Promoting Pneumococcal Immunizations Among Rural Medicare Beneficiaries Using Multiple Strategies

CONTEXT: Vaccine-preventable diseases among adults are major contributing causes of morbidity and mortality in the United States. However, adult immunizations continue to be underutilized in both urban and rural areas. PURPOSE: To evaluate the effectiveness of a community-wide education campaign and mailed reminders promoting pneumococcal immunizations to rural Medicare beneficiaries. METHODS: We implemented a community-wide education campaign, and mailed reminders were sent to Medicare beneficiaries in 1 media market in Montana to increase pneumococcal immunizations. In a second distinct media market, mailed reminders only were sent to beneficiaries. FINDINGS: The proportion of respondents aged 65 years and older aware of pneumococcal immunizations increased significantly from baseline to follow-up among respondents both in the education-plus-reminder (63% to 78%, P = 0.04) and the reminder-only (64% to 74%, P = 0.05) markets. Overall from 1998 to 1999, there was a 3.7-percentage-point increase in pneumococcal immunization claims for Medicare beneficiaries in the education-plus-reminder market and a 1.5-percentage-point increase in the reminder-only market. Medicare beneficiaries sent reminders in the education-plus-reminder market compared to those in the reminder-only market were more likely to have a claim for pneumococcal immunization in 1999 (odds ratio 1.18, 95% confidence interval 1.08 to 1.28). The results suggest that these quality improvement strategies (community education plus reminders and reminders alone) modestly increased pneumococcal immunization awareness and pneumococcal immunization among rural adults. Mailed reminder exposure was associated with an increased prevalence of pneumococcal immunizations between 1998 and 1999 and was augmented somewhat by the education campaign.     

Pneumococcal pneumonia and influenza vaccination: access to and use by US Hispanic Medicare beneficiaries.

OBJECTIVES: This study examined differences between elderly Hispanic Medicare beneficiaries and other Medicare beneficiaries in the probability of being immunized for pneumococcal pneumonia and influenza. METHODS: We used the 1992 national Medicare Current Beneficiary Survey to evaluate influenza and pneumococcal pneumonia immunization rates. RESULTS: Elderly Hispanic Medicare beneficiaries were less likely than non-Hispanic White Medicare beneficiaries to have received an influenza vaccine in the past year or to have ever been immunized for pneumococcal pneumonia. Speaking Spanish was statistically significantly associated with influenza vaccination but not with pneumococcal pneumonia vaccination. Supplemental insurance status, HMO enrollment, having a usual source of care, and being satisfied with access to care were positively associated with immunization. CONCLUSIONS: Strategies that may improve immunization rates among elderly. Hispanics include reducing the inconvenience of being immunized, decreasing out-of-pocket costs, linking beneficiaries with providers, and educating Hispanic beneficiaries in Spanish about the benefits of vaccinations.     

Enhancing influenza immunization. Postcard and telephone reminders and the challenge of immunization site shift

OBJECTIVE: To determine if postcard and telephone reminders increased the rate of influenza immunization of Medicare beneficiaries. DESIGN: Before and after trial (postcard reminders) with systematically allocated control group (telephone reminder intervention). SETTING: A semirural family practice residency program. PATIENTS AND OTHER PARTICIPANTS: All 475 noninstitutionalized persons older than 65 years who had received at least 1 office service in the previous 2 years. INTERVENTION: In September 1996, each of 475 patients received a postcard urging prompt influenza immunization. Those not responding within 1 month were systematically allocated either to a group receiving further telephone contact or to a control group. At the time of telephone contact, any offered information about influenza immunization received outside the Smoky Hill Family Practice Center, Salina, Kan, was recorded. MAIN OUTCOME MEASURES: We measured the percentage of change in practice-administered influenza immunizations compared with the baseline rate of the preceding 2 years; the difference in immunization rates between the telephone intervention group and controls; and the number of patients contacted by telephone who reported receiving influenza immunization at a site other than the Family Practice Center. RESULTS: Twenty-eight percent of patients who received a postcard obtained office influenza immunizations within 1 month, but no additional immunizations could be attributed to the telephone intervention. Thirty-five percent of patients contacted by telephone reported receiving influenza immunization at a site other than the Family Practice Center. CONCLUSIONS: The postcard intervention was associated with a significant increase in the office immunization rate. This increase may have been confounded by "site shift" in which individuals came to the office for an immunization that they might otherwise have received at other community sites.     

