Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures. Increasing immunization rates among inner-city, African American children. A randomized trial of case management. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. Development of a vaccine tracking system to improve the rate of age-appropriate primary immunization in children of lower socioeconomic status. Increasing the pneumococcal vaccination rate of elderly patients in a general internal medicine clinic. Adolescent measles vaccination. Response rates to mailings addressed to patients vs parents. Effectiveness of computer-generated telephone messages in increasing clinic visits. Effectiveness and Cost-effectiveness of Letters, Automated Telephone Messages, or Both for Underimmunized Children in a Health Maintenance Organization Immunization practices of pediatricians and family physicians in the United States. 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. Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance. 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 Patient-Specific Reminder Letters and Pediatric Well-Child-Care Show Rates The organization and evaluation of a computer-assisted, centralized immunization registry. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Drinking water and cancer in Louisiana. A retrospective mortality study. The effect of patient education on pediatric immunization rates. School health nurse interventions to increase immunisation uptake in school entrants. Computer reminders improve on-time immunization rates. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. The cost of tracking a cohort of women in a general practice using rubella immune status as an example. Postcard reminders from GPs for influenza vaccine: Are they more effective than an ad hoc approach? Evaluation of telephoned computer-generated reminders to improve immunization coverage at inner-city clinics. Influenza vaccination in community elderly. A controlled trial of postcard reminders. The impact of the standards for pediatric immunization practices on vaccination coverage levels. Computer-based vs manual health maintenance tracking. A controlled trial. Increasing influenza vaccination among high-risk elderly: a randomized controlled trial of a mail cue in an HMO setting. Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized controlled trial in general practice. Publication bias in clinical research Computer-generated recall letters for underimmunized children: how cost-effective? Understanding and enhancing compliance with the second dose of hepatitis B vaccine: a cohort analysis and a randomized controlled trial. Language bias in randomised controlled trials published in English and German Infant immunization surveillance: cost vs effect. A prospective, controlled evaluation of a large-scale program in Rhode Island. Effectiveness of a mailed reminder on the immunization levels of infants at high risk of failure to complete immunizations. Randomized controlled study of customized preventive medicine reminder letters in a community practice. Minimizing the three stages of publication bias. Effect of blinding and unmasking on the quality of peer review.
BACKGROUND We compared the efficacy of a computer-generated prompt sheet placed on the front of patients ' charts with a patient-carried prompt card to remind physicians to perform selected health maintenance items . METHODS A r and omized prospect i ve single-blind study was performed in private practice offices in rural eastern North Carolina , with 28 family practitioners and nine general internists participating . Twenty-two physicians were r and omized to the computer prompt group and 22 to the card prompt group .  Four physicians in the computer group did not complete the study because of computer software problems , and three physicians did not complete the study because their limited staff was unable to enter patient data into the computer . Before the intervention , 20 patient charts ( 10 males and 10 females ) from each physician were audited for the performance of influenza vaccinations , stool for occult blood , pap smears , breast examinations performed by the physicians , and mammograms . One year after the intervention was instituted , chart audits for the above five items were done again on 20 different patient charts for each physician . RESULTS There was a 7 % increase in the performance of influenza vaccinations  in the card group ( 17 % vs 24 % ) compared with a 6 % increase in the computer group ( 20 % vs 26 % ) . There was a 5 % decrease in the performance of stool for occult blood in the card group ( 28 % vs 23 % ) compared with a 1 % increase in the computer group ( 30 % vs 31 % ) . There was an 11 % decrease in the performance of pap smears in the card group ( 26 % vs 15 % ) compared with a 3 % increase in the computer group ( 23 % vs 26 % ) . There was a 2 % decrease in the performance of breast examinations by the physician in the card group ( 35 % vs 33 % ) compared with a 3 % increase in the computer group ( 30 % vs 33 % ) . Finally , there was a 3 % increase in the performance of mammograms in the card group ( 22 % vs 25 % ) compared with an 11 % increase in the computer group ( 15 % vs 26 % ) . CONCLUSIONS Our data show a greater increase in performance of health maintenance items in the