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Adoption of Reminder and Recall Messages for Immunizations by Pediatricians and Public Health Clinics

Cheryl D. Tierney, MD, MPH^*, Hussain Yusuf, MBBS, MPH, Shawn R. McMahon, MD, MPH, Donna Rusinak, BS, Megan A. O’ Brien, MPH, Mehran S. Massoudi, PhD, MPH and Tracy A. Lieu, MD, MPH^,||

^* Harvard Combined Pediatric Health Services Research Fellowship Program, Boston, Massachusetts
National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia
Center for Child Healthcare Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Healthcare and Harvard Medical School
^|| Division of General Pediatrics, Children’s Hospital, Boston, Massachusetts

	ABSTRACT

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Objective. Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates, yet reports have suggested that only a minority of pediatric practices use such messages. Our aims were to 1) determine the proportions of pediatric practices and public clinics that currently use practice-based reminder or recall messages and routinely undergo immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these practices.

Methods. This study combined qualitative and quantitative methods in sequential phases. In the qualitative phase, we conducted semistructured, open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practices and public health clinics. In the subsequent quantitative phase, we mailed a structured, closed-ended survey to national samples of randomly selected pediatricians (n = 600) and public clinics (n = 600).

Results. Response rates were 75% for pediatricians and 77% for public clinics. Among pediatricians, 38% were conducting regular assessments of immunization coverage but only 16% were currently using routine reminder or recall messages. Among public clinics, 85% were conducting regular assessments and 51% were using reminder or recall messages. Among pediatricians’ practices, the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages. For pediatricians’ practices, the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery (odds ratio: 1.85; 95% confidence interval: 1.08–3.18) and current use of regular immunization assessments (odds ratio: 2.30; 95% confidence interval: 1.33–3.84). Likewise, for public health clinics, having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages.

Conclusions. Reminder and recall messages remain underused by both pediatricians and public health clinics. Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practices develop methods to identify children at specific ages.

Key Words: immunizations • interventions • quality of care • recall • reminder • assessment

Abbreviations: OR, odds ratio • CI, confidence interval

Despite increases in immunization coverage rates over the past decade,¹ national coverage rates for several vaccines remain just below the Healthy People 2010 goals of 90% for each vaccine series among young children.^2,3 Approximately 1 in 4 children aged 19 to 35 months has missed at least 1 recommended vaccine.²

Reminder and recall messages sent by mail or telephone have been found effective at increasing childhood immunization coverage rates in many settings,^4,5 including private practices,⁴ academic centers,^6,7 health maintenance organizations,^8,9 and public health clinics.^10–13 On the basis of this evidence, the Task Force on Community Preventive Services in 1999 strongly recommended that all practices implement these approaches.¹⁴ In addition, both the National Vaccine Advisory Committee^15,16 and the Task Force on Community Preventive Services^17,18 have recommended routine immunization audits to determine immunization coverage levels for preschool-age children in both the public¹⁹ and private²⁰ sectors.

Despite these recommendations and the compelling evidence of effectiveness, a 1995 survey indicated that only 35% of pediatricians and 23% of family physicians were using reminder or recall messages (R. Zimmerman, unpublished data). One study in an urban teaching clinic identified some barriers to implementing such messages.⁷ However, important gaps exist in our understanding of how frequently these barriers occur in varying health care delivery systems on a national basis.¹⁸ Policy makers need more specific information about these barriers, as well as the factors that have helped adopters of reminder or recall messages and assessment/feedback systems overcome them. The perspectives of pediatricians are particularly important because >70% of children receive their vaccines from pediatricians²¹ and >80% receive vaccines in the private sector.²²

The aims of this study were to 1) determine the proportion of pediatric practices and public clinics that currently use practice-based reminder or recall messages and make regular immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these approaches.

	METHODS

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Overview
This 2-phase study began with a qualitative phase in which we conducted semistructured interviews with key informants to identify appropriate issues and questions about catalysts and barriers to adopting reminder, recall, or assessment/feedback approaches. This was followed by a quantitative phase with a cross-sectional design in which we mailed a structured, closed-ended survey to national samples of immunization providers in the private and public sectors. The study was approved by the Human Studies Committee of Harvard Pilgrim Health Care and was classified exempt by the Institutional Review Board of the Centers for Disease Control and Prevention.

Qualitative Phase
We conducted semistructured interviews with a convenience sample of 18 clinician-administrators. We reviewed published literature and interviewed several experts in immunization delivery research to identify domains for the interview. The 8 domains were 1) current immunization practices, 2) messages to parents (reminders, recall messages, or other), 3) barriers to implementation of reminder or recall messaging, 4) assessment and feedback efforts for monitoring immunization coverage rates, 5) insurer and immunization reimbursement, 6) practice characteristics and demographics, 7) immunization registry participation, and 8) practice attitudes about immunizations. We then interviewed 10 adopters of reminder or recall messages (3 providers in private practice, 4 providers in public health clinics, 1 administrator in a health maintenance organization practice, and 2 administrators from insurance plans) and 8 nonadopters (3 in private practice, 2 in public health clinics, and 3 from insurance plans). Interviews were conducted to the point of theoretical saturation such that additional interviews yielded no new issues or themes related to our study questions. The interviews, which lasted 30 to 60 minutes, were conducted by at least 2 investigators (C.D.T., T.A.L., and/or D.L.R.) and were audiotaped. Interview notes and tapes were reviewed for common themes and areas of similarity and contrast between adopters and nonadopters of reminder and recall messages.

