions Mandates appear to be effective For at least 3 years after their implementation In a wider geographic area Effects appear greatest in settings with low coverage rates Mandate may facilitate well care visit Is 75% coverage, in presence of a mandate, acceptable? See little reason this would bias comparison between mandate and no-mandate states