Sarah E. Brewer

Collaborative Centralized Reminder/Recall Notification to Increase Immunization Rates Among Young Children: A Comparative Effectiveness Trial

IMPORTANCE Reminder/recall notifications used by primary care practices increase the rates of childhood immunizations, but fewer than 20% of primary care practitioners nationally deliver such reminders. A reminder/recall notification conducted centrally by health departments in collaboration with primary care practices may reduce practice burden, reach children without a primary care practitioner, and decrease the cost of reminders/recalls. OBJECTIVE To assess the effectiveness and cost-effectiveness of collaborative centralized (CC) vs practice-based (PB) reminder/recall approaches using the Colorado Immunization Information System (CIIS). DESIGN, SETTING, AND PARTICIPANTS We performed a randomized pragmatic trial from September 7, 2012, through March 17, 2013, including 18,235 children aged 19 to 35 months in 15 Colorado counties. INTERVENTIONS In CC counties, children who needed at least 1 immunization were sent as many as 4 reminders/recalls by mail or autodialed telephone calls by the CIIS. Primary care practices in these counties were given the option of endorsing the reminder/recall notification by adding the practice name to the message. In PB counties, primary care practices were invited to web-based reminder/recall training and offered financial support for sending notifications. MAIN OUTCOMES AND MEASURES Documentation of any new immunization within 6 months constituted the primary outcome; achieving up-to-date (UTD) immunization status was secondary. We assessed the cost and cost-effectiveness of each approach and used a generalized linear mixed-effects model to assess the effect of the intervention on outcomes. RESULTS In PB counties, 24 of 308 primary care practices (7.8%) attended reminder/recall training and 2 primary care practices (0.6%) endorsed reminder/recall notifications. Within CC counties, 129 of 229 practices (56.3%) endorsed the reminder/recall letter. Documentation rates for at least 1 immunization were 26.9% for CC vs 21.7% for PB counties (P < .001); 12.8% vs 9.3% of patients, respectively, achieved UTD status (P < .001). The effect of CC counties on childrens UTD status was greater when the reminder/recall notification was endorsed by the primary care practice (19.2% vs 9.8%; P < .001). The total cost of the CC reminder/recall was

Influenza and Pertussis Vaccination Among Pregnant Women and Their Infants' Close Contacts: Reported Practices and Attitudes.

28 620 or

Acceptability of human papillomavirus vaccines among women older than 26 years

11.75 per child for any new immunization and

Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals

24.72 per child achieving UTD status; the total cost to the 2 practices that conducted PB reminders/recalls was

Evidence-based vaccination strategies in obstetrics and gynecology settings: Current practices and methods for assessment.

74.00 per child for any immunization and

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings.

124.45 per child achieving UTD status. The modeling resulted in an adjusted odds ratio of 1.31 (95% CI, 1.16-1.48) for any new immunization in CC vs PB counties. CONCLUSIONS AND RELEVANCE A CC reminder/recall notification was more effective and more cost-effective than a PB system, although the effect size was modest. Endorsement by practices may further increase the effectiveness of CC reminder/recall. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01557621.

Acceptability of a hypothetical group B strep vaccine among pregnant and recently delivered women.

Background: Our objectives were to describe the receipt of influenza and tetanus-diphtheria-acellular pertussis (Tdap) vaccines among postpartum women and their close contacts and the factors associated with cocooning. Methods: A survey between February 2013 and April 2013 of 613 postpartum women from 9 obstetrics practices assessed vaccine receipt among respondents and close contacts, demographics and 5 domains of health beliefs (benefits, barriers, susceptibility, severity and social norms). Multivariable models assessed the association of these factors with Tdap or influenza ”cocooning,” defined as the mother plus at least 1 close contact of her newborn receiving the vaccine. Results: The response rate was 45%; 61% of mothers reported that they and at least 1 close contact of their newborn had received influenza vaccine, and 67% reported this for Tdap. Infants whose mothers received influenza vaccine had a mean of 2.8 close contacts who also received influenza vaccine versus a mean of 0.9 contacts for infants whose mothers did not receive influenza vaccine (P < 0.0001). Infants whose mothers received Tdap vaccine had an average of 2.4 contacts who also received it versus 0.8 for infants whose mothers did not receive Tdap (P < 0.0001). Factors associated with influenza and Tdap cocooning included obstetrician recommendation, high perceived benefits, low perceived barriers and perceived susceptibility to disease. For Tdap, race/ethnicity was associated with cocooning (Hispanic/Latino, adjusted odds ratio 0.26, 95% confidence interval: 0.10–0.64 referent to White). Conclusion: Maternal vaccination and obstetrician recommendation are associated with infant cocooning. Interventions to increase cocooning of infants should focus on encouraging strong provider recommendations, increasing maternal knowledge of disease risk and addressing identified barriers. Reasons for possible racial/ethnic differences should be further explored.

