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Purpose Centralized reminder/recall (C-R/R) using Immunization Information Systems has been effective in increasing childhood immunization rates. Previously, C-R/R using autodialer for human papillomavirus (HPV) vaccine did not raise rates. We assessed C-R/R for HPV vaccine using other modalities and focused on younger adolescents. Methods We conducted a three-arm pragmatic RCT in randomly sampled primary care practices in Colorado (n = 88) and New York (n = 136), proportionate to where adolescents received care. We randomized, within practices, adolescents aged 11-14 years who had not completed the HPV vaccination series to receive C-R/R using different modalities (Colorado: autodialer, mail, or control; New York: autodialer, text, or control). Up to two reminders were sent in intervention arms for each dose needed between 2/2017 and 12/2018. Results In Colorado, no significant differences were found for series initiation (31.3% control, 31.1% autodial, 31.8% mail), with slight improvement for series completion in the autodialer arm (29.7% control, 31.1% autodialer, p = .04) but not the mail arm (30.9%, p = .06). No significant differences were found in New York for series initiation (24.1% for all arms) or completion (17.1% control, 16.9% autodial, 17.9% text). Adjusted analyses showed higher completion rates for the autodialer arm in Colorado but not for other arms. In Colorado, C-R/R reduced time to series completion by around 2 months. Cost per adolescent was $1.81 for mail; under $.40 for all other modalities. Conclusions C-R/R has less benefit for raising HPV vaccination rates than other studies have noted for childhood immunizations, although it may quicken series completion at little cost.

Little is known about Immunization Information System (IIS) attitudes and experiences using Centralized IIS-based Reminder/Recall (CI-R/R), an effective approach to increasing immunization rates. To describe among IIS managers as it relates to CI-R/R: 1) past experiences and future plans conducting it; 2) attitudes and barriers, 3) IIS capabilities and polices that influence, and 4) factors that differentiate IIS who have and have not conducted CI-R/R. Electronic Surveys were sent to all IIS managers in July 2018 using a member listserve. Fifty-seven of 62 IIS programs contacted (92%) responded. The majority (61%) had ever conducted CI-R/R; 34% reported they were “very likely” to conduct CI-R/R within 6 months. The majority (64%) were in favor of CI-R/R. Barriers included lack of staff (78%), competing demands (76%), and cost (63%). Thirty percent reported receiving a ≥75% of immunization data via real-time electronic interfaces (HL7). Overall, 49% and 24% of jurisdictions had mandatory immunization reporting from private and public health entities for childhood and adult immunizations, respectively. Differences between IIS that ever and never performed CI-R/R, respectively, included: mandatory reporting from private and public entities for children (65% v 27%, p = 0.006), having a legal mandate for CI-R/R (50% v 19%, p = 0.02), less likely to prefer practice-based R/R to CI-R/R (68% v. 91%, p = 0.04), and not reporting having too many competing demands (29% v 67%, p = 0.007). Most IIS have conducted CI-R/R and have positive attitudes towards it. Given it effectiveness and low cost, efforts to sustain it should be considered.

Immunization reminder/recall is widely recommended as an effective strategy for increasing vaccination rates. We examined the revenue generated from well-child visits scheduled as a result of reminder/recall activities implemented in a multipractice pediatric organization.Patients aged 19 to 35 months who were due or overdue for vaccines were identified from participating practices and assigned to either standard or enhanced reminder/recall activities. Participants who received standard reminder/recall were observed for the 6-week study period, and the number of appointments in which vaccines were administered was tracked. Participants who received enhanced reminder/recall were contacted up to 3 times and received a letter followed by up to 2 phone calls. Financial information associated with appointments scheduled during the study period was obtained, and revenue was calculated for each dose of vaccine administered. Reminder/recall costs were calculated and overall revenue generated was calculated.We identified 3916 children who were potentially due or overdue for immunizations. After review and manual uploading of missing historical vaccines, a total of 1892 participants received the reminder/recall initiative; 942 received standard reminder/recall, and 950 received enhanced reminder/recall. One hundred eighty-two (19%) standard and 277 (29%) enhanced reminder/recall participants scheduled an appointment by the end of the study period (P .001). After subtracting the cost of reminder/recall activities, an additional $20,066 and $20,235 were generated by standard and enhanced reminder/recall, respectively.We show that conducting reminder/recall is at a minimum financially neutral, and might increase revenue generated by vaccine administration.

