Feasibility of initiating and sustaining registry-based immunization recall in private practices

Primary Immunization Series Coverage of Children With Sickle Cell Disease

INTRODUCTION

Children with sickle cell disease are at increased risk of serious infections, many of which can be prevented by receipt of recommended immunizations. Study objectives were to (1) assess the primary immunization series coverage among children with sickle cell disease and (2) compare the coverage with that of those without sickle cell disease.

METHODS

The Michigan Care Improvement Registry was used to obtain primary immunization series doses and sickle cell disease status for all eligible children in Michigan born in 2001-2016 (analysis was conducted in 2019). Completion of series and each individual vaccine were assessed for every child at ages 19 and 35 months. Proportions were stratified by sickle cell disease status and compared using chi-square tests. Logistic regression was used to model the odds of completing the series at each age, as predicted by sickle cell disease status and adjusting for the presence of Medicaid identification number.

RESULTS

The proportion of children who completed the immunization series was higher for those with sickle cell disease than for those without sickle cell disease at 19 months (58.5% vs 48.0%) and 35 months (74.7% vs 59.6%) (both p<0.0001). The odds of completing the series were 1.4 times higher at 19 months (95% CI=1.2, 1.6) and 1.7 times higher at 35 months (95% CI=1.5, 2.0) for children with sickle cell disease than for those without, adjusting for the presence of Medicaid identification number.

CONCLUSIONS

Although children with sickle cell disease had higher immunization rates than those without sickle cell disease, >40% of children with sickle cell disease did not receive all recommended immunizations by age 19 months. Immunization information systems should be utilized to improve routine immunization coverage of children with sickle cell disease.

Costs of Interventions to Increase Vaccination Coverage Among Children in the United States: A Systematic Review

BACKGROUND

The Community Preventive Services Task Force (CPSTF) has recommended several interventions that have been demonstrated to be effective at increasing vaccination coverage.

OBJECTIVE

Conduct a systematic review to examine the costs of interventions designed to increase vaccination coverage among children and adolescents in the United States.

DATA SOURCES

PubMed, EconLit, Embase, and Cochrane.

STUDY ELIGIBILITY, PARTICIPANTS, AND INTERVENTIONS

Peer-reviewed articles from January 1, 2009 to August 31, 2019.

APPRAISAL AND SYNTHESIS METHODS

Studies were identified with systematic searches of the literature, reviewed for inclusion criteria, abstracted for data on intervention, target population, costs, and risk of bias. Cost measures were reported as costs per child in the target population, costs per vaccinated child, incremental costs per vaccinated child, and costs per vaccine dose administered. Results were stratified by intervention type, vaccine, and age group.

RESULTS

Thirty-seven studies were identified for full-text review. Across all interventions and age groups, the cost per child ranged from $0.10 to $537.38, and the incremental cost per vaccinated child ranged from $6.52 to $5,098.57. Provider assessment and feedback interventions had the lowest (median) cost per child ($0.17) and a healthcare system-based combined intervention with multiple components had the lowest (median) incremental cost per vaccinated child ($26.65). A community-based combined intervention with multiple components had the highest median cost per child ($537.38) and the highest median incremental cost per vaccinated child ($5,098.57).

LIMITATIONS

A small number of included intervention types and inconsistent cost definition.

CONCLUSIONS

There is substantial variability in the costs of CPSTF-recommended interventions.

Postcard reminders for HPV vaccination mainly primed parents for providers' recommendations

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Postcard reminders increased vaccination rates during preventive care visits.

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Postcards may prime parents for provider recommendations.

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Reminders may be most effective if combined with provider-targeted interventions.

Parent-targeted reminders increase human papillomavirus (HPV) vaccination rates. Our postcard reminders increased HPV vaccine initiation (receipt of at least one dose) by 60% among girls, but not substantially among boys. To select a complementary intervention that would maximize the effect of reminders, we assessed the percentage increase in HPV vaccine initiation from reminders increasing preventive care visits or increasing the likelihood of vaccine receipt during preventive care.

We conducted a secondary analysis of the postcard reminders from a quasi-experimental, factorial designed, feasibility trial conducted in 2013–2014 among 2,470 11- to 17-year-old girls enrolled in Florida’s Medicaid or Children’s Health Insurance Programs. We used log-linear models and a 4-way decomposition method to estimate the mediating and interacting effects of preventive visits on the effect of postcards on HPV vaccination.

