Benefits and costs of immunizing children against influenza at school: an economic analysis based on a large-cluster controlled clinical trial. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study. Boosting uptake of influenza immunisation: a randomised controlled trial of telephone appointing in general practice. Increasing immunization rates among inner-city, African American children. A randomized trial of case management. Reducing medical service utilization by encouraging vaccines: randomized controlled trial. Preliminary analysis of short term financial implications of a prevention bonus program: First results from the German statutory health insurance Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Cost-effectiveness of childhood immunization reminder/recall systems in urban private practices. Household-based costs and benefits of vaccinating healthy children in daycare against influenza virus Cost-effectiveness analysis of an intranasal influenza vaccine for the prevention of influenza in healthy children. Effectiveness and Cost-effectiveness of Letters, Automated Telephone Messages, or Both for Underimmunized Children in a Health Maintenance Organization Primary Care Physician Perspectives on Reimbursement for Childhood Immunizations Increasing influenza immunization among high-risk patients: education or financial incentive? The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. The impact of interventions by a community-based organization on inner-city vaccination coverage: Fulton County, Georgia, 1992-1993. Use of reminders to increase compliance with tetanus booster vaccination. Home vaccination for children behind in their immunisation schedule: a randomised controlled trial. Increasing the immunization of preschool children; an evaluation of applied community interventions. A Randomized Study of Tracking With Outreach and Provider Prompting to Improve Immunization Coverage and Primary Care Influenza immunization in a managed care organization A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Effectiveness and Cost-Effectiveness of Linking the Special Supplemental Program for Women, Infants, and Children (WIC) and Immunization Activities Impact of appointment reminders on vaccination coverage at an urban clinic. Increasing pneumococcal vaccination in managed care through telephone outreach. Cost-effectiveness analysis of behavioral interventions to improve vaccination compliance in homeless adults. Cost-effectiveness of live-attenuated influenza vaccine, trivalent in preventing influenza in young children attending day-care centres. Drug users' adherence to a 6-month vaccination protocol: effects of motivational incentives. Does reminder-recall augment the impact of voucher incentives on immunization rates among inner-city infants enrolled in WIC? Special Supplemental Program for Women, Infants, and Children. Influenza vaccination in community elderly. A controlled trial of postcard reminders. Computer-based vs manual health maintenance tracking. A controlled trial. Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial. The costs of registry-based immunization interventions. Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized controlled trial in general practice. The impact of computer-generated messages on childhood immunization coverage. Computer-generated recall letters for underimmunized children: how cost-effective? A program to immunize hospitalized preschool-aged children: evaluation and impact. A Stepped Intervention Increases Well-Child Care and Immunization Rates in a Disadvantaged Population Mailed reminders for area-wide influenza immunization: a randomized controlled trial.
Current influenza vaccination recommendations focus on immunizing high-risk people ; however , influenza mortality and morbidity remain elevated . U.S. policymakers are considering expansion of flu vaccination recommendations to include school-age children ( ages 5 - 18 ) . Children are at risk for flu and propagate epidemic spread . Immunizing children at school offers an efficient approach to covering this population . This study examines the cost consequences of a large multistate , school-based influenza immunization program .  The results show that immunization reduces disease among children and adults and is cost-saving to society . An epidemiologically based influenza immunization policy might be an important supplement to the existing risk-based policy BACKGROUND While the Advisory Committee on Immunization Practice s recommends a st and ing order as the most effective mechanism to increase pneumococcal and influenza vaccination rates , Georgia 's Medical Practice Act does not authorize nurses to screen , order , and administer adult vaccines in inpatient setting s. METHODS The setting was a 1000-bed public teaching hospital in metropolitan Atlanta . A 1-month intervention ( INT1 ) included four wards r and omized to intervention or control . A 5-month hospital-wide intervention ( INT2 ) followed INT1 . The intervention used was provider reminder with in-service training .  Chart review was the measure used . The main outcome was pneumococcal vaccination prior to discharge . RESULTS During INT1 , 534 patients ( 296 intervention and 238 control ) were discharged . Of the 534 patients , 475 ( 89.0 % ) were African American , 188 ( 35.2 % ) were uninsured , and the median age was 48 ( range 19 to 96 ) . Of the 205 intervention patients with vaccine indications and no contraindications , 78 of 205 ( 38 % ) were vaccinated compared to 7 of 143 ( 4.9 % ) of the control patients ( p<0.001 ) . During INT2 , 879 patient charts were review ed . Patient demographics were similar to INT1 . However , of 554 eligible patients , 16 % were vaccinated , significantly higher than control floors during INT1 ( p<0.001 ) . Although nurses initiated the form almost 70 % of the time , physicians assessed fewer than 35 % of patients with indications . CONCLUSIONS Significantly higher proportions of high-risk patients were vaccinated through the use of a preprinted nurse screening and physician order form . However , a significant percentage of patients did not receive the vaccine owing to the physician 's failure to order it . In these cases , use of st and ing orders would have further increased vaccination rates while also promoting a more sustainable program CONTEXT An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations . Disparities in US childhood immunization rates persist , with inner-city , black , and Hispanic children having lower rates . Although practice or clinic-based interventions , such as patient reminder/recall systems , have been found to improve immunization rates in specific setting s , there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level . OBJECTIVE To assess the effect of a community-wide reminder , recall , and outreach ( RRO ) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban population s and among white , black , and Hispanic children within an entire county . SETTING Monroe County , New York ( birth cohort : 10 000 , total population : 750 000 ) , which includes the city of Rochester . Three geographic regions within the county were compared : the inner city of Rochester , which contains the greatest concentration of poverty ( among 2-year-old children , 64 % have Medicaid ) ; the rest of the city of Rochester ( 38 % have Medicaid ) ; and the suburbs of the county ( 8 % have Medicaid ) . INTERVENTIONS An RRO system was implemented in 8 city practice s in 1995 ( covering 64 % of inner-city children ) and was exp and ed to 10 city practice s by 1999 ( covering 74 % of inner-city children , 61 % of rest-of-city children , and 9 % of suburban children ) . The RRO intervention involved lay community-based outreach workers who were assigned to city practice s to track immunization rates of all 0- to 2-year-olds , and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations ( tracking for all children , mail , or telephone reminders for most children , assistance with transportation or scheduling for some children , and home visits for 5 % of children who were most behind in immunizations and who faced complex barriers ) . STUDY PARTICIPANTS Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993 , 1996 , and 1999 . STUDY DESIGN Immunization rates were measured for each geographic region in Monroe County at 3 time periods : before the implementation of a systematic RRO system ( 1993 ) , during early phases of implementation of the RRO system ( 1996 ) , and after implementation of the RRO system in 10 city practice s ( 1999 ) . Immunization rates were compared for children living in the 3 geographic regions , and for white , black , and Hispanic children . Immunization rates were measured by the same methodology in each of the 3 time periods . A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practice s in the county ( covering 85 % to 89 % of county children ) . A r and om sample of children ( > 500 from the suburbs and > 1200 from the city for each sampling period ) was then selected for medical chart review at practice s to determine demographic characteristics ( including race and ethnicity ) and immunization rates . City children were over sample d to allow detection of effects by geographic region and race . Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling . MAIN OUTCOME MEASURES Immunization rates at 12 and 24 months for recommended vaccines ( 4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella : > or = 1 Haemophilus influenzae type b on or after 12 months of age ) . RESULTS DISPARITIES BY GEOGRAPHIC REGION : Baseline immunization rates ( 1993 ) for 24-month-olds were as follows : inner city ( 55 % ) , rest of city ( 64 % ) , and suburbs ( 73 % ) , with an 18 % difference in rates between the inner city and suburbs . By 1996 , immunization rates rose faster in the inner city ( + 21 % points ) than in the suburbs ( + 14 % points ) so that the difference in rates between the inner city and suburbs had narrowed to 11 % . In 1999 , rates were similar across geographic regions : inner city ( 84 % ) , rest of city ( 81 % ) , and suburbs ( 88 % ) , with a 4 % difference between the inner city and suburbs . DISPARITIES BY RACE AND ETHNICITY : Immunization rates were available in 1996 and 1999 by race and ethnicity . Twenty-four-month immunization rates in 1996 showed disparities : white ( 89 % ) , black ( 76 % ) , and Hispanic ( 74 % ) , with a 13 % difference between rates for white and black children and a 15 % difference between white and Hispanic children . In 1999 , rates were similar across the groups : white ( 88 % ) , black ( 81 % ) , and Hispanic ( 87 % ) , with a 7 % difference between rates for white and black children , and a 1 % difference between white and Hispanic children . CONCLUSIONS A community-wide intervention of patient RRO  raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority population s. By targeting a relatively manageable number of primary care practice s that serve city children and using an effective strategy to increase immunization rates in each practice , it is possible to eliminate disparities in immunizations for vulnerable children OBJECTIVE To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income , minority mothers in Washington , DC . DESIGN The experimental design was a r and omized , controlled study in which 286 mother-infant dyads were assigned to either the st and ard social services ( control ) group or to the intervention group .  Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington , DC , hospital sites from April 1995 to April 1997 . The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the st and ard social services available at the hospital sites . A total of 286 postpartum women with inadequate prenatal care were assigned r and omly to the control or the intervention group . Women and their infants were followed for 1 full year . Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant 's life . RESULTS Infants in the intervention group initiated well care at an earlier age than controls ( by 6 weeks , 62.5 % vs 50 % had received their first well infant visit ) . Infants in the intervention group had more frequent well visits ( by 12 months of age , 3.5 vs 2.7 visits ) . Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations ( by 9 months , odds ratio = 2.2 , 95 % confidence interval : 1.09 - 4.53 ) . Those in the intervention group with more frequent contacts ( 30 + visits ) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls ( at 9 months odds ratio = 3.63 , 95 % confidence interval : 1.58 - 8.33 ) . CONCLUSIONS It is possible to influence health care usage patterns of high-risk minority population s through public health interventions that are global in their perspective . Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care re sources BACKGROUND Immunisation against influenza is an effective intervention that reduces serologically confirmed cases by between 60 % and 70 % . Almost all influenza immunisation in the UK is done within general practice . Current evidence on the effectiveness of patient reminders for all types of immunisation programmes is largely based on North American studies . AIM To determine whether telephone appointments offered bygeneral practice receptionists increase the uptake of irfluenza immunisation among the registered population aged over 65 years in east London practice s. DESIGN OF STUDY R and omised controlled trial . SETTING Three research general practice s within the East London and Essex network of research ers ( ELENoR ) . METHOD Participants were 1,820 low-risk patients aged 65 to 74 years who had not previously been in a recall system for influenza immunisation at their general practice . The intervention , during October 2000 , was a telephone call from the practice receptionist to intervention group households , offering an appointment for influenza immunisation at a nurse-run . clinic Main outcome measures were the numbers of individuals in each group receiving immunisation , and practice costs of a telephone-appointing programme . RESULTS intention to treat analysis showed an immunisation rate in the control group of 44 % , compared with 50 % in the intervention group ( odds ratio = 1.29 , 95 % confidence interval = 1.03 to 1.63 ) . Of the patients making a telephone appointment  , 88 % recieved immunisation , while 22 % of those not wanting an appointment went on to be immunised . In the controlgroup , income generated was 11.35 pounds per immunisation , for each additional immunisation in the intervention group the income was 5.20 pounds . The ' number needed to telephone ' was 17 . CONCLUSION Uptake of influenza immunisation among the low-risk older population in inner-city areas can be boosted by around 6 % using a simple intervention by receptionists . Immunisation rates in this low-risk group fell well short of the 60 % government target . Improving immunisation rates will require a sustained public health campaign . Retaining the item-of-service payments to practice s should support costs of practice -based interventions CONTEXT Immunization rates in the inner city remain lower than in the general US population , but efforts to raise immunization levels in inner-city areas have been largely untested . OBJECTIVE To assess the effectiveness of case management in raising immunization levels among infants of inner-city , African American families . DESIGN R and omized controlled trial with follow-up through 1 year of life . SETTING Low-income areas of inner-city Los Angeles , Calif. PATIENTS A representative sample of 419 African American infants and their families . INTERVENTIONS In-depth assessment by case managers before infants were 6 weeks of age , with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed . MAIN OUTCOME MEASURES Percentage of children with up-to- date immunizations at age 1 year , characteristics associated with improved immunization rates , and cost-effectiveness of case management intervention .  RESULTS A total of 365 newborns were followed up to age 1 year . Overall , the immunization completion for the case management group was 13.2 percentage points higher than the control group ( 63.8 % vs 50.6 % ; P=.01 ) . In a logistic model , the case management effect was limited to the 25 % of the sample who reported 3 or fewer well-child visits ( odds ratio , 3.43 ; 95 % confidence interval , 1.26 - 9.35 ) ; for them , immunization levels increased by 28 percentage points . Although for the case management group intervention was not cost-effective ( $ 12022 per additional child immunized ) , it was better ( $ 4546 ) for the 25 % of the sample identified retrospectively to have inadequate utilization of preventive health visits . CONCLUSIONS A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city , African American infants . The intervention was demonstrated to be particularly effective for sub population s that do not access well-child care ; however , currently there are no means to identify these groups prospect ively . For case management to be a useful tool to raise immunizations levels among high-risk population s , better methods of tracking and targeting , such as immunization registries , need to be developed BACKGROUND Vaccination against influenza is associated with reductions in hospitalizations for  heart  disease , cerebrovascular disease , pneumonia , or influenza , and the risk of death from all causes during the influenza season . DESIGN R and omized controlled trial . PARTICIPANTS All members enrolled in the Blue Cross Blue Shield Association 's Government Wide Service Benefit Program in the states of Oklahoma , Rhode Isl and , Kentucky , California , Arizona , Utah , and Colorado in October 2002 . The sample size was 339,220 members . INTERVENTION Two identical influenza/pneumonia direct mail marketing pieces that encouraged members to receive influenza and pneumococcal vaccinations . The study period was October 15 , 2002 through March 15 , 2003 when most influenza cases occur . Data were collected in July 2003 and analyzed during August 2003 . MAIN OUTCOME MEASURES Administrative cl aims based on influenza/pneumonia inpatient admissions and emergency department ( ED ) visits . RESULTS The intervention group experienced a 2.62 % ( p=0.010 ) higher rate of influenza vaccinations ; 4.61 % ( p=0.080 ) higher rate of pneumonia vaccinations ; 9.67 % ( p=0.136 ) lower rate of influenza/pneumonia inpatient admissions ; and 22.64 % ( p=0.002 ) lower rate of influenza/pneumonia ED visits compared to the control group . The benefit-cost ratio ( return on investment ) from this intervention was estimated to be US dollar 2.21 per dollar spent . CONCLUSIONS Administrative cl aims data suggest that members respond to health plan mailings with an increase in influenza vaccination rates . Health plans can cost-effectively impact medical service utilization and vaccination rates by mailing information to their members Summary Objectives : With the