Integrated Health Maintenance Reminders for Improved HPV Vaccine Administration: Toward Improvements in Completion Disparities.

OBJECTIVE: To evaluate the effect of a health maintenance reminder (HMR) on human papillomavirus (HPV) vaccine administration and completion across different age, insurance, and race cohorts. STUDY DESIGN: Retrospective pre-post analysis. SETTING: Academic primary care. METHODS: Patients aged 9 to 26 who had initiated the HPV vaccine series from 2016 to 2021 were analyzed, based on current age-based standards. The cohort was divided based on vaccine uptake before and after the implementation of the HMR program in February 2020. The multivariate analysis estimated the odds of vaccine completion based on sociodemographic factors, and variable interactions were investigated to determine independent associations between sociodemographic factors and HMR implementation. RESULTS: There were 7654 individual patients (mean age was 15.8 years; 46.7 were males; and 50.7% were white). HPV vaccine completion rates increased post-HMR implementation by 59.2% (37% pre-, and 58.9% post-HMR; p < .001) in the entire cohort. Overall, black patients (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.60, 0.70) and patients ≥18 years (aOR = 0.13; 95% CI: 0.11, 0.15) were significantly less likely to complete their vaccine series; however, this improved significantly following HMR in these groups (p < .001). Post-HMR, race, and insurance status were not independently associated with disparate vaccine completion rates, however, age was, and patients ≤14 or younger had higher odds of vaccine completion (aOR = 3.54; 95% CI: 2.91, 4.32). CONCLUSION: The implementation of an HMR was associated with increased HPV vaccine uptake across age and race groups in this single-institution study. Future research should explore barriers to implementing HMRs in different health care settings.

Addressing logistical barriers to childhood vaccination using an automated reminder system and online resource intervention: A randomized controlled trial.

BACKGROUND: As the rates of vaccination decline in children with logistical barriers to vaccination, new strategies to increase vaccination are needed. The goal of this study was to develop and evaluate the effectiveness of the Vaccines For Babies (VFB) intervention, an automated reminder system with online resources to address logistical barriers to vaccination in caregivers of children enrolled in an integrated healthcare system. Effectiveness was evaluated in a randomized controlled trial. METHODS: Qualitative interviews were conducted with parents of children less than two years old to identify logistical barriers to vaccination that were used to develop the VFB intervention. VFB included automated reminders to schedule the 6- and 12-month vaccine visit linking caregivers to resources to address logistic barriers, sent to the preferred mode of outreach (text, email, and/or phone). Parents of children between 3 and 10 months of age with indicators of logistical barriers to vaccination were randomized to receive VFB or usual well child care (UC). The primary outcome was percentage of days undervaccinated at 2 years of life. A difference in differences analysis was conducted. RESULTS: Qualitative interviews with 6 parents of children less than 2 years of age identified transportation, scheduling challenges, and knowledge of vaccine timing as logistical barriers to vaccination. We enrolled 250 participants in the trial, 45% were loss to follow-up. There were no significant differences in vaccination uptake between those enrolled in UC or the VFB intervention (0.51%, p = 0.86). In Medicaid enrolled participants, there was a modest decrease in percentage of days undervaccinated in the VFB intervention compared to UC (6.3%, p = 0.07). CONCLUSION: Automated Reminders and with links to heath system resources was not shown to increase infant vaccination uptake demonstrating additional resources are needed to address the needs of caregivers experiencing logistical barriers to vaccination.

Factors Associated With Opting Out of Automated Text and Telephone Messages Among Adult Members of an Integrated Health Care System.

