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Table.  Characteristics of Outreach Patient Population
Characteristics of Outreach Patient Population
1.
Adhikari  S, Pantaleo  NP, Feldman  JM, Ogedegbe  O, Thorpe  L, Troxel  AB.  Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas.   JAMA Netw Open. 2020;3(7):e2016938. doi:10.1001/jamanetworkopen.2020.16938PubMedGoogle Scholar
2.
Rubin  EJ, Baden  LR, Del Rio  C, Akusobi  C, Morrissey  S.  Audio interview: delivering Covid-19 vaccines to minority communities.   N Engl J Med. 2021;384(13):e60. doi:10.1056/NEJMe2105496PubMedGoogle Scholar
3.
Greenberg  AJ, Haney  D, Blake  KD, Moser  RP, Hesse  BW.  Differences in access to and use of electronic personal health information between rural and urban residents in the united states.   J Rural Health. 2018;34(suppl 1):s30-s38. doi:10.1111/jrh.12228PubMedGoogle ScholarCrossref
4.
Goel  MS, Brown  TL, Williams  A, Hasnain-Wynia  R, Thompson  JA, Baker  DW.  Disparities in enrollment and use of an electronic patient portal.   J Gen Intern Med. 2011;26(10):1112-1116. doi:10.1007/s11606-011-1728-3PubMedGoogle ScholarCrossref
5.
Dai  M, Liu  D, Liu  M,  et al.  Patients with cancer appear more vulnerable to SARS-CoV-2: a multicenter study during the COVID-19 outbreak.   Cancer Discov. 2020;10(6):783-791. doi:10.1158/2159-8290.CD-20-0422PubMedGoogle Scholar
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    Research Letter
    August 19, 2021

    Use of an Analytics and Electronic Health Record–Based Approach for Targeted COVID-19 Vaccine Outreach to Marginalized Populations

    Author Affiliations
    • 1Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill
    • 2Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
    • 3North Carolina Cancer Hospital, UNC Health, Chapel Hill
    • 4Associate Editor, JAMA
    JAMA Oncol. 2021;7(10):1570-1572. doi:10.1001/jamaoncol.2021.3833

    Equity in vaccine outreach and delivery has been prioritized given the disproportionate harms of the COVID-19 pandemic on communities of color and those with lower socioeconomic status.1,2 Health systems have largely communicated availability or signup for vaccines to patients through electronic patient portal messages, emails, or online materials; however, rates of portal use and internet access are limited among rural populations, individuals with lower socioeconomic status, and racial and ethnic minority patients.3,4 For purposes of this analysis, these groups are referred collectively as marginalized populations. Reliance on these media as the primary means for communication may inadvertently widen vaccination disparities.

    Patients with cancer are at increased risk of COVID-19 complications; therefore, they are a priority for vaccination.5 At the North Carolina Cancer Hospital of the University of North Carolina (UNC) Health System (Chapel Hill, North Carolina), we used an analytics-based approach to identify and contact patients who might benefit from targeted nonelectronic communication regarding COVID-19 immunization.

    Methods

    Using the electronic health record, we identified patients who received cancer therapy during the past year with follow-up scheduled, without an active patient portal account, no valid email on file, or who lived in a county with a greater than 20% poverty rate across multiple census points. We applied eligibility criteria for vaccination in North Carolina as they evolved, commencing with those older than 75 years. These criteria were developed over 3 weeks by the analytics and quality-improvement team within the cancer hospital, comprising physician and nursing leadership. A group of 4 nurses then placed scripted, informational telephone calls to each identified patient to provide standardized education about the eligibility, safety, and logistics of vaccination. Their approach was to aid patients in making informed decisions about vaccination, address identified barriers to vaccination when able, and respond to patients’ questions or concerns. Institutional review board approval was performed, and the study was determined to be exempt because it was deemed non–human participants research. Race and ethnicity were self-reported.

    Results

    Between January and March 2021, we identified 536 potentially marginalized UNC patients who were eligible for COVID-19 vaccination (Table). Of these, 326 (61%) were non-Hispanic White and 172 (32%) were Black, with 70 (14%) from counties with persistent poverty. Nearly all identified patients were called (>99%), with 350 (67%) successfully reached and 46 (9%) who received voicemails. Among Black patients, 203 (75%) were reached, and 70 patients (93%) from counties with high levels of poverty were contacted. Overall, the mean (SD) duration of phone calls was 4.3 (4.1) minutes. As of April 2, 2021, 93 of 359 contacted patients (26%) were confirmed to have received vaccination via electronic health record review or self-report, with another 14 of 359 (4%) scheduled for a vaccination appointment at UNC.