implementation of the Health Care Modernization Act in 2004 sickness funds in Germany were given the opportunity to award bonuses to their insured for healthpromoting behavior . The aim of this study was to investigate the financial implication s of a prevention bonus program from a sickness fund perspective . Method : The investigation was design ed as a controlled cohort study ( matched pair study ) comprising 70,429 members in each group . Matching criteria were sex , postal code , insurance status , and cost categories for health care utilization . Insured opted into the program on a voluntary basis . The program consisted of interventions featuring primary prevention , modest exercise and immunization . Differences in cost trends between the two groups were examined using the paired t-test . Results : A reduction in mean costs of 241.11 € per active member for the year 2005 ( 90 % CI = 348.70 , 133.52 ; p-value < 0.001 ) could be achieved in the intervention group compared to the control group . When costs for the implementation of the program and the bonus payments were taken into account , there was a saving of 97.14 € per active member for the year 2005 . Conclusions : Preliminary results of a prevention bonus program in the German Statutory Health Insurance suggest a decrease in mean health care spending per enrollee . These effects may increase with time as long term effects of prevention become effective . However , further research is needed to underst and how much of these short term cost reductions can be attributed to the program itself rather than to possible confounders or volunteer bias and how the short term savings may be accrued OBJECTIVE To assess the impact of a tiered patient immunization navigator intervention ( immunization tracking , reminder/recall , and outreach ) on improving immunization and preventive care visit rates in urban adolescents . DESIGN R and omized clinical trial allocating adolescents ( aged 11 - 15 years ) to intervention vs st and ard of care control . SETTING Eight primary care practice s. PARTICIPANTS Population -based sample of adolescents ( N = 7546 ) .  INTERVENTION Immunization navigators at each practice implemented a tiered protocol : immunization tracking , telephone or mail reminder/recall , and home visits if participants remained unimmunized or behind on preventive care visits . MAIN OUTCOME MEASURES Immunization rates at study end . Secondary outcomes were preventive care visit rates during the previous 12 months and costs . RESULTS The intervention and control groups were similar at baseline for demographics ( mean age , 13.5 years ; 63 % black , 14 % white , and 23 % Hispanic adolescents ; and 74 % receiving Medicaid ) , immunization rates , and preventive care visit rates . Immunization rates at the end of the study were 44.7 % for the intervention group and 32.4 % for the control group ( adjusted risk ratio , 1.4 ; 95 % confidence interval , 1.3 - 1.5 ) ; preventive care visit rates were 68.0 % for the intervention group and 55.2 % for the control group ( 1.2 ; 1.2 - 1.3 ) . Findings were similar across practice s , sexes , ages , and insurance providers . The number needed to treat for immunizations and preventive care visits was 9 . The intervention cost was $ 3.81 per adolescent per month ; the cost per additional adolescent fully vaccinated was $ 465 , and the cost per additional adolescent receiving a preventive care visit was $ 417 . CONCLUSION A tiered tracking , reminder/recall , and outreach intervention improved immunization and preventive care visit rates in urban adolescents . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00581347 OBJECTIVE To assess cost and cost-effectiveness of immunization reminder/recall systems in the private sector . METHODS A manual postcard system ( mail ) was compared with a computer-based telephone system ( autodialer ) and control .  Costs included time costs and the cost of equipment and supplies . The cost per child and the incremental cost of the intervention relative to control were computed . Cost-effectiveness ratios were computed for return visits and for immunizations delivered . RESULTS The average cost per child was $ 2.28 for the mail group and $ 1.47 for the autodialer group . The incremental visit cost relative to the control was higher for the mail group ( $ 9.52 ) than for the autodialer group ( $ 3.48 ) . The autodialer was more cost-effective in delivering immunizations : $ 4 . 06 per extra immunization ( autodialer ) versus $ 12.82 ( mail ) . CONCLUSIONS Excluding start-up costs , the autodialer system was most cost-effective . Including autodialer equipment costs , the autodialer system is more cost-effective only for larger practice Abstract Background : Vaccinating children against influenza virus may reduce infections in immunised children and household contacts , thereby reducing the household-based cost associated with respiratory illnesses . Objective : To evaluate the impact of influenza virus vaccination  of daycare children on costs of respiratory illnesses of the children and their household contacts from the household and societal perspective . Study design : Cost analysis of data from a r and omised controlled trial covering the period November to April of 1996–7 and 1998–9 . Children ( 127 in 1996–7 and 133 in 1998–9 ) from daycare centres in Californian ( USA ) naval bases received influenza virus vaccine ( inactivated ) or hepatitis A virus vaccination .  Outcome measures : Direct and indirect costs ( 1997 and 1999 US dollars ) of respiratory illnesses in households of vaccinated and not vaccinated daycare children , excluding the cost of vaccination . Results : There were no statistically significant differences in household costs of respiratory illness between households with or without influenza virus-vaccinated children ( $ US635 vs $ US492 : p = 0.98 [ 1996–7 ] ; $ US412.70 vs $ US499.50 : p = 0.42 [ 1998–9 ] ) . In 1996–7 , adult and 5- to 17-year-old contacts of vaccinated children had lower household costs than contacts of unvaccinated children ( $ US58.50 vs $ US83.20 , p = 0.01 and $ US32.80 vs $ US59.50 , p = 0.04 , respectively ) , while vaccinated children 0–4 years old had higher household costs than unvaccinated children in the same age group ( $ US383 vs $ US236 , p = 0.05 ) . In 1998–9 , there were no differences within individual age groups . Results from societal perspective were similar . Conclusions : Overall , from both the household and societal perspectives , there were no economic benefits to households from vaccinating daycare children against influenza virus . However , we found some over-time inconsistency in results ; this should be considered if changing recommendations about routine influenza virus vaccination of healthy children . Our study size may limit the generalisability of the results OBJECTIVE Intranasal influenza vaccine has proven clinical efficacy and may be better tolerated by young children and their families than an injectable vaccine . This study determined the potential cost-effectiveness ( CE ) of an intranasal influenza vaccine among healthy children . METHODS We conducted a CE analysis of data collected between 1996 and 1998 during a prospect i ve 2-year efficacy trial of intranasal influenza vaccine , supplemented with data from the literature . The CE analysis included both direct and indirect costs . We enrolled 1602 healthy children aged 15 to 71 months in year 1 , 1358 of whom were enrolled in year 2 . One or 2 doses of intranasal influenza vaccine or placebo were administered to measure the cost per febrile influenza-like illness ( ILI ) day avoided . RESULTS During the 2-year study period , vaccinated children had an average of 1.2 fewer ILI fever days/child than unvaccinated children . In an individual-based vaccine delivery scenario with vaccine given twice in the first year and once each year thereafter at an assumed base case total cost of $ 20 for the vaccine and its administration ( ie , per dose ) , CE was approximately $ 30/febrile ILI day avoided . CE ranged from $ 10 to $ 69/febrile ILI day avoided at $ 10 to $ 40/dose , respectively . In a group-based delivery scenario , vaccination was cost saving compared with placebo and remained so if vaccine cost was < $ 28 ( the break-even price per dose ) . In the individual-based scenario , vaccination was cost saving if vaccine cost was < $ 5 . In this scenario , nearly half of lost productivity in the vaccine group was attributable to vaccine visits , which overshadowed the relatively modest savings in ILI-associated costs averted . CONCLUSIONS Routine use of intranasal influenza vaccine among healthy children may be cost-effective and may be maximized by using group-based vaccination approaches . cost-effectiveness , influenza , vaccine , children Background . Immunization rates have improved in the United States , but are still far from the national 90 % goal for the year 2000 . There is scant evidence about the effectiveness and costs of automated telephone messages to improve immunization rates among privately insured children . Objective . To evaluate the effectiveness and cost-effectiveness of sending letters , automated telephone messages , or both to families of underimmunized 20-month-olds in a health maintenance organization ( HMO ) . Methods . In this r and omized trial , underimmunized 20-month-olds identified by the HMO 's computerized immunization tracking system were assigned to one of four interventions : 1 ) an