Importance: Health care systems deliver automated text or telephone messages to remind patients of appointments and to provide health information. Patients who receive multiple messages may demonstrate message fatigue by opting out of future messages. Objective: To assess whether the volume of automated text or interactive voice response (IVR) telephone messages is associated with the likelihood of patients requesting to opt out of future messages. Design, Setting, and Participants: This retrospective cohort study was conducted at Kaiser Permanente Colorado (KPCO), an integrated health care system. All adult members who received 1 or more automated text or IVR message between October 1, 2018, and September 30, 2019, were included. Exposures: Receipt of automated text or IVR messages. Main Outcomes and Measures: Message volume and opt-out rates obtained from messaging systems over 1 year. Results: Of the 428 242 adults included in this study, 59.7% were women, and 66.5% were White; the mean (SD) age was 52.3 (17.7) years. During the study period, 84.1% received 1 or more text messages (median, 4 messages; interquartile range, 2-8 messages) and 67.8% received 1 or more IVR messages (median, 3 messages; interquartile range, 1-6 messages). A total of 8929 individuals (2.5%) opted out of text messages, and 4392 (1.5%) opted out of IVR messages. In multivariable analyses, individuals who received 10 to 19.9 or 20 or more text messages per year had higher opt-out rates for text messages compared with those who received fewer than 2 messages per year (adjusted odds ratio [aOR]: 10-19.9 vs <2 messages, 1.27 [95% CI, 1.17-1.38]; ≥20 vs <2 messages, 3.58 [95% CI, 3.28-3.91]), whereas opt-out rates increased progressively in association with IVR message volume, with the highest rates among individuals who received 10.0 to 19.9 messages (aOR, 11.11; 95% CI, 9.43-13.08) or 20.0 messages or more (aOR, 49.84; 95% CI, 42.33-58.70). Individuals opting out of text messages were more likely to opt out of IVR messages (aOR, 4.07; 95% CI, 3.65-4.55), and those opting out of IVR messages were more likely to opt out of text messages (aOR, 5.92; 95% CI, 5.29-6.61). Conclusions and Relevance: In this cohort study among adult members of an integrated health care system, requests to discontinue messages were associated with greater message volume. These findings suggest that, to preserve the benefits of automated outreach, health care systems should use these messages judiciously to reduce message fatigue.

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review.

CONTEXT: Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children. OBJECTIVE: We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage. DATA SOURCES: PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched. STUDY SELECTION: Interventions targeting influenza vaccine coverage in children with medical comorbidities. DATA EXTRACTION: Two reviewers independently screened articles, extracting studies' methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias. RESULTS: From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients' parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate. LIMITATIONS: A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods. CONCLUSIONS: Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.

Cost-effectiveness of SMS appointment reminders in increasing vaccination uptake in Lagos, Nigeria: A multi-centered randomized controlled trial.

OBJECTIVE: It is expected that mHealth largely contribute to increasing the coverages of key maternal and child health services. This study aims to estimate the cost-effectiveness of the SMS text reminders in clients' return visits to the health facilities for child vaccinations (incl. vitamin A supplementations), antenatal care (ANC) and family planning (FP), in urban communities of Lagos, Nigeria. METHODS: A multi-centered randomized control trial was conducted at 33 primary health centers (PHCs) in Lagos, Nigeria. All the clients having visited any of the 33 PHCs for child vaccinations, ANC and FP were randomly assigned either to intervention group or to control group. The participants in the intervention group were sent an SMS text reminder two days before their appointments. Those not having showed up on the appointment dates received an additional SMS text reminder seven days after original appointment dates as defaulter tracing. The primary outcome was whether a client made return visit to PHCs for the upcoming appointments. RESULTS: Of 12,779 appointments for 9,368 clients during the period of 1stApril to 30thJune 2019, 12,175 were included in the analysis. The return rate for child vaccinations in the intervention group was significantly higher (p < 0.001) by 4.8% - 6.0% than that in the control group, consistently across all the five different timings (on time as scheduled, and by 7 days, 14 days, 30 days, and 3 months after appointment dates). No significant difference between the two groups was detected in the increase in return rates for ANC and FP services. The incremental recurrent cost was estimated at 7.90 US Dollars per return case. CONCLUSION: SMS text reminders led to a significant increase in the number of return visits for child vaccinations, Lagos, Nigeria, while no significant increase in return visits was confirmed for ANC and FP appointments.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study.