After receiving a preventive visit, 76% (269/356) of girls remained unvaccinated. Nearly half of the effect of postcards on HPV vaccination was mediated by preventive visits (44%; 95% CI = 9.2% to 78.0%). Postcards increased HPV vaccine initiation mainly by increasing the likelihood of HPV vaccine receipt during preventive visits (pure indirect effect = 32.3%; 95% CI = 1.5% to 63.1%), and also by increasing the occurrence of preventive visits (mediated interaction = 11.3%; 95% CI = 1.5 to 21.1).

Reminders likely increased vaccination rates during well visits by priming parents for HPV vaccine conversations with their child’s health care provider. Thus, reminder effectiveness may be increased if timed closely to preventive care visits and/or combined with interventions that improve provider recommendations.

Trial Registration: ClinicalTrials.gov, NCT04208269, Registered 23, December 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04208269.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Understanding the Financial Implications of Immunization Reminder/Recall in a Multipractice Pediatric Group

OBJECTIVE

Immunization reminder/recall is widely recommended as an effective strategy for increasing vaccination rates. We examined the revenue generated from well-child visits scheduled as a result of reminder/recall activities implemented in a multipractice pediatric organization.

METHODS

Patients aged 19 to 35 months who were due or overdue for vaccines were identified from participating practices and assigned to either standard or enhanced reminder/recall activities. Participants who received standard reminder/recall were observed for the 6-week study period, and the number of appointments in which vaccines were administered was tracked. Participants who received enhanced reminder/recall were contacted up to 3 times and received a letter followed by up to 2 phone calls. Financial information associated with appointments scheduled during the study period was obtained, and revenue was calculated for each dose of vaccine administered. Reminder/recall costs were calculated and overall revenue generated was calculated.

RESULTS

We identified 3916 children who were potentially due or overdue for immunizations. After review and manual uploading of missing historical vaccines, a total of 1892 participants received the reminder/recall initiative; 942 received standard reminder/recall, and 950 received enhanced reminder/recall. One hundred eighty-two (19%) standard and 277 (29%) enhanced reminder/recall participants scheduled an appointment by the end of the study period (P < .001). After subtracting the cost of reminder/recall activities, an additional $20,066 and $20,235 were generated by standard and enhanced reminder/recall, respectively.

CONCLUSIONS

We show that conducting reminder/recall is at a minimum financially neutral, and might increase revenue generated by vaccine administration.

Centralized Reminder/Recall to Increase Immunization Rates in Young Children: How Much Bang for the Buck?

OBJECTIVE

We compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the child's provider.

METHODS

We conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates.

RESULTS

C-R/R was more effective in trials 1 to 3 (relative risk = 1.11; 95% confidence interval 1.01-1.20; P = .009). Effectiveness did not decrease with decreasing intervention intensity (P = .59). Costs decreased with decreasing intensity in the C-R/R arm, from $18.72 per child brought UTD in trial 1 to $10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from $20.63 to $237.81 per child brought UTD. C-R/R was significantly more effective if the child's practice name was included (P < .0001).

CONCLUSIONS

C-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child's provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials.

Factors Associated With Provider Reporting of Child and Adolescent Vaccination History to Immunization Information Systems: Results From the National Immunization Survey, 2006-2012

CONTEXT

Use of Immunization information systems (IISs) by providers can improve vaccination rates by identifying missed opportunities. However, provider reporting of children's vaccination histories to IISs remains suboptimal.

OBJECTIVE

To assess factors associated with provider reporting to an IIS.

DESIGN

Analysis of 2006-2012 National Immunization Survey (NIS) and NIS-Teen data. NIS and NIS-Teen are ongoing random-digit-dial telephone surveys of households with children and adolescents, respectively, followed by a mail survey to providers to obtain the patient's vaccination history.

SETTING AND PARTICIPANTS

A total of 115 285 children aged 19 to 35 months and 83 612 adolescents aged 13 to 17 years and their immunization providers in the United States.

MAIN OUTCOME MEASURES

The percentage of children and adolescents with 1 or more providers reporting to or obtaining vaccination information from their local IISs. Multivariable logistic regression was used to examine patient and provider factors associated with provider reporting to IISs and adjusted prevalence of children and adolescents with 1 or more providers reporting to IISs.