Pneumococcal immunizations at flu clinics: the impact of community-wide outreach

This study examined the effectiveness of a community-wide outreach campaign to promote the use of pneumococcal vaccine at public flu immunization clinics, and assessed whether this intervention was more effective than simply making pneumococcal vaccination available at such clinics. In 1997, a community-wide outreach campaign promoting pneumococcal and influenza immunizations was launched in a 17 zip code area of Dutchess County, NY. The campaign was aimed at 7,961 Medicare beneficiaries urging them to obtain pneumococcal immunization from local flu clinics. Medicare reimbursement data were used to assess the countywide pneumococcal vaccination rate, and to analyze differences between rates for beneficiaries in the target area and elsewhere in the county. Between 1996 and 1997 there was a 94% increase in pneumococcal vaccination billed to Medicare beneficiaries in Dutchess County. The 1997 annual rate of pneumococcal immunization in the target area reached 16.3% versus 12.2% elsewhere in the county (p < 0.001), with an increase over the previous year of 8.7% and 5.6%, respectively. Nearly all of the increase is accounted for by pneumococcal vaccination delivered at flu clinics. It is possible to significantly increase the use of pneumococcal immunization by linking its delivery to community-based flu clinics and by developing local outreach strategies. The outreach campaign has a significant additive effect over simply making PPV available at flu shot clinics. Additional community-wide outreach can further improve pneumococcal immunization utilization rates.     

Immunization disparities in older Americans: determinants and future research needs

BACKGROUND: Marked racial disparities persist in influenza and pneumococcal vaccinations among Medicare beneficiaries. This study sought to assess the contribution that patient, physician, health system, and area-level characteristics make to these racial disparities in immunization. METHODS: Cross-sectional and decomposition analyses were performed on a nationally representative sample of 18,013 non-institutionalized Medicare beneficiaries who responded to the Medicare Current Beneficiary Survey (MCBS) in 2000 to 2002. The physician characteristics of interest included specialty type, accessibility, information-giving skills, perceived quality, and continuity of care. Health system characteristics included HMO enrollment and numbers of primary care physicians per elderly. The outcomes were receipt of influenza vaccine in the past year and ever having received a pneumococcal vaccine. RESULTS: Immunization rates were below recommended levels for all Medicare beneficiaries. Disparities between white and black beneficiaries in the receipt of vaccinations were large-an absolute 17% difference for each vaccine. After adjusting for patient, physician, health system, and area-level characteristics, white beneficiaries had significantly higher odds of vaccination than did black beneficiaries: adjusted odds ratio (aOR) = 1.52 (95% confidence interval [CI] = 1.35-1.71) for influenza vaccination, and aOR = 1.82 (95% CI = 1.61-2.07) for pneumococcal vaccination. Beneficiaries with a usual physician that they rated as having good information-giving skills and whose practice was more accessible, had higher immunization rates. Beneficiaries with a primary care generalist as their usual physician had higher odds of immunization than those with a specialist as their usual physician. At the county level, a higher number of primary care physicians per elderly resident was associated with higher odds of immunization. Only 7% of the racial disparity in influenza immunization was explained by the measured characteristics of beneficiaries and their health systems. CONCLUSIONS: Despite similar insurance coverage and presence of a usual physician, black beneficiaries were significantly less likely than their white counterparts to receive influenza and pneumococcal vaccinations. The implications for future research are discussed, including the need for system-based interventions that make the offering and discussion of vaccination routine.     

Understanding differences in influenza immunization rates: a survey of African-American and caucasian medicare beneficiaries in Texas

A goal of Healthy People 2010 is to increase the influenza immunization rate among high-risk populations to at least 90 percent. This article presents the results of a survey on influenza immunizations among African-Americans and Caucasian Medicare beneficiaries in a 25-county project intervention area in Texas. Information on the burden of suffering from pneumonia and influenza, the benefits of influenza immunization, and recommendations are included. Data are presented on the characteristics of the African-American and Caucasian Medicare beneficiary survey respondents, their influenza immunization rates, health status and sources of health care, and factors that influence them to obtain an annual influenza immunization.     

