Reminder Letter Research Articles

Information nudges for influenza vaccination: Evidence from a large-scale cluster-randomized controlled trial in Finland.

Vaccination is the most effective means of preventing the spread of infectious diseases. Despite the proven benefits of vaccination, vaccine hesitancy keeps many people from getting vaccinated. We conducted a large-scale cluster randomized controlled trial in Finland to test the effectiveness of centralized written reminders (distributed via mail) on influenza vaccination coverage. The study included the entire older adult population (aged 65 years and above) in 2 culturally and geographically distinct regions with historically low (31.8%, n = 7,398, mean age 75.5 years) and high (57.7%, n = 40,727, mean age 74.0 years) influenza vaccination coverage. The study population was randomized into 3 treatments: (i) no reminder (only in the region with low vaccination coverage); (ii) an individual-benefits reminder, informing recipients about the individual benefits of vaccination; and (iii) an individual- and social-benefits reminder, informing recipients about the additional social benefits of vaccination in the form of herd immunity. There was no control treatment group in the region with high vaccination coverage as general reminders had been sent in previous years. The primary endpoint was a record of influenza vaccination in the Finnish National Vaccination Register during a 5-month follow-up period (from October 18, 2018 to March 18, 2019). Vaccination coverage after the intervention in the region with historically low coverage was 41.8% in the individual-benefits treatment, 38.9% in the individual- and social-benefits treatment and 34.0% in the control treatment group. Vaccination coverage after the intervention in the region with historically high coverage was 59.0% in the individual-benefits treatment and 59.2% in the individual- and social-benefits treatment. The effect of receiving any type of reminder letter in comparison to control treatment group (no reminder) was 6.4 percentage points (95% CI: 3.6 to 9.1, p < 0.001). The effect of reminders was particularly large among individuals with no prior influenza vaccination (8.8 pp, 95% CI: 6.5 to 11.1, p < 0.001). There was a substantial positive effect (5.3 pp, 95% CI: 2.8 to 7.8, p < 0.001) among the most consistently unvaccinated individuals who had not received any type of vaccine during the 9 years prior to the study. There was no difference in influenza vaccination coverage between the individual-benefit reminder and the individual- and social-benefit reminder (region with low vaccination coverage: 2.9 pp, 95% CI: -0.4 to 6.1, p = 0.087, region with high vaccination coverage: 0.2 pp, 95% CI: -1.0 to 1.3, p = 0.724). Study limitations included potential contamination between the treatments due to information spillovers and the lack of control treatment group in the region with high vaccination coverage. In this study, we found that sending reminders was an effective and scalable intervention strategy to increase vaccination coverage in an older adult population with low vaccination coverage. Communicating the social benefits of vaccinations, in addition to individual benefits, did not enhance vaccination coverage. The effectiveness of letter reminders about the benefits of vaccination to improve influenza vaccination coverage may depend on the prior vaccination history of the population. AEA RCT registry AEARCTR-0003520 and ClinicalTrials.gov NCT03748160.

Digitization in health-related self-help - Results of an online survey among self-help organizations in Germany.

BackgroundNowadays, much hope and expectations are associated with digitization in the health sector. The digital change also affects health-related self-help. A nationwide survey of self-help organizations (SHOs) aimed to show chances and limitations in the use of interactive IT tools like webforums, online meetings or social media as well as digital infrastructures for their organizational management. In this survey, we also determined whether SHO staff themselves have support and qualification needs with regard to this topic.DesignThe online survey was conducted between 14 November and 8 December 2019, i.e., immediately before the outbreak of the Covid-19 pandemic. The questionnaire consisted of 50 questions consisting of 180 single items which could be answered in 30–40 min. After two reminder letters, 119 questionnaires of the SHOs were gathered and analysed.ResultsSHOs already have a lot of experience with digital media/tools (e.g., own homepage, social media, cloud computing). Some tools are attested a “high” or “very high” benefit by more than 80% of users. Perceived benefits, however, are also facing a number of problems, ranging from lack of resources to data protection issues. Despite, or even because of the limits of digitization, there is great desire and need for support and further training in SHOs (and self-help groups).ConclusionsAt many points in the survey it was shown that digital media can be a useful extension of “traditional” collective self-help. Taking into account the risks and limitations associated with digital tools, SHOs can be central stakeholders in digitization in health-related self-help.Patient or Public ContributionThe study was financially supported by the Federal Ministry of Health, Germany. A detailed representation of the results is publicly available at: https://www.uke.de/dish.