OBJECTIVE: To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS: We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION: While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

Clinician Perceptions of Timing and Presentation of Drug-Drug Interaction Alerts.

OBJECTIVE: Alert presentation of clinical decision support recommendations is a common method for providing information; however, many alerts are overridden suggesting presentation design improvements can be made. This study attempts to assess pediatric prescriber information needs for drug-drug interactions (DDIs) alerts and to evaluate the optimal presentation timing and presentation in the medication ordering process. METHODS: Six case scenarios presented interactions between medications used in pediatric specialties of general medicine, infectious disease, cardiology, and neurology. Timing varied to include alert interruption at medication selection versus order submission; or was noninterruptive. Interviews were audiotaped, transcribed, and independently analyzed to derive central themes. RESULTS: Fourteen trainee and attending clinicians trained in pediatrics, cardiology, and neurology participated. Coders derived 8 central themes from 929 quotes. Discordance exists between medication prescribing frequency and DDI knowledge; providers may commonly prescribe medications for which they do not recognize DDIs. Providers wanted alerts at medication selection rather than at order signature. Alert presentation themes included standardizing text, providing interaction-specific incidence/risk information, DDI rating scales, consolidating alerts, and providing alternative therapies. Providers want alerts to be actionable, for example, allowing medication discontinuation and color visual cues for essential information. Despite alert volume, participants did not "mind being reminded because there is always the chance that at that particular moment (they) do not remember it" and acknowledged the importance of alerts as "essential in terms of patient safety." CONCLUSION: Clinicians unanimously agreed on the importance of receiving DDI alerts to improve patient safety. The perceived alert value can be improved by incorporating clinician preferences for timing and presentation.

Patient Engagement With an Automated Telephone Symptom Management Intervention: Predictors and Outcomes.

BACKGROUND: Self-management of symptoms related to cancer and its treatment is important for maintaining treatment regimens and improving outcomes. PURPOSE: To determine factors associated with engagement in a symptom self-management intervention among patients initiating oral anticancer treatment. METHODS: This secondary analysis included 127 patients randomized to the medication adherence reminder and symptom management intervention in a recently completed trial. Patients were recruited from six Comprehensive Cancer Centers, interviewed at intake, and mailed a Symptom Management Toolkit (Toolkit) with self-care management strategies for 18 symptoms. During eight automated telephone weekly calls, patients were asked to use the Toolkit to manage elevated symptoms. Toolkit use and symptoms were tracked weekly, and generalized linear mixed-effects models were used to determine factors predictive of Toolkit use. General linear modeling was used to relate the Toolkit use during intervention to postintervention symptom severity. RESULTS: Better cognitive function at intake into the trial and higher symptom burden were predictive of the patients' initial decision to try the Toolkit during Week 1. In subsequent weeks, Toolkit use in the previous week and worsening of symptoms were associated with greater odds of Toolkit use. The extent of Toolkit use modified the relationship between intake and 8 week symptom severity: among patients with higher levels of severity at intake, use of the Toolkit conferred greater benefit at 8 weeks. CONCLUSIONS: Patients make realistic decisions regarding when to use a self-directed approach to self-management and are likely to use strategies when their symptoms are higher and to forego use once symptoms subside. CLINICAL TRIAL REGISTRATION: NCT02043184.

Moving 2 Mindful (M2M) study protocol: testing a mindfulness group plus ecological momentary intervention to decrease stress and anxiety in adolescents from high-conflict homes with a mixed-method longitudinal design.