computer-prompted group . The performance of stool for occult blood , pap smears , breast examinations performed by the physician , and mammograms were increased more in the computer-prompted group than in the card group . However , there was not a statistically significant difference after intervention for any of the audited health maintenance items for either the computer group or the card group . Overall , health maintenance measures were performed in only a minority of appropriate patients 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 PURPOSE To assess whether we could export a successful multifaceted influenza vaccination program from an academic medical center to a community setting . DESIGN Pre/post study using concurrent control groups . SETTING Clinics in a staff model Health Maintenance Organization ( HMO ) . One urban and one suburban clinic were chosen as intervention clinics , while two similar clinics were selected as control clinics . PATIENTS All patients aged 65 and over enrolled in the four clinics . INTERVENTIONS An informational mailing to patients , a st and ing-order policy allowing nurses to administer vaccine , a vaccination reminder on daily appointment lists , and availability of walk-in visits for vaccination .  Patients in the control clinics received usual care . MEASUREMENTS Vaccination rates were determined using a vali date d postcard survey of 150 r and omly selected patients at each clinic both at baseline ( 1988 - 89 ) and after the intervention ( 1989 - 90 ) . RESULTS The baseline vaccination rates ranged from 51.4 % to 74.6 % , with nearly all vaccinations taking place at the HMO . In one intervention clinic , the vaccination rate improved from 56.4 % to 72.3 % , P = 0.01 . In the other , the baseline rate was 74.6 % and did not change significantly after the intervention . There was no change in the vaccination rate in the control clinics after the intervention period . CONCLUSIONS An influenza vaccination program that combines several organizational interventions may be successfully exported from an academic to a community setting and may serve as a useful model for others We conducted a r and omized , controlled trial to determine the effectiveness of an immunization tracking system design ed to increase the number of infants of lower socioeconomic status who receive their primary series of vaccinations at age-appropriate times . By 7 months of age , 91 % ( 274/301 ) of the infants in the intervention group were up-to- date on their primary series of vaccinations versus 72 % ( 214/296 ) of the infants in the control group ( p < 0.0001 ) . The estimated cost of follow-up for each infant in the intervention group was $ 18.05 . ( J PEDIATR 1995 ; 126:583 - 6 To improve the  pneumococcal vaccination status of an elderly patients group , those older than 64 years of age were identified from a computer file of all continuing care patients in a general internal medicine clinic . In a r and omly chosen study group ( N = 163 ) , 91 elderly patients ( 56 per cent ) had received the pneumococcal vaccine .  Factors associated with a higher rate of pneumococcal vaccination  included receiving the previous year 's influenza vaccine , a medical problem list attached to the patient 's chart , active clinic status ( i.e. , seen in the year before the study began ) , and more than two problems listed in the computer record . Letters encouraging pneumococcal vaccination were then sent to patients who had not been vaccinated . Twenty of 72 patients ( 28 per cent ) who received the letter were vaccinated during the next year ; 8 per cent of control patients ( three of 39 ) who did not receive the letter were vaccinated . The 95 per cent confidence limit for the relative difference between the study and control group is 6 to 53 per cent . The relative difference was also significant for influenza vaccination  between the intervention group and the portion of the control group that had not been vaccinated at the first chart review . Factors associated with pneumococcal vaccination rate following the mailing of the reminder letter were active clinic status and being up to date for either influenza or tetanus vaccination . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE To determine the measles vaccination rate in adolescents that could be achieved with a mailed notification of the recommendation , and to determine if the response rate differed if the mailing was addressed to the parents or to the adolescents . DESIGN R and omized trial . SETTING A family medicine residency training clinic serving a low-socioeconomic population . PATIENTS OR OTHER PARTICIPANTS Four hundred forty-nine adolescents aged 12 through 18 years who were seen in the clinic within the previous 21 months without receiving a documented second dose of measles vaccine were r and omized into two groups . INTERVENTION A letter recommending measles revaccination was sent to the parents in one group ( parent group ) and to the adolescents themselves in the second group ( adolescent group ) . The content of both letters was basically the same , but they differed in style and reading level . MAIN OUTCOME MEASURE Measles vaccinations administered to adolescents during the 2-month period following mailing of the letters . RESULTS Twenty-eight patients were excluded after r and