1. Children’s Outcomes Research Program The Children’s Hospital Aurora, CO Children’s Outcomes Research Program The Children’s Hospital Aurora, CO Colorado Health Outcomes Program U. Colorado Denver Aurora, CO How Successful is Reminder/Recall at Improving Immunization Rates for Adolescents? Christina A. Suh MD Instructor of Pediatrics University of Colorado Denver

2. Disclosures The investigators have no relevant financial relationships with any commercial interests No reference will be made to the use of medications in manners not licensed by the Food and Drug Administration.

3. Adolescent Immunizations  Historically, adolescent vaccination focused on booster doses and “catch-up” vaccines  Since 2005, several new vaccines licensed and recommended for use in adolescents  Renewed focus on improving the delivery of immunizations to adolescents with a target of immunizing 11-12 year olds

4. Barriers to Adolescent Immunization  Lack of regular preventative care visits in this age group  Lack of awareness of recommended vaccines  Missed vaccination opportunities  Record scatter—due to multiple sites of care  Difficulty obtaining parent consent  Costs to adolescent/family  Lack of insurance Szilagyi et al Pediatrics 2008

5. Patient Reminder/Recall Systems  Patients receive a reminder notification for upcoming immunizations or a recall notice for overdue immunization  Generally effective in increasing immunization rates in young children and adults* Range 1 – 20 absolute percentage point increase Most studies raised rates by greater than 5 percentage points  Very few studies of reminder/recall systems previously done in adolescent populations *Jacobson, Cochrane Review 2005

6. Study Objectives  Primary Objective To assess, using a randomized controlled trial, the effectiveness of reminder/recall at increasing adolescent immunization rates  Secondary Objective To assess differences in effectiveness of reminder/recall in pediatrics (Peds) vs. family medicine (FM) practices

7. Methods: Study Setting  4 private Peds practices and 3 private FM practices Located in the Denver-metro area Participate in Colorado Information Immunization System (CIIS)  Providers per practice range: 2-22  # adolescents per practice range: Peds: 2,500 – 5,300 FM: 600-700

8. Methods: Population  Inclusion Criteria Age 11 – 18 years Seen for any visit type by the practice in the past 24 months Needed one or more of the following immunizations: Tdap, MCV4, 1 st dose HPV (females only)  Exclusion Criterion Any adolescent who opted to not be included in the CIIS (<1%)

9. Definition  For this study, considered following vaccines: Tdap MCV4 First dose HPV only—did not look at all doses of HPV  “All required immunizations”

10. Methods: Study Subjects  Study Subject Selection Billing data from each practice uploaded into CIIS to ensure that registry had record of most recent immunizations Determined each adolescent’s vaccination status using data from CIIS  300-400 adolescents selected per practice that had not received all required vaccines  Patients randomized within each practice to either intervention or control groups

11. Methods: Intervention  Immunizations for which recall conducted Tdap MCV4 1 st dose HPV (females only)  Families received up to 2 mailings and 2 phone calls Initial Letter Phone call #1 (week 1 later) Phone call #2 (2 months after initial letter) Final letter (3 months after initial letter)

12. Methods: Intervention  Families able to “opt out” of further mailings/phone calls by returning a form sent with initial letter for following reasons: Refused one or more of the vaccines Wanted to defer vaccines to a later time Parent reported adolescent had already received vaccines

13. Outcomes  Proportion of adolescents receiving at least 1 vaccine 6 months after first recall Peds and FM  Proportion of adolescents receiving all vaccines they required 6 months after first recall Peds and FM  Proportion of adolescents in intervention vs. control who received individual vaccines Entire study group

14. Results: Study Population InterventionControlP value N13601361 Mean age yrs (std. dev.) 14.8 (2.32)14.7 (2.24)NS % female60.456.00.02

15. Proportion adolescents who received at least 1 vaccine: Peds Overall difference: 11% Range: 13%-18% p<.001 p=.001 p=0.6 p=.007 p<.001

16. Proportion adolescents who received at least 1 vaccine: FM Overall difference:12% Range: 13%-15% p<.001 p=.003 p=.06 p=.003

17. Proportion adolescents who received all required vaccines: Peds Overall difference: 9% Range: 12%-16% p<.001 p=.006 p=.65 p=.07 p<.001

18. Proportion adolescents who received all required vaccines: FM Overall difference: 6% I vs. C difference: 9% p=.002p=.16p=.18p=.003

19. Proportion who got Tdap, among those who needed (Peds and FM) p=.007 I vs. C difference: 7%

20. Proportion who got MCV4, among those who needed (Peds and FM) I vs. C difference: 12% p<.001

21. Proportion who got HPV#1, among those who needed (Peds and FM) I vs. C difference: 9% p<.001

22. Probability of adolescent receiving at least 1 vaccine Interaction between practice type and intervention not significant (p=0.36) Practice Type Adjusted* Odds Ratio95% CI Pediatrics1.631.33-2.01 Family Medicine1.951.47-2.59 Overall1.721.46-2.02 *Adjusted for gender and age

23. Probability of adolescent receiving all vaccines required Interaction between practice type and intervention not significant (p=0.67) Practice Type Adjusted* Odds Ratio95% CI Pediatrics1.731.38-2.17 Family Medicine1.801.26-2.59 Overall1.721.42-2.07 *Adjusted for gender and age

24. Summary of Findings  Reminder/recall significantly increased adolescent immunization rates in Peds and FM practices with similar increases in rates  Reminder/recall significantly increased adolescent immunization rates for each of the individual vaccines studied

25. Summary of Findings  No significant increase in rates seen in 2 practices (1 FM and 1 Peds)  In 2 other practices (1 FM and 1 Peds) Increase in rates who received at least 1 shot No increase in rates who received all required shots

26. Limitations  Despite random allocation, some difference in gender between study groups  Data only generalizable to urban/suburban pediatric and family medicine practices  No exploration to date of why reminder/recall was not successful in some practices  Did not study sustainability of intervention

27. Conclusions  Letter and telephone reminders were effective in increasing adolescent immunization rates in both pediatrics and family medicine practices  Effect sizes are comparable to those reported for reminder/recall interventions in younger children

28.  Although effective in most, reminder/recall not effective in all practices  Unclear why in some practices, adolescents who responded to reminders did not receive all required shots Vaccine supply issues? Physician not stocking vaccine? Insurance issues? Deferred by parents? Conclusions

29.  Christina Suh, MD  Matthew F. Daley, MD  L. Miriam Dickinson, PhD  Alison Saville, MSPH, MSW  Jennifer Barrow, MSPH  Kathryn Benton, MPH  Fran Dong, MS  Judith Glazner, MS CDC Collaborators  Shannon Stokley, MPH Principal Investigator – Allison Kempe, MD, MPH Adolescent Reminder/Recall Project University of Colorado Denver Funding Centers for Disease Control and Prevention