    Discussion

    Our targeted outreach efforts identified and connected with patients who do not regularly use electronic communication and whose community networks may have been disrupted by the social isolation of the COVID-19 pandemic. This novel intervention demonstrated the potential benefits of an analytics-based strategy to reach marginalized patients at high risk for exclusion from electronic outreach and may be built on for future outreach programs. A limitation of this analysis is that this is likely an underestimation of vaccination rates, as vaccines received or scheduled at outside sites were not captured in the electronic health record. No control arm was included; thus, we do not know how many patients would have received vaccines without this initiative. However, these patients would likely have been missed by our electronic outreach efforts, and preliminary qualitative feedback from patients suggests that the calls aided them in their decision to proceed with vaccination. Additionally, our calls identified numerous patients with unmet clinical or social needs. While not the intended goal of this project, and thus not consistently tracked, mitigating barriers became an integral part of this effort and may have yielded positive patient experiences and increased the ability for patients to become vaccinated.

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    Article Information

    Accepted for Publication: June 29, 2021.

    Published Online: August 19, 2021. doi:10.1001/jamaoncol.2021.3833

    Corresponding Author: Jacob Stein, MD, MPH, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 170 Manning Dr, 3rd Floor, CB #7305, Chapel Hill, NC 27599 (jacob.stein@unchealth.unc.edu).

    Author Contributions Drs Basch and Stein had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Stein, Fasold.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Stein, Fasold, Cheek.

    Critical revision of the manuscript for important intellectual content: Stein, Fasold, Daguerre, Richardson, Charlot, Basch.

    Statistical analysis: Stein, Fasold.

    Administrative, technical, or material support: Stein, Fasold.

    Supervision: Fasold, Charlot, Basch.

    Other - participated in the project work this article is referencing: Cheek.

    Other - active participant in outreach; designed workflows; assisted with edits.: Daguerre.

    Other - participated in outreach calls to patients regarding the COVID-19 vaccine: Richardson.

    Conflict of Interest Disclosures: Dr Daguerre reported her spouse holding stock in AstraZeneca and CVS outside the submitted work. Dr Basch reported being a scientific advisor/consultant for AstraZeneca, Sivan Healthcare, CareVive Systems, and Navigating Cancer outside the submitted work. No other disclosures were reported.

    References
    1.
    Adhikari  S, Pantaleo  NP, Feldman  JM, Ogedegbe  O, Thorpe  L, Troxel  AB.  Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas.   JAMA Netw Open. 2020;3(7):e2016938. doi:10.1001/jamanetworkopen.2020.16938PubMedGoogle Scholar
    2.
    Rubin  EJ, Baden  LR, Del Rio  C, Akusobi  C, Morrissey  S.  Audio interview: delivering Covid-19 vaccines to minority communities.   N Engl J Med. 2021;384(13):e60. doi:10.1056/NEJMe2105496PubMedGoogle Scholar
    3.
    Greenberg  AJ, Haney  D, Blake  KD, Moser  RP, Hesse  BW.  Differences in access to and use of electronic personal health information between rural and urban residents in the united states.   J Rural Health. 2018;34(suppl 1):s30-s38. doi:10.1111/jrh.12228PubMedGoogle ScholarCrossref
    4.
    Goel  MS, Brown  TL, Williams  A, Hasnain-Wynia  R, Thompson  JA, Baker  DW.  Disparities in enrollment and use of an electronic patient portal.   J Gen Intern Med. 2011;26(10):1112-1116. doi:10.1007/s11606-011-1728-3PubMedGoogle ScholarCrossref
    5.
    Dai  M, Liu  D, Liu  M,  et al.  Patients with cancer appear more vulnerable to SARS-CoV-2: a multicenter study during the COVID-19 outbreak.   Cancer Discov. 2020;10(6):783-791. doi:10.1158/2159-8290.CD-20-0422PubMedGoogle Scholar
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