Including a pen and/or cover letter, containing social incentive text, had no effect on questionnaire response rate: a factorial randomised controlled Study within a Trial.

Background: Postal questionnaires are frequently used in randomised controlled trials to collect outcome data on participants; however, poor response can introduce bias, affect generalisability and validity, and reduce statistical power. The objective of this study was to assess whether a pen and/or social incentive text cover letter sent with a postal follow-up questionnaire increased response rates in a trial. Method: A two-by-two factorial randomised controlled trial was embedded within the OTIS host trial. Participants due their 12-month (final) follow-up questionnaire were randomised to be sent: a pen; a social incentive text cover letter; both; or neither. The primary outcome measure was the proportion of participants in each group who returned the questionnaire. Secondary outcomes were: time to return, completeness of the questionnaire, necessity of a reminder letter, and the cost effectiveness. Results: The overall 12-month questionnaire response rate was 721 out of 755 (95.5%). Neither the pen nor social incentive cover letter had a statistically significant effect on response rate: pen 95.2% vs. no pen 95.8%, adjusted OR 0.90 (95% CI 0.45 to 1.80; p=0.77); social incentive cover letter 95.2% vs. no social incentive cover letter 95.8%, adjusted OR 0.84 (95% CI 0.42 to 1.69, p=0.63). No statistically significant differences were observed between either of the intervention groups on time to response, need for a reminder or completeness. Therefore, neither intervention was cost-effective. Conclusions: We found no evidence of a difference in response rates associated with the inclusion of a pen and/or social incentive cover letter with the final follow-up postal questionnaire of the host trial. However, when these results are combined with previous SWATs, the meta-analysis evidence remains that including a pen increases response rates. The social incentive cover letter warrants further investigation to determine effectiveness. Trial registration: ISRCTN22202133(21st June 2020).

Predictors for participation in DNA self-sampling of childhood cancer survivors in Switzerland

BackgroundResearch on germline genetic variants relies on enough eligible participants which is difficult to achieve for rare diseases such as childhood cancer. With self-collection kits, participants can contribute genetic samples conveniently from their home. Demographic and clinical factors were identified previously that influenced participation in mailed self-collection. People with pre-existing heritable diagnoses might participate differently in germline DNA collection which might render sampling biased in this group. In this nationwide cross-sectional study, we analysed predictive factors of participation in DNA self-collection including heritable diagnoses.MethodsWe identified childhood cancer survivors from the Swiss Childhood Cancer Registry for invitation to germline DNA self-sampling in September 2019. Participants received saliva sampling kits by postal mail at their home, were asked to fill them, sign an informed consent, and send them back by mail. Two reminders were sent to non-participants by mail. We compared demographic, clinical, and treatment information of participants with non-participants using univariable and multivariable logistic regression models.ResultsWe invited 928 childhood cancer survivors in Switzerland with a median age of 26.5 years (interquartile range 19-37), of which 463 (50%) participated. After the initial send out of the sampling kit, 291 (63%) had participated, while reminder letters led to 172 additional participants (37%). Foreign nationality (odds ratio [OR] 0.5; 95%-confidence interval [CI] 0.4-0.7), survivors aged 30-39 years at study versus other age groups (OR 0.5; CI 0.4-0.8), and survivors with a known cancer predisposition syndrome (OR 0.5; CI 0.3-1.0) were less likely to participate in germline DNA collection. Survivors with a second primary neoplasm (OR 1.9; CI 1.0-3.8) or those living in a French or Italian speaking region (OR 1.3; CI 1.0-1.8) tended to participate more.ConclusionsWe showed that half of childhood cancer survivors participated in germline DNA self-sampling relying completely on mailing of sample kits. Written reminders increased the response by about one third. More targeted recruitment strategies may be advocated for people of foreign nationality, aged 30-39 years, and those with cancer predisposition syndromes. Perceptions of genetic research and potential barriers to participation of survivors need to be better understood.Trial registrationBiobank: https://directory.bbmri-eric.eu/#/collection/bbmri-eric:ID:CH_HopitauxUniversitairesGeneve:collection:CH_BaHOP Research project: Clinicaltrials.gov: NCT04702321.

