The objective of the project was to analyze the extent and total cost associated with duplication of immunization services in Monroe County’s pediatric refugee population in 2015. Recommendations for strategies to improve cohesion and cooperation among public health agencies, eliminate duplication of services and produce cost savings will be included

Murphy, Bridget

English

The College at Brockport, State University of New York: Digital Commons @Brockport

The College at Brockport: State University of New York
Digital Commons @Brockport
Senior Honors Theses Master's Theses and Honors Projects
5-2-2017
The Opportunity Cost Associated with
Duplication of Publicly Provided Immunization
Services for the Refugee Population
Bridget Murphy
The College at Brockport, bridgetmurphy223@gmail.com
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Repository Citation
Murphy, Bridget, "The Opportunity Cost Associated with Duplication of Publicly Provided Immunization Services for the Refugee
Population" (2017). Senior Honors Theses. 165.
http://digitalcommons.brockport.edu/honors/165
 
 
 
The Opportunity Cost Associated with Duplication of Publicly Provided Immunization 
Services for the Refugee Population 
 
 
 
A Senior Honors Thesis 
 
 
 
Submitted in Partial Fulfillment of the Requirements for Graduation in the Honors 
College 
 
 
 
 
By: Bridget Murphy 
Nursing Major 
 
 
  
 
The College at Brockport 
May 2, 2017 
 
 
 
Thesis Director: Elizabeth Heavey, PhD, MS, RN, CNM, Associate Professor of Nursing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Educational use of this paper is permitted for the purpose of providing future students a model example of 
an Honors senior thesis project. 
 
COST	OF	DUPLICATE	VACCINATIONS		 2	
Introduction 
According the Department of State: Bureau of Population, Refugees and 
Migration, in the 2016 fiscal year (October 2015-September 2016), 84,995 refugees were 
admitted to the United States. This is the highest number of refugees in any year during 
Obama’s presidency (Connor, 2016). Nearly 1,200 refugees arrived in Rochester, NY in 
Monroe County in 2016, a 56% spike from 2015 (Murphy, 2016). Many refugees arrive 
with pre-existing health issues acquired from fleeing their home country and living in 
refugee camps. Refugees are more susceptible to infectious disease than general 
immigrants (Amara & Aljunid, 2014). Before admission to the U.S., refugees must be 
interviewed, screened and cleared by multiple different agencies. The U.S. government 
provides a multiple services to address the unique health needs of this vulnerable 
population. In our area, the Monroe County Department of Health (Department of Health, 
2013) provides the initial infectious disease screening and immunizations for the refugee 
population during the resettlement process. As of January 2008, New York State 
legislature passed the Immunization Registry Law, requiring health care providers to 
report all vaccinations administered to patients under 19 years old and the person’s 
immunization history to the New York State Department of Health using the New York 
State Immunization Information System (NYSIIS). The goal of NYSIIS is to “establish 
complete, accurate, secure, real-time immunization medical record that is easily 
accessible and promotes public health” (Department of Health, 2013). One main benefit 
of an immunization registry is decreasing unnecessary duplicate immunizations thus 
decreasing health care costs (Patel et al, 2015). Preventing duplicate immunizations 
reduces both patient costs such as time and pain of vaccination and public cost by saving 
COST	OF	DUPLICATE	VACCINATIONS		 3	
public resources. However, if NYSIIS is not kept up-to-date or care providers do not 
utilize the system appropriately, the effectiveness of the system is diminished. Electronic 
immunization registries can be an efficient tool if they are kept up-to-date and are 
routinely utilized (McKenna, Sager, Gunn, Tormey & Barry, 2002).  
The DOH runs an immunization clinic that helps ensure refugee children are 
healthy, and prepared to attend school in New York State. Required immunizations are 
administered at the DOH and may be inadvertently repeated at other primary care 
practices later in the refugee resettlement process. The resettlement process includes 
establishing a medical home and Medicaid coverage for the provision of primary care 
that is not available at the DOH. Immunizations that are administered at the DOH are 
documented in the state-wide NYSIIS system, which is accessible to all registered health 
care providers. The transition of care to the secondary site is associated with duplication 
of immunization services related to not using NYSIIS appropriately at the secondary care 
site, poor documentation and/or errors in tracking (such as misspelled names which is a 
common issue in this population). This results in unnecessary administration of expensive 
vaccines within a very resource-limited state environment.  
NYSIIS provides an opportunity to examine and quantify the cost of invalid 
vaccinations administered and then subsequently billed to Medicaid at the secondary 
provider location. This paper will present the initial data gathered by a team of personnel 
during a quality improvement initiative conducted in Monroe County in the spring of 
2016.  
 
