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Randall J. Nett, MD, MPH

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State-generated vaccine recall letter for Medicaid-enrolled children aged 19–23 months — Montana, 2011. Randall J. Nett, MD, MPH. CDR, United States Public Health Service Career Epidemiology Field Officer — assigned to Montana 2012 Annual CSTE Conference June 5, 2012. Office of the Director. - PowerPoint PPT Presentation
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State-generated vaccine recall letter for Medicaid-enrolled children aged 19–23 months — Montana, 2011 Randall J. Nett, MD, MPH CDR, United States Public Health Service Career Epidemiology Field Officer — assigned to Montana 2012 Annual CSTE Conference June 5, 2012 Office of the Director Career Epidemiology Field Officer Program
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Page 1: Randall J. Nett, MD, MPH

State-generated vaccine recall letter for Medicaid-enrolled children aged

19–23 months — Montana, 2011

Randall J. Nett, MD, MPHCDR, United States Public Health Service

Career Epidemiology Field Officer — assigned to Montana

2012 Annual CSTE ConferenceJune 5, 2012

Office of the DirectorCareer Epidemiology Field Officer Program

Page 2: Randall J. Nett, MD, MPH

Background Advisory Committee on Immunization

Practices (ACIP) Recommends children aged 0–18 months receive routine

vaccinations for protection against 14 vaccine-preventable diseases

National Immunization Survey (NIS) — 2009 Estimated coverage for recommended modified series

(Hib excluded) for children aged 19–35 months• Nationally = ~70% • Montana = 61.7% (lowest quintile among states)

1. http://www.cdc.gov/vaccines/recs/schedules/default.htm 2. http://www.cdc.gov/nchs/nis.htm

Page 3: Randall J. Nett, MD, MPH

Vaccine Reminder/Recall Systems Reminder/recall systems alert the parents

of children due (reminder) or overdue (recall) for vaccinations

Task Force on Community Preventive Services recommends use of reminder/recall systems

Effective at increasing child/adult vaccination coverage Healthcare provider Academic center Health department

1. http://www.thecommunityguide.org/vaccines/universally/index.html 2. Jacobson VJ, Szilagyi P. Patient reminder and patient recall systems to improve immunization rates. Cochrane

Database Syst Rev. 2005(3):CD003941.

Page 4: Randall J. Nett, MD, MPH

Vaccine Reminder/Recall System Variables

Method (telephone, letter, postcard, chart, etc.)

Population (adult, pediatric, privately insured, Medicaid, rural, urban, etc.)

Vaccine (series, influenza, single vaccine, etc.)

Schedule (one-time vs. multiple)

Intensity (one attempt vs. repeat attempts until contact)

Page 5: Randall J. Nett, MD, MPH

Vaccine Reminder/Recall Systems Irregularly used by surveyed U.S. physicians

28% of pediatricians 19% of Family Medicine physicians

Only 21% of surveyed Montana physicians caring for adolescents reported using reminder/recall systems

Not previously used by Montana Department of Public Health and Human Services (DPHHS)

1. 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.

2. http://www.dphhs.mt.gov/publichealth/immunization/documents/barriersreport.pdf

Page 6: Randall J. Nett, MD, MPH

Methods Identified children enrolled in Montana

Medicaid with birthdates December 2, 2008–May 1, 2009

Data as of December 28, 2010 entered into Comprehensive Clinic Assessment Software Application Medicaid billing data through December 1, 2010 Montana’s Web-based ImmuniZation Registry Database

(WIZRD)

Medicaid Billing Data Claims submitted to DPHHS following completion of

services Average 4-week delay from service to submission of billing

claim Prior to this study, billing data not used for public health

purposes

Page 7: Randall J. Nett, MD, MPH

Methods Children enrolled in study if not known to

have received each vaccine in study vaccination series

Page 8: Randall J. Nett, MD, MPH

Study Vaccination Series ≥4 doses of diphtheria, tetanus toxoid, and

acellular pertussis vaccine (DTaP) ≥3 doses of inactivated poliovirus vaccine

(IPV) ≥1 dose of measles, mumps, and rubella

vaccine (MMR) ≥4 doses of Haemophilus influenzae type b

conjugate vaccine (Hib) ≥3 doses of hepatitis B vaccine (HepB) ≥1 dose of varicella vaccine (VAR) ≥4 doses of pneumococcal vaccine (PCV)