Objective To evaluate the effect of different modalities of centralized reminder/recall (autodialer, text, mailed reminders) on increasing childhood influenza vaccination. Study design Two simultaneous randomized clinical trials conducted from October 2017 to April 1, 2018, in New York State and Colorado. There were 61 931 children in New York (136 practices) and 23 845 children in Colorado (42 practices) who were randomized to different centralized reminder/recall modalities—4 arms in New York (autodialer, text, mailed, and no reminder control) and 3 arms in Colorado (autodialer, mailed, and no reminder control). The message content was similar across modalities. Up to 3 reminders were sent for intervention arms. The main outcome measure was receipt of ≥1 influenza vaccine. Results In New York, compared with the control arm (26.6%), postintervention influenza vaccination rates in the autodialer arm (28.0%) were 1.4 percentage points higher (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10), but the rates for text (27.6%) and mail (26.8%) arms were not different from controls. In Colorado, compared with the control arm (29.9%), postintervention influenza vaccination rates for the autodialer (32.9%) and mail (31.5%) arms were 3.0 percentage points (adjusted risk ratio, 1.08; 95% CI, 1.03-1.12) and 1.6 percentage points (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10) higher, respectively. Compared with the control arm, the incremental cost per additional vaccine delivered was $20 (New York) and $16 (Colorado) for autodialer messages. Conclusions Centralized reminder/recall for childhood influenza vaccine was most effective via autodialer, less effective via mail, and not effective via text messages. The impact of each modality was modest. Compared with no reminders, the incremental cost per additional vaccine delivered was also modest for autodialer messages. Trial registration ClinicalTrials.gov : NCT03294473 and NCT03246100 .

Objective Centralized reminder/recall (C-R/R) by health departments using Immunization Information Systems (IIS) is more effective and cost-effective than practice-based approaches for increasing childhood vaccines but has not been studied for influenza vaccination. We assessed effectiveness and cost of C-R/R for increasing childhood influenza vaccination compared with usual care. Methods Within Colorado (CO) and New York (NY), random samples of primary care practices (pediatric, family medicine, health center) were selected proportionate to where children are served– 65 practices (N=54,353 children) in CO; 101 practices (N=65,777) in NY. We conducted 4-arm RCTs per state (1, 2 or 3 autodial reminders versus usual care), with randomization at the patient level within practices from 10/2016-1/2017. Results In CO, the maximum absolute difference in receipt of ≥1 influenza vaccine was 1.7% between the 2 R/R group and control [adjusted risk ratio (ARR) of 1.06 (1.01, 1.10)]; other R/R arms did not differ significantly. In NY, ARRs for the study arms versus control varied from 1.05 (1.01, 1.10) for 3 R/R to 1.06 (1.01, 1.11) for 1-2 R/R groups and maximum absolute increase in vaccination was 0.6%. In time-to-event analyses, study arm was a significant predictor of vaccination in CO (p=.001) but not in NY. Costs/child randomized to one message were $.17 in CO and $.23 in NY. Conclusions C-R/R for influenza vaccine using autodial had low-level effects on increasing influenza rates in 2 states. Given the feasibility and low cost of C-R/R in previous trials, its utility for influenza should be re-examined using different modalities.

Objective To assess among providers in 7 Colorado counties where a collaborative centralized reminder/recall (CC-R/R) using the Colorado Immunization Information System (CIIS) was performed: 1) preferences about CC-R/R conducted by the public health department (PHD); 2) preferences for future CC-R/R for different vaccines with and without practice names; and 3) experiences with including their name on CC-R/R notices. Methods A mailed survey was sent to all primary care sites where CC-R/R had been previously conducted. Respondents self-identified as the "the person in charge of immunization policy within the practice." Results Overall response rate was 69.9% (160 of 229). Twenty-one were removed because they did not provide immunizations to children. Among respondents, 65.0% were from family medicine and 26.3% from pediatric practices; 32.1% physicians or midlevel providers; 34.3% nurses or medical assistants; and 33.6% office managers. Taking into account all issues, 57.6% were "okay" with either the PHD or their practice conducting recall; 27.3% preferred the PHD; and 14.4% preferred their practice conduct R/R. Fifty-six percent of active CIIS practices (n = 95) included their practice's name on CC-R/R notices. Interest in future CC-R/R for different ages and vaccines was strongly related to whether reminders included the practice name: 77.8% for routine immunizations in 4- to 6-year-olds; 74.8% for immunizations for 0- to 3-year-olds; 73.3% for vaccines administered to adolescents; and 59.7% for influenza ( P Conclusions Most practices are accepting of the PHD centrally conducting R/R, but most prefer collaboration that includes their name. Given the success and support of this method, it should be more widely adopted.

