WK 7 DIS DATA

Walden University

College of Nursing

This is to certify that the doctoral study by

Terrie LaVern Hazel

has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made.

Review Committee Dr. Barbara Niedz, Committee Chairperson, Nursing Faculty

Dr. Marisa Wilson, Committee Member, Nursing Faculty

Chief Academic Officer and Provost Sue Subocz, Ph.D.

Walden University 2023

Executive Summary: Quality Improvement Initiative

Pediatric Vaccine Appointment Compliance After Text Messaging Reminders: A

Retrospective Program Evaluation of a Local Quality Improvement Initiative

by

Terrie Hazel

MS, Walden University, 2016

BS, Kaplan University, 2012

Executive Summary Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Nursing Practice

Walden University

November 2023

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Summary

This DNP project presents an evaluation of a local quality improvement initiative

assessing whether the deployment of phone call reminders improved child immunization

appointment adherence in an underserved pediatric patient population. Childhood

immunizations are critical to preventive healthcare, reducing the burden of vaccine-

preventable diseases. Insufficient appointment completion wastes healthcare resources

and increases the frustration of personnel and clients who are forced to wait weeks for an

available visit, compromising access. Data across 12 months on appointment completion

for well-child visits were analyzed; 6 months of data were provided from 2021, prior to

the implementation of the telephone reminders. Data were also provided from an

additional 6-month period in 2022 following the telephone reminder strategy. A

comparative analysis demonstrated an increase in appointment completion from 44.29%

in 2021 to 50.71% in 2022. Correlational analyses showed a strong correlation (r = .710,

p = .004) between completed appointments and time. The proposals of this initiative

center on the need to develop an effective evidence-based intervention to help decrease

no-show appointments and boost vaccination adherence. A key recommendation from

this DNP project emerged: the pediatric practice must keep the automated reminder

system in place to maintain compliance and reduce wasteful spending. The project

confirms that the telephone reminder system is working to improve available

appointments and reduce access disparity in the patient population, a positive social

change that addresses diversity, inclusion, and equity in this underserved population.

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Background

Primary preventive healthcare focuses on keeping people well, preventing illness

and injury, and educating people about adopting healthier behaviors (Posadzki et al.,

2016). Childhood immunizations are fundamental to preventing the spread of infectious

diseases and safeguarding public health. Despite advancements in immunization

programs, challenges related to adherence to recommended vaccine schedules persist.

The COVID pandemic exacerbated the already prevalent problem of missed

appointments. In the early phases of the global health crisis, the Centers for Disease

Control in 2020 instructed health personnel to delay nonemergency and routine medical

procedures to help maintain the healthcare system's capacity and minimize the possibility

of spread. Pediatric outpatient care visits for children under the age of 18 fell by 70% in

2021 due to parental concerns about COVID-19 exposure to their children and

themselves (Teasdale et al., 2022). Between 18.7 and 20.1 million minors failed to obtain

a final injection of diphtheria, tetanus toxoid, pertussis-containing antigens (DTP3), or

measles vaccine (Gibson et al., 2017). Child immunization is crucial in mitigating and

eradicating infectious diseases; however, adherence remains a pivotal challenge. Engaged

parental participation in immunization services is among the most significant obstacles to

achieving adequate immunization coverage (Feldman et al., 2022). A review of the local

pediatric primary care clinic discovered a 44.28% gap in patients keeping their planned

well-child immunization appointments in 2021. In a time with the growing complexity of

vaccination timelines, higher standards for healthcare provider efficiency, and mounting

requirements on medical providers, it is imperative to recognize and support effective

initiatives in clinical settings. Vaccinations are often skipped for plausible explanations,

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such as individuals' forgetfulness, skipping visits, or being unfamiliar with immunization

schedules (Jacobson Vann et al., 2018). In recent years, adherence to child immunization

schedules has been identified as a crucial aspect of public health, significantly reducing

the prevalence of preventable diseases. Primary preventive healthcare focuses on

maintaining good health, avoiding illness and injury, and encouraging healthy lifestyle

choices. With children missing out on timely vaccinations, there has been a noted gap in

practice. Addressing these challenges requires innovative strategies, such as phone call

reminders, which leverage technology to enhance patient engagement and adherence.

Evidence suggests that theory-driven behavior change interventions can dramatically

improve health behaviors (Muathe et al., 2020). The project question that guided this

initiative was “Will a retrospective program evaluation of a local QI initiative at the site

demonstrate that child immunization care adherence improves with the deployment of

phone call reminders?” Experts have recommended centralized reminders from state

immunization information systems or healthcare systems as a scalable strategy (Szilagyi

et al., 2020). This quality improvement project occurred at a local pediatric primary care

health center serving a low-income, minority population. The center's historical

immunization data revealed suboptimal up-to-date vaccination rates among pediatric

patients each month. Phone call reminders are a feasible strategy to augment

immunization coverage even in low-resource settings (Brown & Oluwatosin, 2017).