 
COST	OF	DUPLICATE	VACCINATIONS		 4	
Objective 
The objective of the project was to analyze the extent and total cost associated 
with duplication of immunization services in Monroe County’s pediatric refugee 
population in 2015.  Recommendations for strategies to improve cohesion and 
cooperation among public health agencies, eliminate duplication of services and produce 
cost savings will be included. 
Methods 
In this retrospective study, data was collected in April 2016 at the Monroe 
Country Department of Health. Data collection included review of all pediatric patient’s 
charts initially seen in the Monday morning Refugee Services Health Clinic in 2015 
(N=250). The NYSIIS system was then utilized to identify what vaccinations were 
duplicated or administered inappropriately at the secondary care site after transfer from 
the DOH. The type of vaccine that was duplicated or administered inappropriately (i.e. 
too soon after DOH vaccination) was documented. Of the 250 patient charts, 100 were 
dual reviewed by the researchers to ensure inter-rater reliability for what we identified as 
inappropriately administered vaccines. Inter-rater reliability was established at 99%.  
The CDC price list for vaccines (see appendix A) and a $20.00 administration fee 
(Medicaid) was used to establish the cost associated with inappropriate administered 
vaccines at the secondary care practice. Sometimes providers administer combination 
vaccines to avoid administering multiple injections to children. In this study, when 
combination vaccines were administered to children and at least two components of the 
vaccination were required, we consider this to be “provider judgment.” These instances 
were classified as appropriate vaccination administration even if all components were not 
COST	OF	DUPLICATE	VACCINATIONS		 5	
necessary. If combination vaccines were administered and only one component was 
necessary these instances were identified as inappropriate duplication of vaccinations.  
Results 
We identified 64 inappropriately administered pediatric vaccinations at the 
secondary care provider site. The total cost of the inappropriately vaccinations 
themselves was $3,263.00. The administrative costs associated with the inappropriate 
vaccines was $1,280.00. The total cost associated with inappropriate vaccinations of 
pediatric refugee patients transferred from the Monday morning clinic in 2015 was 
$4,543.00. The total DOH budget for the initial cost of the appropriate pediatric vaccines 
themselves and administering the pediatric vaccines on Monday mornings in 2015 was 
$61, 268 (personal communication, Mary Young, 6/7/16). Readministering these 
vaccines at the secondary care site is duplicating 7.4% of the initial budget allotted for 
these services.  
Discussion 
The primary limitations of this study include the under-detection of potentially 
greater levels of inappropriately administered vaccines that exist because we did not 
count the fairly frequently noted use of a combination vaccine if at least two components 
of the vaccine were required and multiple injections to pediatric patients were avoided. 
Also, the costs we found were gathered after following the small population of clinic 
visits that occurred for the pediatric refugee population seen only on Monday mornings 
after they transferred care to the secondary provider site. If these costs also exist for all 
patients seen throughout all clinic sessions at the DOH who later transfer care, this would 
COST	OF	DUPLICATE	VACCINATIONS		 6	
create a substantially greater Medicaid cost burden on an already limited county and state 
budget. 
Implications 
 Our results indicate that during the transition of care period from the DOH to the 
secondary care providers, data in NYSIIS could be used more effectively than it is right 
now. The cost of administering invalid vaccinations at the secondary care site is 
approximately 7% of the totally budget associated with the initial management of the 
refugee patients at the DOH. There is a potential for lost work and school time for 
children and their parents when unnecessary immunizations are given and they can 
potentially feel ill or have a low temperature after receiving the immunization. This 
unnecessary discomfort and the additional demands on short staffing to provide the 
immunization are also costs associated with the duplication administration of 
immunizations. Improved utilization of the NYSIIS system at the secondary care site 
could be associated with a decrease in duplication of services and substantial cost savings 
within the Medicaid managed care system. It could also save potential pain, discomfort 
and lost work or school time for patients and their families. 
Human Participant Protection 
 This study was approved by the Institutional Review Board at The College at 
Brockport. See Appendix D.  
 