Little is known about adult patients' attitudes toward vaccination and preferences for reminder/recall. The objective of this study was to determine patient perspectives on adult vaccines generally; attitudes about Tdap, pneumococcal polysaccharide (PPSV-23), and seasonal influenza vaccines specifically; and preferences for adult reminder/recall delivery. Twelve focus groups were conducted with 68 patients in a safety net health system. The sample was stratified by preferred language (English or Spanish), age (18-64 or 65+), and health status (with or without chronic conditions). Participants expressed positive attitudes toward vaccines generally, but had little knowledge of specific vaccines other than influenza, about which they expressed concerns. Although none reported previous experience receiving reminder/recall notices for adult vaccines, all were in favor of receiving them. These results suggest potential patient interest in greater adoption of evidence-based methods to improve immunization rates, and highlight the need for improved communication between providers and patients about adult vaccines.

Reminders are often part of interventions to help older people adhere to complicated medication regimes. Computer-generated (synthetic) speech is ideal for tailoring reminders to different medication regimes. Since synthetic speech may be less intelligible than human speech, in particular under difficult listening conditions, we assessed how well older people can recall synthetic speech reminders for medications. 44 participants aged 50–80 with no cognitive impairment recalled reminders for one or four medications after a short distraction. We varied background noise, speech quality, and message design. Reminders were presented using a human voice and two synthetic voices. Data were analyzed using generalized linear mixed models. Reminder recall was satisfactory if reminders were restricted to one familiar medication, regardless of the voice used. Repeating medication names supported recall of lists of medications. We conclude that spoken reminders should build on familiar information and be integrated with other adherence support measures.

Objective To assess the following among parents of young children: 1) preferences about the source of immunization reminder/recall (R/R) messages, 2) the degree of acceptability of different R/R modalities, and 3) factors that influence preferences, including rural and urban characteristics. Methods We conducted a survey among parents of children 19 to 35 months old who needed ≥1 immunization according to the Colorado Immunization Information System (CIIS). Equal numbers of urban and rural respondents were randomly selected. Up to 4 surveys were mailed to each parent who had a valid address. Results After removing invalid addresses, the response rate was 55% (334 of 607). Half of parents (49.7%) had no preference about whether the public health department or their child's doctor sent reminders. Urban parents were more likely to prefer R/R come from their child's doctor (46.7%) compared to rural parents (33.7%), P = .003. Mail was the preferred R/R method (57.7%), then telephone (17.0%), e-mail (12.7%), and text message (10.7%). Although not preferred, 60.1% reported it would be acceptable to receive R/R by e-mail and 46.2% by text message. Factors associated with preferring to receive R/R from their child's doctor were urban residence and educational level of college graduate or greater. Conclusions A large portion of parents are willing to be reminded about vaccinations by their health department rather than their child's provider and via novel modalities, such as e-mail or text messaging. Urbanicity and higher educational level were associated with preferring that R/R come from a provider.

Background We sought to: (1) explore the feasibility of using email for seasonal influenza vaccination reminders to parents of adolescents and (2) assess influenza vaccination rates among adolescents whose parents were randomized to either receive or not receive email reminders. Methods Email addresses were obtained for parents of patients 10–18 years from 4 practices in Michigan. Addresses were randomized to either receive email reminders, or not. Reminder messages were sent during October 2012-March 2013 (Season 1) and October 2013-March 2014 (Season 2). Vaccination status was determined 60 days following the last email reminder for each season using the statewide Michigan Care Improvement Registry (MCIR); per protocol bivariate and multivariate logistic regression analyses were conducted to evaluate reminder notification. Results After email cleaning, testing, and matching with MCIR, approximately half of email addresses (2348 of 5312 in Season 1; 3457 of 6549 in Season 2) were randomized. Bivariate analyses found that influenza vaccination within 60 days after notification date was similar among those notified (34%) versus not notified (29%) in both Season 1 (p = 0.06) and Season 2 (39% vs. 37%, p = 0.20). However, multivariate models adjusted for season, site, and receipt of notification in two seasons found a higher likelihood of influenza vaccination among children that received notification (aOR = 1.28, 95% CI = 1.09, 1.51); in addition, differences in influenza vaccination were also observed between practice sites (range: p = 0.15 to p Conclusions We found that practice-based email influenza vaccine reminders to parents of adolescents are feasible, but not without complications. Our study demonstrates that email reminders from practices can yield increases in influenza vaccination rates among adolescents. Practices should consider email as an option for influenza reminders and establish business practices for collecting and maintaining patient email addresses. This study is registered at www.ClinicalTrials.gov id # NCT01732315 .

Objective We compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the child's provider. Methods We conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates. Results C-R/R was more effective in trials 1 to 3 (relative risk = 1.11; 95% confidence interval 1.01–1.20; P = .009). Effectiveness did not decrease with decreasing intervention intensity ( P = .59). Costs decreased with decreasing intensity in the C-R/R arm, from $18.72 per child brought UTD in trial 1 to $10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from $20.63 to $237.81 per child brought UTD. C-R/R was significantly more effective if the child's practice name was included ( P Conclusions C-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child's provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials.