Page 9: Randall J. Nett, MD, MPH

Study Vaccination Series

Page 10: Randall J. Nett, MD, MPH

Study Vaccination Series

Page 11: Randall J. Nett, MD, MPH

Methods Children randomly selected to intervention

or control cohorts Intervention cohort = parents sent recall letter on

January 21, 2011 Control cohort = no recall letter sent

Used addresses listed in Montana Medicaid If letter returned, re-sent using address

listed in WIZRD, if different Vaccination coverage assessed at baseline

and in June 2011 for vaccines received through April 30, 2011

SAS® Enterprise Guide 4.22.0.9238

Page 12: Randall J. Nett, MD, MPH

Recall Letter Generalized letter

No mention ofspecific vaccines

Urged parents to visit their healthcare provider to be brought up-to-date

Sent one-time

Page 13: Randall J. Nett, MD, MPH

Results1865 Medicaid enrolled children aged 19–23 months

Page 14: Randall J. Nett, MD, MPH

Results1865 Medicaid enrolled children aged 19–23 months

987 children excluded

Page 15: Randall J. Nett, MD, MPH

Results1865 Medicaid enrolled children aged 19–23 months

878 children eligible to participate

987 children excluded

Page 16: Randall J. Nett, MD, MPH

Results1865 Medicaid enrolled children aged 19–23 months

878 children eligible to participate

987 children excluded

440 (50%) children not sent letter

Page 17: Randall J. Nett, MD, MPH

Results1865 Medicaid enrolled children aged 19–23 months

878 children eligible to participate

987 children excluded

438 (50%) children sent recall letter

440 (50%) children not sent letter

Page 18: Randall J. Nett, MD, MPH

Results438 children sent recall letter

Page 19: Randall J. Nett, MD, MPH

Results438 children sent recall letter

355 (80%) letters not returned

Page 20: Randall J. Nett, MD, MPH

Results438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

Page 21: Randall J. Nett, MD, MPH

Results438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

45 letters re-sent

Page 22: Randall J. Nett, MD, MPH

Results438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

45 letters re-sent

38 letters not resent

Page 23: Randall J. Nett, MD, MPH

Study Participants (n = 878) Male = 464 (53%) Median age = 21 months American Indian/Alaskan Native (AI/AN) =

184 (21%) Rural or frontier county = 768 (87%) Number of missing vaccines

1–2 = 357 (41%) 3–5 = 204 (23%) 6–10 = 121 (14%) 11–20 = 196 (22%)

No significant difference in above characteristics between intervention and control cohorts (p>0.05)

Page 24: Randall J. Nett, MD, MPH

Coverage for Selected Vaccines at Baseline

DTaP-4 HepB-3 Hib-4 IPV-3 MMR-1 PCV-4 VAR-10

10

20

30

40

50

60

70Interven-tion

Vaccine

% c

over

age

*P-value >0.05 for each vaccine

Page 25: Randall J. Nett, MD, MPH

Coverage for Study Vaccination Series at 3 Months

All Valid address

Urban Rural Frontier AI/AN0

20

40

60

80

100

Interven-tion

Characteristic

% c

over

age

*P-value >0.05 for each characteristic

Page 26: Randall J. Nett, MD, MPH

DTaP — % Increase in Coverage from Baseline

1st 2nd 3rd 4th0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for each dose

Page 27: Randall J. Nett, MD, MPH

HepB — % Increase in Coverage from Baseline

1st 2nd 3rd0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for each dose

Page 28: Randall J. Nett, MD, MPH

Hib — % Increase in Coverage from Baseline

1st 2nd 3rd 4th0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for each dose

