Estimating influenza vaccination uptake trends in near real time: Third-party claims data from physician offices March 31, 2011 Gary L. Euler, DrPH; Carla.

Estimating influenza vaccination uptake trends in near real time: Third-party claims data from physician offices March 31, 2011 Gary L. Euler, DrPH; Carla L. Black, PhD Assessment Branch/ISD/NCIRD 45th National Immunization Conference Washington, DC (Read title of talk.) Nearly three quarters of all physician offices in the country are enrolled in this system and currently send in their claims for all of their vaccinations to a central data warehouse using a completed CMS 1500 form. Estimates and projections can be made in near real time based on the earliest claims. These estimates have been validated by being compared to counts after the claims database is complete and methodologies have been refined to produce reliable weekly uptake estimates by state. These weekly estimates are available with only one or two week lag. One advantage of having access to databases with third party claims for influenza vaccination within a couple of weeks after vaccination occurs in the physicians office is knowing information such as we will see on the next slide.

Show and tell National packet of 7 figures from claims data: near real time influenza vaccination uptake by age groups Examples of states with a variety of trend patterns for Compare claims data monthly pattern to distribution from our standardized telephone and in-home surveys Demonstrate how claims can provide both vaccination and disease data for linking FluVaxView as place to go

Objectives Demonstrate the utility of existing influenza vaccination claims data for disease control purposes during state flu campaigns. Request your ideas on how to use influenza vaccination uptake data available within month of vaccination; updates weekly? Request your ideas on how to expand the claims database so that smaller and smaller jurisdictions will have same estimates now available only for the 20 largest cities

July 10 – 41 states (10-adult; 3-child)
Week of onset of influenza vaccination in physician offices by state July 10 – 41 states (10-adult; 3-child) 3,900 vaccinations (37 m by end Dec) July 31 – 45 states (25,400 doses) Aug 07 – 49 states Aug 28 – All states (all age groups) Some of you may find data like this interesting, some may think of ways it could be useful to increase influenza vaccination in your state or city. (Review and comment on contents of slide.) In addition to some new potentially useful facts from the claims, data==providing the public sector insight into what the private sector is doing before they are even collectively aware of it. Today we are talking about providing on line 7 trend slides comparing the current to the two previous seasons. These 7 slides are updated weekly from the claims data base. They start becoming available by mid July and show uptake by state. The claims data can even allow estimates like this for the 20 largest cities in the country.

Use of trends for current & past two seasons
To evaluate novel ways to motivate and remind patients and vaccinators For Public Health to play a stronger leadership role with private providers and professional medical organization Enhance presentations and media interviews to more effectively get your messages out and lobby for change / innovation and for greater resources using state and local near real time uptake estimates

National weekly uptake of 2010-11 trivalent (seasonal) vaccine – age ≥6m through Feb 26, 2010
Administrations (Describe the figure in the slide and summarize the key finding.) First we will present the set of 7 figures. Then we will compare the national picture to selected state-specific variations of each figure. These slides will give you a sense of what is available and then we are asking for feedback from you about the potential usefulness of these figures for your state influenza campaign. July Aug Sept Oct Nov Dec Jan Feb Mar April *Excludes vaccinees who received only the influenza 2009 monovalent H1N1 vaccination Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National cumulative doses administered
of seasonal vaccine – age ≥6m through Dec 25, 2010 Cumulative administrations (Describe the figure in the slide and summarize the key finding.) Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National weekly uptake of seasonal vaccine – children age 6m–18y through Dec 25, 2010
Administrations The previous two slides were for all ages and next we have the same two for children followed by 2 for adults. Review key findings shown. July Aug Sept Oct Nov Dec Jan Feb Mar April Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National cumulative doses administered of seasonal vaccine – children age 6m-18y
through Dec 25, 2010 Administrations (Describe the figure in the slide and summarize the key finding.) Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National weekly uptake of seasonal vaccine – adults age ≥19y through Dec 25, 2010
Administrations (Describe the figure in the slide and summarize the key finding.) Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National cumulative doses administered of seasonal vaccine – adults age ≥19y through Dec 25, 2010
Administrations (Describe the figure in the slide and summarize the key finding.) Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National 2010-11 weekly uptake of seasonal vaccine in physician offices
Administrations (Describe the figure in the slide and summarize the key finding.) Since this season was the first for the ‘universal’ recommendation which included healthy non contact age group for the first time—about 15% of the US population. The red bars here look to me like less than 10% of the vaccinee population, but the age group includes 40% of the US population. Next we will look at a few state-specific figures for each of the 7 slides we just reviewed. First the national picture. Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010 12 12

