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
Vaccine Coverage US MT
Vaccine
Avg
Max
Rank
Gap
Complete Series (4:3:1:3:3:1)
76.1
82.3
59.2 50
-16.9
Varicella
90.7
95.3
77.7 49
-13.0
4+DTaP
84.6
90.3
74.4
-10.2
3+Hib
90.9
98.4
81.1 48
-9.8
3+HepB
93.5
98.1
86.6
-6.9
1+MMR
92.1
95.6
85.9
-6.2
3+Polio
93.6
99.5
88.5
-5.1

4. 2010 National Immunization Survey (19–35 months) — Montana’s rank and opportunity to improve
Vaccine Coverage US MT
Vaccine
Avg
Max
Rank
Gap
Complete Series (4:3:1:0:3:1:4)
70.5
78.1
64.9 45
-5.6
Varicella
90.4
96.2
80.6 50
-9.8
4+DTaP
84.4
92.2
76.6
-7.8
3+Hib
99.5
80.8 49
-9.6
3+HepB
91.8
98.3
87.0 47
-4.8
1+MMR
91.5
97.8
85.1
-10.4
3+Polio
93.3
98.5
84.3
-9.0
4+PCV
83.3
93.2
72.6
-10.7

5. 2010 National Immunization Survey (13–17 years) — Montana’s rank and opportunity to improve

6. 2010 National Immunization Survey (13–17 years) — Montana’s rank and opportunity to improve

7. 2010 Adult Influenza Vaccine Coverage — Montana and US
% vaccinated (95% CI)
Age category (years) MT US
MT lower than US?
≥18
37.7 (35.7–39.7)
40.5 (40.1–40.9)
Yes
18–49
27.1 (24.0–30.2)
30.5 (29.6–31.1)
Maybe
18–49 high risk
27.3 (18.9–35.7)
39.0 (36.8–41.2)
50–64
39.9 (37.0–42.8)
44.5 (43.9–45.1)
18–64 high risk
40.1 (34.1–46.1)
46.7 (45.3–48.1)
≥65
63.0 (60.1–65.9)
66.6 (66.0–67.2)
Behavioral Risk Factor Surveillance System (BRFSS) and National Immunization Survey (NIS), September June 2011 retrieved November 22, 2011 from

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

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
Cohort
Characteristic
Total N (percent)
Intervention N (percent)
Control N (percent)
P-value*
Number of participants†
878
438
440
Sex
.46
Male
464 (53)
237 (54)
227 (52)
Female
414 (47)
201 (46)
213 (48)
Median age
21 months —
American Indian/Alaskan Native§
184 (21)
89 (20)
95 (22)
.68
County of residence¶
.09
Urban
110 (13)
64 (15)
46 (10)
Rural
537 (61)
269 (61)
268 (61)
Frontier
231 (26)
105 (24)
126 (29)
Number of missing vaccines
.96
1–2
357 (41)
175 (40)
182 (41)
3­–5
204 (23)
101 (23)
103 (24)
6–10
121 (14)
62 (14)
59 (13)
11–20
196 (22)
100 (23)
96 (22)

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 3 reminder 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
IZ visits compared with no intervention
Intervention
aOR
95% CI
Effective?
Pre-recorded general vaccine reminder (1st cohort)
1.33
1.07–1.66
Yes
Pre-recorded general vaccine reminder (2nd cohort)
1.00
0.79–1.27 No
Pre-recorded general vaccine recall (1st cohort)
1.76
1.30–2.37
Pre-recorded general vaccine recall (2nd cohort)
2.56
1.81–3.61
Computer generated general vaccine reminder
1.63
1.33–1.98
Computer generated vaccine-specific reminder
1.49
1.22–1.82
Computer generated general vaccine recall
2.52
1.69–3.77
Computer-generated vaccine-specific recall
2.31
1.52–3.51
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
Telephone: CDC-INFO ( )/TTY:
Web:
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