Research by Gibson et al. (2017) and a systematic review by Jacobson Vann et al. (2018)

have further demonstrated the effectiveness of mobile phone-delivered reminders in

improving childhood immunization coverage and timeliness. Given the rapid

advancements in technology and increased accessibility to mobile phones, this project

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explored the impact of phone call reminders on child immunization adherence through a

retrospective program evaluation of a local quality improvement (QI) initiative.

Project Development

I designed this initiative to implement and assess the impact of mobile text

messaging on well-child visits and immunization care adherence. I aimed to reduce

missed well-child visit appointments and increase vaccination compliance. These

outcomes were assessed by comparing the cumulative data of missed well-child

appointments and vaccine completion in 2021 to those collected on missed well-child

appointments and vaccine completion in 2022 following implementation. Obtaining de-

identified data for this retrospective project was performed by the principal owner of the

pediatric medical practice and the office manager. Successful implementation of the

initiative depended on the collaboration and participation of healthcare personnel within

the organizational structure. The office manager and staff thoroughly understood the

disparity and the proposed protocol by engaging in the early phases of the project

development. Three nurses and four administrative staff members implemented the text

messaging protocol in June 2022. Medical staff texted appointment reminders to the

patients 24 hours before scheduled appointments. Frequent progress updates and open

dialogue were crucial to maintaining worker engagement and guaranteeing the

dissemination of information. Data obtained from 2021 historical appointment attendance

and vaccination records did not contain any personally identifiable information (PII) to

maintain patient privacy. I analyzed the project's data using comparative analysis. Data

was collected from June 2021 to December 2021 before the process and from June 2022

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to December 2022 after initiation. The comparative period spanned from June 2022 to

December 2022 post initiative launch.

Results

Historical data from June through December 2021 for well-child vaccination

appointment completion (Table 1) and postimplementation data from June through

December 2022 (Table 2) were evaluated through descriptive and correlational analysis.

The attendance rates were calculated by dividing the total number of appointment

completions by the total number of appointments scheduled. There was an overall

increase from 44.29% in 2021 to 50.71% in 2022. Correlational analysis showed a

statistically significant relationship between the passage of time (2021 to 2022) on

completed appointments (r = .710, p =.004). Thus, nearly half of the variance in

appointment completion can be explained by a comparison of 2021 to 2022 appointment

completion rates (r2 = 0.505), see Figure 1. Based on the trend analysis of the intervention

outcome, there was an increase in appointment completion for well-child vaccination

appointments beginning July 2022 that continued through December 2022 as compared

to the same timeframe in 2021. The relationship of the completed appointments to

vaccination rates was 100%. That is, when appointments were completed, vaccinations

were given 100% of the time. Cancelled or no show appointments compromise the

workflow at the site and sometimes result in delayed vaccinations, and at worst,

incomplete or lost vaccinations. Thus, the appointment completion rate in this DNP

project serves as a proxy for completed vaccinations.

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Table 1 2021 Appointments Pediatric Primary Care Dates Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21

Total attendance

152 155 170 190 165 156 128

Total appointments scheduled

350 380 380 375 350 350 300

Total appointment completion rate

43.00% 40.00% 44.00% 50.00% 47.00% 44.00% 42.00%

Table 2 2022 Appointment Pediatric Primary Care Dates Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22

Total attendance

138 158 208 205 187 180 146

Total appointments scheduled

300 325 375 375 350 350 300

Total appointment completion rate

46.00% 48.00% 55.00% 54.00% 53.00% 51.00% 48.00%

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Figure 1 Scatterplot: Appointment Completion Rates by Month/Year

The text messaging reminders impacted the pediatric clinic by enhancing

convenience, reducing missed appointments, and ultimately contributing to better

healthcare outcomes for children while improving overall clinic productivity. A

limitation of the effort was that the pediatric clinic treats underserved patients. The

primary challenge does not lie in providing care for this particular population but in the

relatively successful implementation of the intervention, hindered by the difficulty of

ensuring that patients attend their healthcare sessions. That is, the underserved patients

may have other factors that compromise their ability to keep appointments like

transportation issues, interruption of patient caregiver work schedules, and perhaps some

lacking technology advantages (Jacobson Vann et al., 2018). The importance of this

initiative beyond the local site where it took place was the positive social change it

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brought. It promoted access to care, reduced disparities, and contributed to better

community health. Text messaging reminders for pediatric clinic appointments are

essential to ensure healthcare services are accessible, respectful, and inclusive to all

patients regardless of their socio-economic status or abilities (Brown & Oluwatosin,

2017). It also fostered diversity, equity, inclusion, and justice.