INTRODUCTION: Interparental conflict exposure places adolescents at risk for problems with stress and anxiety; existing prevention/intervention strategies focus on reducing interparental conflict. Mindfulness-based programmes may be a promising treatment strategy for this population, but studies have not yet tested whether they are effective in this high-conflict context. In addition, evidence suggests that extensions to traditional treatments, such as delivering components in daily life that are tailored to moments of need, can increase treatment efficacy, particularly when combined with in-person treatments and particularly for adolescents. However, there are no such extensions to mindfulness interventions available. The Moving 2 Mindful study aims to (1) develop an ecological momentary intervention (EMI) supplement to Learning to BREATHE (L2B), an evidence-based mindfulness intervention for adolescents; (2) refine the EMI programme and determine the best delivery plan; (3) examine the feasibility and acceptability of L2B Plus (L2B plus the developed supplement) and (4) examine the potential for L2B Plus to reduce stress and anxiety for adolescents from high-conflict homes. METHODS AND ANALYSIS: The Moving 2 Mindful study proposes a mixed-methods approach to developing and refining a multimethod adaptive supplement to L2B. Feasibility, acceptability and potential effectiveness will be tested in a sample of 38 families, who will be randomly assigned to receive L2B Plus or an active health and wellness control condition and followed until 3 months postintervention. A range of psychosocial and physiological factors will be assessed at multiple time points. This study is registered with clinicaltrials.gov (ID NCT03869749; pre-results). ETHICS AND DISSEMINATION: The Institutional Review Board at Colorado State University has approved this study. Findings will be disseminated in scientific journals and conferences, whether they are positive, negative or inconclusive.

Temporary Stoppages and Burden of Treatment in Patients With Cancer.

OBJECTIVES: To examine the effect of burden of treatment and multimorbidity on the relationship between baseline characteristics and oral oncolytic agent (OOA) temporary stoppages. SAMPLE & SETTING: 272 patients newly prescribed OOAs at six National Cancer Institute-designated comprehensive cancer centers. METHODS & VARIABLES: Patients were randomly assigned to an adherence and symptom management group or a usual care/control group. Temporary OOA stoppages, symptom interference, OOA regimen complexity, and multimorbidities were explored. Data were collected at four-week intervals for 12 weeks. RESULTS: Burden of treatment variables and multimorbidity had no significant effect on OOA temporary stoppages. Women and those prescribed kinase inhibitors were significantly more likely to experience a temporary stoppage. IMPLICATIONS FOR NURSING: Oncology nurses are in a crucial position to educate patients on self-management of OOAs and symptoms. Nurses should be aware of patients who may be more susceptible to severe symptoms, including those with multimorbidities. Future research is needed to better understand OOA stoppages and factors associated with preventing stoppages.

How and how much is spirituality discussed in palliative care consultations for advanced cancer patients with and without a question prompt list?

OBJECTIVE: Patients want to discuss spirituality more with their doctors but feel disempowered. Question prompt lists (QPLs) assist conversations. This study assessed the impact of a QPL on spirituality discussions in Palliative Care (PC). METHODS: This was a sub-study of a trial in which PC patients were randomised to either receive a QPL prior to a consultation or not, to see whether its provision influenced advanced cancer patients'/caregivers' questions and discussion of topics relevant to end-of-life care during consultations with a PC physician. Consultations were recorded and transcribed. Transcriptions were analysed to examine the frequency and content of spirituality discussions. We conducted logistic regression to investigate the impact of the QPL and other predictors. RESULTS: 174 patients participated. Spirituality was discussed in half the consultations. Patients receiving a QPL discussed spirituality 1.38 times more than controls. This finding did not reach statistical significance. First PC consultation and being asked about their concerns by the doctor were significant predictors of a spiritual discussion. CONCLUSION: Patients are more likely to discuss spirituality in their first PC consultation, and when their doctor asks them about their concerns. PRACTICE IMPLICATIONS: Doctors caring for patients at the end of life should routinely raise spiritual issues.

Establishing the feasibility, acceptability and preliminary efficacy of a multi-component behavioral intervention to reduce pain and substance use and improve physical performance in older persons living with HIV.

