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 Director

Career Epidemiology Field Officer Program

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

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.

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)

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

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

Methods

Children enrolled in study if not known to have received each vaccine in study vaccination series

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)

Study Vaccination Series

Study Vaccination Series

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

Recall Letter

Generalized letter

No mention ofspecific vaccines

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

Sent one-time

Results

1865 Medicaid enrolled children aged 19–23 months

Results

1865 Medicaid enrolled children aged 19–23 months

987 children excluded

Results

1865 Medicaid enrolled children aged 19–23 months

878 children eligible to participate

987 children excluded

Results

1865 Medicaid enrolled children aged 19–23 months

878 children eligible to participate

987 children excluded

440 (50%) children not sent letter

Results

1865 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

Results

438 children sent recall letter

Results

438 children sent recall letter

355 (80%) letters not returned

Results

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

Results

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

45 letters re-sent

Results

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

45 letters re-sent

38 letters not resent

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)

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

overa

ge

*P-value >0.05 for each vaccine

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

overa

ge

*P-value >0.05 for each characteristic

DTaP — % Increase in Coverage from Baseline

1st 2nd 3rd 4th0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for each dose

HepB — % Increase in Coverage from Baseline

1st 2nd 3rd0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for each dose

Hib — % Increase in Coverage from Baseline

1st 2nd 3rd 4th0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for each dose

IPV — % Increase in Coverage from Baseline

1st 2nd 3rd0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for each dose

MMR — % Increase in Coverage from Baseline

1st0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for 1st dose

PCV — % Increase in Coverage from Baseline

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

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

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

VAR — % Increase in Coverage from Baseline

1st0

5

10

15

20

25

Interven-tion

Dose

% in

cre

ase

*P-value >0.05 for 1st dose

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

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

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

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

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

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

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

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

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

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: 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

Career Epidemiology Field Officer Program

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

Acknowledgments

Bekki WehnerKathleen GradyVicci StroopHeather Zimmerman

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.