Cost utility of public clinics to increase pneumococcal vaccines in the elderly.

BACKGROUND: Pneumococcal immunization has been shown to be cost effective, is recommended by the Advisory Committee on Immunization Practices, and is covered by Medicare. Despite that, over 50% of the population aged > or =65 is not vaccinated, leading to significant mortality and morbidity. The objective of this study is to evaluate the costs and the cost utility of immunization in nontraditional settings (community clinics set up to provide influenza and pneumococcal vaccinations) as a strategy to increase pneumococcal immunization rates. METHODS: A cost-utility analysis of public immunization clinics in Monroe County, New York, during the fall of 1998. The study included 1207 adults aged > or =65. Costs of operating the clinics and of vaccine administration were measured. The cost of health sequela and estimates of quality-adjusted life years (QALYs) were obtained from prior studies. Sensitivity analyses were performed to test several important assumptions. RESULTS: Unlike immunizations in physician offices, immunizations in nontraditional settings are not cost saving. Estimates of incremental cost-utility ratios ranged from $4215 per QALY to $12,617 per QALY, depending on the underlying assumptions of the model. CONCLUSIONS: Clinics in nontraditional settings offering pneumococcal immunization have cost-utility ratios near and below those of other recommended vaccines. These results suggest that such clinics should be considered a viable strategy for increasing pneumococcal immunization rates.     

Driving immunization through the Medicare Annual Wellness Visit: A growing opportunity

IntroductionThe Annual Wellness Visit (AWV) is a Medicare benefit designed to help prevent disease and disability based on individualized health and risk factors.MethodsThis study analyzes Medicare Part B fee-for-service claims from 2011 to 2016 to assess AWV and seasonal influenza and pneumococcal conjugate vaccinations utilization over time.ResultsUtilization of the AWV has increased from 8% of Medicare beneficiaries in 2011 to 19% in 2015. In each year, influenza and PCV13 vaccination rates are higher among those who utilize the benefit. More than one-third (33%) of patients who had an AWV in 2015 received a PCV13 vaccination in that same year, compared to 14% of those who did not. Similarly, the seasonal influenza vaccination rate was 64% among those with an AWV and 44% among those without.ConclusionThe AWV demonstrates promise for improving immunization rates among Medicare beneficiaries particularly at the point of care.     

The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries

OBJECTIVE: To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers. DATA SOURCES: Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746). STUDY DESIGN: We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks. PRINCIPAL FINDINGS: White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (-11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for <2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6-5 x higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination. CONCLUSION: Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.     

Improving Physician Coverage of Pneumococcal Vaccine: A Randomized Trial of a Telephone Intervention

Improved pneumococcal vaccine (PPV) immunization for seniors is a national goal of the Medicare program. This study examined whether adding a simple telephone follow-up to an existing mailed physician performance feedback under the Medicare program would increase the impact on billed pneumococcal immunizations. Medicare fee-for-service claims data were used to select New York primary care physicians with high volume (n = 732) or African-American serving (n = 329) practices. All practices received mailed feedback on their 1999 Medicare practice specific PPV coverage rates, along with educational materials and offers of assistance. Practices were also randomized to receive telephone calls directing attention to the mailing and further promoting improvements in PPV coverage or no active follow-up. Physicians randomized to telephone follow-up showed significantly higher rates of practice specific PPV coverage in 2000 than those receiving the routine mailing only, and 27% vs. 17% (p = 0.01) of high volume physicians and 34% vs. 22% (p = .052) of African American serving physicians achieved at least a 5% increase in their cumulative PPV claims coverage. This study concludes that telephone follow-up is an effective and straightforward method to enhance the impact of practice specific feedback to promote improvements in Medicare PPV immunization. However, improved methods may be needed to induce a large percentage of physicians to change.     

Promoting influenza and pneumococcal immunization in older adults

BACKGROUND: Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicare's Quality Improvement Organization (QIO) program and parallels the Joint Commission's National Patient Safety Goal 10. ADDRESSING THE GOAL: Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS: During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS: Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.     

Vaccination among Medicare-fee-for service beneficiaries: Characteristics and predictors of vaccine receipt, 2014–2017

Background

Vaccination coverage rates for older adults are low. To better understand utilization of Medicare vaccination benefits we examined a retrospective cohort of more than 26 million Medicare fee-for-service beneficiaries age 65?years and older from 2014 to 2017.