SP10.2.10Efficacy of Outpatient Appointment Reminders in Colorectal Surgery: A Prospective Analysis

Abstract Introduction There is increasing mandate to improve attendance in outpatient clinics to support delivery of High-Quality Care. Non-attendance in Colorectal Cancer (CRC) has clinical and financial implications. Patient appointment reminders (letters, text-messages and telephone) have been implemented to reduce non-attendance. We examine the efficacy of patient appointment reminders in CRC patients. Methods A prospective study was conducted for 3-months in our CRC department surveying patients on their appointment reminders. Non-attending patients were surveyed via telephone to ascertain cause of non-attendance and preference of patient reminders. Data collected was analysed on SPSS. Results 547 patients were prospectively surveyed. 19% did not receive appointments letters, from which 73% were made aware via Text message and 25% via Phone calls. 50% received letters &amp;gt; 2 weeks’ notice. 183 patients did not attend (DNA) their appointment from which 100 were successfully surveyed through telephone. 60% of patients did not received an appointment reminder (letter), or received it following the date of their appointment. 79% patients preferred to be contacted via text messaging or an appointment app vs 13% via letters. Cost analysis releveled significant losses due to missed appointments. Conclusion Patient appointment reminders are fundamental in reducing non-attendance in clinics. Our study demonstrates that appointment letters are an unreliable method of patient communication. In an ever-increasing digital age, methods such as timely text-messages or an appointment app for CRC patients’ needs urgent implementation as per patient preferences. Further research is required to assess non-attendance and causality in other specialities for comparison.

S250 Increasing Fecal Immunochemical Test Return Rates by Patient Reminders: A Quality Improvement Study

Introduction: The incidence of colorectal cancer (CRC) in the United States is increasing, and it remains the second leading cause of cancer death in the United States for men and women combined. The American Cancer Society now recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high sensitivity stool-based test or structural (visual) examination, depending on patient preference and test availability. The primary objective of this quality improvement project was to determine if reminder methods, such as telephone or letter reminders, increased the return rate of fecal immunochemical tests (FIT) for colorectal cancer screening. Methods: At public outreach events and daily clinics in the West Texas Panhandle area, participants in the GET FIT program were provided with FIT kits after completing the education on colorectal cancer. Participants who fit the inclusion criteria and had received a FIT kit from the program were included. They were instructed on how to perform the test and mail it back. Participants that did not return the completed kits within two weeks were reminded either by 1) through a reminder letter or 2) by telephone every 2 weeks (+/- 3 days) for 60 days or 5 attempts to contact. We de-identified and analyzed the FIT kit return data from June-November 2019 before instituting these reminder methods. We then calculated the change in return rates from December 2019 to February 2020. Our goal was to increase the FIT return rates by 25% over the baseline return rate. Results: The pre-intervention return rate of kits for June-November 2019 was 67.58%, and the postintervention return rate for December 2019-February 2020 was 81.87%. This rate was equal to an approximately 21% increase in return rates. The average return rate of FIT kits overall was 72.34%. The average rate of returned new patient kits was 69%, and the average % of new patient return kits was 68.51%. We also noticed a significant increase in return of FIT tests after a community cancer screening in October 2019. Conclusion: Fecal immunohistochemical test (FIT) remains one of the primary options for colorectal cancer screening. Due to its lower cost and noninvasiveness, FIT was offered to patients at average risk.We did achieve a significant increase in return rates, although we did not meet our target goal for this project. Our project was limited to studying 3 months post-intervention due to the COVID pandemic and barrier in returning tests. (Table Presented).

