1. 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.

2. 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)

3. Adolescent HB Vaccination Coverage
NHIS data – 1997 vs (Stokley, 2001)
HB Series completion among year olds
Parent recall 57% to 69%
With written documentation 15% to 27%
HMO data – 1996 vs (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

4. 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)

5. 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?

6. 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%

7. 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 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%

8. 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%

9. 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

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

11. 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

12. 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

13. 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%

14. 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 ( )
1.7 ( )
1.6 ( )
1.6 ( )
1.5 ( )
3.4 ( ) NS
1.5 ( )
3.1 ( )
2.2 ( )

15. 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

16. 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