Variations in Influenza and Pneumonia Immunizations for Medicare Beneficiaries Served by Rural Health Clinics

The availability of a rural health clinic (RHC) database over the period of 6 years (2008–2013) offers a unique opportunity to examine the trends and patterns of disparities in immunization for influenza and pneumonia among Medicare beneficiaries in the southeastern states. The purpose of this exploratory study was twofold. First, it examined the rural trends and patterns of immunization rates before (2008–2009) and after (2010–2013) the Affordable Care Act (ACA) enactment by state and year. Second, it investigated how contextual, organizational, and aggregate patient characteristics may influence the variations in immunization for influenza and pneumonia of Medicare beneficiaries served by RHCs. Four data sources from federal agencies were merged to perform a longitudinal analysis of the influences of contextual, organizational, and aggregate patient characteristics on the disparities in immunization rates of rural Medicare beneficiaries for influenza and pneumonia. We included both time-varying and time-constant predictors in a multivariate analysis using Generalized Estimating Equation. This study revealed the increased immunization rates for both influenza and pneumonia over a period of 6 years. The ACA had a positive effect on increased immunization rates for pneumonia, but not for influenza, in rural Medicare beneficiaries in the eight states. The RHCs that served more dually-eligible patients had higher immunization rates. For influenza immunization, provider-based RHCs had a higher rate than the independent RHCs. For pneumonia immunization, no organizational variables were relevant in the explanation of the variability. The results also showed that no single dominant factor influenced health care disparities. This investigation suggested further improvements in preventive care are needed to target poor and isolated rural beneficiaries. Furthermore, the integration of immunization data from multiple sources is critically needed for understanding health disparities.     

Implementing a standing order immunization policy: a minimalist intervention

INTRODUCTION: Standing order immunization policies (SOIPs) for influenza and pneumococcal vaccinations have been found to be among the most effective strategies for increasing immunizations rates. Despite their proven efficacy these policies have not been widely adopted and there has been limited attention focused on testing particular adoption/implementation strategies. This pilot research assessed the efficacy of a minimalist strategy to implement an SOIP. METHODS: A convenience sample of 3 primary care outpatient clinics in North Carolina agreed to participate in this study and adopt and implement an SOIP for influenza and pneumococcal immunizations for their patients >or=65 years old. The adoption procedure included 1-hour training for clinic nurses and providers, the provision of appropriate forms, and 2 brief reminders of protocols during the study period. Chart audits of appropriate patients who had a clinic visit during flu season (October through February) at each clinic during the baseline year of policy implementation (1999) and the year after (2000) allowed calculation of influenza and pneumococcal immunization rates as primary outcome measures. RESULTS: There was little evidence to indicate that these clinics made changes to implement a SOIP policy. Immunization flow sheet use, a critical process measure of SOIP implementation, was found to be less consistent than would be expected under a well-implemented SOIP. It was also found that, although influenza immunization rates did increase slightly in the 3 intervention clinics, the changes were not statistically significant. Pneumococcal immunization rate changes were also inconsistent across clinics and from baseline to post-intervention periods. CONCLUSIONS: This minimalist effort to implement the SOIP seems not to have had sufficient impact to significantly change clinic practices. Flow sheet use, as one critical measure of SOIP implementation, did not change over the course of the intervention period. We did not find the expected increase in influenza and pneumococcal immunization rates as a result of a newly adopted SOIP. Additional research on improved strategies to fully implement SOIPs is needed to insure effective adoption of this proven systems intervention.     

