Immunization Recall: Realizing the Financial Benefit to the Pediatrician

1. Immunization Recall: Realizing the Financial Benefit to the Pediatrician 43rd National Immunization Conference Leila C. Sahni* Immunization Project,Texas Children’s Hospital March 30, 2009 *No financial disclosures or conflicts of interest

2. Objectives • To identify and immunize children ages 19-35 months who are in need of routinely recommended immunizations; • To examine the revenue generated from the increased office visits prompted by the recall initiative. Texas Children’s Hospital

3. What is reminder recall? Texas Children’s Hospital

4. Reminder Recall: An Overview • Reminder recall systems notify patients who are due (reminder) or overdue (recall) for immunizations • An immunization best practice and a proven method of raising childhood immunization rates • Routinely implemented in dental and veterinary practices, but have yet to be widely adopted by pediatric health care providers Szilagyi PG. Pediatrics 1994;94:517-523.

5. What does the literature say about reminder recall? Texas Children’s Hospital

6. Effectiveness of Reminder Recall • Reminder recall systems are effective among both pediatric and adult populations • Effective in all medical settings (private practices, academic medical centers, and public health department clinics) • Effective for both routinely-recommended vaccines and targeted populations • Increases in immunization rates after implementation range from 5-20% Alto W et al. J Am Board Fam Pract. 1994;7 (6):472-477. Buffington J et al. JGIM. 1991;6 (3):204-209. Jacobson Vann JC & Szilagyi PG. Cochrane Database Syst Rev 2005, Art. No.: CD003941

7. Methods of Contact • All types of reminder and recall are effective • Person-to-person telephone reminders are the most effective • Letter reminders are more effective than postcards • Multiple reminders are more effective than single reminders Buchner D et al. J Am Geriatr Soc. 1987;35(8):755-760 Campbell J, et al. Clin Pediatr. 1994:268-272. Hogg, et al. Can Fam Physician 1998;44:81-88. Lieu TA, et al. Pediatrics 1998;101 (4): e3-13.

8. Additional Benefits of Reminder Recall Systems • Patients who are immunization-delayed are often overdue for other preventive services, such as well-child care and hearing screenings • Reminder recall systems targeting immunizations can increase other aspects of preventive care if implemented in primary care settings Fairbrother G, et al. Pediatrics 1996;97:785-790 Rodewald LE, et al. Arch of Ped and Adol Med 1995;149:393-397. Rodewald LE, et al. Pediatrics 1999;103:31-38.

9. If reminder recall systems are effective, why aren’t they used more frequently? Texas Children’s Hospital

10. Barriers to Recall • Providers may not perceive that studies apply to their practices • Recommendations about how to implement reminder recall systems are vague • Primary care practices have traditionally lacked the capability to track responses and measure effectiveness • Complexity of childhood immunization schedule Linkins RW, et al. Pediatr Ann 1998;27:349-354. Taskforce on Community Preventive Services. MMWR 1999;48:1-15. Udovich S & Lieu TA. Pediatr Ann. 1998;27:355-361.

11. Can immunization registries assist in performing reminder recall activities? Texas Children’s Hospital

12. Registry-Based Reminder Recall • Lists of immunization-delayed children are readily available in electronic format • Forecasting algorithms are accurate and minimize medical decision-making • Letters and mailing labels for immunization-delayed children can be printed easily Texas Children’s Hospital

13. An Example of Recall • Summer of 2007; 19-35 month olds from 8 participating practices • 2,980 potentially immunization-delayed children were identified from the local immunization registry • 968 (32%) were UTD after chart review, 255 (8%) MOGE, 205 (7%) inactive • 1,556 children were recalled • 695 appointments were scheduled by recalled children, with an average of $135 billed per appointment

14. Does Recall Make Financial Sense? • Recall activities were conducted in 10 Texas Children’s Pediatric Associates practices • A list of children ages 19-35 months at each participating practice who, based on registry data, were behind on their immunizations was generated • 4,471 children at study sites were identified as needing immunizations Texas Children’s Hospital

15. Methods and Timeline • June – August, 2008: • Students compared registry-generated lists of immunization-delayed children to the practices’ medical records • Parents of immunization-delayed children were contacted by mail and phone twice • Recall was conducted for a six-week period from June – August, 2008

16. Methods and Timeline • October, 2008: • Billing information was reviewed to determine the amount of reimbursement for any type of visit (either well-child care, sick, follow-up or nursing visit) that resulted from the recall initiative • The additional revenue generated by the practice as a result of implementation of the recall initiative was calculated

18. Initial Record Review In need of immunizations (n=2,196) 53% Texas Children’s Hospital

19. Recall Results • 182/1,096 (17%) observed patients scheduled appointments • 280/1,100 (25%) enhanced patients scheduled appointments • Patients who received enhanced recall were significantly more likely to schedule an appointment and return for immunizations (p<0.0001) Texas Children’s Hospital

20. Recall Program Expenses • Recall-associated expenses $5,746.75 • Student salaries $5,196.75 • Letters and postage $550.00 • Vaccine costs $4,306.00 Total: $10,052.75 Texas Children’s Hospital

21. Recall Program Outcomes

22. The Bottom Line • Reimbursements for patients receiving enhanced recall were $11,958 more than for children in the observed group • Costs of the program were $5,746.75 • Vaccine costs totaled $4,306.00 • Total costs: $10,052.75 • Net reimbursement per appointment: $19.44 • Reducing student salaries to minimum wage ($6.55/hr) increased reimbursement to $31.47

23. Recall Observations • Recall was more effective at the beginning of the summer • Observed children who scheduled appointments did so at the end of the summer • Appointment scheduling increased as the number of contacts increased • Letters were no more effective than phone calls • Many patients scheduled appointments at the time they were contacted by phone

24. Areas for Future Study • Implementation of recall using a fully-populated EMR or immunization registry with an advanced forecasting algorithm could eliminate the need to review charts • Eliminating student costs increased reimbursement to $72.47 per additional appointment • Use of autodialers to further minimize costs associated with contacting immunization-delayed patients • Effect of public/private payor mix on reimbursement rates

25. In Summary • Registry-based recall can aid in increasing childhood immunization rates, thus protecting against vaccine-preventable diseases • Immunization recall can be cost beneficial, especially if: • Implemented during early summer months when patient volume is traditionally low; • Automated systems are fully utilized; • Additional staff support and salaries are minimized

26. Contributors • Leila Sahni, Immunization Action Plan Coordinator • Monica Banes, Nurse Health Educator • Julie Boom, Medical Director • Nathan Bunker, Senior Programmer • Daniel Fischer, Database Coordinator • Wen Li, Registry Security and Data Analyst • Kay Tittle, President, TCPA

27. Questions? Leila C. Sahni Texas Children’s Hospital lcsahni@texaschildrens.org (832) 824-2057