RESULTS

In 2012, 79.4% of children and 77.4% of adolescents had 1 or more providers report any of their vaccination data to an IIS, and 41.9% of children and 51.5% of adolescents had providers who obtained any of their vaccination histories from an IIS. During 2006-2012, children and adolescents were more likely to have any of their vaccination data reported to an IIS if they received care from all public versus all private providers (children: 84.4% vs 69.6%, P < .0001; adolescents: 84.6% vs 66.4%, P < .0001), had 1 or more providers who ordered vaccines from a state or local health department (children: 76.7% vs 59.5%, P < .0001; adolescents: 77.0% vs 55.6%, P < .0001), or had 1 or more providers obtain vaccination information from the IIS (children: 86.1% vs 71.2%, P < .0001; adolescents: 83.7% vs 64.6%, P < .0001).

CONCLUSIONS

Health department staff should target providers less likely to use IIS services, including private providers, and providers not ordering vaccines from health departments to ensure they use IIS services.

Use of Immunization Information Systems in Primary Care

INTRODUCTION

Immunization information systems (IISs) are highly effective for increasing vaccination rates but information about how primary care physicians use them is limited.

METHODS

Pediatricians, family physicians (FPs), and general internists (GIMs) were surveyed by e-mail and mail from January 2015 to April 2015 from all states with an existing IIS. Providers were recruited to be representative of national provider organization memberships. Multivariable log binomial regression examined factors associated with IIS use (October 2015-April 2016).

RESULTS

Response rates among pediatricians, FPs, and GIMs, respectively, were 75% (325/435), 68% (310/459), and 63% (272/431). A proportion of pediatricians (5%), FPs (14%), and GIMs (48%) did not know there was a state/local IIS; 81%, 72%, and 27% reported using an IIS (p<0.0001). Among those who used IISs, 64% of pediatricians, 61% of FPs, and 22% of GIMs thought the IIS could tell them a patient's immunization needs; 22%, 29%, and 51% did not know. The most frequently reported major barriers to use included the IIS not updating the electronic medical record (29%, 28%, 35%) and lack of ability to submit data electronically (22%, 27%, 31%). Factors associated with lower IIS use included FP (adjusted risk ratio=0.85; 95% CI=0.75, 0.97) or GIM (adjusted risk ratio=0.33; 95% CI=0.25, 0.42) versus pediatric specialty and older versus younger provider age (adjusted risk ratio=0.96; 95 CI%=0.94, 0.98).

CONCLUSIONS

There are substantial gaps in knowledge of IIS capabilities, especially among GIMs; barriers to interoperability between IISs and electronic medical records affect all specialties. Closing these gaps may increase use of proven IIS functions including decision support and reminder/recall.

Effects of Phone and Text Message Reminders on Completion of the Human Papillomavirus Vaccine Series

PURPOSE

To assess the effect of phone or text message reminders to parents of adolescents on human papillomavirus (HPV) vaccine series completion in Rochester, NY.

METHODS

We performed parallel randomized controlled trials of phone and text reminders for HPV vaccine for parents of 11- to 17-year olds in three urban primary care clinics. The main outcome measures were time to receipt of the third dose of HPV vaccine and HPV vaccination rates.

RESULTS

We enrolled 178 phone intervention (180 control) and 191 text intervention (200 control) participants. In multivariate survival analysis controlling for gender, age, practice, insurance, race, and ethnicity, the time from enrollment to receipt of the third HPV dose for those receiving a phone reminder compared with controls was not significant overall (hazard ratio [HR] = 1.30, p = .12) but was for those enrolling at dose 1 (HR = 1.91, p = .007). There was a significant difference in those receiving a text reminder compared with controls (HR = 2.34, p < .0001; an average of 71 days earlier). At the end of the study, 48% of phone intervention versus 40% of phone control (p = .34), and 49% of text intervention versus 30% of text control (p = .001) adolescents had received 3 HPV vaccine doses.

CONCLUSIONS

In this urban population of parents of adolescents, text message reminders for HPV vaccine completion for those who had already started the series were effective, whereas phone message reminders were only effective for those enrolled at dose 1.

Age-specific strategies for immunization reminders and recalls: a registry-based randomized trial

BACKGROUND

Although previous studies have found reminder/recall to be effective in increasing immunization rates, little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices.

PURPOSE

To assess the relative effectiveness of centralized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009.

METHODS

Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry (MCIR), a statewide immunization information system: a 7-month recall strategy, a 12-month reminder strategy, and a 19-month recall strategy. Eligible children were randomized to notification (intervention) or no notification groups (control). Primary study outcomes included MCIR-recorded immunization activity (administration of ≥1 new dose, entry of ≥1 historic dose, entry of immunization waiver) within 60 days following each notification cycle.

