Influenza Vaccination Among Children With
Asthma in Medicaid Managed Care
Sangeeth K. Gnanasekaran, MD, MPH; Jonathan A. Finkelstein, MD, MPH;
Paula Lozano, MD, MPH; Harold J. Farber, MD; Felicia W. Chi, MPH;
Tracy A. Lieu, MD, MPH
Objective.–To describe influenza vaccination rates and identify
risk factors for missing vaccination among children with asthma
in managed Medicaid.
Methods.–As part of a longitudinal study of asthma care quality,
parents of children aged 2–16 years with asthma enrolled in
Medicaid managed care organizations in Massachusetts, Wash-
ington, and California were surveyed by telephone at baseline
and 1 year. We evaluated influenza vaccination rates during the
Results.–The study population included 1058 children with
asthma. The influenza vaccination rate was 16% among all
children with asthma and 21% among those with persistent
asthma. Children with persistent asthma (odds ratio [OR] 0.53,
95% confidence interval [CI] 0.36–0.79) and those who had
been hospitalized during the follow-up year (OR 0.29, 95% CI
0.11–0.76) were less likely to miss vaccination.Children older
than their peers.1–9National guidelines recommend influ-
enza vaccination for children with asthma, but past studies
suggest that only 10% to 30% of children with asthma
actually receive this vaccine.10–18
In the past decade, states have increasingly used man-
aged care programs to deliver services to Medicaid-in-
sured children. Studies of the quality of care delivered in
Medicaid managed care programs have yielded conflicting
results. Although some studies have suggested that man-
aged Medicaid programs deliver preventive services at
least as effectively as fee-for-service settings,19–21others
than 9 years (OR 1.66, 95% CI 1.13–2.46) and children of
parents with less than a high school education (OR 2.29, 95% CI
1.05–5.03), compared with a college degree, were at risk for
missing vaccination. Among children with persistent asthma,
older children (OR 1.65, 95% CI 1.01–2.69) and children of
parents with less than a high school education (OR 4.13, 95% CI
1.43–11.90) were more likely to miss influenza vaccination.
Conclusions.–Our findings suggest that interventions directed
toward older children and families with lower educational levels
may help improve influenza vaccination rates among this high-
risk group. The low overall vaccination rate highlights the need
for improvement in this important component of asthma care
quality for all children with asthma.
KEY WORDS: asthma; influenza vaccination; managed care;
Ambulatory Pediatrics 2006;6:1–7
oor and minority children are at heightened risk of
asthma hospitalization, and they tend to receive
fewer preventive visits and controller medications
have found deficiencies in quality of care.22One study
found an improvement in racial disparities in routine
childhood immunization coverage after the implementa-
tion of Medicaid managed care.21More evidence is
needed about how children with chronic conditions fare in
Medicaid managed care.
Influenza vaccination is a marker for quality of care
among Medicaid-insured children with asthma, but little
information is available on how effectively it is delivered
in managed care programs. This study sought to address
this gap in information by addressing these questions: 1)
What is the rate of influenza vaccination among children
with asthma in managed Medicaid? 2) Are those children
with the most severe asthma more likely to receive influ-
enza vaccination? and 3) How can policy makers and
clinicians identify the children at highest risk of missing
the vaccine? Because past studies have observed racial/
ethnic and socioeconomic disparities in health care for
children with asthma in Medicaid fee-for-service9and
general populations,23we tested the specific hypotheses
that minority children and poorer children would be at
higher risk of missing influenza vaccination in managed
Design and Settings
The Asthma Care Quality Assessment (ACQA) Project
was a prospective cohort study of Medicaid-insured chil-
dren with asthma in 5 large, nonprofit managed care plans
From the Harvard Pediatric Health Services Research Fellowship
Program, Boston, Mass (Drs Gnanasekaran, Finkelstein, and Lieu); the
Center for Child Health Care Studies, Department of Ambulatory Care
and Prevention, Harvard Pilgrim Health Care and Harvard Medical
School, Boston, Mass (Drs Gnanasekaran, Finkelstein, and Lieu); Divi-
sion of General Pediatrics, Children’s Hospital Boston, Boston, Mass
(Drs Gnanasekaran, Finkelstein, and Lieu); Center for Health Studies,
Group Health Cooperative, and Child Health Institute, Department of
Pediatrics, University of Washington, Seattle, Wash (Dr Lozano); De-
partment of Pediatrics, Kaiser Permanente, Vallejo, Calif (Dr Farber);
and Division of Research, Kaiser Permanente, Oakland, Calif (Ms Chi).
Address correspondence to Sangeeth K. Gnanasekaran, MD, MPH,
Center for Child and Adolescent Health Policy, Massachusetts General
Hospital, 50 Staniford Street, Suite 901, Boston, MA 02114. (e-mail:
Received for publication March 23, 2005; accepted August 23, 2005.
Copyright © 2006 by Ambulatory Pediatric Association
Volume 6, Number 1
34. Isaacs SL, Schroeder SA. Class-the ignored determinant of the na-
tion’s health. N Engl J Med. 2004;351:1137–1142.
35. Daley MF, Barrow J, Pearson K, et al. Identification and recall of
children with chronic medical conditions for influenza vaccination.
36. Daley MF, Crane LA, Barrow J, et al. Parental knowledge, attitudes,
and beliefs (KABs) regarding influenza immunization in healthy
young children. Pediatr Res. 2004(suppl);55:317A.
37. Hemingway CO, Poehling KA. Change in recommendation affects
influenza vaccinations among children 6 to 59 months of age.
38. Gnanasekaran SK, Finkelstein JA, Hohman K, et al. Parental per-
spectives on influenza vaccination among children with asthma.
Public Health Rep. In press.
39. Four children die of flu in Colorado. New York Times. November 27,
40. Richardson F. Flu vaccine shortage critical. Boston Herald. Decem-
ber 5, 2003;News 001.
AMBULATORY PEDIATRICS Influenza Vaccination Among Children With Asthma7