National weekly uptake of 2010-11 trivalent (seasonal) vaccine – age ≥6m through Feb 26, 2010
Administrations Here is the national curve again for reference and we’ll look at selected states and compare. (Flip back and forth for clear comparison of differences between states and to the national picture. Here note that the curves for these three seasons are similar with timing last year earliest and later with current season midway between past two seasons. Note a bit more vaccination activity this season after the usual December bump. ) (The next 27 slides will be covered quickly in the same manner. We can move faster as people become more familiar with what they are looking at.) *Excludes vaccinees who received only the 2009 monovalent H1N1 vaccination Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

Colorado weekly uptake of seasonal vaccine – age ≥6m through Dec 25, 2010
Administrations (Proceed through next 27 slides.) Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

Hawaii weekly uptake of seasonal vaccine – age ≥6m+ through Dec 25, 2010
Administrations Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National cumulative doses administered
of seasonal vaccine – age ≥6m through Dec 25, 2010 Administrations Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

California cumulative doses administered of seasonal vaccine – age ≥6m through Dec 25, 2010

District of Columbia cumulative doses of seasonal vaccine – age ≥6m through Dec 25, 2010

National weekly uptake of seasonal vaccine – children age 6m–18y through Dec 25, 2010

Oregon weekly uptake of seasonal vaccine – children age 6m–18y through Dec 25, 2010

Pennsylvania weekly uptake of seasonal vaccine – children age 6m–18y through Dec 25, 2010

National cumulative doses administered of seasonal vaccine – children age 6m–18y through Dec 25, 2010 Administrations Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

Alabama cumulative doses administered of seasonal vaccine – children age 6m–18y through Dec 25, 2010

Kentucky cumulative doses administered of seasonal vaccine – children age 6m–18y through Dec 25, 2010 Administrations Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010

National weekly uptake of seasonal vaccine – adults age ≥19y through Dec 25, 2010

Hawaii weekly uptake of seasonal vaccine – adults age ≥19y through Dec 25, 2010

North Dakota weekly uptake of seasonal vaccine – adults age ≥19y through Dec 25, 2010

National cumulative doses administered of seasonal vaccine – adults age ≥19y through Dec 25, 2010

Minnesota cumulative doses administered of seasonal vaccine – adults age ≥19y through Dec 25, 2010

Colorado cumulative doses administered of seasonal vaccine – adults age ≥19y through Dec 25, 2010

Ohio cumulative doses administered of seasonal vaccine – adults age ≥19y through Dec 25, 2010

National 2010-11 influenza vaccination weekly uptake by age group
Administrations Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010 32 32

Hawaii 2010-11 influenza vaccination weekly uptake by age group

Maryland 2010-11 influenza vaccination weekly uptake by age group
Administrations Proportionally higher children than many states like in last slide for HI which could be because and number of possibility: 1. VFC vaccinations that were coded using antigen code instead of administration code. Can be checked by looking at the amount charged which for VFC vaccine would be less than the average cost of vaccine ($18) usually a dollar for a VFC dose--$7 or $8. The administration code without an antigen code that would also indicate a FVC dose. These practices vary from state to state and are determined in the state by the state vaccine coordinator. Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010 34 34

Florida 2010-11 influenza vaccination weekly uptake by age group

District of Columbia 2010-11 influenza vaccination weekly uptake by age group

Delaware 2010-11 influenza vaccination weekly uptake by age group

Utah 2010-11 Influenza vaccination weekly uptake by age group

Alaska 2010-11 influenza vaccination weekly uptake by age group

Arkansas 2010-11 influenza vaccination weekly uptake by age group
Administrations We have seen the variety patterns between states and the national picture. Do you find any useful information here you could use in your state during the season? How would you use it if you had it? The next question many of you may have is how similar is the pattern of uptake in physician offices to the entire uptake. The next few slides address this question by comparing monthly patterns of claims data estimates to telephone collected self reported influenza vaccination by age subgroups with BRFSS and to the NHIS house hold in-person interview estimates. Confidential and Proprietary – No Reproduction Without Prior Permission – SDI (C) 2010 40 40

Validation study of monthly uptake distributions from claims data
Compare to the Behavior Risk Factor Surveillance System (BRFSS) Compare to National Health Interview Survey (NHIS)

Flu Summit Dallas, 2009 -- G.L. Euler
Influenza vaccinations: percentage of total uptake by month, United States NHIS* BRFSS** SDI*** Flu Summit Dallas, G.L. Euler 9/27/2019 9:01 PM Age Group: 19y-64y *CDC/NCHS, National Health Interview Survey, 2008 preliminary data. Estimates based on household interviews and self-report, 1,763 vaccinees. **All states, RDD telephone survey n=138,534 vaccinees The white line here represents the monthly distribution of vaccination according to third party claims data. Compared to the distributions with NHIS and BRFSS there are a few differences for year-olds. NHIS is a national in home survey of about 30,000 households while BRFSS is a state based national telephone survey. (Slides will be covered quickly as a second packet of slides. The primary message here is just that the distribution of uptake across months from the claims is very similar to the distribution seen from our standard surveys widely depended on for the past three decades.) ***Data collected from electronic medical claims processed by physicians on CMS-1500 forms, n≈483,000 vaccinations, for 19yr-64yr from 8/2007-3/ Excludes vaccinations given by employers, pharmacies, schools, senior centers, etc. Wednesday 11:30-11:50 AM

