2014.ISDS.Abstracts.Final.pdf


ISDS Annual Conference Proceedings 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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ISDS 2014 Conference Abstracts

Return to Public Health- Undeliverable letters of 
Communicable Disease Patients
Uzay Kirbiyik*1, 2, Hassan Shah4, 2, Patrick T. Lai4, 2, Jennifer L. Williams2, Brian E. Dixon1, 2 
and Shaun Grannis3, 2

1IU Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA; 2Regenstrief Institute, Indianapolis, IN, USA; 3Indiana 
University, School of Medicine, Indianapolis, IN, USA; 4School of Informatics and Computing, Indianapolis, IN, USA

Objective
Explore causes of undelivered letters sent by public health 

departments to patients with communicable diseases.

Introduction
Preventing communicable disease spread is a primary objective 

for public health (PH). Reaching contagious people in a timely 
manner is essential to limit disease spread. Notifying patients of their 
infectious status also serves as an official reminder of social and 
legal responsibilities. The Marion County Public Health Department 
(MCPHD) sends disease information and Notice of Privacy Practices 
to patients using the United States Postal Service (USPS). We 
examined communicable disease cases with undelivered mail to 
ascertain failure causes and rates.

Methods
We reviewed completed case files for 3 communicable diseases 

investigated by MCPHD. MCPHD sends a letter to each of these 
new positive cases. The addresses are gathered from provider and lab 
reports and from other sources. When the letters are undeliverable, 
PH staff logs these mails to the case files. We reviewed all cases with 
undelivered letters and identified source of address, reason for return, 
and patient demographics.

Results
The letter return rates among diseases were significantly different 

(X2 p=0.0006). The age distributions among races were also 
significantly different (t-test p=0.002); mean age for Caucasian and 
African American were 36 vs. 49 years respectively. The proportions 
of USPS endorsements for the undelivered mail were as follows:

Attempted- not known 36%
Not deliverable as addressed 22%
No such number 16%
Moved left no address 10%
Insufficient Address 9%
Forward time expired 2%
No Mail Receptacle 1%
Refused 1%
Vacant 1% 
Analysis of root causes for undeliverable addresses yielded 

a framework of address information flow (fig. 1). Since the 
communication between the patient and the provider is not 
documented, it is not possible to accurately discern the source of the 
initial error.

Conclusions
Several factors contributed to undeliverable mail. MCHD staff 

suggests some of these are due to patients giving false information 
to avoid health bills. We have come across a significant number of 
institutions (15%), like churches and shelters for homeless, used 
for address. We also noted many drug abuse and incarceration 
reports among the undeliverable cases. This is expected due to 

socio-economic problems and communicable diseases being common 
with these groups. The differences among racial groups also suggest 
other cultural factors in play and need further exploration.

PH staff resends the notification if they can figure out the reason 
for the returned mail (e.g. typos, choose different address, check 
the address with the provider/patient). While this is another burden 
for PH, the actual delivery rates are likely higher than what initially 
reported.

However, letters may not always be delivered to the person 
intended. An earlier study found 13.3% of letter sent to fictitious 
people did not return, but all invalid addresses did [1]. Further, we 
were able to geo-locate 31% of undeliverable addresses labelled as 
“No such number” by USPS which we classified as postal error (5%).

Due to its fragmented nature, there is no one solution to 
undeliverable mail problem. Technical solutions may include 
incorporating USPS address verification system, sending an initial 
confirmatory mail by the provider or using phone or email as 
alternative. Our framework allows us to establish a baseline for future 
research including cost-effectiveness analyses for streaming lining the 
process for process improvements.

Keywords
Return to Sender; Undeliverable mail; Communicable disease 
notification; Patient address

Acknowledgments

We thank the staff at MCPHD for their help with this research.

References

1. Sandler RS, Holland KL. Fate of incorrectly addressed mailed
questionnaires. J Clin Epidemiol. 1990;43:45–7.

*Uzay Kirbiyik
E-mail: ukirbiyi@iupui.edu    

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * (1):e138, 201