omization . Fifty-six letters were undeliverable after two mailing attempts . Eleven ( 6.3 % ) of 176 adolescents in the parent group and five ( 2.6 % ) of 189 adolescents in the adolescent group received the measles vaccination ( P > .05 ) . CONCLUSIONS Although the adolescents whose parents received the letter were twice as likely to be vaccinated , the response rate was poor in both groups . The letter campaign was not an effective method to reach adolescents for measles revaccination OBJECTIVE To evaluate the effectiveness of computer-generated telephone reminder calls in increasing kept appointment rates in a public health setting . DESIGN R and omized controlled trial . SETTING Public health clinic , Georgia . PATIENTS Five hundred seventeen clients with scheduled appointments during a 4-week period at immunization , women , infant , and children ; well-child ; or family-planning programs . INTERVENTION A single computer-generated telephone reminder 1 day before each client 's scheduled appointment . MAIN OUTCOME MEASURE Rates of kept appointments . RESULTS Of the 277 clients assigned to receive the intervention , 144 ( 52 % ) kept their appointments , compared with only 78 ( 32.5 % ) of 240 who were not assigned to receive a message ( P < .05 ) . Improvement in kept appointment rates associated with receiving the message was highest for the immunization-program ( 183 % increase , P < .05 ) , with increases of 64 % , 53 % , and 44 % for the well-child ; women , infant , and children ; and family-planning programs , respectively . CONCLUSIONS These results suggest a simple and effective method to increase kept appointment rates in a variety of public health programs 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 OBJECTIVE To assess current practice s and attitudes among pediatricians and family physicians across the United States regarding immunizations . DESIGN Survey of a r and om sample of pediatricians and family physicians . SUBJECTS Fellows of the American Academy of Pediatrics ( N = 746 ) and American Academy of Family Medicine ( N = 429 ) . SURVEY TOPICS : General immunization practice s ( eg , types of visits during which vaccinations are provided , mechanisms to identify undervaccinated children ) ; and opinions about perceived barriers to immunizations , acceptance of alternative sites for immunizations , and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women , Infants , and Children ( WIC ) . RESULTS Pediatricians and family physicians ( combined ) reported the following : immunizing children during acute illness visits ( 28 % ) , follow-up visits ( 90 % ) , and chronic illness visits ( 77 % ) ; using computer or reminder files to identify undervaccinated children ( 13 % ) ; and simultaneously administering four vaccines ( diphtheria-tetanus-pertussis , oral poliovaccine , measles , mumps , and rubella and Haemophilus influenzae type b ) to an eligible 18-month-old child ( 66 % ) . Physicians perceived the following as barriers to immunizations : missed preventive visits ( 40 % ) , vaccine costs ( 24 % ) , lack of insurance coverage ( 24 % ) , inability to track undervaccinated patients ( 22 % ) , incomplete immunization records ( 12 % ) , and missed vaccination opportunities ( 12 % ) . Physicians agreed with offering vaccinations during hospitalizations ( 51 % ) or emergency department visits ( 30 % ) , and with immunization requirements for continued eligibility for Medicaid ( 66 % ) or WIC ( 64 % ) . Pediatricians were more likely to vaccinate during chronic illness and follow-up visits , and were more likely to use systems to track undervaccinated children ( P < .05 ) ; however , most immunization practice s and attitudes of pediatricians and family physicians were similar . Physicians who graduated from medical school more recently and those in high-risk urban practice s were more likely to vaccinate during acute illness visits , provide simultaneous vaccinations , and favor vaccinations in hospital setting s. CONCLUSIONS Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations , by developing systems to identify undervaccinated children , and by reducing patient costs for vaccinations . Current immunization practice s fall short of the immunization guidelines ; changes in individual practice styles will be required to conform with these st and ards 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 Fewer than 10 % of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practice s Advisory Committee that all such children be vaccinated annually . Patient , provider , and system factors leading to this poor vaccination rate are not well understood . This study tested the effectiveness of a computerized reminder system in improving  influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital . A computer data base identified 124 children with moderate or severe asthma . Patients were r and omly assigned either to study group ( n = 63 ) , who were sent a personalized letter reminder about the need for an influenza vaccination , or to a control group ( n = 61 ) , who received no reminder . Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination , including demographic features , parental worry about asthma and vaccine side effects , the four dimensions of the Health Belief Model , and health locus of control beliefs .  