Conclusions

In conclusion, ensuring that children receive their vaccinations on time is crucial

for individual health, the well-being of communities, and the resilience of public health

systems. Text messaging reminders can support healthcare duties, such as illness

prevention and chronic condition management, and even bridge the gap between those

needing care and those who can provide it (Feldman et al., 2022). Evidence showed that

using mobile-delivered reminders considerably increased the rate of childhood

vaccination coverage. In particular, text messaging reminder strategies have shown

efficacy in enhancing vaccination rates and alleviating potential burdens on healthcare

systems and providers by streamlining information delivery and reminder systems

(Posadzki et al., 2016). Recommendations for this initiative focus on the disparity, which

was well defined as the need to implement an effective evidence-based intervention to

help reduce no-show appointments and increase vaccination adherence. Continued use of

the automated reminder system should remain intact for continued compliance and cost-

effectiveness improvements. Despite the hurdles introduced by the pandemic, nursing

observed a positive trend in immunization adherence rates following the implementation

of phone call reminders. Regarding the effect this initiative had on nursing practice, the

COVID-19 pandemic served as a reminder of the importance of maintaining essential

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healthcare services, and this study reaffirms the role of evidence-based practices, such as

phone call reminders, in achieving this goal. It emphasizes the resilience of pediatric

healthcare and its capacity to overcome obstacles and continue to provide essential care

to children (see Teasdale et al., 2022).

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References

Brown, V. B., & Oluwatosin, O. A. (2017). Feasibility of implementing a cellphone-

based reminder/recall strategy to improve childhood routine immunization in a

low-resource setting: a descriptive report. BMC Health Services Research,

17(Suppl 2), 703. https://doi.org/10.1186/s12913-017-2639-8

Feldman, A. G., Moore, S., Bull, S., Morris, M. A., Wilson, K., Bell, C., Collins, M. M.,

Denize, K. M., & Kempe, A. (2022). A smartphone app to increase

immunizations in the pediatric solid organ transplant population: Development

and initial usability study. JMIR Formative Research, 6(1), e32273.

https://doi.org/10.2196/32273

Gibson, D. G., Ochieng, B., Kagucia, E., Were, J., Hayford, K., Moulton, L. H., Levine,

O. S., Odhiambo, F., O'Brien, K. L., & Feikin, D. R. (2017). Mobile phone-

delivered reminders and incentives to improve childhood immunization coverage

and timeliness in Kenya (m-simu): A randomized controlled trial. Lancet Global

Health, 5(4), e428–e438. https://doi.org/10.1016/s2214-109x(17)30072-4

Jacobson Vann, J. C., Jacobson, R. M., Coyne-Beasley, T., Asafu-Adjei, J. K., &

Szilagyi, P. G. (2018). Patient reminder and recall interventions to improve

immunization rates. Cochrane Database of Systematic Reviews, 2018(1).

https://doi.org/10.1002/14651858.cd003941.pub3

Muathe, E., Kamau, M., & Rajula, E. (2020). Exploring strategies to improve adherence

to immunization schedule: A study among children attending maternal and child

health clinic at Kenyatta National Hospital, Nairobi, Kenya. International Journal

of Pediatrics, 2020, Article 4730205, 1–8. https://doi.org/10.1155/2020/4730205

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Posadzki, P., Mastellos, N., Ryan, R., Gunn, L. H., Felix, L. M., Pappas, Y., Gagnon, M.-

P., Julious, S. A., Xiang, L., Oldenburg, B., & Car, J. (2016). Automated

telephone communication systems for preventive healthcare and management of

long-term conditions. Cochrane Database of Systematic Reviews, 2016(12).

https://doi.org/10.1002/14651858.cd009921.pub2

Szilagyi, P. G., Albertin, C., Casillas, A., Valderrama, R., Duru, O., Ong, M. K.,

Vangala, S., Tseng, C.-H., Rand, C. M., Humiston, S. G., Evans, S., Sloyan, M.,

& Lerner, C. (2020). Effect of patient portal reminders sent by a health care

system on influenza vaccination rates. JAMA Internal Medicine, 180(7), 962.

https://doi.org/10.1001/jamainternmed.2020.1602

Teasdale, C. A., Borrell, L. N., Shen, Y., Kimball, S., Zimba, R., Kulkarni, S., Rane, M.,

Rinke, M. L., Fleary, S. A., & Nash, D. (2022). Missed routine pediatric care and

vaccinations in us children during the first year of the COVID-19 pandemic.

Preventive Medicine, 158, 107025. https://doi.org/10.1016/j.ypmed.2022.107025