Page 29: Randall J. Nett, MD, MPH

IPV — % Increase in Coverage from Baseline

1st 2nd 3rd0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for each dose

Page 30: Randall J. Nett, MD, MPH

MMR — % Increase in Coverage from Baseline

1st0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for 1st dose

Page 31: Randall J. Nett, MD, MPH

PCV — % Increase in Coverage from Baseline

1st* 2nd* 3rd** 4th**0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for each dose**P-value <0.05 for each dose

Page 32: Randall J. Nett, MD, MPH

VAR — % Increase in Coverage from Baseline

1st0

5

10

15

20

25Interven-tion

Dose

% in

crea

se

*P-value >0.05 for 1st dose

Page 33: Randall J. Nett, MD, MPH

Discussion Single, state-generated recall letter

resulted in limited increase in vaccination coverage among predominantly rural Medicaid-enrolled children aged 19–23 months No statistically significant increase in coverage for study

vaccination series Significant increase in third and fourth dose of PCV Non-statistically significant increase in coverage for

some antigens

Study demonstrated specific reminder/recall systems not effective in every setting

Study described potential use for Medicaid billing data

Page 34: Randall J. Nett, MD, MPH

Why Less Successful than Other Studies?

Letter was sent one-time only

Letter was generalized and not more specific

Letter originated from DPHHS and not individual healthcare provider

Letter might not be preferred delivery method for younger parents

Rural population

Other confounders

Page 35: Randall J. Nett, MD, MPH

Influences on Vaccination Coverage Parental beliefs and attitudes Perceived low-risk from vaccine preventable

diseases School entry, childcare entry, and work

entry requirements Access to healthcare Cost of vaccines Healthcare provider practices

Page 36: Randall J. Nett, MD, MPH

Influences on Vaccination Coverage Parental beliefs and attitudes Perceived low-risk from vaccine preventable

diseases School entry, childcare entry, and work

entry requirements Access to healthcare Cost of vaccines Healthcare provider practices

Healthcare provider beliefs and attitudes Office practices Personal emphasis placed on immunizations Use of reminder/recall systems

Page 37: Randall J. Nett, MD, MPH

Influences on Vaccination Coverage Parental beliefs and attitudes Perceived low-risk from vaccine preventable

diseases School entry, childcare entry, and work

entry requirements Access to healthcare Cost of vaccines Healthcare provider practices

Healthcare provider beliefs and attitudes Office practices Personal emphasis placed on immunizations Use of reminder/recall systems

Page 38: Randall J. Nett, MD, MPH

Limitations Letters not sent by certified mail

Potential delay in healthcare provider billing

Only 93% of public healthcare providers and 74% of private healthcare providers known WIZRD users

Medical records of study participants not reviewed

Page 39: Randall J. Nett, MD, MPH

Conclusions Vaccine reminder/recall systems effective at

increasing vaccination coverage

Single state-generated recall letter sent to parents of Montana Medicaid-enrolled children aged 19–23 months had limited effectiveness

Medicaid billing data are important source of public health data

Page 40: Randall J. Nett, MD, MPH

Recommendations Clinicians should use reminder/recall

systems to improve vaccination coverage among their patients

State and local health departments should use reminder/recall system(s) most likely to improve vaccination coverage in their population

Users of reminder/recall systems should evaluate system to determine effectiveness and adjust strategy

Public health authorities should conduct further research to identify effective reminder/recall systems

Page 41: Randall J. Nett, MD, MPH

Next Steps imMTrax

Montana’s new IIS Higher functionality Advocating for vaccination providers to use

reminder/recall systems Alternative reminder/recall methods

Continued use of Medicaid billing data for public health purposes

Page 42: Randall J. Nett, MD, MPH

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] 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 DirectorCareer Epidemiology Field Officer Program

Carolyn A. ParrySteven D. HelgersonCody L. CustisJames S. MurphyCarol BallewEric Higginbotham

AcknowledgmentsBekki WehnerKathleen GradyVicci StroopHeather Zimmerman

Page 43: Randall J. Nett, MD, MPH

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.


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