Nineteen study group patients ( 30 % ) received an  influenza vaccination  , compared with only 4 control patients ( 7 % ) ( P < .01 ) . Forty-three mothers of children in the study group were interviewed ; 14 ( 33 % ) of these children had received the vaccination . Of the characteristics investigated , two significantly correlated with vaccination compliance : high levels of parental worry about asthma ( positively correlated : odds ratio = 23.3 , P < .01 ) and high levels of parental worry about vaccine side effects ( negatively correlated : odds ratio = 0.087 , P = .025 ) . ( ABSTRACT TRUNCATED AT 250 WORDS 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 The objective of this study was to determine whether patient-specific letters , which describe the content of an upcoming well-child appointment , improve the show rate of well-child appointments better than postcard reminders . In this prospect i ve clinical trial conducted at a pediatric continuity clinic in a teaching hospital , 288 newborns were r and omized to a letter , postcard , or control group . For every well-child appointment , families were sent either a letter pertaining to the particular well-child appointment or a postcard ; the control group received no reminders . There were no differences in demographics among the groups . The show rates between the letter and postcard groups were not different , but were significantly higher than the show rate for the control group ( 75.0 % , 73.7 % , and 67.5 % , respectively ; P < .05 ) . A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former . We concluded postcard reminders are effective in improving show rates for well-child-care visits , and that patient-specific letters have no additional benefit above that of postcard reminders The rationale for , and establishment of , a computer-assisted , central ized immunization registry are described . This registry was created to improve the quality and quantity of information regarding immunization status for a defined population receiving primary care from a variety of providers , principally public clinics and private practitioners . An evaluation of the feasibility of the registry after one year 's function shows that 93 per cent of eligible providers initially agreed to participate and 73 per cent continue to do so . Their reports have result ed in the creation of 17,500 individual patient files . Of a prospect i ve cohort of newborns , 23 per cent were identified as " high-risk " for overdue immunizations . After one year , the immunization rates in audited groups improved significantly . The direct cost of this registry is less than 65 cents per currently registered child per year PURPOSE To enhance influenza vaccination rates for high-risk out patients at the Department of Veterans Affairs Medical Center ( VAMC ) in Minneapolis , Minnesota , an institution-wide immunization program was implemented during 1987 . PATIENTS AND METHODS The program consisted of : ( 1 ) a hospital policy allowing nurses to vaccinate without a signed physician 's order ; ( 2 ) stamped reminders on all clinic progress notes ; ( 3 ) a 2-week walk-in flu shot clinic ; ( 4 ) influenza vaccination " stations " in the busiest clinic areas ; and ( 5 ) a mailing to all out patients . Risk characteristics and vaccination rates for patients were estimated from a vali date d self-administered postcard question naire mailed to 500 r and omly selected out patients . For comparison , 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs . RESULTS Overall , 70.6 % of Minneapolis patients were high-risk and 58.3 % of them were vaccinated . In contrast , 69.9 % of patients at the comparison medical centers were high-risk , but only 29.9 % of them were vaccinated . CONCLUSION The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization Thirteen Louisiana parishes ( counties ) using the  Mississippi river  as a source of potable water have the highest mortality rates ( 1950 - 1969 ) in the drinking water source , a comparison of cancer deaths and noncancer deaths from 1960 - 1975 in selected southern Louisiana parishes was conducted . Parishes were grouped for similarities in industrialization and approximately equal exposure of the population to surface water and ground water . Cancers were studied in groups by hypothesized risk : high for bladder , colon , kidney , liver , lymphoma , rectum , and stomach ; low for Hodgkin 's lymphoma , leukemia , lung , malignant melanoma , multiple myeloma , and prostate ; and question able for breast , brain , esophagus , and pancreas . Noncancer deaths were r and omly selected and matched 1:1 to cancer deaths on age , race , sex , and year and parish group of death . Water source at death was based on residence at death , surface or ground water , and chlorinated or nonchlorinated water . The risk associated with using surface water least likely due solely to change occurred for cancer of the rectum . Other risks which were lower but still greater than 1.0 occurred for cancer of the kidney and breast . No risk was observed for other cancers of the gastrointestinal or urinary tract . Risk for multiple myeloma was associated with use of ground water BACKGROUND Over the last decade , the immunization rate among preschool children has decreased , especially in the lower socioeconomic population . During this period , reports of outbreaks of immunizable diseases , especially pertussis and measles , have correspondingly increased . This study was design ed to evaluate the effect of a brief patient education encounter with new mothers on pediatric immunization rates . METHODS Two hundred thirty-eight mothers and infants were assigned to an intervention or control group . On the first day postpartum , the mothers in the intervention group participated in a 10- to 15-minute discussion on the importance of immunizations and were given a patient education h and out . A reminder letter was mailed to the intervention group at 2 months postpartum . The control group received no special intervention . Infants were followed for their 2- and 4-month immunizations for diphtheria , pertussis , and tetanus and oral polio vaccine ( DPT/OPV ) . At 1 year of age , the infants ' immunization records were assessed for the completion of their first three DPT/OPV immunizations . RESULTS There was no statistically significant difference , by chi-square analysis , in the immunization rates of the control and intervention groups at 2 , 4 , or 12 months of age . At 1 year of age , 29 of 122 ( 24 % ) of the control group had received all three DPT/OPV immunizations , compared with 33 ( 28 % ) of 116 infants in the intervention group . CONCLUSIONS Concordant with similar studies , the immunization rate among infants of parents of lower socioeconomic status ( 26 % ) is low . An educational intervention presented to mothers in the postpartum period did not improve the rate of immunization by the age of 12 months . There are undoubtedly several reasons for this failure . Other means to improve immunization rates of infants should be developed and tested In New South Wales , health screening of school entrants provides the only mechanism for routine monitoring of immunisation uptake in children . School health nurses are in the best position to improve the compliance with immunisation at this age . We compared two interventions to be used by the nurses to increase immunisation uptake in school entrants who reported missing either the measles-mumps vaccine and /or the pre-school diphtheria-tetanus toxoid and oral polio vaccine boosters . Parents in the passive intervention group were sent a letter and leaflet encouraging immunisation ; the active intervention group received a telephone reminder from the nurse in addition to the written material s. Both groups were followed up at a later date to assess final immunisation outcome . Of 817 children screened , 88.2 % had been immunised against measles and 73.6 % had received the booster ; 239 children were r and omised to the two interventions . Excluding children lost to follow up and those fully immunised at the start of the study , 20 ( 37 % ) of 54 were immunised following the passive intervention , and 35 ( 71 % ) out of 49 following the active intervention ( P = 0.001 ) . Receipt of the letter and leaflet was associated with an increased uptake of booster vaccination ( P = 0.036 ) . The active intervention required 14.7 telephone calls and 1.6 uses of the interpreter service per completed immunisation . The passive intervention result ed in worthwhile increases in immunisation rate with minimum cost . A greater improvement in immunisation outcome was achieved by the active intervention , but its use was labour intensive and may only be warranted if high immunisation rates in this age-group are given priority OBJECTIVES This study examines the effectiveness of computer-generated telephone reminders in improving infants receiving on-time immunizations .  A computer called parents at home , reminded them of their child 's visit , and asked if they could keep the appointment . If parents either canceled or failed to honor the appointment , the computer called back a few days later and asked them to reschedule . METHODS A medical assistant recruited 124 consecutive mothers to receive automated computer reminders .  These mothers ' infants were younger than 6 months , were being seen at an outpatient clinic for a first visit , and were patients of three attending physicians and three nurse practitioners . These infants were compared to 89 infants from the same clinic , in the same age range , who were being seen for the first time during the same period by the same providers but not contacted by the medical assistant . Subjects were selected from mothers who brought their infants for their first visit in an outpatient urban clinic that serves predominantly minority clients . A research assistant review ed patients ' medical records and collected the infants ' birthday , mothers ' age , race , source of payments , and the immunization record of the infants . Immunization was considered to be late if , at the time of the first visit , it was more than 30 days past due for any of the recommended immunizations of the American Academy of Pediatrics , except for Hepatitis B vaccine which was not recommended at the time of the study . The dependent variable was on-time immunization . The independent variables were age of the mother at baseline , age of the child at baseline , and membership in either the comparison or the experimental group . Chi-square tests and logistic regression were used to analyze the data . RESULTS The participation rate for