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BackgroundThere is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.MethodsThis explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.ResultsSurvey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.ConclusionsMulti-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Including a pen and/or cover letter, containing social incentive text, had no effect on questionnaire response rate: a factorial randomised controlled Study within a Trial [version 1; peer review: 1 approved with reservations

Background: Postal questionnaires are frequently used in randomised controlled trials to collect outcome data on participants; however, poor response can introduce bias, affect generalisability and validity, and reduce statistical power. The objective of this study was to assess whether a pen and/or social incentive text cover letter sent with a postal follow-up questionnaire increased response rates in a trial. Method: A two-by-two factorial randomised controlled trial was embedded within the OTIS host trial. Participants due their 12-month (final) follow-up questionnaire were randomised to be sent: a pen; a social incentive text cover letter; both; or neither. The primary outcome measure was the proportion of participants in each group who returned the questionnaire. Secondary outcomes were: time to return, completeness of the questionnaire, necessity of a reminder letter, and the cost effectiveness. Results: The overall 12-month questionnaire response rate was 721 out of 755 (95.5%). Neither the pen nor social incentive cover letter had a statistically significant effect on response rate: pen 95.2% vs. no pen 95.8%, adjusted OR 0.90 (95% CI 0.45 to 1.80; p=0.77); social incentive cover letter 95.2% vs. no social incentive cover letter 95.8%, adjusted OR 0.84 (95% CI 0.42 to 1.69, p=0.63). No statistically significant differences were observed between either of the intervention groups on time to response, need for a reminder or completeness. Therefore, neither intervention was cost-effective. Conclusions: We found no evidence of a difference in response rates associated with the inclusion of a pen and/or social incentive cover letter with the final follow-up postal questionnaire of the host trial. However, when these results are combined with previous SWATs, the meta-analysis evidence remains that including a pen increases response rates. The social incentive cover letter warrants further investigation to determine effectiveness. Trial registration: ISRCTN22202133 (21st June 2020).

Monitoring lithium therapy in a CMHRS during the COVID-19 pandemic

AimsThe COVID-19 pandemic has presented a challenge in ensuring that routine monitoring can still be offered and occur in a safe and effective manner. Our aim was to continue the regular physical health monitoring of North East Hampshire CMHRS patients who are prescribed lithium during the COVID-19 pandemic, and to achieve above 90% compliance for the monitoring standards. Lithium monitoring clinics have been established in our CMHRS since 2017, Lithium is a high-risk medication as recognised by a National Patient Safety Alert in 2009. Previous annual POMH-UK audits have identified suboptimal monitoring of Lithium patients at local and national levels.MethodThe ‘Plan-Do-Study-Act’ (PDSA) approach was utilised and a ‘QI Bundle’ formed. A database of patients who are prescribed lithium has been created and maintained. Synchronised standardised reminder letters are sent to the patients twice yearly. NICE recommends that patients on lithium have their lithium levels checked every 3 months for the first year and then at least every 6 months, plus TFTs, U&amp;Es, calcium and weight every 6 months (or more frequently if impaired). The Specialist Pharmacist Service advise that during the COVID-19 pandemic, if patients are not in the at-risk category then monitoring intervals can be extended by up to 3 months, but that patients in the at-risk category should have their normal monitoring intervals continued.Lithium clinics have been held every April and October since 2017 by the Junior Doctors allocated to NE Hampshire CMHRS. This year they were conducted via telephone appointment or face to face where safe to do so with clinician in full PPE. An audit was subsequently carried out in December 2020 to assess our patient's compliance with the aforementioned NICE recommendations for lithium monitoring, the results of which were compared to previous annual audits.ResultSeventeen patients were currently prescribed lithium within the NE Hampshire CMHRS. Over 90% compliance with monitoring was achieved in December 2020 apart from the checking of calcium levels which was slightly below target at 82%, and weight which was at 88%. There was no significant reduction in monitoring standards obtained compared to data from the previous three years.ConclusionRoutine monitoring for our patients who are prescribed Lithium was effectively and safely continued during the pandemic. Above 90% compliance with lithium monitoring standards was nearly obtained across all areas. We will continue to offer lithium monitoring twice yearly.

