POPULATION VS. PRACTICE- BASED INTERVENTIONS TO INCREASE IMMUNIZATION RATES IN YOUNG CHILDREN. Colorado Immunization Information System

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1 POPULATION VS. PRACTICE- BASED INTERVENTIONS TO INCREASE IMMUNIZATION RATES IN YOUNG CHILDREN Colorado Immunization Information System

2 Outline Background Objective Methods Results Cost to Recruit Practices Subsequent Study Currently Underway

3 Background Study Team University of Colorado Denver Colorado Department of Public Health and Environment Supported by a Challenge Grant from the National Institutes of Health Reminder/recall (R/R) conducted by practices effective at increasing immunization rates R/R difficult to implement even within highly motivated practices using an Immunization Information System (IIS) Estimated that 16% of physicians nationally are conducting practicebased R/R (1) Population-based R/R conducted centrally by public health departments, may: Reduce burden of conducting R/R by practices Reach children without usual source of primary care (1) Tierney CD, Yusuf H, McMahon SR et al. Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics. Pediatrics 2003;112(5):

4 Background Comparative Effectiveness Trial of Two Recall Methods to Increase Immunizations in Young Children RCT with 14 urban & rural counties Proximity to 80% minimum saturation rate Similar economic and population profiles and geography Mesa Cohort: months needing 1+ shots from the Montrose primary series San Miguel Moffat Rio Blanco Dolores Montezuma Delta Garfield Routt Ouray Hinsdale San Juan La Plata Pitkin Gunnison Jackson Lake Chaffee Saguache Mineral Rio Alamosa Grande Archuleta Conejos Larimer Morgan Grand Broomfield Boulder Gilpin Denver Adams Eagle Clear Washington Creek Arapahoe Summit Park Fremont Custer Costilla Douglas Huerfano Weld El Paso Pueblo Elbert Lincoln Crowley Otero Las Animas Logan Bent Sedgwick Phillips Yuma Kit Carson Cheyenne Kiowa Prowers Baca

5 Objective To compare the effectiveness and cost of conducting Recall using two methodologies: Population-based Recall: conducted centrally by the state health department using the Colorado Immunization Information System (CIIS) Practice-based Recall: conducted at the level of the primary care practice using CIIS

6 Methods: Intervention Practice-based recall counties: All practices participating in CIIS invited to attend web-based CIIS Recall training in May/June 2010 Recall methodology suggested 3 mailings to children months not UTD June September 2010 Financial support for mailings offered to practices

7 Methods: Intervention Population-based recall counties: Centralized recall effort conducted by the State Public Health Department June September 2010 R/R notices were printed with county health department logos and immunization clinic hours R/R methodology same as recommended in practicebased counties

8 Methods: Cost Assessment Population-based Recall (performed centrally) Staff time for training and implementation Mailing and printing costs for up to 3 mailings Updating bad mailing addresses Practice-based Recall (performed differently at each practice) Average staff time among practices conducting R/R Average mailing costs or phone calls

9 Results Population-based Reach 188 practice sites; n=12,832 eligible children Practice-based Reach 195 practice sites; n=18,735 eligible children 5% 15% 85% 95% Received >=1 Recall Notice (assuming 85% received notice) Did not receive a Recall notice Received >=1 Recall Notice (assuming 100% received Notice Did not receive Recall notice

10 % Brought UTD w/in 6 months (of those needing vaccines at baseline) 20% 18% 19% 16% 14% 12% 10% 8% 6% 4% 2% 0% Absolute Effect Difference 6% p< % Population-based Recall Counties Practice-based Recall Counties

11 % Receiving Any Vaccine w/in 6 months (of those needing vaccines at baseline) 35% 32% 30% 25% 20% 15% Absolute Effect Difference 9% P < % 10% 5% 0% n=12,832 Population-based Recall Counties n=18,735 Practice-based Recall Counties