Older persons living with HIV (PLWH), often defined as age 50 years and older, are a rapidly growing population, with high rates of chronic pain, substance use, and decreased physical functioning. No interventions currently exist that address all three of these health outcomes simultaneously. An 8-week behavioral intervention combining cognitive-behavioral therapy and tai chi reinforced with text messaging (CBT/TC/TXT) was developed and pilot tested in a community-based AIDS service organization with substance using PLWH aged 50 years and older who experienced chronic pain. Fifty-five participants were enrolled in a three arm randomized controlled trial that compared the CBT/TC/TXT intervention (N = 18) to routine Support Group (SG) (N = 19) and Assessment Only (AO) (N = 18) to assess the intervention's feasibility, acceptability and preliminary efficacy to reduce pain and substance use and improve physical performance. Participants were assessed at baseline, treatment-end (week 8) and week 12. Feasibility and acceptability indicators showed moderate levels of participant enrollment (62% of those eligible), excellent 12-week assessment completion (84%) and high attendance at CBT and tai chi sessions (>60% attended at least 6 of 8 sessions). Efficacy indicators showed within-group improvements from baseline to week 12 in the CBT/TC/TXT group, including all four substance use outcomes, percent pain relief in the past 24 h, and in two physical performance measures. Observed between-group changes included greater reductions in days of heavy drinking in the past 30 days for both CBT/TC/TXT (19%) and SG (13%) compared to the AO group. Percent pain relief in the past 24 h improved in the CBT/TC/TXT group relative to SG, and the CBT/TC/TXT's physical performance score improved relative to both the SG and AO groups. Findings demonstrate that the CBT/TC/TXT intervention is feasible to implement, acceptable and has preliminary efficacy for reducing substance use and pain and improving physical performance among a vulnerable population of older PLWH.

Quality and effectiveness of counselling at antiretroviral therapy centres in India: capturing counsellor and beneficiary perspectives.

BACKGROUND: Ensuring the quality and effectiveness of counselling is imperative for enabling people living with HIV to cope with treatment adherence. Countrywide assessment of antiretroviral therapy (ART) centres was undertaken to assess the quality and effectiveness of counselling. The insights gained from the assessment are expected to build an improved understanding of the counselling aspect and contribute to informing decisions strengthening the counselling provided at ART centres. METHODS: Assessment of counselling at 357 ART centres entailed interviews with counsellors and beneficiaries using a structured questionnaire administered by trained technical experts. Two counsellors and five beneficiaries at each ART centre were interviewed to assess both the quality and effectiveness of counselling. Beneficiaries were selected from different risk groups to understand their varied concerns and experiences. RESULTS: During the assessment, 618 counsellors were interviewed (45% women); also, 1785 beneficiaries were interviewed, consisting of 892 (49.9%) men, 857 (48.1%) women and 36 (2.0%) transgender. Counsellors were found to be relatively well informed on topics pertaining to pre-ART, ART preparedness and positive healthy living, and the psychosocial support extended to patients. Counsellors surveyed were not aware of critical areas such as counselling of pregnant women (44.5%) , drug adherence (44.8%) and the use of information, education and communication material during counselling, and pill count. The majority of beneficiaries reported being informed on issues pertaining to retention; however, 30-40% of beneficiaries were not informed regarding the critical elements of adherence such as counselling on ART side effects (68.5%), pill count (62.8%) and information on access to social benefit schemes (25.7%). Factors such as client volume, the training of the counsellors and adequate space for counselling affected the quality of counselling. CONCLUSION: With concerted efforts in bridging the gaps in knowledge, infrastructure and information needs, India's national AIDS control programme (NACP) can enhance the counselling services at ART centres and improve the quality of services for patient retention.

Beyond the reminder: The next steps in pharmacist-driven, mHealth patient engagement.