Influenza immunization: the impact of notifying patients of high-risk status

BACKGROUND. The influenza immunization rate in the high-risk military and retired military population has not been reported. To determine this rate, and to test whether the rate could be improved by notifying patients of their high-risk status, a clinical trial was conducted using a postcard reminder as an intervention. METHODS. All 1068 high-risk patients enrolled in a large, residency-affiliated, military family practice department were identified. Of these, 519 patients were randomly selected to receive a reminder postcard; the remainder (549) were not sent a card. The immunization rates of each group were compared. RESULTS. A significantly higher percentage of those to whom postcards were sent received an influenza immunization (25.2% vs 9.1%, P less than .001). This difference was significant in all demographic groups except in those less than 21 years of age and those 21 to 40 years of age, in which very few patients presented for immunization. In those in the study group aged 65 years and over, 46.7% were immunized vs 20% of controls (P less than .001). Those aged 65 years and older and those in the higher income group had higher immunization rates, while those aged 40 years and under had very low immunization rates. CONCLUSIONS. The influenza immunization rate among military beneficiaries in high-risk groups is low, but can be significantly improved with a reminder postcard. This intervention may be more effective in the older and higher-income segments of the high-risk population. The low immunization rates of the lower-income group and the younger age groups have significant public health implications and should be studied further.     

Impact of influenza immunization on medical expenditures among Medicare elderly, 1999-2003

BACKGROUND: The impact of influenza immunization on expenditures for inpatient, outpatient, and professional services among elderly Medicare beneficiaries between 1999 and 2003 was examined. METHODS: Data were from independent annual survey samples of 175,000 beneficiaries. Response rates ranged from 64% to 71%. Survey data included beneficiaries' demographics, education, supplemental insurance, perceived health, and influenza vaccination. Baseline measures, derived from Medicare claims for the year prior to influenza season, included service utilization, comorbidities, influenza immunization, and health status. The outcome measure was medical expenditures for acute and chronic respiratory conditions (ACRCs) for each 33-week annual influenza season. RESULTS: Total expenditures for ACRCs were lower among the immunized population during all four seasons. The amount and statistical significance of the savings varied with the severity of the virus and the vaccine match to the prevalent influenza strains. During the 1999-2000 influenza season, which had the most severe virus and a close vaccine match, average costs for ACRCs were $88 lower among immunized beneficiaries than among nonimmunized beneficiaries (equivalent to a 3.06% savings). During the 2002-2003 season, which had a less severe virus but the highest vaccine match rate, average costs for ACRCs were $103 lower for immunized beneficiaries than for nonvaccinated beneficiaries (equivalent to a 3.12% savings). The relative reduction in ACRC expenditures among vaccinated beneficiaries is attributable to less frequent use of inpatient services. CONCLUSIONS: In addition to improving the health of older Americans, meeting the Healthy People 2010 influenza immunization goal of 90% among the elderly should also result in lower Medicare expenditures.     

Brief Report: Quality Improvement in Critical Access Hospitals: Addressing Immunizations Prior to Discharge

CONTEXT: Many patients hospitalized in critical access hospitals (CAHs) are at high risk for influenza and pneumonia. These hospitalizations may represent a missed opportunity to address immunizations. Addressing these missed immunizations could provide an opportunity for CAHs to gain practical experience in data-driven quality improvement. PURPOSE: To improve documentation and delivery of influenza and pneumococcal immunizations prior to hospital discharge and provide CAHs with quality improvement experience. METHODS: We recruited 17 CAHs in Kansas to participate in a rapid-cycle quality improvement project to address inpatient immunizations. Each hospital identified patient discharges on a monthly basis and abstracted medical records to see if the patient's immunization status had been assessed and if patients had been vaccinated prior to discharge. FINDINGS: Documentation of influenza immunization status improved from 17% of admissions at baseline to 62% at follow-up (P < 0.001). Documentation of pneumococcal immunization status increased from 36% at baseline to 51% at follow-up (P < 0.001). Documentation of immunizations was significantly higher among the 8 hospitals that developed standard charting forms for recording immunization status (P < 0.01). Despite improved documentation of immunization status, at remeasurement only 3.4% received an influenza vaccination and 1.3% received a pneumococcal vaccination prior to discharge. CONCLUSIONS: Critical access hospitals can effectively participate in quality improvement activities, but increased involvement of medical staff or standing immunization orders may be needed to improve actual vaccine administration prior to discharge.     

How much does a reminder letter increase cervical screening among under‐screened women in NSW?

OBJECTIVE: To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months. METHODS: Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups. RESULTS: After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups. CONCLUSIONS AND IMPLICATIONS: Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.     

Office Systems and Their Influence on Mammography Use in Rural and Urban Primary Care

CONTEXT: Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention. PURPOSE: Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization. METHODS: We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems. FINDINGS: Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets. CONCLUSIONS: Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.