Impact of a veterans affairs primary care collaboration to provide remote team‐based care and telehealth introductory pharmacy practice experiences

AbstractIntroductionDeveloping remote team‐based care and telehealth introductory pharmacy practice experiences (IPPEs) in primary care is desirable. The Department of Veterans Affairs (VA) endorses interdisciplinary teams to provide primary care services for Veterans and utilizes clinical dashboards to support population management. Pharmacy students, during IPPEs, can perform several patient care activities typically done by VA team members.ObjectiveThe primary objective was to describe the economic impact of a collaboration between a VA health care system and a school of pharmacy to provide remote IPPEs.MethodsDuring Fall 2019, activities of second‐year pharmacy students in a required VA population health IPPE were tracked. Select population management activities typically conducted by nurses, clinical pharmacy specialists (CPS), or primary care providers were assigned to pharmacy students. Students were granted remote access privileges to VA's electronic health record (EHR) and precepted by VA CPS at the university. Students performed prescription drug monitoring program (PDMP) activities, reviewed outside medical records for laboratory results, ordered laboratory tests, conducted telephone pain assessments, and documented progress notes. The average time to complete each function and the average salary for the team member who typically completed the function was used to perform a cost‐benefit analysis.ResultsDuring the semester, 58 students spent 2 hours per week in the IPPE. Students wrote 2118 PDMP progress notes, ordered 1723 laboratory tests for provider signature and sent patients laboratory reminder letters, entered 171 outside laboratory results into VA's EHR, and conducted 183 pain assessments. The semester cost of preceptor salaries was $13 937. Direct benefits to the health system included a salary savings of $24 388.56 to $31 402.03. The net benefit of $10 451.56 to $17 465 resulted in a 75% to 125% return on investment.ConclusionIdentifying practice‐appropriate experiences for pharmacy students enabled active participation in remote team‐based care and telehealth activities, facilitated primary care student experiences, and offered cost savings to the health care system.

How Research Affects Policy: Experimental Evidence from 2,150 Brazilian Municipalities

Can research findings change political leaders’ beliefs and policies? We use experiments with 2,150 Brazilian municipalities to measure mayors’ demand for and response to research information. In one experiment, we find that mayors are willing to pay to learn the results of evaluation studies, and update their beliefs when informed of the findings. They value larger-sample studies more, while not distinguishing between studies in rich and poor countries. In a second experiment, we find that informing mayors about research on a simple and effective policy, taxpayer reminder letters, increases the probability the policy is implemented by 10 percentage points. (JEL D72, D78, D83, O17, O18)

Gastroenterology visitation and reminders predict surveillance uptake for patients with adenomas with high-risk features

Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2–2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6–4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.

Disparity of Cervical Cancer Risk in Young Japanese Women: Bipolarized Status of HPV Vaccination and Cancer Screening.

Women born between 1994 and 1999 achieved high vaccination rates for human papillomavirus (HPV); they are now reaching the age of cervical cancer screening programs in Japan. In this study, we aimed to investigate the health awareness of HPV-vaccinated and unvaccinated women and to create tailored leaflets recommending cervical cancer screening for each. Surveys on the cancer screening rates for HPV-vaccinated and unvaccinated women aged 20 and 21 have demonstrated that the rate was significantly higher (p < 0.01) in vaccinated (6.2%) than in unvaccinated women (3.1%). Next, interviews and Internet questionnaires clarified that there was a trend that vaccinated women have a better health consciousness than the unvaccinated ones, and that in unvaccinated women, their willingness to receive cervical cancer screening was significantly enhanced by the fear of developing cancer. Finally, in a prospective study, the increase in the screening rate for both vaccinated and unvaccinated groups after they read tailored leaflets, from 6.4% to 7.4% and from 3.9% to 5.1%, respectively, was not statistically significant compared to the groups provided with a standard reminder letter. Cervical cancer control measures might be enhanced by recommending cervical cancer screening in ways better tailored to HPV vaccination status.

