Sharon G. Humiston

A Randomized Study of Tracking With Outreach and Provider Prompting to Improve Immunization Coverage and Primary Care

Objective. To compare and measure the effects and cost-effectiveness of two interventions designed to raise immunization rates. Settings. Nine primary care sites serving impoverished and middle-class children. Subjects. Complete birth cohorts (ages 0 to 12 months; n = 3015) from these sites. Interventions. Two 18-month duration interventions: 1) tracking with outreach [tracking/outreach] to bring underimmunized children to their primary care provider office, and 2) a primary care provider office policy change to identify and reduce missed immunization opportunities (prompting). Design. Randomized, controlled trial, randomizing within sites using a two-by-two factorial design. Subjects were allocated to one of four study groups: control, prompting only, tracking/outreach only, and combined prompting with tracking/outreach. Outcomes were obtained by blinded chart abstraction. Measures. Immunization status for age; number of days of delay in immunization; primary care utilization; and rates of screening for occult disease. Results. Out of 3015 subjects, 274 subjects (9%) transferred out of the participating sites or had incomplete charts and were excluded. The 2741 (91%) remaining subjects were assessed. At baseline, study groups did not differ in age, gender, insurance type, or immunization status. Of the remaining subjects, 63% received Medicaid. Final series-complete immunization coverage levels were: control, 74%; prompting-only, 76%; tracking/outreach-only 95%; and combined tracking/outreach with prompting, 95%. Analysis of variance showed that: 1) tracking/outreach increased immunization rates 20 percentage points; 2) tracking/outreach decreased mean immunization delay 63 days; 3) tracking/outreach increased mean health supervision visits 0.44 visits per child; 4) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child; 5) impact of tracking/outreach was greatest for uninsured and impoverished patients; and 6) the prompting intervention had no impact on the studied outcomes, and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted. Using tracking/outreach, the cost per additional child fully immunized was

Recommendations for Effective Newborn Screening Communication: Results of Focus Groups With Parents, Providers, and Experts

474. Each

Challenges to Vaccinating Adolescents: Vaccine Implementation Issues

1000 spent on the tracking/outreach intervention resulted in: 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider; and 1.8 additional anemia screenings and 1.3 additional lead screenings. Conclusions. Outreach directed toward children not up-to-date on immunizations improves not only immunization status, but also health supervision visit attendance and screening rates. The cost per additional child immunized was high, but should be interpreted in view of the spillover benefits that accompanied improved immunization. Effective means to improve coverage by reducing missed immunization opportunities still need to be identified. immunization, primary care, randomized, controlled trial, missed immunization opportunities, outreach.

Patient Navigation for Breast and Colorectal Cancer Treatment: A Randomized Trial

OBJECTIVES. The aims of this study were to determine parent and provider knowledge and awareness of newborn screening; to gather opinions from parents, providers, and newborn screening professionals about the content and timing of newborn screening education; and to use consensus data to formulate recommendations and to develop educational materials for parents and providers. METHODS. We conducted 22 focus groups and 3 individual interviews between October 2003 and May 2004, with English- and Spanish-speaking parents of infants <1 year of age who had experience with initial testing, retesting, or false-positive screenings; health professionals who provide prenatal care or health care for newborns; and state newborn screening program health professionals. RESULTS. Parents and providers had limited knowledge and awareness about newborn screening practices. Parents wanted brief to-the-point information on newborn screening and its benefits, including the possible need for retesting and the importance of returning promptly for retesting if initial results are abnormal. Parents wanted the information orally from the primary care provider. Parents, providers, and newborn screening professionals all thought that an accompanying concise, easy-to-read brochure with contact information would be helpful. All focus group participants thought that parents should receive this information before the birth of the infant, preferably in the third trimester of pregnancy. Providers wanted a brief checklist of information and resources to prepare them to educate parents effectively. CONCLUSIONS. We recommend prenatal and primary care providers be more involved in educating parents about newborn screening. Professional societies and state health officials should work together to encourage parent and provider education. User-friendly patient and provider education materials, such as those we developed, could form the basis for this educational approach.