Influenza vaccinations: percentage of total uptake by month United States, NHIS vs. claims Flu Summit Dallas, G.L. Euler 9/27/2019 9:01 PM Age Group: 6m–18y CHILDREN The shift to the right or later months by the claims database is more pronounced when we remove the adults and look at the children only. One possible explanation may be that NHIS collects information about one dose, while the claims database includes both doses for those children receiving two. Wednesday 11:30-11:50 AM

Influenza vaccinations: percentage of total uptake by month United States, NHIS vs. claims Flu Summit Dallas, G.L. Euler 9/27/2019 9:01 PM Age Group: ≥65y SDI, ≈530,000 vaccinees NHIS, 1,150 vaccinees The proportional distribution by month in the season is similar for physician-processed medical claims data vs. self-report in all adults 65 years and over. However, physician processed claims are more prominent in Oct and less so in Jan and Feb. Wednesday 11:30-11:50 AM

Influenza vaccinations: percentage of total uptake by month United States, NHIS vs. claims Flu Summit Dallas, G.L. Euler 9/27/2019 9:01 PM Age Group: ≥6 months NHIS (3,807 vaccinees) SDI (≈1,600,000 vaccinees) Differences are not as apparent when looking at the entire indicated population. If this relationship between claims and surveys would be consistent from one year to the next a fairly accurate estimate of uptake could be attained by using claims data by benchmarking the claims to the survey results from the prior season to project an estimate of the current season’s uptake in total and possibly by subgroups of interest. A thorough validation study of this potential would be needed before we would be comfortable with this method. If valid this technology could make near real time estimates of uptake available on line by state and even metropolitan areas in future seasons. Another option would be to explore ways of including with the claims data, vaccinations that occur in venues other than physician offices. Wednesday 11:30-11:50 AM

Illustration: Presentation of 2009 H1N1 pandemic
Illustration: Presentation of 2009 H1N1 pandemic* with monovalent 2009 H1N1 vaccination coverage† overlay— state-to-state animation , United States Representative state samples hospitals population Larger sample size of claims database analyses of smaller subgroups We will start with the week of June 15 which was the week before the first state was involved according the index used here, where the trend line of the number of child ED visits with physician diagnosis of influenza begins to rise above pre-pandemic level and increases from that point on and will show with a darker blue when the curve drops back to baseline as the as the end of the state involvement according to our index. As we go forward notice the date at the top under the slide title. Keep in mind this is only an illustration and only represents a preliminary draft state-to-state sequence. At the first weeks of October H1N1 vaccination is added using state labels. *Trend line of percent of all ED visits of children with physician diagnosis of influenza, rises and stays above the pre-pandemic baseline for ED sample in state. †National telephone survey: National 2009 H1N1 Flu Survey (NHFS) combined with the Behavioral Risk Factor System (BRFSS)s

Having access to these claims data allowed a unique comparison of a novel measure of disease occurrence by state with simultaneous estimates of vaccination coverage levels by month. We have a series of 17 maps that show a progress of involvement by states in the pandemic. Our threshold of state involvement was when the proportion of all child ED visits with a physician diagnosis of influenza of all child ED visits exceeded baseline for the state, based on third party payer billings in the claims data set.

In June the first signs of influenza occurred in EDs in Florida and California.
9/27/2019

In July cases showed up in EDs in Louisiana and Georgia
9/27/2019

And also then in Nebraska
9/27/2019

9/27/2019

Other southern states EDs were having increases in child physician diagnosed influenza by early Aug
9/27/2019

Central US and Alaska were added later in Aug
9/27/2019

9/27/2019

By the end of Aug ED child visits for physician diagnosed flu were occurring above baseline in the center column of states, the south west and south east. 9/27/2019

By early Sept all the states in the southern half of the country were submitting claims for ED child visits for physician diagnosed flu. 9/27/2019

9/27/2019

By the end of Sept you will see that only a few mid western states and the northeastern states had not seen ED visits for influenza increase above baseline in the claims database 9/27/2019

The next slide jumps forward to the end of October after monovalent H1N1 vaccination had been ongoing for up to three weeks. Those 14 states seen here in lightest blue are pre state pandemic as we defined it for this illustration but over the next 3-4 weeks 3-5 states each week went to the pandemic stage. Most states were starting vaccination at about the time their pandemic had started to impact the Emergency Departments with excess physician diagnosed influenza. 9/27/2019

Here influenza according the child visits to ED had not yet arrived in HI, but vaccination was well underway in all states. 9/27/2019

Some of the state outbreaks apparently were starting to subside in Nov and vaccination levels reached above 10% in all but 5 southern states.