Quantitative Phase
Survey Development
Results of the qualitative phase were used to identify content areas and questions for the national surveys. The 21-item survey covered 5 domains: 1) messages to parents (reminders, recall messages, or other), 2) barriers to implementation of reminder or recall messaging systems, 3) other immunization practices (eg, assessment/feedback efforts, immunization registry participation), 4) practice attitudes about immunizations, and 5) practice characteristics and demographics.

Routine use of immunization assessments was defined as measuring immunization coverage rates at least every 2 years. Use of a reminder system was defined as routinely sending messages by either telephone or mail to parents of children at preselected ages (eg, all 24-month-olds) to remind them of an upcoming immunization or well visit, regardless of whether the child had an appointment scheduled. Use of a recall message system was defined as routinely sending messages to parents of children at preselected ages to notify them of a past-due immunization or well visit. In our survey, we defined these messaging protocols as having a "practice-based" system. The survey asked whether the group had an individual who led efforts to improve immunization delivery, which we defined as an immunization "champion."

Data Collection
The surveys were mailed to 2 subgroups: a random sample of 600 pediatricians from the American Medical Association master file and a random sample of 600 public health clinic providers from the National Association of City and Community Health Officers database. Two waves of surveys were mailed in winter 2001. The first mailing included a pen as a thank-you gift. An error by the mail house that conducted the first mailing resulted in our not being able to track surveys to separate responders from nonresponders. The second mailing was sent to each person in the original sample, with a cover letter asking them to ignore the request if they had already completed the survey. In the pediatrician subgroup, results include the responses to both waves. However, in the public health clinic subgroup, the responses to both waves combined yielded a response rate of >100%. To avoid the problem of duplicate surveys for public health clinics, we included only the responses from the first wave in analyses.

Statistical Methods
Response rates were calculated using the method described by the American Association for Public Opinion Research.²³ Bivariate analyses included the ² test, the Wilcoxon rank-sum test, and the Spearman correlation coefficient. Multivariate analyses were conducted using logistic regression for dichotomous outcomes and linear regression for ordinal outcomes. Predictors that were significant at P < .20 in bivariate analyses were included in multivariate models. We used an iterative, forced-entry approach, entering variables in successive models and removing variables when a correlation matrix suggested that they were highly correlated with other variables in the model.

	RESULTS

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Qualitative Findings
As Table 1 shows, both adopters and nonadopters of reminder or recall messages identified time and money as the most important barriers to implementing these methods. However, several areas of contrast suggest how adopters overcame these barriers. Adopters were more likely than nonadopters to identify immunization delivery as a responsibility of the health care system, rather than the responsibility of the parent or the individual provider alone. Adopters were also more likely to identify immunization delivery as a top priority and to have a single person who led improvement efforts. In addition, several adopters identified an immunization registry or feedback to staff about successes and problems in immunization efforts as an important factor.

In the pediatrician sample (Table 2), the most common types of practice were solo or 2-physician practices (32%) and single-specialty groups (44%). The majority of pediatricians in the study population (55%) were in suburban settings, and 52% had < 20% Medicaid patients. In contrast, most public health clinics in the study population (66%) were in rural settings and most had >20% Medicaid patients (77%).

We also conducted bivariate and multivariate analyses to identify predictors of agreement with the statement, "During the next year, our practice is likely to adopt a new system that involves sending messages to improve immunization delivery." In the final linear regression model, pediatricians were more likely to report plans for future adoption of recall or reminder messages when they had a champion who led efforts to improve immunization delivery (P < .03), when they conducted routine assessments for immunization coverage (P < .05), when they believed that their current immunization delivery system needed improvement (P < .001), and when >20% of their patients were Medicaid insured (P < .007). In addition, they were less likely to report plans to adopt a new system when they already had a computerized billing system (P < .004), when they received immunization delinquency reports or lists from an outside source (P < .02), or when they practiced in urban or suburban rather than rural settings (P < .005).

Other Findings
We conducted multivariate analyses to identify predictors of 1) current use of reminder or recall messages by public health clinics, 2) current use of assessments by pediatricians and public health clinics, and 3) future plans by pediatricians to implement routine immunization coverage assessments. Current use of reminder or recall messages by public health clinics was associated with having a champion who led efforts to improve immunization delivery (OR: 3.01; 95% CI: 1.34–6.73) and believing that the current immunization delivery system needed improvement (OR: 1.70; 95% CI: 1.29–2.24).