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Asthma is a major public health concern in the U.S. pediatric population. Children with asthma tend to fare worse when they acquire respiratory illnesses such as influenza, requiring more episodic office visits and hospitalizations than do healthy children with the same illnesses. Despite the American Academy of Pediatrics recommendation that children with chronic diseases be immunized for seasonal influenza annually, influenza immunization rates in this population peaks at30%. The purpose of this literature review was to examine the effectiveness of reminder/recall systems in improving influenza immunization rates among children with asthma.This literature review was conducted using PubMed, CINAHL, EMBASE, and Cochrane. Of the 178 articles found, 12 met criteria for inclusion. Articles were included if they addressed influenza vaccination in asthmatic children and "high-risk" children and considered asthmatics in the definition of "high risk." Additionally, inclusion criteria required discussion of at least one mode of reminder method or recall method that was used to influence the rate of influenza vaccination in children with asthma. For the purposes of this review, "reminders" is defined as any action performed by health provider or representative of the health provider that was aimed at informing and/or reiterating to patients the importance of influenza vaccination for asthmatic children and/or the potential for increased morbidity with acquisition of the flu and/or availability of the vaccine. "Recall" methods included all efforts made by the health provider or his/her representative to encourage patients to return to clinics for vaccination during the influenza season. Articles were excluded if they focused on improving influenza vaccination rates in healthy children and if they used reminder/recall systems to influence vaccination against diseases other than influenza. No systematic review was found on this particular topic.Providers have used reminder and recall systems that alert patients of the need for vaccination and encourage compliance with this recommendation. Implemented techniques included verbal and mailed reminders, electronically generated alerts, and year-round scheduling of flu vaccination appointments.Improvements have been seen in influenza immunization rates with the implementation of reminder/recall systems; however, most have been modest. Enhancements in patient education and access to vaccination are other areas of needed improvement.

In order to verify whether a telephone recall system directly managed by pediatricians who usually follow up children for their asthma is more effective than an anonymous recall system, we randomly assigned 285 asthmatic children (177 males; mean age 10.3 ± 3.4 years) to one of three groups: those whose mothers were to be called by a pediatrician not previously involved in caring for their asthmatic children and who received the vaccine in our immunisation clinic (group 1); those whose mothers were to be called by a pediatrician from our asthma clinic and who received the vaccine in the immunisation clinic (group 2); and those whose mothers were to be called by a pediatrician from our asthma clinic and who received the vaccine in the same clinic (group 3). Our findings highlight that the use of a reminder/recall system increases vaccination rates in asthmatic children, and show that the best results are obtained when the mothers are contacted and the vaccine administered by the pediatricians who usually follow up the child for asthma.

Inner-city infants (n = 565) enrolled in the WIC program were randomly assigned at 6 months of age to either of 2 groups: (1) voucher incentive (frequency of issuance of food vouchers based on immunization status) plus reminder-recall (calls and/or letters to families of under-vaccinated children) or (2) voucher incentive alone. At 12 months, both groups’ immunization levels were high and not significantly different: 80% ± 4% versus 79% ± 5% ( P = .749). (J Pediatr 1999;135:261-3)

Profound racial/ethnic immunization rate disparities exist among young children in Chicago. We created BIRTH PIP, a program combining immunization education at birth with ongoing reminder-recall, to achieve greater than 90% on-time adherence with AAP/ACIP immunization recommendations among inner-city children aged 0-35 months. The study also examines the cost of this effort.A total of 400 neonates were enrolled. At all examined time points, on-time immunization rates exceeded city-wide data. Of those completing the program, 92% of children had 100% compliance with prescribed immunizations by 24 months. No child required follow-up past 29 months. Retention was an important problem, primarily due to pre-set eligibility requirements. Mean cost per child to complete recommended immunizations was $288. Compliant families were less expensive to maintain.Outreach workers met with post-partum mothers who were English speaking, Chicago residents and receiving Medicaid, to provide immunization education and determine a contact strategy. Parents were reminded of each well-child appointment. Those missing appointments were re-contacted and rescheduled. Home visits were made when there was no contact by phone and mail. Enrollees and immunizations were tracked until all recommended immunizations were received. On-time immunization rates were compared with city-wide immunization data. Costs were calculated by assessing outreach worker effort and other programmatic costs.BIRTH PIP is effective in improving immunization rates in underserved children. Economies of scale will decrease the per child cost. Preventing even a few cases of vaccine-preventable illness would likely render this initiative cost-effective.

The Effectiveness of Patient Reminder/Recall Interventions on Immunization Rates: A Critical Review of the Literature ♦ 695

Improving Return Visits In Private Provider Offices Through Immunization Reminder/Recall. † 649