automated telephone message alone ; 2 ) a letter alone ; 3 ) an automated telephone message followed by a letter 1 week later ; and 4 ) a letter followed by an automated telephone message 1 week later . The primary outcome was receipt of any needed immunization by 24 months of age . Decision analysis was used to evaluate the projected cost-effectiveness of the alternative strategies . Results . A total of 648 children were r and omized . A letter followed by a telephone message ( 58 % immunized ) was significantly better than either a letter alone ( 44 % immunized ) or a telephone message alone ( 44 % immunized ) . A telephone message followed by a letter ( 53 % immunized ) also was more effective than either alone , although the differences were not statistically significant . Among a similar comparison group that received no systematic intervention , 36 % were immunized . The estimated cost per child immunized was $ 7.00 using letters followed by automated telephone messages , $ 9.80 using automated telephone messages alone , and $ 10.50 using letters alone . Under alternative cost assumptions for automated telephone messages and mailed messages , the cost per child immunized ranged from $ 2.20 to $ 6.50 . Conclusions . For underimmunized 20-month-olds in this HMO setting , letters followed by automated telephone messages were more effective and cost-effective than either message alone . The cost-effectiveness of automated telephone messages and letters may vary widely depending on the setting , and choices among strategies should be tailored to the population s being served OBJECTIVES : The purpose of this research was to explore physicians ' attitudes and behaviors related to vaccine financing issues within their practice . Amid the increasing number of vaccine doses recommended for children and adolescents , anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children . Whether these sentiments are widely held among immunization providers is unknown . METHODS : We conducted a cross-sectional mail survey from July to September 2007 of a r and om sample of 1280 US pediatricians and family physicians engaged in direct patient care . Main outcome measures included delay in the purchase of specific vaccines for financial reasons ; reported decrease in profit margin from immunizations ; and practice consideration of whether to stop providing all vaccines to privately insured children . RESULTS : The response rate was 70 % for pediatricians and 60 % for family physicians . Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons ( 49 % ) and experienced decreased profit margin from immunizations ( 53 % ) in the previous 3 years . Twenty-one percent of respondents strongly disagreed that “ reimbursement for vaccine purchase is adequate , ” and 17 % strongly disagreed that “ reimbursement for vaccine administration is adequate . ” Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year . CONCLUSIONS : Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations . Although large-scale withdrawal of immunization providers does not seem to be imminent , efforts to address root causes of financial pressures should be undertaken PURPOSE To determine whether an educational brochure or a lottery-type incentive increases influenza immunization rates . PATIENTS AND METHODS In a prospect i ve , single-blind factorial design r and omized trial at an urban community health center , all high-risk patients ( n = 797 ) seen in the preceding 18 months were r and omly assigned to one of four groups : a control group ; a group mailed a large print , illustrated educational brochure emphasizing factors important to patients in making a decision about influenza immunization ; a group mailed a lottery-type incentive announcing that all patients receiving influenza immunization  would be eligible for grocery gift certificates ; and a group mailed both educational brochure and incentive . Immunization was free , available without an appointment , and recorded by a computerized tracking system . RESULTS The group mailed the brochure was more likely to be immunized than control ( odds ratio [ OR ] = 2.29 , 95 % confidence interval [ CI ] 1.45 to 3.61 ) , as was the group mailed the incentive ( OR = 1.68 , 95 % CI 1.05 to 2.68 ) , but there was no difference between the group mailed both interventions and the control group . The effectiveness of the brochure was more striking for individuals who had not accepted immunization in the prior year ( OR = 4.21 , 95 % CI 2.48 to 7.14 ) , suggesting a true educational effect rather than simply a reminder . CONCLUSION In this community health center setting , an illustrated educational brochure increased influenza immunization among high-risk patients , a lottery-type incentive was much less effective , and both together was not effective BACKGROUND Reminder-recall interventions have improved immunization rates in numerous studies . OBJECTIVE To evaluate the impact of large-scale , registry-based reminder-recall interventions on low immunization rates in an inner-city population . DESIGN R and omized , controlled , effectiveness trial . SETTING Fulton County , Georgia . PARTICIPANTS A total of 3050 children ( 76 % black , 14 % Hispanic , 7 % white , and 3 % other or unknown ; median age , 9 months ; range , 1 - 14 months ) identified in an immunization registry as receiving health care in the public sector . INTERVENTIONS Each child was r and omly assigned to 1 of 4 groups : control ( usual care ) , autodialer ( automated telephone or mail reminder recall ) , outreach ( in-person telephone , mail , or home visit recall ) , and combination ( autodialer with outreach backup ) . Interventions continued until the child reached 24 months of age . MAIN OUTCOME MEASURE Completion by the age of 24 months of the 4 - 3 - 1 - 3 vaccination series based on intention-to-treat analysis . RESULTS A total of 260 ( 34 % ) of the 763 patients in the control group , 306 ( 40 % ) of the 763 in the autodialer group , 284 ( 37 % ) of the 760 in the outreach group , and 293 ( 38 % ) of 764 in the combination group completed the vaccination series . CONCLUSION Large-scale , registry-based reminder-recall interventions produced only small improvements in low immunization rates of an inner-city population OBJECTIVE To evaluate the impact of interventions by a community-based organization on immunization rates . DESIGN Controlled community intervention trial . SETTING AND PARTICIPANTS Children aged 3 to 59 months in Fulton County , Georgia , who were patients of 1 of 4 public clinics ( clinic based ) , or residents of 1 of 9 inner-city communities ( residence based ) . INTERVENTIONS ( 1 ) Clinic-based intervention included monthly review of clinic vaccination records to identify undervaccinated children followed by contact with family ( reminder-recall strategy ) ; ( 2 ) residence-based intervention included door-to-door assessment and education campaigns followed by mobile van vaccinations , temporary on-site vaccination stations , free child care and transportation to providers , incentives of food and baby products , focus groups , and coalitions with local organizations ( community saturation with vaccination messages and opportunities ) . OUTCOME MEASURES Change in vaccination rates after 1 year based on clinic record review s and population surveys . RESULTS For clinic-based intervention , series completion rates improved from 43 % ( 87/204 ) to 58 % ( 99/170 ) in intervention clinics ( P=.003 ) , while rates in control clinics did not change from the baseline of 52 % ( 81/157 to 78/150 ) , for a net difference between intervention and control arms of + 15 percentage points ( P=.046 ) . For residence-based intervention , age-appropriate vaccination rates improved from 44 % ( 154/347 ) to 61 % ( 260/429 ) in intervention communities ( + 17 percentage points ; P<.001 ) compared with improvement of 44 % ( 78/178 ) to 58 % ( 129/221 ) for control communities ( + 14 percentage points ; P=.004 ) , but the difference between arms was not significant ( + 3 percentage points , P=.78 ) . CONCLUSIONS Reminder-recall activities by the community-based organization improved vaccination rates in intervention clinics compared with control clinics . A statistically significant impact on vaccination rates could not be detected for residence-based interventions by the community-based organization OBJECTIVE To assess the effect of three computerized reminder systems on compliance with tetanus vaccination . DESIGN Prospect i ve r and omized controlled trial . SETTING Ottawa Civic Hospital Family Medicine Centre . PARTICIPANTS Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were r and omly assigned , by family , to a control group , a physician reminder group , a telephone reminder group or a letter reminder group .  