84539 Developing a Multilevel Intervention to Increase Hepatitis C Virus Screening of Baby Boomers in Primary Care

ABSTRACT IMPACT: This research will improve human health by increasing screening for hepatitis C virus, thereby decreasing morbidity and mortality from hepatitis C-related disease. OBJECTIVES/GOALS: The worldwide incidence of liver cancer increased 75% from 1990 to 2015 due, in part, to chronic hepatitis C virus (HCV) infection. Individuals born 1945-1965 (baby boomers) have five times the prevalence of HCV infection compared to other birth cohorts, but fewer than 15% of this cohort have ever been screened. METHODS/STUDY POPULATION: Effective interventions to increase HCV screening among baby boomers are urgently needed. In partnership with a provider advisory board and a community advisory board, we will develop a multilevel intervention designed to increase HCV screening that will be delivered to both providers and patients in primary care. We will assess whether the intervention is feasible, acceptable, and usable from the perspectives of the target audiences (providers and patients) by conducting Concurrent Think Aloud (CTA) interviews with eight patients and eight providers. RESULTS/ANTICIPATED RESULTS: While the specific content of both intervention components will not be finalized until the completion of the study, we envision that the provider-level intervention will likely include a one-time educational session and monthly performance feedback provided via e-mail reporting each provider’s HCV screening rates. The patient-level intervention may include mailed reminder letters prior to a scheduled clinic visit informing them that HCV screening is recommended and a tablet-based in-clinic computer program to educate, engage, and activate patients to be screened. DISCUSSION/SIGNIFICANCE OF FINDINGS: The goals of this project are to: 1) develop an acceptable, feasible, and usable multilevel intervention aimed at increasing HCV screening in primary care; and 2) understand the relationship between the intervention components and HCV screening; and 3) reduce HCV-related morbidity and mortality.

The importance and availability of adjustments to improve access for autistic adults who need mental and physical healthcare: findings from UK surveys

ObjectivesTo investigate autistic people’s views on the importance and availability of adjustments to mental and physical healthcare provision. To explore whether specific categories of adjustments can be identified and to...

Inattention or reluctance? Parental responses to vaccination reminder letters

This paper studies non-adherence in the Danish Childhood Vaccination Program using a nationwide introduction of a vaccination reminder letter policy and administrative data from 2011–2017. First, I provide causal estimates of how the reminder letter policy affects vaccination adherence using a Regression Discontinuity Design (RDD). Second, I link parental responses to the reminder letter to parents’ causes for being non-adherent. I find that the reminder letter policy positively affects adherence. However, 72% of non-adherent parents are non-responsive to the reminder letter indicating that reluctance and not inattention is the leading cause for non-adherence. Thus, other policies beyond reminder letters – such as mandatory vaccination laws – are necessary to substantially increase vaccination coverage.

Improving Fecal Immunochemical Testing Rates for Colon Cancer Screening in the Outpatient Setting.

The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

Effect of reminder letters after health checkups on the consultation behavior of participants with possible hypertension, hyperglycemia, and dyslipidemia: A retrospective cohort study using administrative claims data in Japan.