Acceptability of using standing orders to deliver human papillomavirus vaccines in the outpatient obstetrician/gynecologist setting

OBJECTIVE To examine older womens (>26 years) acceptance of the human papillomavirus (HPV) vaccine, and factors associated with this outcome. STUDY DESIGN A convenience sample of 872 women age 26-77 years were surveyed regarding the likelihood they would accept the HPV vaccine if offered to them by their provider, and factors associated with this outcome. Binomial regression, Chi square and MacNemars analyses were used to determine associations of this outcome with demographic, attitudinal, and experiential variables. RESULTS The response rate was 60.8%. Half the respondents indicated they would want the vaccine, even if they had to pay for it. In multivariable analyses, the only factor associated with wanting the vaccine was higher self-reported knowledge about HPV (risk ratio 1.43, 95% Confidence Interval 1.12, 1.83). A majority of participants also believed that older women in general would want the vaccine if it were covered by insurance. However, this perspective was significantly diminished if the vaccine had to be paid for out of pocket (97% vs. 22% for 26-45 year olds; 84% vs. 20% for 46-65 year olds, 60% vs. 8% for 66+ year olds, p<0.001). Nearly all (93%) believed primary care physicians should routinely discuss the vaccine with older women. CONCLUSIONS A high proportion of women over 26 would want the HPV vaccine if offered by their provider, even if they had to pay for it out of pocket. This suggests that if providers were to routinely offer the HPV vaccine to their older patients, many women would choose to get vaccinated.

Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics

IMPORTANCE Medicaid quality indicators track diabetes mellitus and cardiovascular disease screening in adults receiving antipsychotics and/or those with serious mental illness. OBJECTIVE To inform performance improvement interventions by evaluating the relative importance of patient, prescriber, and practice factors affecting metabolic testing. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using Missouri Medicaid administrative claims data (January 1, 2010, to December 31, 2012) linked with prescriber market data. The analysis included 9316 adults (age, 18-64 years) who were starting antipsychotic medication. Secondary analysis included the subset of adults (n = 1813) for whom prescriber knowledge, attitudes, and behavior survey data were available. Generalized estimating equations were performed to identify factors associated with failure to receive annual testing during antipsychotic treatment (adjusted odds ratio [OR], <1 favor testing). Data analysis was performed from October 1, 2014, to February 18, 2016. EXPOSURE Oral second-generation antipsychotics. MAIN OUTCOMES AND MEASURES A medical claim for glucose or lipid testing occurring within 180 days before and after the antipsychotic prescription claim. RESULTS The 9317 patients (mean [SD] age, 37.6 [12.0] years) initiated antipsychotic medication in a variety of prescriber specialty-settings: 24.3%, community mental health center (CMHC); 27.6%, non-CMHC behavioral health; 24.3%, primary care practitioners; and 23.8%, other/unknown. Annual testing rates were 79.6% for glucose and 41.2% for lipids. Failure to test glucose and lipids was most strongly associated with patient factors and health care utilization. To illustrate by using findings from glucose modeling (reported as adjusted OR [95% CI]), lower failure to receive testing was associated with older age (40-49 vs 18-29 years; 0.64 [0.55-0.74]), diagnosis of schizophrenia or bipolar disorder (0.55 [0.44-0.67]), cardiometabolic comorbidity (dyslipidemia, 0.28 [0.22-0.37]), hypertension (0.59 [0.50-0.69]), and greater outpatient utilization (>6 encounters vs none; 0.33 [0.28-0.39]). Analysis incorporating prescriber practice information found lower failure to receive glucose testing if the patient received care at a CMHC (0.74 [0.64-0.85]) or if the initiating prescriber was a primary care practitioner (0.81 [0.66-1.00]). However, the initiating prescriber specialty-setting was not associated with lipid testing. CONCLUSIONS AND RELEVANCE Compared with prior reports, progress has been made to improve diabetes screening, but lipid screening remains particularly underutilized. Medicaid performance improvement initiatives should target all prescriber settings and not just behavioral health.

Glucose Testing for Adults Receiving Medicaid and Antipsychotics: A Population-Based Prescriber Survey on Behaviors, Attitudes, and Barriers

Obstetrician-gynecologists have the potential to play an important role in the delivery of immunizations to women. However, despite national recommendations, immunization rates among pregnant women and adults in general remain low. Pragmatic immunization delivery trials are needed to demonstrate how best to deliver vaccines in such settings. We report the development and implementation of 2 novel methodologies for immunization delivery research and quality improvement in such settings. The first was the development and application of a 47-point Immunization Delivery Scale that formally assessed variability among practices in their engagement in a variety of evidence-based practices for improving immunization rates. The second was a covariate-constrained randomization technique – a method for achieving balance between study arms in cluster-randomized trials that is especially applicable to pragmatic trials.. To best achieve meaningful and interpretable findings, we recommend use of these or similar techniques in future immunization research and quality improvement projects in OB/GYN settings.