The remaining 2480 patients were not included in the r and omized portion of the study but were monitored . Results are presented for the 5242 r and omized patients and the 2369 nonr and omized patients for whom there was no up-to- date record of tetanus vaccination at the start of the trial . INTERVENTIONS For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient 's tetanus vaccination status and to recommend vaccination ; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose . MAIN OUTCOME MEASURE Proportion of patients who received tetanus toxoid during the study year or who had a cl aim of vaccination in the previous 10 years . MAIN RESULTS The rate of recorded tetanus vaccination in the r and omized control group was 3.2 % . The difference between that rate and those for the three reminder groups was 19.6 % in the physician reminder group ( 95 % confidence interval [ CI ] 17.1 % to 22.2 % , p less than 0.00001 ) , 20.8 % in the telephone reminder group ( 95 % CI 18.3 % to 23.5 % , p less than 0.00001 ) and 27.4 % in the letter reminder group ( 95 % CI 24.8 % to 30.2 % , p less than 0.00001 ) ) . The letter reminders were more effective than either the telephone reminders ( p = 0.00013 ) or the physician reminders ( p less than 0.00001 ) in improving compliance . The cost to the practice per additional vaccination recorded was 43 for the physician reminders , $ 5.43 for the telephone reminders and $ 6.05 for the letter reminders . CONCLUSIONS Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage . More intensive interventions would be required to approach that goal . However , such interventions do not appear to be justified given the rarity of tetanus OBJECTIVE To ascertain the effectiveness of a home vaccination service for children behind in their vaccination schedule . DESIGN R and omised controlled trial of nurse-administered vaccination at home .  Children were allocated at r and om to the intervention or the control group before any contact with the parents was made . SETTING 10 council areas in north-west metropolitan Melbourne defined by 56 postcode zones . Six-week intervention period from November 1996 . PARTICIPANTS 405 children -- all those in the study area ( n = 2610 ) 90 days late ( age 9 months ) for their third diphtheria-tetanus-pertussis/poliomyelitis/Haemophilus influenzae type B ( DTP/OPV/Hib ) vaccination , or 120 days late ( age 16 months ) for their measles-mumps-rubella ( MMR ) vaccination , according to the Australia Childhood Immunisation Register . MAIN OUTCOME MEASURES Number of children completing DTP/OPV/Hib or MMR during the intervention period , and number up to date before intervention . RESULTS Verification of vaccination status with the parents revealed that 123 ( 60 % ) of the children in the intervention group and 113 ( 56 % ) of those in the control group were up to date with their vaccinations , leaving a study population of 81 ( intervention group ) and 88 ( control group ) . Vaccination was achieved in 46 ( 57 % ) intervention children and 24 ( 27 % ) control children ( risk ratio [ RR ] , 2.08 ; 95 % CI , 1.4 - 3.1 ; P < 0.001 ) . For DTP/OPV/Hib , 18/32 ( 56 % ) intervention children and 12/36 ( 33 % ) control children were vaccinated , ( P = 0.06 ) . For MMR , 28/49 ( 57 % ) and 12/52 ( 23 % ) children were vaccinated , respectively ( P < 0.001 ) . Home vaccinations were completed with 26 families ( including five siblings ) . The average cost per child vaccinated as a result of the home program was $ 92.52 . CONCLUSION Home vaccination for children behind in their immunisation schedule is an effective , acceptable and relatively cheap method of completing recommended vaccinations . We recommend that a home vaccination program be widely implemented and made available , particularly for disadvantaged families We evaluated the relative impact of four procedures design ed to encourage parents to obtain immunizations for their children . In a public health setting , the families of 1,133 immunization-deficient preschool children were r and omly assigned to six conditions : ( a ) a general prompt ; ( b ) a more client-specific prompt ; ( c ) a specific prompt and increased public health clinic access ; ( d ) a specific prompt and monetary incentives ; ( e ) contact control ; and ( f ) no contact control . All interventions , except the general prompt , produced some evidence of improvement when compared with the control groups . The monetary incentive group revealed the largest effect , followed by the increased access group , specific prompt group , and general prompt group , respectively . The data suggest that relatively powerful and immediate effects on preschoolers ' clinic attendance for immunization may be produced by monetary incentives in conjunction with client-specific prompts . However , client-specific prompts alone appear to be the most cost-effective of the interventions Objective . To compare and measure the effects and cost-effectiveness of two interventions design ed to raise immunization rates . Setting s. Nine primary care sites serving impoverished and middle-class children . Subjects . Complete birth cohorts ( ages 0 to 12 months ; n = 3015 ) from these sites . Interventions . Two 18-month duration interventions : 1 ) tracking with outreach [ tracking/outreach ] to bring underimmunized children to their primary care provider office , and 2 ) a primary care provider office policy change to identify and reduce missed immunization opportunities ( prompting ) . Design . R and omized , controlled trial , r and omizing within sites using a two-by-two factorial design . Subjects were allocated to one of four study groups : control , prompting only , tracking/outreach only , and combined prompting with tracking/outreach . Outcomes were obtained by blinded chart abstract ion . Measures . Immunization status for age ; number of days of delay in immunization ; primary care utilization ; and rates of screening for occult disease . Results . Out of 3015 subjects , 274 subjects ( 9 % ) transferred out of the participating sites or had incomplete charts and were excluded . The 2741 ( 91 % ) remaining subjects were assessed . At baseline , study groups did not differ in age , gender , insurance type , or immunization status . Of the remaining subjects , 63 % received Medicaid . Final series-complete immunization coverage levels were : control , 74 % ; prompting-only , 76 % ; tracking/outreach-only 95 % ; and combined tracking/outreach with prompting , 95 % . Analysis of variance showed that : 1 ) tracking/outreach increased immunization rates 20 percentage points ; 2 ) tracking/outreach decreased mean immunization delay 63 days ; 3 ) tracking/outreach increased mean health supervision visits 0.44 visits per child ; 4 ) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child ; 5 ) impact of tracking/outreach was greatest for uninsured and impoverished patients ; and 6 ) the prompting intervention had no impact on the studied outcomes , and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted . Using tracking/outreach , the cost per additional child fully immunized was $ 474 . Each $ 1000 spent on the tracking/outreach intervention result ed in : 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization ; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider ; and 1.8 additional anemia screenings and 1.3 additional lead screenings . Conclusions . Outreach directed toward children not up-to- date on immunizations improves not only immunization status , but also health supervision visit attendance and screening rates . The cost per additional child immunized was high , but should be interpreted in view of the spillover benefits that accompanied improved immunization . Effective means to improve coverage by reducing missed immunization opportunities still need to be identified . immunization , primary care , r and omized , controlled trial , missed immunization opportunities , outreach Abstract OBJECTIVE : To compare the effects of different types of computer-generated , mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders . DESIGN : R and omized controlled trial . SETTING : Multispeciality group practice . PATIENTS : We studied 24,743 high-risk adult patients aligned with a primary care physician . INTERVENTION : Patients were r and omized to one of four interventions : ( 1 ) no reminder , which served as control ; ( 2 ) a generic postcard ; ( 3 ) a personalized postcard from their physician ; and ( 4 ) a personalized letter from their physician , tailored to their health risk . MEASUREMENTS : The immunization rate was measured using billing data . A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders . To evaluate the cost-effectiveness , a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs . MAIN RESULTS : All three of the reminders studied increased the influenza vaccination rate when compared with the control group . The vaccination rate was 40.6 % in the control group , 43.5 % in the generic postcard group , 44.7 % in the personalized postcard group , and 45.2 % in the tailored letter group . The rates of immunization increased as the intensity of the intervention increased ( p < .0001 ) . Seventy-eight percent of patients in the letter group deemed the intervention useful , and 86 % reported that they would like to get reminders in the future . The cost-effectiveness analysis estimated that in a nonepidemic year , the net savings per 100 reminders sent would be $ 659 for the personalized postcard intervention and $ 735 for the tailored letter intervention . When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients , the estimated total net savings was $ 162,940 for the postcard and $ 181,858 for the tailored letter . CONCLUSIONS : Although the absolute increase in immunization rates with the use of reminders appeared small , the increases translated into substantial cost savings when applied to a large high-risk population . Personalized reminders were somewhat more effective in increasing immunization , and personalized letters tailored to the patients ’ condition were deemed useful and important by the individuals who received them and had a beneficial indirect effect on patient satisfaction BACKGROUND Injection drug users ( IDUs ) are at high-risk for hepatitis B virus ( HBV ) and HIV . Due to concerns about non-adherence to multi-dose vaccine regimens however , IDUs are severely under-immunized against HBV and have been excluded from phase III trials of multi-dose c and i date HIV vaccines in the United States . METHODS Through a r and omized controlled trial , we compared the effectiveness of monetary incentives versus outreach to improve IDUs ' adherence to the 3-dose hepatitis B vaccine .  