Vaccination reached into the 20’s in many states and children were still coming into the ED with diagnoses of influenza only in a handful of states in Dec 9/27/2019

Here by the end of January vaccination levels were highest in some of those north eastern states where the flu outbreaks were just hitting the EDs at about the time vaccine arrived. 9/27/2019

State ED involvement as we defined our State outbreaks had ended by Feb and vaccination levels reached above 30 in 4 and above 40 in two north eastern states that had experienced the later ED involvement. Maybe the lower vaccination coverage in the southern states was in part due to less unknown about the pandemic, and fewer susceptibles by the time vaccine was available. Maybe many more people in those states had already had influenza and so saw no need to get their H1N1 vaccination. This concludes our example of how claims data bases allowed us in to pilot this potential linkage of influenza disease by state with state monthly vaccination levels. What might be possible like this in future seasons depends on available resources. 9/27/2019

Influenza vaccination uptake estimates presented here from claims did not include:
Uptake in venues other than physician offices, because for most no claim made or currently not included* with the contract: Pharmacies, grocery stores, workplace, senior centers, public health clinics, HMOs,† other clinics, schools, airports, EDs, etc.; or An accurate estimate of VFC vaccination Because cost of VFC vax not billed, and Procedure code is not specific to flu vaccine *Data are available for pharmacies, urgent care centers, and EDs † Vaccination for HMO providers are imputed using geography and specialty characteristics Does knowing when and how much influenza vaccination is going on in physician offices with in your state appeal to Immunization Program Managers and their influenza vaccination campaign leaders? Would state epidemiologists find that information useful? Would knowing this information about your state and other states around yours be helpful? Would physicians like to know how much vaccination is occurring in other physician offices in the state? It is possible this information could be made available on the CDC influenza vaccination web sites—FluVaxView and it is possible this information could be updated weekly starting as early as July each season. If you would find it useful let someone in ISD know.

Options to maximize usefulness of claims data – 1
Pharmacy claims can potentially be combined with physician office claims Community vaccinators have started to show interest in adding their data if funding becomes available Public health clinics may consider increasing claims for administration of influenza vaccinations New CMS codes may assist with identification of VFC and influenza vaccination (50%+ of child vaccinees in US) Provider VFC data could be used to facilitate accurate in- season estimates of state-specific influenza vaccination uptake in children

Options to maximize usefulness of claims data* – 2
The utility to CDC of the claims source of near real-time estimates may be enhanced as a few of these steps are accomplished in future seasons As data base grows there will be more local estimates possible Representativeness Main issue to be addressed Improved by above additions *Note: Claims records of vaccination are medically recorded data vs. self-reported as are most vaccination coverage data.

Influenza vaccination coverage data:
Historically available only after the next season started Indicated only slow improvements each year Recently have shown a few large improvements Recently have been available in near real time Recently have measured impact of multiple expanded vaccination recommendations This week became available for states on a new CDC web page—”FluVaxView” Uses by public health and immunization in campaign planning pre season and during season? Uses for the local and national media? Uses for documentation, evaluation and promotion and motivation? Review slide bullets. Mention CDC’s new interactive vaccination coverage web page with eventually monthly updated state estimates.

A new paradigm Interactive Custom Expanding Powerful Near real time

These last two slides show the new influenza vaccination coverage estimate web page. The page just went live last week. You get to it from the CDC flu web site where you will find a link. The seven figures we saw at the beginning of this presentation by the US and by each state and HHS region will be available through a link on this new vaccination page soon—we may call the new vaccination interactive web site FluVaxView.

Here is the second interactive report that allows a bar chart comparison between national, regional and state estimates by age, risk and race and ethnicity sub groups. Be sure to check it out and let us know ways you might use it. Training sessions were provided last week at the BRFSS conference for state coordinators and those that conduct the BRFSS survey in each state. Training sessions were provided this week here from 12-2 pm Tuesday and Wednesday. If you find a training session would be helpful let us know.

(Review slide.) THANK YOU

Estimating influenza vaccination uptake trends in near real time: Third-party claims data from physician offices March 31, 2011 Gary L. Euler, DrPH; Carla.

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Estimating influenza vaccination uptake trends in near real time: Third-party claims data from physician offices March 31, 2011 Gary L. Euler, DrPH; Carla.

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Presentation on theme: "Estimating influenza vaccination uptake trends in near real time: Third-party claims data from physician offices March 31, 2011 Gary L. Euler, DrPH; Carla."— Presentation transcript:

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