State generated vaccine recall letter for medicaid enrolled children aged 19 23 months montana 2011
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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.

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State generated vaccine recall letter for medicaid enrolled children aged 19 23 months montana 2011
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 ServiceCareer Epidemiology Field Officer — assigned to Montana

2012 Annual CSTE Conference

June 5, 2012

Office of the Director

Career Epidemiology Field Officer Program


Background
Background children aged

  • 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)

http://www.cdc.gov/vaccines/recs/schedules/default.htm

http://www.cdc.gov/nchs/nis.htm


Vaccine reminder recall systems
Vaccine Reminder/Recall Systems children aged

  • 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

http://www.thecommunityguide.org/vaccines/universally/index.html

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
Vaccine Reminder/Recall System Variables children aged

  • 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 systems1
Vaccine Reminder/Recall Systems children aged

  • 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)

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.

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


Methods
Methods children aged

  • 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


Methods1
Methods children aged

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


Study vaccination series
Study Vaccination Series children aged

  • ≥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)




Methods2
Methods children aged

  • 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
Recall Letter children aged

  • Generalized letter

  • No mention ofspecific vaccines

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

  • Sent one-time


Results
Results children aged

1865 Medicaid enrolled children aged 19–23 months


Results1
Results children aged

1865 Medicaid enrolled children aged 19–23 months

987 children excluded


Results2
Results children aged

1865 Medicaid enrolled children aged 19–23 months

987 children excluded

878 children eligible to participate


Results3
Results children aged

1865 Medicaid enrolled children aged 19–23 months

987 children excluded

878 children eligible to participate

440 (50%) children not sent letter


Results4
Results children aged

1865 Medicaid enrolled children aged 19–23 months

987 children excluded

878 children eligible to participate

440 (50%) children not sent letter

438 (50%) children sent recall letter


Results5
Results children aged

438 children sent recall letter


Results6
Results children aged

438 children sent recall letter

355 (80%) letters not returned


Results7
Results children aged

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable


Results8
Results children aged

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

45 letters re-sent


Results9
Results children aged

438 children sent recall letter

355 (80%) letters not returned

83 (20%) letters returned undeliverable

38 letters not resent

45 letters re-sent


Study participants n 878
Study Participants (n = 878) children aged

  • 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
Coverage for Selected Vaccines at Baseline children aged

*P-value >0.05 for each vaccine


Coverage for study vaccination series at 3 months
Coverage for Study Vaccination Series at 3 Months children aged

*P-value >0.05 for each characteristic


Dtap increase in coverage from baseline
DTaP — % Increase in Coverage from Baseline children aged

*P-value >0.05 for each dose


Hepb increase in coverage from baseline
HepB — % Increase in Coverage from Baseline children aged

*P-value >0.05 for each dose


Hib increase in coverage from baseline
Hib — % Increase in Coverage from Baseline children aged

*P-value >0.05 for each dose


Ipv increase in coverage from baseline
IPV — % Increase in Coverage from Baseline children aged

*P-value >0.05 for each dose


Mmr increase in coverage from baseline
MMR — % Increase in Coverage from Baseline children aged

*P-value >0.05 for 1st dose


Pcv increase in coverage from baseline
PCV — % Increase in Coverage from Baseline children aged

*P-value >0.05 for each dose

**P-value <0.05 for each dose


Var increase in coverage from baseline
VAR — % Increase in Coverage from Baseline children aged

*P-value >0.05 for 1st dose


Discussion
Discussion children aged

  • 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
Why Less Successful than Other Studies? children aged

  • 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
Influences on Vaccination Coverage children aged

  • 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 coverage1
Influences on Vaccination Coverage children aged

  • 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 coverage2
Influences on Vaccination Coverage children aged

  • 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
Limitations children aged

  • 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
Conclusions children aged

  • 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
Recommendations children aged

  • 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
Next Steps children aged

  • 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


Carolyn a parry steven d helgerson cody l custis james s murphy carol ballew eric higginbotham
Carolyn A. Parry children aged Steven D. HelgersonCody L. CustisJames S. MurphyCarol BallewEric Higginbotham

Acknowledgments

Bekki WehnerKathleen Grady

Vicci StroopHeather Zimmerman

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-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 Director

Career Epidemiology Field Officer Program


Patient preferences for reminder recall systems
Patient Preferences for Reminder/Recall Systems children aged

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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