In 1998 - 1999 , HBV-susceptible IDUs were recruited from San Francisco streets . Eligible participants received their first dose of vaccine  and were r and omized to either receive monthly monetary incentives ( n=48 ) or maintain weekly contact with an outreach worker ( n=48 ) during the 6-month vaccine series . RESULTS All 3 doses of vaccine were received by 33 ( 69 % ) of IDUs in the monetary incentive arm and 11 ( 23 % ) in the outreach arm ( odds ratio=13.8 ; 95 % confidence interval , 2.9 , 128 ; P<0.0001 ) . In a multivariate model , receiving monetary incentives was independently associated with vaccine completion ( AOR=10.3 ; 95 % CI=3.7 , 29.0 ) . CONCLUSIONS Among IDUs , monetary incentives are superior to outreach in achieving adherence to the multi-dose hepatitis B vaccine series . Monetary incentives may be adapted to future multi-dose c and i date HIV vaccine trials in IDUs Objective : To raise immunization coverage among children at risk for underimmunization , we evaluated the effectiveness and cost-effectiveness of immunization activities in the Special Supplemental Program for Women , Infants and Children ( WIC ) . Method : A controlled intervention trial was conducted in seven WIC sites in Chicago between October 1990 and March 1994 . At intervention sites , staff screened children for vaccination status at every visit , referred vaccine-eligible children to either an on-site WIC nurse , on-site clinic , or off-site community provider , and issued either a 3-month supply of food vouchers to up-to- date children or a 1-month supply to children not up-to- date —a usual practice for high-risk WIC children . Our primary measure of effectiveness was the change in the baseline percentage of up-to- date children at the second birthday ; cost-effectiveness was approximated for each of the three referral interventions . Results : After one year , up-to- date vaccination coverage increased 23 % above baseline for intervention groups and decreased 9 % in the control group . After the second year , up-to- date vaccination further increased to 38 % above baseline in intervention groups and did not change in the control group . The total cost per additional up-to- date child ranged from $ 30 for sites referring children off-site to $ 73 for sites referring children on-site to a nurse . Conclusion : This controlled intervention trial of screening , referral , and a voucher incentive in the WIC program demonstrated a substantial increase in immunization coverage at a low cost . Continuing to design linkages between WIC and immunization programs by building on WIC 's access to at-risk population s is worth the investment OBJECTIVE To test if appointment reminders blinded to immunization status improve kept-appointment and vaccination coverage rates . Design . Controlled trial . SETTING Pediatric clinic serving a low-income community in New York City . INTERVENTION Children ages 4 through 18 months ( n = 1273 ) scheduled sequentially for clinic appointments were systematic ally assigned to 1 of 4 study groups : control ( n = 346 ) ; postcard ( n = 314 ) ; telephone call ( n = 307 ) ; and postcard and telephone call ( n = 306 ) . OUTCOME MEASURES Kept-appointment and vaccination coverage rates . RESULTS Children assigned to the postcard and telephone group were 1.75 times more likely to keep their appointments than controls ( 95 % confidence interval [ CI ] = 1.2 , 2.5 ) . Children who actually received the postcard and telephone reminders were 2.3 times more likely to keep an appointment than controls ( 95 % CI = 1.4 , 3.7 ) . Children who kept appointments were 2.3 times more likely to be up-to- date with their immunizations ( 95 % CI = 1.7 , 3.2 ) . The reminders selectively increased vaccination coverage for the subgroup of children who were not up-to- date before the appointment ( chi(2 ) = 11.2 ) . The cost of the reminders was $ .67 for the postcard and $ 1.58 for the postcard and telephone . Assuming 5000 visits per year and $ 100 reimbursement per visit , the return on each dollar invested was $ 10 for the postcard and $ 7.28 for the postcard and telephone reminder . CONCLUSIONS Appointment reminders blind to immunization status are a practical and cost-effective strategy to increase kept-appointment rates for all children , and , through this mechanism , reach and vaccinate children who are not up-to- date .appointment  reminder , vaccination coverage OBJECTIVES To determine the effectiveness of a telephone reminder to increase pneumococcal vaccination in a population that had received mailed reminders and to evaluate whether the intervention effect is similar for clinics serving primarily non-Hispanic black or non-Hispanic white patient population s. STUDY DESIGN R and omized trial within a managed care network . METHODS All unvaccinated patients 18 years and older with chronic medical conditions and 65 years and older without chronic medical conditions ( N = 6106 ) were r and omized to receive telephone intervention or st and ard care and followed up for 6-month vaccination status . The intervention was a telephone call initiated by a nurse to inform patients that pneumococcal vaccination was recommended and was a covered benefit of their insurance . RESULTS Intervention patients were 2.3 times as likely to be vaccinated during the study period than control patients ( P < .001 ) . The success of telephone intervention versus control was similar across clinics ( P = .16 ) and across the chronic disease and elderly groups ( P = .14 ) . In subanalyses of individuals reached by telephone intervention , unvaccinated black subjects were less likely to be vaccinated during the study than unvaccinated white subjects ( 34 % vs 25 % , P = .03 ) . Nurse staff time for telephone intervention cost $ 147.35 per additional patient vaccinated . CONCLUSIONS Telephone intervention was successful at increasing vaccination rates in a diverse managed care population that had already received mailed reminders . Tailored messaging for pneumococcal vaccination through telephone reminders increases patient dem and for vaccination and should be implemented by managed care organizations seeking to increase their vaccination rates AIMS To estimate the cost-effectiveness of three behavioral interventions provided to enhance hepatitis A virus ( HAV ) and hepatitis B virus ( HBV ) joint vaccination ( HAV/HBV ) compliance among homeless persons living in Los Angeles County . SCOPE A cost-effectiveness analysis ( CEA ) based on data from a r and omized trial where the costs and compliance data from the trial are incorporated into two Markov models , simulating the natural history of acute and chronic hepatitis infection , following HAV/HBV vaccination . CONCLUSIONS Reductions in HBV-related disease is cost-effective to society and is associated with substantial improvements in quality of life Vaccinating children at day-care may be a cost-effective approach for improving influenza immunization rates in this high-risk group . This study uses influenza attack-rate data from a r and omized , blinded , placebo-controlled clinical trial of live-attenuated influenza vaccine , trivalent in day-care centres from two consecutive influenza seasons , one with a moderate attack rate ( H1N1 dominant ) and one with a high attack rate ( H3N2 dominant ) . Costs were measured in US dollars . In the moderate attack-rate season ( vaccinated , 2.2 % ; placebo , 13.4 % ) , vaccination saved US$ 5.47 per child in societal costs . In the high attack-rate season ( vaccinated , 4.7 % ; placebo , 32.1 % ) , vaccination led to a societal costs savings of US$ 144.44 per child Vaccines represent a new and promising avenue of treatment for drug abuse but pose new medication adherence challenges due to prolonged and widely spaced administration schedules . This study examined effects of prize-based incentives on retention and medication adherence among 26 cocaine users involved in a 6-month hepatitis B vaccination series . Participants could meet with research staff weekly for 24 weeks and receive 7 injections containing either the Hepatitis B vaccine or a placebo . All participants received $ 10 at each weekly visit ( maximum of $ 240 ) . Those r and omly assigned to the incentive program received additional monetary payments on an escalating schedule for attendance at weekly monitoring and vaccination visits with maximum possible earnings of $ 751 . Group attendance diverged after study week 8 with attendance better sustained in the incentive than control group ( group by time interaction , p=.035 ) . Overall percent of weekly sessions attended was 82 % for incentive versus 64 % for control ( p=.139 ) . Receiving all scheduled injections were 77 % of incentive versus 46 % of control participants ( p=.107 ) . A significantly larger percentage ( 74 % versus 51 % ; p=.016 ) of injections were received by incentive versus control participants on the originally scheduled day . Results suggest that monetary incentives can successfully