Current use of assessments by pediatricians’ practices was associated with having a champion who led efforts to improve immunization delivery (OR: 1.38; 95% CI: 0.89–2.13) and participating in a local or statewide immunization registry (OR: 1.85; 95% CI: 1.20–2.85). Current use of assessments by public health clinics was associated with participation in a local or statewide immunization registry (OR: 1.75; 95% CI: 1.00–3.07). Private providers were more likely to report plans to implement immunization assessment efforts in the next year when they had a champion who leads efforts to improve immunization delivery (P < .002), believed that the current immunization delivery system needs improvement (P < .008), or did not have a computerized billing system (P < .03).

	DISCUSSION

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Major Findings
This study suggests that fewer than 1 in 5 pediatric or multispecialty group practices are currently using immunization reminder or recall messages. Practices in which a champion was leading efforts to improve immunizations or that conduct routine assessments of immunization coverage were approximately twice as likely to be using reminder or recall messages as other practices. These factors were also highly associated with the reported likelihood of adopting a new reminder or recall system during the next year.

Both adopters and nonadopters of immunization reminder or recall messages named lack of time and funding as the most important barriers to implementing such methods. The qualitative phase of our study found that adopters had used many different methods to overcome these barriers, including eliciting staff interest through feedback reports and participation in local or state immunization registries. The qualitative interviews also suggested that adoption of reminder or recall messages is associated with the perception that immunization delivery is a responsibility of the health care system, rather than of the parent or the individual provider alone.

Interpretation and Context
In the national survey, having a champion to lead efforts to improve immunization delivery was strongly and independently associated with both current use of reminder or recall efforts and plans to initiate assessments of immunization coverage rates in the next year. This finding is aligned with ideas described by Rogers in the book Diffusion of Innovations.²⁴ Rogers suggested that opinion leaders, who are respected and influential in the community, play an important role in the adoption of new practices. Experts in clinical practice improvement believe that it is possible to identify people who are predisposed to be champions and to enable and reinforce their work (Dennis Ross-Degnan, ScD, personal communication).

These results suggest that it may be useful to try to identify and train champions to promote the adoption of reminder or recall messages in their own practices or clinics. It may also be possible to have such champions act as opinion leaders to promote the adoption of immunization assessment and message systems by other practice groups. The use of peers as opinion leaders to disseminate clinical practice changes has succeeded in several other health care delivery issues, including the management of acute myocardial infarction.^25,26

The lack of a simple way to identify children at a specific age was a barrier cited by more than one third of the respondents to the national survey. The adoption of reminder messages might be enhanced by helping practices to develop strategies for identifying children at specific ages using either manual systems or computer programs linked with billing systems. Most pediatricians (83%) reported having a computerized billing system. We were surprised by the finding that practices with computerized billing systems were actually less likely than those without to report plans to adopt a new reminder or recall messaging system within the next year. It is possible that existing computerized billing systems may actually impede adoption of new practices as a result of either true technologic limitations or the perception that they would be difficult to adapt for use in messaging.

Participation in immunization registries was associated with immunization assessment efforts in both the pediatrician and public health clinic subgroups. Assessment efforts alone may be an effective strategy for improving immunization rates,²⁷ and in the current study, they were associated with the current use of reminder or recall messages.

Limitations
One strength of this study is the use of both qualitative and quantitative methods that enabled us to describe barriers and supports from the perspectives of both specific practices and the national population. In the national survey, the response rates were relatively high compared with other studies of health care providers. However, because survey respondents tend to give socially acceptable answers, our results may overestimate the true rates of use of reminder or recall and assessment practices. In addition, the cross-sectional design of this study enabled us to identify associations but precludes making causal inferences between predictors and immunization practices.

Policy Implications
Recall and reminder messages remain underused by both pediatricians and public health clinics. Encouraging pediatric practices to adopt these approaches is particularly important because most US children receive their vaccines from private sector providers. For both pediatricians and public health clinics, adopting these practices will require overcoming limits on time, funding, and practices’ inability to identify children at specific age groups. Promising strategies to promote adoption of these practices include encouraging use and expansion of immunization registries, recruiting and training champions to promote immunization delivery improvement efforts, and helping practices to develop methods to identify children at specific ages.

	ACKNOWLEDGMENTS

 
This study was supported by the Centers for Disease Control and Prevention via the American Association of Health Plans (contract 0957-053). Dr Tierney’s work was supported by a grant (T32 HP10018) from the Health Resources and Services Administration, Department of Health and Human Services, to the Harvard Pediatric Health Services Research Fellowship Program.

We gratefully acknowledge the contributions of the many clinicians and administrators who contributed to the qualitative interviews and the national survey. We appreciate the advice of Henry Bernstein, DO, James Cooley, MD, Gary Freed, MD, Victoria Freeman, DrPH, Peter Margolis, MD, Lance Rodewald, MD, Stacie Smith, MPH, and Richard Wasserman, MD, during the study’s planning stages. We thank Tungela Grayson of the American Association of Health Plans and Deborah Mercy of the Centers for Disease Control and Prevention for administrative guidance and Charlene Gay for excellent assistance with manuscript preparation.

	FOOTNOTES

 
Received for publication Oct 23, 2002; Accepted Apr 24, 2003.

Reprint requests to (C.D.T.), Baystate Health System, High Street Health Center, 140 High St, Pediatrics, Springfield, MA 01199. E-mail: cheryl.tierney{at}bhs.org

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