Improving Montana’s Vaccine Coverage by Using Reminder/Recall Systems

1. Improving Montana’s Vaccine Coverage by Using Reminder/Recall Systems Randall J. Nett, MD, MPH CDR, United States Public Health Service Career Epidemiology Field Officer — Assigned to Montana DPHHS Montana Regional Immunization Workshop Spring 2012 Office of the Director Office of Public Health Preparedness and Response

2. Agenda • Discuss Montana’s childhood vaccine coverage • Discuss Montana’s adolescent immunization provider practices • Describe vaccine reminder/recall systems, and evidence for their use • Discuss DPHHS vaccine recall system pilot study • Discuss local health department’s role • Summary and recommendations • Questions and discussion

3. 2008 National Immunization Survey (19–35 months) — Montana’s rank and opportunity to improve http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis

4. 2010 National Immunization Survey (19–35 months) — Montana’s rank and opportunity to improve http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis

5. 2010 National Immunization Survey (13–17 years) — Montana’s rank and opportunity to improve http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nisteen

6. 2010 National Immunization Survey (13–17 years) — Montana’s rank and opportunity to improve http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nisteen

7. 2010 Adult Influenza Vaccine Coverage — Montana and US Behavioral Risk Factor Surveillance System (BRFSS) and National Immunization Survey (NIS), September 2010- June 2011 retrieved November 22, 2011 from www.cdc.gov/flu/professional/vaccination/reprt.1011

8. What Contributes to Montana’s Vaccine Coverage? • Multifactorial • Parental beliefs and attitudes • Perceived low-risk from vaccine-preventable diseases • School entry, daycare entry, and work requirements • Access to care • Cost of some vaccines • Healthcare provider practices

9. What Contributes to Montana’s Vaccine Coverage? • Multifactorial • Parental beliefs and attitudes • Perceived low-risk from vaccine-preventable diseases • School entry, daycare entry, and work requirements • Access to care • Cost of some vaccines • Healthcare provider practices

10. What Contributes to Montana’s Vaccine Coverage? • Multifactorial • Parental beliefs and attitudes • Perceived low-risk from vaccine-preventable diseases • School entry, daycare entry, and work requirements • Access to care • Cost of some vaccines • Healthcare provider practices • Medical exemptions • Immunization beliefs • Office practices • Personal practices • Use of reminder/recall systems

11. Reminder/Recall Systems • Reminder system — a healthcare provider notifies the parent(s) of a child who is due or will be due for a vaccine(s) • Recall system — a healthcare provider notifies the parent(s) of a child who is overdue for a vaccine(s) • ACIP, AAP, AAFP recommended vaccination providers use reminder/recall systems

12. Survey of Adolescent Immunization Providers in Montana — 2009 • 60-question survey sent to all known Montana pediatricians and family medicine physicians • n = 632 • 35% response rate • Majority of respondents agreed it is “very important” for adolescents to stay up-to-date on immunizations • Number of physicians scheduling return visits for immunizations was low • Only 21% reported using reminder/recall systems

13. Survey of Adolescent Immunization Providers in Montana — 2009 • 60-question survey sent to all known Montana pediatricians and family medicine physicians • n = 632 • 35% response rate • Majority of respondents agreed it is “very important” for adolescents to stay up-to-date on immunizations • Number of physicians scheduling return visits for immunizations was low • Only 21% reported using reminder/recall systems • In 1999 national survey — 18% of family physicians and 28% of pediatricians reported using reminder/recall systems Oster NV, McPhillips-Tangum CA, Averhoff F,,Howell K. Barriers to adolescent immunization: a survey of family physicians and pediatricians. J Am Board Fam Pract 2005; 18:13-19.

14. Question How many in the audience work in a healthcare provider office that uses vaccine reminder/recall systems?

15. Question How many in the audience work in a healthcare provider office that uses vaccine reminder/recall systems? What type of system?

16. Question How many in the audience work in a local health department that uses vaccine reminder/recall systems?

17. Question How many in the audience work in a local health department that uses vaccine reminder/recall systems? What type of system?