OBJECTIVE: To describe opportunities for pharmacists to use mobile messaging and real-time monitoring to engage with patients taking long-term medications. SUMMARY: The proliferation of mobile phone use across the United States has been met with increased application of these devices by the medical community. However, beyond simple text messages and app-based functions, use of these devices by pharmacies and pharmacists has not been leveraged to improve patient outcomes, such as medication adherence. Resources now exist that can facilitate more advanced mobile communication between patients and pharmacists, which can be managed and informed by data available in most pharmacies. Such tailored messaging can be personalized further by being reactive to patient behavior using real-time medication use monitoring tools, facilitating low-cost, high-reach interventions for patients in need of ongoing guidance. CONCLUSION: Mechanisms now exist for pharmacies to engage patients more proactively with their prescribed therapy using mobile communication and devices. By facilitating such engagement, pharmacists can remain connected with patients throughout their care, better interpret their needs, navigate adherence-related issues, and more holistically counsel patients based on observed behaviors. Community pharmacy leadership should pursue the use of these advanced mobile messaging techniques as another tool in their arsenal to improve patient outcomes.

Short message service cancellation intervention to reduce integrated sexual health and HIV 'did not attend' appointment rates.

Did not attend (DNA) appointments create a significant impact upon resource and finance efficiency in the NHS. Despite introduction of short-message service (SMS) reminders to our patients, DNA rates remained persistently high. An option to send an SMS to cancel a booked appointment was piloted from 15 January to 16 April 2018 for integrated sexual health and human immunodeficiency virus (HIV) appointments. Absolute monthly mean DNA rates as a proportion of total bookable appointments fell by 2.24% (14.42% pre-intervention [95% CI: 13.15-15.79%] to 12.18% post-intervention [95% CI: 10.98-13.50%]). Cancellation rates increased proportionally by 14.28% from 24.4% to 38.68% (786/3224 pre-intervention [95% CI: 22.70%-26.15%] to 1184/3061 post-intervention [95% CI: 36.52-40.93%]). Findings suggest that SMS cancellations are a viable solution to reduce DNA rates in this setting.

An Automated Intervention Did Not Improve Adherence to Oral Oncolytic Agents While Managing Symptoms: Results From a Two-Arm Randomized Controlled Trial.

CONTEXT: An increasing number of oral cancer treatments require patient adherence and symptom self-management. OBJECTIVES: The report presents the effects of a medication reminder and symptom management intervention directed at patients initiating new oral oncolytic agents. METHODS: Patients (N = 272) were recruited at six comprehensive cancer centers, interviewed over the telephone after oral agent initiation, and randomized to either standard care or a medication reminder and symptom management intervention. In the intervention arm, the automated system called patients daily to remind them about taking their medications and weekly to assess 18 symptoms and refer patients to a printed Medication Management and Symptom Management Toolkit. Severity of 18 symptoms was also assessed during telephone interviews at Week 4 (midintervention), Week 8 (postintervention), and Week 12 (follow-up). Adherence was measured using the relative dose intensity, the ratio of dose taken by patient out of dose prescribed by the oncologist, and assessed using pill counts at Weeks 4, 8, and 12 and prescribing information from medical records. RESULTS: The relative dose intensity was high and did not differ by trial arm. Symptom severity was significantly lower (P < 0.01) in the experimental arm at Week 8 but not at Weeks 4 or 12. CONCLUSION: Adherence may be less of a problem than originally anticipated, and intervention was not efficacious possibly because of already high rates of patient adherence to oral oncolytic medication during first 12 weeks. Longer follow-up in future research may identify subgroups of patients who need interventions to sustain adherence.

Practices and Attitudes of Michigan-Based Occupational Physicians Regarding Adult Immunization.

OBJECTIVE: To assess practices and barriers regarding adult immunizations, among occupational and environmental physicians in Michigan. METHODS: A 10-item multiple choice web based questionnaire was designed after reviewing the Centers for Disease Control and Prevention recommendations and the current literature on adult immunization standards. RESULTS: Assessing immunization status is common practice for 62% of respondents. 92% of respondents recommend the annual influenza vaccination, unless contraindicated. The most commonly reported barriers included the cost of providing immunizations and the prioritization of acute over preventative care. Use of standing order vaccinations and reminder-recall systems were popular strategies used to improve vaccination rates. CONCLUSIONS: Occupational physicians frequently recommend influenza, tetanus, and hepatitis B vaccines when indicated, but are less likely to order other vaccines for patients. Promotion of a more comprehensive assessment of immunity needs in the workplace may improve national vaccine coverage.