motivate drug users to attend sessions regularly and to receive injected medications in a more reliable and timely manner than may be seen under usual care procedures . Thus , incentives may be useful for addressing adherence and allowing participants to reap the full benefits of newly developed medications Inner-city infants ( n = 565 ) enrolled in the WIC program were r and omly assigned at 6 months of age to either of 2 groups : ( 1 ) voucher incentive ( frequency of issuance of food vouchers based on immunization status ) plus reminder-recall ( calls and /or letters to families of under-vaccinated children ) or ( 2 ) voucher incentive alone . At 12 months , both groups ' immunization levels were high and not significantly different : 80 % + /- 4 % versus 79 % + /- 5 % ( P = .749 ) Available strategies to increase  influenza vaccination rates in the elderly have not been tested in the private sector where most elderly receive care . We performed a r and omized controlled trial of a postcard reminder in the three private general internal medicine practice s. The observed vaccination rates of 55 % in experimental patients ( N = 262 ) and 54 % in control patients ( N = 278 ) were similar , though much higher than estimated national rates of 20 % . The data indicated that the baseline ( control group ) vaccination rate was high probably because study participants were exposed to many community vaccination cues , separate from the study cue . That vaccination rates were not higher after additional exposure to the study cue suggests that a " ceiling effect " occurred . Including 70 patients not r and omized into the trial because they received flu shots prior to r and omization , the vaccination rate in patients who had a clinic visit during autumn months was 75 % compared to a rate of 52 % in patients not visiting the clinic ( P less than .001 ) . Our results suggest that vaccination rates can be considerably higher in the private sector than those reported in the past , and that both vaccination cues and direct patient contact appear important to promote vaccination . This and other studies suggest that traditional cues may have a ceiling effect , yielding vaccination rates no higher than 55 to 65 % ; further increases in rates will require other approaches OBJECTIVE To compare computer-based with manual health maintenance tracking systems to determine whether ( 1 ) a computer-based system will result in better provider compliance with the practice health maintenance protocol , ( 2 ) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs , and ( 3 ) inactive patients will respond to health maintenance reminders . DESIGN Two-year prospect i ve , r and omized , controlled trial . SETTING Rural , multiple-office , nonprofit , fee-for-service family practice . PATIENTS Adult members of families in which at least one member had been seen by the practice within the past 2 years . INTERVENTION A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request . OUTCOME MEASURES Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits , costs of computer-based tracking , and response of inactive patients to health maintenance reminders . RESULTS Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group . The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures . The computer-based tracking system cost 78 cents per patient per year to operate . It was not associated with increased office visits or patient billings . CONCLUSIONS Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system . The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other setting s but suggests that considerable health maintenance can be incorporated into ongoing patient care BACKGROUND Hepatitis B vaccine provides a model for improving uptake and completion of multidose vaccinations in the drug-using community . METHODS The Drugs , AIDS , STDs , and Hepatitis ( DASH ) project conducted a r and omized controlled trial among not-in-treatment current drug users in 2 urban neighborhoods . Neighborhoods were cluster-r and omized to receive a st and ard behavioral intervention ( which provided information on human immunodeficiency virus [ HIV ] ) or an enhanced behavioral intervention ( design ed to increase acceptance of or adherence to the hepatitis B vaccination protocol ) . Participants within clusters were r and omized to a st and ard vaccination schedule ( vaccines at 0 , 1 , and 6 months ) or an accelerated vaccination schedule ( vaccines at 0 , 1 , and 2 months ) . The outcomes were completion of the 3-dose vaccine and seroprotection against hepatitis B virus ( HBV ) . RESULTS Of participants with negative screening results for HIV and HBV , 77 % accepted hepatitis B vaccination , and 75 % of vaccinees received all 3 doses . Injection drug users ( IDUs ) on the accelerated schedule were significantly more likely to receive 3 doses ( 76 % ) than those on the st and ard schedule ( 66 % ; P = .04 ) , although for drug users as a whole the corresponding adherence rates were 77 % and 73 % , respectively . No difference in adherence was observed between the behavioral intervention groups . Predictors of adherence were older age , African American race , stable housing , and alcohol use . Cumulative HBV seroprotection ( ≥10 mIU/mL ) was gained within 12 months by 65 % of those completing the schedule . Seroprotection at 6 months was greater for those on the accelerated schedule . CONCLUSION The accelerated vaccination schedule improves hepatitis B vaccination adherence among IDUs BACKGROUND Part of the payoff of immunization registries may be to lower costs of immunization intervention . However , registry-based intervention costs have not been evaluated in a community setting . METHODS The purpose of this study was to prospect ively measure the cost of three equally effective registry-based interventions , evaluate how the size of the targeted population affects cost estimates , and compare these results with previously reported studies . A total of 3050 children aged < 12 months were r and omized to one of four study arms : ( 1 ) computer-generated telephone messages ( autodialer ) , ( 2 ) outreach worker , ( 3 ) autodialer with outreach worker backup , or ( 4 ) usual care . The cost data collected included capital equipment , supplies , travel , and personnel . RESULTS Monthly costs of the three registry-based intervention types were ( 1 ) autodialer , $ 1.34 per child ; ( 2 ) outreach worker , $ 1.87 per child , and ( 3 ) combination , $ 2.76 per child . Personnel costs represented the majority of incremental costs for all three interventions . Increasing the number of children targeted sharply decreased the cost per child for the autodialer but had only a modest effect on outreach costs . The monthly costs for outreach were substantially lower than previously reported for nonregistry-based interventions in part because of differences in the number of children who were followed up . Monthly costs for the autodialer intervention were slightly higher than previously reported , but several published studies excluded important costs . CONCLUSIONS By facilitating the management of a larger cohort of children , some registry-based immunization interventions appear to be less costly than nonregistry interventions . Further work is needed to establish whether registry maintenance costs may be recouped in part by these savings OBJECTIVE To examine the impact of postal invitations and user fee on influenza vaccination rates . DESIGN A controlled r and omized trial in 13 general practice s. One third of the participating patients received postal invitations to influenza vaccination free of charge . Another third received postal invitations to influenza vaccination on paying the usual fee ( US$ 40 - 60 ) . The last third served as a control group , being vaccinated at their own request and paying the usual fee . SETTING General practice in the Counties of Funen and Vejle , Denmark . PATIENTS Five hundred and eighty-five patients aged 65 years or older , recognized by their general practitioner ( GP ) as being in the risk group for whom influenza vaccination is recommended . MAIN OUTCOME MEASURES Influenza vaccination rates . RESULTS In the control group 25 % ( 19 - 31 % , 95 % confidence interval ) of the patients were vaccinated , compared with 49 % ( 42 - 56 % ) in the group who received a postal reminder and paid the usual fee , and 72 % ( 65 - 78 % ) in the group invited to be vaccinated free of charge . CONCLUSION It is suggested that GPs send postal invitations to their elderly patients in the risk groups urgently recommending influenza vaccination . Attention should also be given to offering free influenza vaccination to elderly patients who have recognized indications for vaccination INTRODUCTION Recent evaluations of computer-generated reminder/recall messages have suggested that they are an inexpensive , labor-saving method of improving office visitation rates of childhood immunization providers . This study assesses the sustained impact of computer-generated messages on immunization coverage during the first two years of life . DESIGN R and omized , controlled trial . SETTING County health department in the Denver metropolitan area . STUDY PARTICIPANTS Children ( n = 1227 ) 60 to 90 days of age who had received the first dose of diphtheria-tetanus-pertussis ( DTP ) and /or poliovirus vaccines . INTERVENTION Households of children were r and omized into four groups to receive : telephone messages followed by letters ( Group A ) ; telephone messages alone ( Group B ) ; letters only ( Group C ) ; or no notification ( Group D ) . Households in the intervention groups ( A , B , and C ) received up to five computer-generated telephone messages and /or up to four letters each time their children became due for immunization(s ) . MAIN OUTCOME MEASURE Immunization series completion at 24 months of age . RESULTS Children whose families were r and omized to receive any of the interventions were 21 % more likely to have completed the immunization series by 24 months of age than were children r and omized into the control group ( 49.2 % vs 40.9 % ; RR [ rate ratio ] = .21 ; CI [ confidence interval ] = 1.01 , 1.44 ) . While not statistically significant , children in Group A were 23 % more likely to complete their immunization series by 24 months of age than those in the control group ( 50.2 % vs 40.9 % ; RR = 1.23 ; CI = 1.00 , 1.52 ) . No differences were detected among the intervention groups . The costs per additional child completing the series by 24 months of age in Group A was $ 226 ( $ 79 after start-up costs were discounted ) . CONCLUSION Computer-generated contacts , either by phone or by mail ( or both combined ) , used each time vaccines become due , are efficacious in increasing immunization coverage of children under 2 years of age OBJECTIVE To evaluate the effectiveness and cost effectiveness of computer-generated recall letters to parents of children overdue for immunizations . METHODS This r and omized controlled trial included children of two facilities in a regional health maintenance organization . Parents of 20-month-olds who had not yet received a measles-mumps-rubella ( MMR ) immunization were identified via a computerized immunization tracking system . One half were mailed personalized letters that included the recommended immunization schedule and a request to call for an appointment ; the other half served as a control group . Receipt of the MMR between 20 and 24 months of age was evaluated with the computerized tracking system . A telephone survey was conducted with parents whose children had not received the MMR by 24 months . Decision analysis was used to project the theoretical outcomes and costs of a recall letter policy for other population s. RESULTS Among 20-month-old children 10 % had not received the MMR ; 289 families were included in the analysis . Of families who were mailed letters , 54 % ( 82 of 153 ) received the  MMR  by 24 months of age , compared with 35 % ( 47 of 136 ) of those in the control group ( P = 0.001 ) . The telephone survey was completed with 110 parents of children who still did not appear on the health plan computer as having received the MMR by 24 months . Fifteen percent said the child had received an immunization at an outside provider , and of the rest 62 % said they had not been aware that an immunization was due . In the cost effectiveness analysis it was projected that recall letters would increase the immunization rate for the regional population of approximately 30000 children from 86 % to 90 % at a total cost of $ 5031 annually . The cost per additional child appropriately immunized was $ 4.04 . In sensitivity analyses this cost effectiveness ratio varied depending on the baseline population coverage rate as well as the estimated effectiveness of recall letters . CONCLUSIONS Computer-generated letters to recall children overdue for immunizations result ed in a higher proportion of children appropriately immunized in this setting . However , the strategy was not as cost-effective as intuition might suggest . Further studies in health maintenance organization ( HMO ) setting s should compare the cost effectiveness of letters with other low cost strategies including automated telephone reminders OBJECTIVE The St and ards for Pediatric Immunization Practice s suggest that hospitalization be viewed as an opportunity to vaccinate children . The purpose of the present study is 1 ) to determine the immunization status of an urban population of hospitalized preschool-aged children , 2 ) to study the impact of an immunization program design ed to vaccinate hospitalized 0 to 2-year-old children who are underimmunized at admission , and 3 ) to make immunization a routine part of care for the hospitalized child . METHODS Prospect i ve evaluation of the immunization status of hospitalized 0 to 2-year-old residents of Philadelphia admitted to an urban children 's hospital was performed . With verification of the child 's immunization record through the primary care provider ( PCP ) , needed immunizations were given and records were forwarded to notify the PCP . Educational information was provided to families and health care providers . MAIN OUTCOME MEASURE The percentage of children fully immunized on admission compared with the percentage at the time of discharge . Results . Two thous and three hundred twenty-nine children from 0 to 2 years of age were hospitalized during the 22-month study period . Immunization records were verified in 86 % ( 2006 ) , requiring an average of 1.5 phone calls to the PCP . The mean patient age was 10 months . Average hospital length of stay was 4 days . On admission , 49 % ( 980 ) of the 2006 study patients were fully immunized . The remaining 51 % ( 1026 ) were eligible for vaccination . Immunizations were delayed greater than or equal to 2 months in 18 % ( 355 ) of the children . Neither type of health care insurance nor site of primary care affected the immunization status of those evaluated at the time of admission . Sixty-six percent ( N = 674 ) of eligible patients received at least one vaccination before hospital discharge . Medical contraindications accounted for only 4 % of the reasons eligible patients were not immunized . Of the 2006 children evaluated , the percentage of those fully vaccinated for age increased significantly from 44 % on admission to 70 % on discharge . CONCLUSION As a result of this program , there was a significant improvement in vaccination percentage at the time of hospital discharge in this group of urban preschool-aged children . The development of an immunization program to vaccinate hospitalized preschool children is an opportunity to immunize in the urban setting where there is a high prevalence of underimmunization . In addition , it provides an opening for educational programs for families , nurses , and housestaff and linkage to the community PCPs OBJECTIVE : To test a stepped intervention of reminder/recall/case management to increase infant well-child visits and immunization rates . METHODS : We conducted a r and omized , controlled , practical , clinical trial with 811 infants born in an urban safety-net hospital and followed through 15 months of life . Step 1 ( all infants ) involved language -appropriate reminder postcards for every well-child visit . Step 2 ( infants who missed an appointment or immunization ) involved telephone reminders plus postcard and telephone recall . Step 3 ( infants still behind on preventive care after steps 1 and 2 ) involved intensive case management and home visitation . RESULTS : Infants in the intervention arm , compared with control infants , had significantly fewer days without immunization coverage in the first 15 months of life ( 109 vs 192 days P < .01 ) and were more likely to have ≥5 well-child visits ( 65 % vs 47 % P < .01 ) . In multivariate analyses , infants in the intervention arm were more likely than control infants to be up to date with 12-month immunizations and to have had ≥5 well-child visits . The cost per child was $ 23.30 per month . CONCLUSION : This stepped intervention of tracking and case management improved infant immunization status and receipt of preventive care in a population of high-risk urban infants of low socioeconomic status OBJECTIVE To determine if mailed reminders would increase area-wide influenza immunization for persons aged 65 and older . DESIGN A r and omized , controlled trial . SETTING Ten counties in Indiana . PARTICIPANTS Using a Medicare data base , 10,000 subjects were selected r and omly from 10 counties in Indiana and r and omized for the study . Using pre-established criteria , 4503 persons in the control group and 4508 in the intervention group were eligible for study . INTERVENTION Intervention subjects received mailed reminders during the immunization season of 1995 . MEASUREMENTS Data from mailed surveys , Medicare cl aims , and phone calls were used to determine immunization rates . RESULTS Of those surveyed who received immunization , only 63.4 % filed a Medicare cl aim . Immunization rates were high in both groups but higher in the intervention group , 69.0 % versus 64.2 % . Age , presence of lung disease , assignment to the intervention group , presence of heart disease , and an age-sex interaction term were significantly and independently related to immunization . CONCLUSIONS The Healthy People Year 2000 goal ( 60 % immunization for persons 65 and older ) was exceeded in this population . Medicare cl aims data do not reflect immunization rates accurately . Mailed reminders , an inexpensive intervention , increased immunization rates area-wide and have potential for cost savings
CONTEXT Population -level coverage for immunization against many vaccine-preventable diseases remains below optimal rates in the U.S. The Community Preventive Services Task Force recently recommended several interventions to increase vaccination coverage based on systematic review s of the evaluation literature .