RESULTS

A total of 10,175 children were included: 2,072 for the 7-month recall, 3,502 for the 12-month reminder, and 4,601 for the 19-month recall. Immunization activity was similar between notification versus no notification groups at both 7 and 12 months. Significantly more 19-month-old children in the recall group (26%) had immunization activity compared to their counterparts who did not receive a recall notification (19%).

CONCLUSIONS

Although recall notifications can positively affect immunization activity, the effect may vary by targeted age group. Many 7- and 12-month-olds had immunization activity following reminder/recall; however, levels of activity were similar irrespective of notification, suggesting that these groups were likely to receive medical care or immunization services without prompting.

Using a scripted data entry process to transfer legacy immunization data while transitioning between electronic medical record systems

BACKGROUND

Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion.

OBJECTIVES

We sought to transfer immunization data from two of our health system's soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility.

METHODS

We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Control's CVX immunization codes we developed a bridge between immunization identifiers within our system's EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review.

RESULTS

We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data - 500,906 records - just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data - 1,695 records - was migrated using the same process with minimal additional effort.

CONCLUSIONS

Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR.

Provider attitudes toward public-private collaboration to improve immunization reminder/recall: a mixed-methods study

OBJECTIVE

To assess primary care providers' current reminder/recall practices, preferences for collaboration with health departments in reminder/recall efforts, attitudes toward practice-based and population-based reminder/recall, and experiences with a population-based reminder/recall intervention.

METHODS

Providers responsible for making decisions about immunization delivery at all primary care practices that participate in the Colorado Immunization Information System were surveyed. Data collection was preceded by an intervention in which half of 14 counties received a population-based reminder/recall intervention conducted by the health department. Practice staff involved in immunization activities were then selected for semistructured telephone interviews that were based on the location of their practice within specified strata, including whether they were in the intervention counties, urban/rural location, and practice type.

RESULTS

A total of 282 (73.6%) of 383 of providers responded to the survey, and 253 who administered vaccines to children 19 to 35 months were retained; 82 staff members at 36 practices were interviewed. Providers' preferences for who should conduct reminder/recall were almost evenly split, with slightly more indicating that it should be conducted by the health department. Cost and feasibility issues were perceived barriers to conducting practice-based recall, particularly among urban practices. Support for population-based reminder/recall was highest among rural practices. Concern about perceived inaccuracies in immunization registry data was the major barrier to conducting population-based reminder/recall. The population-based intervention did not create an undue burden on practices.

CONCLUSIONS

A collaborative approach to reminder/recall involving both providers and health departments is preferable for many providers and may be a viable solution to the barriers of practice-based reminder/recall.

Statewide pandemic influenza vaccination reminders for children with chronic conditions

OBJECTIVES

We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic.

METHODS

We used Michigan's IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202,133). Reminders were mailed on December 7, 2009. We retrospectively assessed children's eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status.

RESULTS

Of the children sent reminders, 53,516 were ineligible. Of the remaining 148,617 children, vaccination rates were higher among the 142,383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142,383 control group children without chronic conditions who were not sent reminders.

CONCLUSIONS

Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.

Evaluation of the frequency of immunization information system use for public health research

Immunization information systems (IIS) have been useful for consolidating immunization data and increasing coverage, and have the potential to be a valuable resource for immunization research, but the extent which IIS data are used for research purposes has not been evaluated. We reviewed studies conducted using data from federally supported state and city immunization program IIS, and categorized research type based on study objectives to evaluate patterns in the types of research conducted. Research papers using IIS data published between 1999 and July 3, 2012 were identified by searching the CDC IIS publication database and PubMed. These searches produced 304 and 884 papers, respectively, 44 of which were eligible to be included in this evaluation. The most common research category was evaluation of factors associated with vaccine coverage and vaccine coverage estimates (n = 20). This study shows that IIS may not be used to their full potential with regards to research. Further research is needed to determine barriers to using IIS data for research purposes.

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents

OBJECTIVE

To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents.

METHODS

We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end.

RESULTS

Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost $18.78 (mailed) or $16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was $463.99 for mailed and $714.98 for telephone; the cost per additional adolescent receiving a preventive visit was $324.75 and $487.03.

CONCLUSIONS

Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits, with modest costs and modest impact.