18. Reminder/Recall System Variables • Method (telephone, letter, postcard, chart, etc.) • Population (adult, pediatric, privately insured, Medicaid, rural, urban, etc.) • Vaccine (routine, influenza, single vaccine, series, etc.) • Schedule (one-time vs. multiple) • Intensity (one attempt vs. repeat attempts until contact)

19. Chart Reminders • Can be as simple as colorful sticker on chart or part of comprehensive preventive check list • Electronic record reminders • Reminders that require provider acknowledgment are more effective

20. Mail Reminder/Recall (Letter or Postcard) • Advantages: • Reaches patient who might not have otherwise scheduled a visit • Easy to implement • Disadvantages: • Relies on patient to keep appointment • Not useful in practices with high patient turnover • Generating list of patients overdue for vaccines can be difficult for some practices • Resources required: • Staff time, paper, postage

21. Reminder/Recall System Postcard https://www.sendoutcards.com/catalog/#from-home-page-icon

22. Reminder/Recall System Letter

23. Telephone Reminder/Recall • Personal phone call by staff • Ensures message is understood by patient or parent and offers opportunity for appointment • Time intensive • Automated phone call • Less personal • No opportunity to make appointment during call • Less time intensive

24. Example Reminder/Recall Study • Randomized controlled trial • Rhode Island Medicaid-enrolled children at Hasbro Children’s Hospital (10% of RI Medicaid-enrolled children) • Children enrolled in one of 4 groups (n = 264) • Control group (n = 71) • Telephone reminder group (n = 60) • Mail reminder group (n = 63) • Sequential mail/telephone reminder group (n = 70) • Immunization rates assessed at 10-week follow up

25. Example Reminder/Recall Study • 53% of telephone reminder group could not be reached because of incorrect or outdated phone number • 30% of letters sent were returned in mail reminder group because address was not current • Children in intervention groups were >2X more likely to make an appointment compared with control group • Children in each intervention group more likely to be up-to-date on vaccinations compared with control group (all 3 groups within statistical significance of each other)

26. Example Reminder/Recall Study • 53% of telephone reminder group could not be reached because of incorrect or outdated phone number • 30% of letters sent were returned in mail reminder group because address was not current • Children in intervention groups were >2X more likely to make an appointment compared with control group • Children in each intervention group more likely to be up-to-date on vaccinations compared with control group (all 3 groups within statistical significance of each other)

27. Benefits of Reminder/Recall Systems • Reminder/recall systems effective* at increasing: • Childhood vaccination coverage — 1 to 20 percentage points OR = 1.5 (95% CI = 1.3–1.7) • Childhood influenza vaccination — OR = 2.2 (95% CI = 1.3–3.7) • Adult pneumococcus, tetanus, hep B — OR = 2.2 (95% CI = 1.2–4.0) • Adult influenza vaccination — OR = 1.7 (95% CI = 1.3–2.1) *2009 Cochrane Database review of 47 studies

28. Reminder/Recall System Challenges • Infrequently used in Montana and Nationally • Providers might not feel individual studies apply to their practice • Pediatricians might not recognize that studies in adult populations apply to their practice • Internists might not recognize that studies in pediatric populations apply to their practice • Recommendations on use of reminder/recall systems have not been specific (method, number of reminders, etc.) • Providers might lack computer technology to track immunizations

29. 2011 Montana Medicaid Recall Letter Study • Pilot study • Study participants • Aged 19–23 months on December 1, 2010 • Enrolled in Montana Medicaid • Not known to be up-to-date on ACIP-recommended vaccines for children aged 18 months (WIZRD and Medicaid billing data) • Control group and intervention group (one-time letter) • Percentage of children up-to-date assessed at 12-weeks follow-up

30. Participant Characteristics

31. Recall Letter and Percentage of Children Vaccinated at Baseline and 3-month Follow-up

32. Results? • At follow-up, no significant difference existed between intervention and control cohorts for percentage of children known to be up-to-date on the recommended vaccine • All children • Sex • AI/AN classification • Population density for county of residence • No difference existed between the intervention and control cohorts for percentage of children known to have received individual antigens (except 3rd and 4th doses of PCV)

33. Why Limited Success? • Letter might not be as effective as other methods • Letter from state might not be as effective as those from healthcare provider or local health department • Letter was general and not personalized • Letter was sent one-time only • Medicaid population • More rural population than many other studies • Not enough time to see change

34. Patient Preferences for Reminder/Recall Systems • Internet-based survey of 1612 parents of children aged 0–17 years • 31% of parents reported receiving notice that their child was due for a vaccination • Child’s physician (51%) • Child’s school (21%) • Health department (14%) • Child’s health plan (10%) Clark SJ, Butchart A, Kennedy A, Dombkowski KJ. Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics 2011;128:e1100–5.