Outreach and Reminders to Improve Human Papillomavirus Vaccination in an Integrated Primary Care System.

This study evaluated the impact of health system-based outreach and reminders on human papillomavirus (HPV) vaccine series initiation and completion. Parents of 10 to 12 year olds (n = 1805) were randomized to receive either (1) an outreach letter and brochure recommending HPV vaccination followed by automated HPV vaccine reminders or (2) usual care. We interviewed a subset of 50 parents to assess program acceptability. Outcomes were HPV vaccine initiation during the study period and on-time series completion. Rates of HPV vaccine initiation during the study period (July 2015 to August 2016) were similar between the intervention and control groups, but initiation within 120 days of randomization was higher in the intervention group (23.6% and 18.8%, P = .04) as was completion during the study period (10.3% vs 6.8%, P = .04). Reminders for doses 2 and 3 did not affect completion. The program was acceptable to parents. This study provides evidence that health system-based outreach and reminders can improve HPV vaccination.

Feasibility of an online mindfulness-based program for patients with melanoma: study protocol for a randomised controlled trial.

BACKGROUND: People with a melanoma diagnosis are at risk of recurrence, developing a new primary or experiencing disease progression. Previous studies have suggested that fear of a cancer recurrence is clinically relevant in this group of patients and, if not addressed, can lead to distress. Mindfulness-based interventions have been shown to alleviate symptoms of anxiety and depression among various groups of cancer patients. Online mindfulness-based interventions have the potential to reach people unable to attend face-to-face interventions due to limitations such as cancer-related illness, transportation or time constraints. This study aims to (1) examine whether individuals with a melanoma diagnosis are willing to participate and adhere to a 6-week online mindfulness-based intervention and (2) explore potential benefits of the program on fear of cancer recurrence, worries, rumination, perceived stress and trait mindfulness to inform the design of a clinical trial. METHODS/DESIGN: This is a single-site randomised controlled trial of a feasibility study. Seventy-five participants with stage 2c or 3 melanoma will be recruited from a melanoma outpatient clinic and randomised (2:1) either to an online mindfulness-based program (intervention) or to usual care (control). The intervention is a 6-week program specifically developed for this study. It consists of videos describing the concept of mindfulness, short daily guided meditation practices (5-10 min), automated meditation reminders and instructions for applying mindfulness in daily life to enhance wellbeing. All participants will complete questionnaires at baseline and at 6-week post-randomisation. Participants in the control group will be given access to the online program at the end of the study. Primary outcomes are overall recruitment; retention; extent of questionnaire completion; and usability and acceptability of, and adherence to, the program. The secondary outcomes are fear of cancer recurrence, worries, rumination, perceived stress and trait mindfulness measured using validated instruments. DISCUSSION: This feasibility study will evaluate participants' satisfaction with the program and identify barriers to recruitment and adherence. The recruitment and data collection process will highlight methodological aspects to address in the planning of a larger scale study assessing the impact of an online mindfulness-based intervention on fear of cancer recurrence and wellbeing. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000081314 . Registered on 16 January 2017.

Optimizing Digital Integrated Care via Micro-Randomized Trials.

Mobile health (mHealth) interventions are a promising tool in providing digitally mediated integrative care. They can extend care outside of the clinic by providing reminders to take medications, assisting in managing symptoms, and supporting healthy behaviors including physical activity, healthy eating, and stress management. mHealth interventions can adapt the delivery of care across time in order to optimize treatment effectiveness. Yet there exists limited empirical evidence useful to the development of adaptive mHealth interventions. This article describes a new randomized trial design, the Micro-Randomized Trial (MRT), for informing the development of mHealth interventions. We provide examples of scientific questions important to the development of an mHealth intervention, and describe how these questions can be answered using an MRT.