ObjectivesPrevention of and early treatment for noncommunicable diseases such as hypertension, hyperglycemia, and dyslipidemia are important, as these diseases are asymptomatic in early stages but can lead to critical conditions such as macro‐ and microvascular disorders later on. While screening is conducted worldwide, low rates of hospital visits after screening is a common issue. We aimed to investigate the effect of reminder letters on the consultation behavior of screened participants.MethodsWe used administrative claims data from a database managed by JMDC Inc for participants of health checkups in 2014, 2015, 2016, and 2017, who belonged to a health insurance society. Reminder letters were sent regularly 6 months after checkups to improve participant consultation behavior. Participants who screened positive for hypertension, hyperglycemia, and dyslipidemia, and who were not taking medication for any of these diseases at the time of health checkups, were included in the analyses.ResultsA total of 1739 participants in 2014, 1693 in 2015, 2002 in 2016, and 2144 in 2017 were included in the analysis for hypertension. The cumulative proportion of hospital visits gradually increased over the course of 12 months after checkups in all years. After 2015, spikes, albeit very small ones, were observed at 6 months after checkups in accordance with the timing of reminder letters. Similar trends were observed for hyperglycemia and dyslipidemia.ConclusionsSending reminder letters is a potentially effective approach to increase hospital visits, but further improvements (ie, multiple reminders) may be necessary to affect enhancements in participant consultation behavior.

Good for you or good for us? A field experiment on motivating citizen behavior change

In recent years, public sector agencies have increasingly been moving citizen services online to reduce administrative burdens for citizens and costs for governments. However, motivating citizens to make the transition to online services can be difficult. In this paper, I report on a randomized control trial with the Philadelphia Licenses and Inspections Department, testing a letter intervention with 11,579 rental license holders designed to encourage them to register for an account and renew online. Subjects were randomly assigned to either a control group that did not receive a letter or one of three treatment groups: 1) Standard (a simple reminder letter); 2) Personal Benefits (a letter with added language emphasizing the reduced burden for citizens from online renewal); and 3) City Benefits (a letter with added language emphasizing the benefits to the city from online renewal). I find a statistically significant, positive effect of letter receipt on both online registration and renewal; for example, the treatment letters increased the probability of renewing at least one license online from 12.3% in the control to 20.4% for the treatments pooled together. Furthermore, the City Benefits letter was the least effective treatment, though there were only small differences between treatments. Finally, the letters were generally more effective for subjects not residing in Philadelphia, suggesting that “nudge” campaigns to reduce administrative burden may be most effective for those facing the highest burdens from in-person public service delivery.

A Module in Medication Safety Involving Remote Access and Review of Veterans’ Health Records

Objective. To describe and assess the effectiveness of an ambulatory care introductory pharmacy practice experience (IPPE) module in medication safety monitoring that was conducted remotely for first- and second-year pharmacy students in collaboration with a Department of Veterans Affairs (VA) health care system.Methods. A module in medication safety was developed and piloted as part of a required, one-unit IPPE in ambulatory care. The module encompassed three sessions of the 15-week course. Working remotely at the school under the direct supervision of VA clinical pharmacists, students accessed the electronic health records (EHRs) of veterans for whom methotrexate, sulfasalazine, or mineralocorticoid receptor antagonists had been prescribed as such patients require ongoing laboratory monitoring to screen for adverse drug effects. After reviewing the record, students ordered laboratory tests under the prescriber's name, documented notes in the patient's EHR, and sent laboratory reminder letters to patients. Students completed a brief survey at the beginning and end of the course. Differences in survey responses were compared using the Wilcoxon signed rank test.Results. Fifty-eight students reviewed 148 patient records, including non-VA electronic records, and ordered laboratory tests for 79 patients. On the follow-up survey at course completion, students reported significant changes in their ability to monitor laboratory tests, use an actual (non-simulated) EHR to perform patient care, and explain the role of a clinical dashboard to conduct population health activities.Conclusion. Remotely conducting an ambulatory care IPPE course in which pharmacy students used an actual EHR to participate in medication safety monitoring for ambulatory patients expanded the pharmacy school's ability to provide crucial practice experience. Other pharmacy schools struggling with logistical challenges and limited resources should explore this approach to fulfilling the experiential education requirements for pharmacy students.