appointments for the experimental group was 82 % , as compared to a 69 % overall participation rate for the clinic providers . The on-time immunization rate for experimental subjects was 67.8 % , whereas the comparison group had an on-time immunization rate of 43.4 % ( differences were significant at alpha levels less than 0.01 ) . CONCLUSIONS Computerized reminders sent to the parents led to an increase in participation rate at the clinic and an increase in on-time immunization for their infants OBJECTIVE To assess the effectiveness of computer-generated telephone reminder and recall messages in increasing  preschool immunization visits . DESIGN R and omized , controlled trial . SETTING Fourteen counties in urban and rural Georgia . STUDY PARTICIPANTS Children ( N = 8002 ) who were younger than 2 years ; had telephone numbers listed in preexisting computerized immunization data bases ; and were due or late for immunization(s ) during the 4-month enrollment period . INTERVENTION Households of children were r and omized to receive or not receive a general or vaccine-specific computer-generated telephone reminder or recall message the day before the child was due , or immediately after r and omization if the child was late . MAIN OUTCOME MEASURE The rates of immunization visits during the 30-day follow-up period . RESULTS Of the 4636 children whose households were r and omized to receive a message , 1684 ( 36.3 % ) visited the health department within 30 days compared with 955 ( 28.4 % ) of the 3366 children whose households were not contacted ( risk ratio [ RR ] = 1.28 ; 95 % confidence interval [ CI ] = 1.20 to 1.37 ; P < .01 ) . Immunization visits were more frequent ( 41.1 % ) among the 3257 children whose households actually received the message ( RR = 1.45 ; 95 % CI = 1.36 to 1.56 ; P < .01 ) . Improvement in immunization visits was similar for general and specific messages , greater for recall than reminder messages , and greatest for children who were late for the third dose of the diphtheria-tetanus-pertussis vaccine and the measles-mumps-rubella vaccine . CONCLUSION These data suggest a simple and effective way to increase preschool immunization visits , particularly for vaccines associated with the lowest immunization rates AIM To measure the cost of tracking for rubella immunisation status . METHOD A 6 month prospect i ve cohort study tracking all 25 and 26 year old women registered with suburban middle class general practice . RESULTS 357 women were registered as at 12 October 1992 . 44 % lived more than 3 km from the general practice building and 14 % had no contact telephone .  Culling the clinical records gave the general practice information on rubella status for 28 % of women . Sending two letters and two telephone calls to the remainder result ed in an increase to 59 % of women where the general practice had information about rubella status ( chi 2 = 71.26 , df = 1 , p < 0.001 ) . An inability to contact women was the major reason why 143 women did not have their rubella status known by the general practice . Information on rubella status was available in only 20 % of women who had not given a contact telephone number to the general practice , compared to 67 % of women who had given a contact telephone number ( chi 2 = 38.38 , df = 1 , p < 0.001 ) . Culling records and sending one letter was the most efficient use of re sources . The total cost per woman screened in this study was $ 9.94 . CONCLUSION More general practice research is needed to determine all the costs of screening for important medical conditions All persons 65 years and older are recommended to be immunised against influenza each autumn . As immunisation rates remain low , we conducted a r and omised control trial in a three‐partner urban general practice to evaluate the differential effectiveness of a single postcard reminder in a general practice setting compared to usual care . All non‐residential patients aged 65 years and over were identified from the age/sex/disease register . After exclusions , 325 patients were stratified by sex ( 125 men and 200 women ) and r and omised to receive either a postcard reminder in large print mailed in April or usual care . General practitioners ( GPs ) were blind to the r and omisation . A blinded record audit performed in July demonstrated that the postcard was effective in increasing immunisation for men ( X21df=3.85 ; p=0.05 ) but not for women ( X21df=0.45 ; p=0.50 ) . After adjusting for 1995 immunisation status , the effect of the  postcard  on immunisation rates was even stronger in men ( Wald X21df=6.20 ; p=0.01 ) but remained non‐significant in women ( Wald x21df=1.38 ; p=0.24 ) . With this adjustment , the odds of having the 1996 flu vaccine for men sent the postcard reminder were three times that of men in the control group ( OR=3.0 ; 95 % Cl 1.3–6.9 ) . In a general practice setting , a single postcard reminder appears to be a promising way to boost influenza immunisation rates among ageing men . Replication of the study is recommended The authors evaluated the effectiveness of computer-generated telephoned reminders used to raise the rates of on-time immunization  among preschool-age children in two public clinics in Atlanta , GA . The overall effect of the intervention on immunization levels appeared to be minimal ( crude