Improving Immunization Rates in Underserved Neighborhoods

Background: Immunization refusal rates in the United States are increasing. Ohio is below the national average for immunization rates, with even lower rates among children who are publicly insured. Our two hospital-based pediatric primary care offices serve 25,000 children from urban, underserved neighborhoods, with 90% publicly insured and 75% Black. Our immunization refusal rate is 2%, but nearly 10% of families refuse select immunizations or request alternative schedules. The drivers of local immunization rates are unknown. Our objective was to explore families' immunization beliefs and perspectives through interviews to allow for development of tailored information. The secondary objective was to evaluate caregiver impression of the newly developed educational information and measure the acceptability of these materials. Methods: This content analysis took place at a large, urban pediatric hospital's primary care offices. Caregivers of patients were recruited for interviews. We developed semi-structured interview guides after conducting a literature review and holding informal discussions with families at community meetings. The interview script included eight questions related to educational materials, desired topics, preferred learning format and reasons for vaccine refusal. Interviews were audio recorded, transcribed, and coded by one team member, then collectively analyzed by three team members to identify initial codes. The entire team discussed codes and resolved any discrepancies and then created categories. Educational materials were created based on the results of these interviews. Finally, caregivers at well child visits were approached to review the educational materials and provide written feedback, through pre- and post-surveys, to assess acceptability and impression of the materials. Results: Eighteen family were initially interviewed. Key educational topics identified by families included vaccine ingredients, side effects, and general benefits of immunizations. Reasons for vaccine refusal included concerns that vaccines cause disease, adverse side effects, and a fear of developing autism (Table 1). Written materials and videos were the preferred educational format, and families reported wanting these materials in conjunction with inperson discussions with the health care providers. Several educational resources were created: 1) a timeline displaying a typical vaccine schedule with descriptions of each vaccine, 2) a brochure addressing common concerns, and 3) a testimonial video with clinicians and caregivers describing “Why I Vaccinate.” The educational information was piloted with 51 families, and the majority of caregivers reported their questions were answered and they would likely share the information with family and friends (Table 2). Conclusion: Caregivers indicated preferences for written and digital materials to augment vaccinerelated discussions with healthcare providers. Educational materials tailored to address family concerns and learning preferences may enhance quality of conversations and ultimately decrease immunization refusal in our community. Next steps include distributing educational materials more broadly within primary care and evaluating impact on immunization rates. Similar approaches could be considered for newer vaccines, including COVID-19.

Telehealth in primary care: Meeting patient and family needs

Background: Telehealth is a novel way to provide care to patients and families and may be especiallyimportant for families with transportation challenges. The COVID-19 pandemic with social distancingrequirements further accelerated the need for the utilization and expansion of telehealth services. Objective:To evaluate the feasibility of rapidly scaling primary-care telehealth and its impact on families' location of careand associated transportation costs. Methods: A retrospective study was conducted at a large, urban,academic primary care center consisting of 6 primary care sites, with approximately 85% of patients coveredby Medicaid. In February 2020, just prior to the COVID-19 pandemic, telehealth was launched for routinefollow-up of chronic medical conditions (e.g., ADHD, asthma) and acute complaints (e.g., rashes) two half-daysper week. Due to COVID-19, rapid escalation of telehealth was necessary and during these telehealth visits,families were asked the location of care they would have chosen if telehealth was not available (in-personprimary care, Emergency Department (ED), Urgent Care (UC), or opt for no care). Miles saved (measured bydistance from family residence zip code to the hospital main campus where the ED, UC, and most primary care sites are located) and cost saved (as measured by federal reimbursement amounts for mileage) weredetermined from demographic information in the electronic health record. Results: Five physicians trained anadditional 16 clinicians over 2 weeks, providing the ability to expand telehealth to six days per week. FromFebruary-March 2020, 245 unique telehealth encounters were completed. Providers asked 60% (n=147) offamilies where they would have sought in-person care if telehealth was not available, with the largest percent(68.7% (n= 101)) indicating a primary care visit. In addition, 14.2% (n= 21) of families reported intent to visit theED, 4.8% (n=7) an UC and 12.2% (n=18) would have opted for no care. Regarding savings related to distance toan alternative location of care, families saved an average of 16 miles ($9.30) for an in-person primary care visit,13 miles ($7.19) for an ED visit, and 11.4 miles ($6.23) for an urgent care visit. Families who would have optedfor no care lived the farthest, with an average 21 miles. A substantial percent of families (19%;n=28) reportedthat they would have sought more costly care options (ED or UC). Conclusion: Rapid scaling of primary carebased telehealth was feasible serving a mostly publically insured population. The majority of families reportedthat without telehealth, they would have sought in-person visits, but those who lived farthest would not havesought care. Telehealth appears to be a cost saving alternative for families and the medical system. Next stepsinclude a trial of social risk and mental health screening during telehealth visits.