Assessment of Newborn Screening Parent Education Materials

Background: Adolescent immunization is a growing field, with many new vaccines in development and new or expanded immunization recommendations on the horizon. Methods: Characteristics of adolescents and their health care are discussed, focusing specifically on the challenges of incorporating a potential recommendation to replace tetanus-diphtheria toxoid with tetanus-diphtheria-acellular pertussis vaccine during early or middle adolescence as part of routine preventive care. Using the framework created by the Centers for Disease Control and Preventions Task Force on Community Preventive Services, three overlapping levels at which there are opportunities for vaccine intervention are reviewed: (1) health care systems (enhancing access to vaccination services); (2) health care providers (provider-based interventions); and (3) patients and families (“increasing community demand”). Results: There are several barriers to vaccine implementation that make achieving high immunization coverage rates among adolescents a challenge. Promising interventions for improving vaccination rates at the health care system level include reducing out-of-pocket costs, expanding access to immunizations, and implementing vaccination programs in schools. Provider-based interventions for improving vaccination rates include regular assessments of immunization rate with feedback to all office personnel, provider reminders, and standing orders. Client recall and reminders, education, and requirements for school entry can assist in “increasing community demand” for vaccinations in that they motivate parents and adolescents to follow through with immunizations. Conclusions: Adolescents are unique from other populations. Previously studied interventions need to be tested in this age group as immunization becomes a more salient issue in adolescent health care.

A Randomized Trial of the Effect of Centralized Reminder/Recall on Immunizations and Preventive Care Visits for Adolescents

Background: There is limited high-quality evidence about the impact of patient navigation (PN) on outcomes for patients with diagnosed cancer. Methods: We pooled data from two sites from the national Patient Navigation Research Program. Patients (n = 438) with newly diagnosed breast (n = 353) or colorectal cancer (n = 85) were randomized to PN or usual care. Trained lay navigators met with patients randomized to PN to help them assess treatment barriers and identify resources to overcome barriers. We used intent-to-treat analysis to assess time to completion of primary treatment, psychologic distress (impact of events scale), and satisfaction (patient satisfaction with cancer-related care) within 3 months after initiation of cancer treatment. Results: The sample was predominantly middle-aged (mean age = 57) and female (90%); 44% were race-ethnic minorities (44%), 46% reported lower education levels, 18% were uninsured, and 9% reported a non-English primary language. The randomized groups were comparable in baseline characteristics. Primary analysis showed no statistically significant group differences in time to completion of primary cancer treatment, satisfaction with cancer-related care, or psychologic distress. Subgroup analysis showed that socially disadvantaged patients (i.e., uninsured, low English proficiency, and non-English primary language) who received PN reported higher satisfaction than those receiving usual care (all P < 0.05). Navigated patients living alone reported greater distress than those receiving usual care. Conclusions: Although the primary analysis showed no overall benefit, the subgroup analysis suggests that PN may improve satisfaction with care for certain disadvantaged individuals. Impact: PN for cancer patients may not necessarily reduce treatment time nor distress. Cancer Epidemiol Biomarkers Prev; 21(10); 1673–81. ©2012 AACR.

Effectiveness of a Citywide Patient Immunization Navigator Program on Improving Adolescent Immunizations and Preventive Care Visit Rates

OBJECTIVE. The purpose of this study was to measure the readability and user-friendliness (clarity, complexity, organization, appearance, and cultural appropriateness of materials) of parent education brochures on newborn screening. METHODS. We studied English-language versions of the brochures that state newborn screening programs prepare and distribute. We obtained brochures from 48 states and Puerto Rico. We evaluated each brochure for readability with the Flesch reading ease formula. User-friendliness of the brochures was assessed with an instrument we created that contained 22 specific criteria grouped into 5 categories, ie, layout, illustrations, message, manageable information, and cultural appropriateness. RESULTS. Most current newborn screening brochures should be revised to make them more readable and user-friendly for parents. Ninety-two percent of brochures were written at a reading level that is higher than the average reading level of US adults (eighth-grade level). In most brochures, the essential information for parents was buried. Although all brochures were brief and focused on the newborn screening tests being performed, 81% needed improvement in getting to the point quickly and making it easy for parents to identify what they needed to know or to do. None of the brochures scored high in all 22 criteria on the user-friendliness checklist. CONCLUSIONS. Parent education materials about newborn screening should be revised to be easier to read and more user-friendly, by lowering the reading difficulty to eighth-grade level and focusing on issues such as layout, illustrations, message, information, and cultural appropriateness. It is important that state newborn screening programs and organizations work with parents to develop and to evaluate materials to ensure that they are user-friendly.

Patient—Provider Communication and Human Papillomavirus Vaccine Acceptance

OBJECTIVE To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents. METHODS We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end. RESULTS Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost

Study Protocol: A randomized controlled trial of patient navigation-activation to reduce cancer health disparities

18.78 (mailed) or

Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing.

16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was