35. Patient Preferences for Reminder/Recall Systems Clark SJ, Butchart A, Kennedy A, Dombkowski KJ. Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics 2011;128:e1100–5.

36. Patient Preferences for Reminder/Recall Systems Clark SJ, Butchart A, Kennedy A, Dombkowski KJ. Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics 2011;128:e1100–5.

37. Patient Preferences for Reminder/Recall Systems Clark SJ, Butchart A, Kennedy A, Dombkowski KJ. Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics 2011;128:e1100–5.

38. Reminder/Recall Systems — Success Story #1 • Setting: • Nonprofit Community Health Center in Fort Lupton, CO • Patient population: • Predominantly Hispanic and of lower socioeconomic status • Previous history: • Reminder cards ineffective at this clinic for increasing frequency of laboratory testing among adult patients with diabetes • Intervention: • Up to 3reminder cards sent by mail in primary language to parents of underimmunized children aged 13–35 months Hicks P, Tarr GA, Hicks XP. Reminder cards and immunization rates among Latinos and the rural poor in Northeast Colorado. J Am Board Fam Med. 2007;20(6):581–6.

39. Reminder/Recall Systems — Success Story #1 Hicks P, Tarr GA, Hicks XP. Reminder cards and immunization rates among Latinos and the rural poor in Northeast Colorado. J Am Board Fam Med. 2007;20(6):581–6

40. Reminder/Recall Systems — Success Story #1 Hicks P, Tarr GA, Hicks XP. Reminder cards and immunization rates among Latinos and the rural poor in Northeast Colorado. J Am Board Fam Med. 2007;20(6):581–6

41. Reminder/Recall Systems — Success Story #2 • Setting: • Fourteen counties in rural and urban Georgia • Interventions: • Telephone calls to parents of children aged <2 years if due for immunization in upcoming 4 months. Parents called twice daily for 7 days until successful contact made • (a) pre-recorded general vaccine reminder message • (b) pre-recorded general vaccine recall message • (c) computer generated general reminder message • (d) computer generated general recall message • (e) computer generated vaccine-specific reminder message • (f) computer generated vaccine-specific recall message Linkins RW, Dini EF, Watson G, Patriarca PA. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Arch Pediatr Adolesc Med. 1994;148(9):908–14.

42. Reminder/Recall Systems — Success Story #2 Linkins RW, Dini EF, Watson G, Patriarca PA. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Arch Pediatr Adolesc Med. 1994;148(9):908–14.

43. Summary • Montana’s childhood/adolescent vaccine coverage low • Relatively few of Montana’s healthcare providers that administer adolescent immunizations are known to utilize reminder/recall systems • Reminder/recall systems are, in general, an evidence-based approach to improve childhood and adult immunization rates

44. Summary • Several reminder/recall system methods are available • DPHHS-originating single recall letter not effective for Montana Medicaid population aged 19–23 months • Use of reminder/recall systems by local health departments and healthcare providers are likely integral to improving Montana’s immunization rates for children and adults • Reminder/recall systems only one of several factors contributing to vaccine coverage

45. Recommendations • Local health departments should begin (or continue) using vaccine reminder/recall systems • Local health departments should work with local healthcare providers to ensure they are using vaccine reminder/recall systems • Vaccine histories should be entered into imMTrax to ensure most accurate vaccine history — allows for improved used of vaccine reminder/recall systems • Users of reminder/recall systems should evaluate their system and improve if necessary!

46. Questions?rnett@mt.gov or (406) 444-5917 For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Office of the Director Office of Public Health Preparedness and Response