Pediatric Vaccination and Vaccine-preventable Disease Acquisition: Associations with Care by Complementary and Alternative Medicine Providers

Lois Downey; Patrick T. Tyree; Colleen E. Huebner; William E. Lafferty


Matern Child Health J. 2010;14(6):922-930. 

In This Article


Study Sample and Outcomes

The study was based on secondary analysis of de-identified enrollment and claims data collected in 2000–2003 by two large Washington State insurance companies. We used two subsets of these data for analyses.

Analysis of pediatric vaccination included data for enrollees whose first and second birthdays occurred during the data collection period and who were continuously enrolled during the two calendar years in which those birthdays occurred. The data record for each enrollee encompassed this 2-year time slice and included dichotomous indicators for CAM provider use and vaccination receipt occurring any time during the 2-year period.

Analysis of disease acquisition included data for enrollees for any of the data-collection years in which they were between the ages of 1 and 17 years and were enrolled for the full calendar year. The data record for each enrollee encompassed a 1- to 4-year time slice, depending upon the number of years during the data collection period when they met the age and continuous-enrollment requirements. Each record included yes/no indicators for CAM provider use, a yes/no indicator for diagnosis with any vaccine-preventable disease, and the number of complete years of pediatric coverage during the time slice.

For each of the two analyses we included only records containing at least one claim for healthcare service. The University of Washington Human Subjects Division approved all research procedures.

We used the healthcare effectiveness data and information set (HEDIS)[37] standards as our benchmark for evaluating vaccination adherence. HEDIS criteria are stricter than the goals set forth in Healthy People 2010. HEDIS vaccination standards for 2003 required four vaccinations between ages 1 and 2 years: measles/mumps/rubella, chickenpox, diphtheria/tetanus/pertussis, and H. influenzae type B. (Although HEDIS standards exist for additional vaccinations recommended for universal pediatric use, they can be met by treatment prior to the child's first birthday—a year for which we lacked complete data.) A child met the measles/mumps/rubella standard with receipt of a vaccination for each of the three diseases, either separately or in combination, on or between the first and second birthdays. The chickenpox standard required receipt of a vaccination on or between the first and second birthdays. Diphtheria/tetanus/pertussis immunization required four vaccinations by the second birthday, with one or more vaccinations for (at least) diphtheria and tetanus occurring on or between the first and second birthdays. The H. influenzae type B standard was met with three vaccinations by the second birthday, at least one occurring on or between the first and second birthdays. We evaluated vaccination status using codes from Current Procedural Terminology (CPT)[38] (Appendix 1).

Because of restrictions imposed by the health insurance portability and accountability act (HIPAA),[39] insurance companies provided us with only the child's year of birth, rather than the exact birth date. Lacking the ability to evaluate whether vaccinations occurred precisely "on or between the first and second birthdays," we gave credit for all vaccinations received at any time during the calendar years of first and second birthdays. Thus, we almost certainly included some vaccinations that occurred outside the HEDIS windows. We coded each of the four vaccinations as a dichotomy: 0 = not received during the 2-year period; 1 = received during the period.

Because incidence of vaccine-preventable disease in the sample was low, we used a single outcome to evaluate pediatric disease acquisition. The dichotomous outcome indicated an insurance claim showing diagnosis with any of ten diseases included in federal pediatric vaccination guidelines: diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, H. influenzae type B, hepatitis B, or chickenpox. The result was a dichotomous outcome based on codes from the International Classification of Diseases (ICD-9):[40] 0 = no diagnoses during the time period, 1 = diagnosis with one or more vaccine-preventable diseases (Appendix 2).


Six dichotomous predictors for the vaccination outcomes measured whether there were visits with each of five specific provider types (naturopathic physician, chiropractor, acupuncturist, massage therapist, or conventional care provider) and whether other members of the enrollee's family received care from a CAM provider. For analysis of disease acquisition, predictors of interest were the four variables measuring use of each CAM provider type by the pediatric enrollee and a variable measuring family use of any CAM provider during the enrollee's relevant time slice.


We adjusted for the following covariates in multiple regression models of vaccination: insurance company, gender, birth year, insurance product type, and the enrollee's residential rural–urban-commuting-area (RUCA) code. In addition to these adjustments, we adjusted the disease acquisition model for the number of years of insurance coverage reflected in the enrollee's data record. Insurance product type had four values: preferred provider organization, point of service, health maintenance organization, and fee-for-service. The RUCA code is an ordinal variable measuring the "rural-ness" of the enrollee's place of residence: 0 (metropolitan core) to 10 (rural).[41]


We used logistic regression models to evaluate both vaccination status and disease acquisition. Software included Microsoft Access for data management, SPSS[42] for descriptive statistics, and Stata[43] for regression models.


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