12 Cost to Recall per Practice $1,400 $1,315 $1,200 $1,000 $800 $600 $400 $200 $0 $215 n = 188 n = 10 Population-based Recall Counties Practice-based Recall Counties $40,367 $13,153

13 Cost of Recall/Child Receiving 1+ vaccines $40 $38 $30 $20 $10 $0 $10 n = 4,083 n = 348 Population-based Recall Counties Practice-based Recall Counties

14 Cost of Recall/Child Brought UTD $70 $60 $62 $50 $40 $30 $20 $17 $10 n = 2,394 n = 212 $0 Population-based Recall Counties Practice-based Recall Counties

15 Cost to Recruit CIIS and contract staff recruited practices in the 14 counties to ensure each met 80% saturation Recruitment period: January June 2010 Staff stressed benefits participation Funds provided to support technology enhancements and data entry for recruited practices

16 Results A total of $80,573 was spent on recruitment Recruited 25 practices in the 14 counties Staff resources: $39,592 88% spent on contract/ciis Coordinators Average of $1584 spent per practice Technology enhancements & data entry: $40,980 Total of 8,289 children 0 3 years of age added Cost of $4.94 per child $3, per practice recruited

17 Results Saturation Rate - Baseline: 77% January 2010 Saturation Rate - After Recruitment: 83% July 2010 Total Saturation Rate Increase: 6% $13,428 was spent per percentage point increase.

18 Limitations Population impossible to accurately denominate in all counties but same method of approximation used in both intervention arms Population-based recall hampered by many inaccurate addresses Practices may have conducted recall after the 6 month period of F/U despite incentives Costs were based on personnel report, rather than direct observation

19 Conclusions Both practice-based and population-based recall effective practice-based slightly more effective when practices participated Overall, population-based recall was more effective than practice-based recall because of unwillingness of practices to perform recall, even when incentivized Cost per practice or per child vaccinated were much lower for population-based recall Cost to recruit practices to participate in CIIS is significant in counties with an already relatively high saturation rate. IIS resources may need to be enhanced to realize higher provider saturation rates in states that do not have a participation mandate.

20 Implications Centralized population-based Recall conducted by State or Local Health Departments may be a more effective and less costly alternative to practice-based Recall Optimal approach could involve collaborative approach between practices and public health Recall notices could appear to come from practice and public health dept. or either alone Could be less costly if collaboratively conducted with practices, allowing updating of addresses New NIH Grant to explore!

21 Current Study Comparative Effectiveness Trial of Two Recall Methods to Increase Immunizations in Young Children (19-35 months) RCT involving 8 urban and 8 rural counties Similar methodology to prior RCT EXCEPT Morgan Development of collaborative Grand Broomfield strategy Rio Blanco Boulder Gilpin in population-based counties Denver Adams Washington Garfield Eagle Arapahoe * * * Maximize connectivity of practices Elbert to CIIS Mesa Pitkin Park Douglas in practice- based counties Lake Delta El Paso Gunnison Randomize children to receive Chaffee Lincoln Fremont Montrose Crowley Kiowa * auto-dialer messages Ouray Saguache Pueblo Moffat San Miguel Dolores Montezuma San Juan Hinsdale Routt Jackson Larimer Custer Mineral Rio Alamosa Huerfano Grande * La Plata Archuleta Conejos Costilla Weld Otero Las Animas KEY: GREEN= Population-based Counties; PURPLE= Practice-based Counties Logan Sedgw ick Phillips Yuma Kit Carson Cheyenne Bent Prowers Baca

22 Current Study Population-based Counties (Year 1): Design a collaborative component between practices and health departments for conducting population-based recall Perform key informant interviews with providers, parents and local public health Consensus development by Collaborative Intervention Advisory Committee Maximize electronic files sent from practices to CIIS Practice-based Counties (Year 1) Offer recall training to all practices using CIIS web-based tool Encourage practice-based recall during same time frame of population-based recall

23 Questions? Diana Herrero, MS, CIIS Manager

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