 
 
 
 
 
 
COST	OF	DUPLICATE	VACCINATIONS		 7	
References 
 
Amara, A.H., Aljunid, S.M. (2014) Non-communicable diseases among urban refugees
 and asylum-seekers in developing countries: a neglected health care need.
 Globalization and Health, 10(24), 1–14. doi: 10.1186/1744-8603-10-24 
 
Centers for Disease Control and Prevention. (2016).  CDC vaccine price list. Retrieved
 from: www.cdc.gov/vaccines/programs/vfc/awardees/vaccine--management.  
 
Connor, P. (2016, October 5). U.S. admits record number of muslim refugees in 2016.
 Retrieved from http://www.pewresearch.org/fact-tank/2016/10/05/u-sadmits
 record-number-of-muslim-refugees-in-2016/ 
 
Department of Health. (2013, August). New york state immunization information system
 (NYSIIS). Retrieved from
 https://www.health.ny.gov/prevention/immunization/information_system/ 
 
McKenna ,V.B., Sager A., Gunn J.E., Tormey P., Barry M.A. (2002) Immunization 
registries: costs and savings. Public Health Rep.117(4), 386 
 
Murphy, J. (2016, December 27). Rochester’s refugee population booms. Democrat &
 Chronicle. Retrieved from http://www.democratandchronicle.com 
 
Patel, M., Pabst, L., Chattopadhyay, S., Hopkins, D., Groom, H., Myerburg, S., &
 Murphy Morgan, J. (2015). Economic review of immunization information
 systems to increase vaccination rates: a community guide systematic
 review. Journal Of Public Health Management & Practice, 21(3), 253-262.
 doi:10.1097/PHH.0000000000000100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COST	OF	DUPLICATE	VACCINATIONS		 8	
Appendix A: CDC Price List 
 
Vaccine Cost of (1)  
Dtap $55 
HepB $12 
Hib $10 
Influenza $19 
MMR $114 
Pneum $120 
Polio $13 
Varicella $88 
Tdap $31 
HPV $142 
HepA $18 
Rota $66 
Centers for Disease Control and Prevention. (2016).  CDC Vaccine Price List.  Available at: 
www.cdc.gov/vaccines/programs/vfc/awardees/vaccine--management.  
 
Appendix B: Inappropriate Vaccines Administered by Type 
 
 
 
 
 
 
 
 
 
COST	OF	DUPLICATE	VACCINATIONS		 9	
Appendix C: Cost Associated with Inappropriate Vaccines by Type  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COST	OF	DUPLICATE	VACCINATIONS		 10	
 
 
Appendix D: IRB Approval  	
 
 
 
*EXEMPT DETERMINATION* 
 
Date:     4/18/2016 
 
To:        Elizabeth Heavey 
 
From:    Julie Wilkens 
              IRB Compliance Officer 
  jwilkens@brockport.edu 
 
Re:        IRB Proposal # 2015-128 
 
Project Title: Cost Associated With Duplication Of Publically Provided 
Immunization Services For the Refugee Population 
 
Your proposal has been determined to be exempt as of 4/18/2016. IRB approval is good 
for one calendar year. 
 
Before 4/18/2017, submit a Continuation Request by e-mail to the IRB office. A reminder 
will also be sent to you in eleven months by the IRB office, but it is the researcher’s 
responsibility to make sure the protocol approval does not expire.  
 
You may use only the documents and procedures that have been approved by the IRB in 
conducting your research. If you wish to make any changes to these documents or 
procedures, you must submit a new proposal and obtain approval from the IRB prior to 
implementing any changes. The exception to this is including adding research assistants or 
new investigators, which may be requested using Form K. You may use the original proposal 
as a template for the new proposal.  
 
Any injury to a subject due to the procedures must be reported immediately. 
 
When signed consent documents are required, the primary investigator must retain the 
signed consent documents for a minimum of three years past completion of the research 
activity. 
 
If continuing review is not granted before the expiration date of 4/18/2017, approval of this 
protocol expires on that date. 
 
Best wishes in conducting your research. 
 
Institutional Review Board 	
COST	OF	DUPLICATE	VACCINATIONS		 11	
 
Appendix E: Dissemination  
 
These results were presented in a poster presentation at the North American Refugee 
Health Conference in June 2016 and at the National Conference for Undergraduate 
Research in April 2017.  
 
             


The Opportunity Cost Associated with Duplication of Publicly Provided Immunization Services for the Refugee Population

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The Opportunity Cost Associated with Duplication of Publicly Provided Immunization Services for the Refugee Population

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