relative risk = 1.07 , 95 percent confidence interval = 0.78 , 1.46 ) , in part because only about 80 percent of children in both the r and omly selected intervention group and in the control group were members of a household with a telephone number listed in clinic records . However , logistic regression analysis indicated that 36 of 68 children ( 52.9 percent ) in the intervention group whose households were reached were vaccinated within 30 days of their due date s , compared to 31 of 75 children ( 41.3 percent ) in the control group whose household telephone numbers were recorded but not called ( adjusted odds ratio = 2.12 , 95 percent confidence interval = 1.01 , 4.46 ) . This analysis indicates that telephoned reminders demonstrated a level of effectiveness in improving immunization levels at inner-city clinics that recommends further trial and study 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 assess the impact on clinic-specific vaccination coverage of implementing the St and ards for Pediatric Immunization Practice s. DESIGN A nonr and omized intervention trial conducted for 1 year . SETTING Two public health clinics in Albuquerque , NM : 1 intervention site and 1 control site , each serving 1 of 4 city quadrants . PARTICIPANTS All children enrolled in the 2 city public health clinics . INTERVENTIONS Implementation of the St and ards for Pediatric Immunization Practice s. OUTCOME MEASURES Assessment of up-to- date vaccination coverage levels  prior to and at the conclusion of the project . The impact on the proportion of children who dropped out of vaccination services after receiving 1 dose by 3 months of age . RESULTS At the intervention site , up-to- date coverage at 12 months of age rose from 57.5 % to 80.4 % , while levels at the control site decreased from 42.1 % to 41.9 % . Before the intervention , 24 % of children at the intervention site who received the first dose of diphtheria and tetanus toxoids and pertussis vaccine ( DTP 1 ) by 3 months of age failed to receive the third dose of  DTP ( DTP 3 ) by 12 months of age vs 5 % after the intervention . At the control site , the proportion of children who received DTP 1 by 3 months of age , but not DTP 3 by 12 months of age , increased from 39 % to 51 % . CONCLUSION Implementation of the St and ards for Pediatric Immunization Practice s in a public health clinic was associated with important increases in vaccination coverage levels and a reduction in the proportion of children who dropped out of vaccination services 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 A r and omized controlled trial demonstrated that a single mailed influenza vaccination cue increased the vaccination rate among elderly HMO members with high-risk chronic conditions ( n = 2217 ) from 30 per cent to 39 per cent during the fall and winter of 1984/85 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 In a retrospective survey , 487 research projects approved by the Central Oxford Research Ethics Committee between 1984 and 1987 , were studied for evidence of publication bias . As of May , 1990 , 285 of the studies had been analysed by the investigators , and 52 % of these had been published . Studies with statistically significant results were more likely to be published than those finding no difference between the study groups ( adjusted odds ratio [ OR ] 2.32 ; 95 % confidence interval [ Cl ] 1.25 - 4.28 ) . Studies with significant results were also more likely to lead to a greater number of publications and presentations and to be published in journals with a high citation impact factor . An increased likelihood of publication was also associated with a high rating by the investigator of the importance of the study results , and with increasing sample size . The tendency towards publication bias was greater with observational and laboratory-based experimental studies ( OR = 3.79 ; 95 % Cl = 1.47 - 9.76 ) than with r and omised clinical trials ( OR = 0.84 ; 95 % Cl = 0.34 - 2.09 ) . We have confirmed the presence of publication bias in a cohort of clinical research studies . These findings suggest that conclusions based only on a review of published data should be interpreted cautiously , especially for observational studies . Improved strategies are needed to identify the results of unpublished as well as published studies 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 To determine the predictors and extent of noncompliance with a second dose of hepatitis B vaccine and the effectiveness of a compliance enhancement strategy . DESIGN Cohort analysis and r and omized clinical trial . SUBJECTS A total of 256 consecutive adults attending a sexually transmitted diseases clinic from October 1992 to July 1993 who were seronegative for hepatitis B virus and agreed to receive hepatitis B vaccination . SETTING Hamilton , Ont . INTERVENTION Subjects were followed up for 4 months . Those who did not return for the second dose of vaccine by 6 weeks after the first ( 2 weeks overdue ) were r and omly assigned to the enhanced intervention group ( telephone and mail reminders ) or the regular intervention group ( mail reminder only ) . Subjects were considered noncompliant if they did not return for the second dose by 4 months after the first . RESULTS The risk of not returning for the second dose of vaccine within 4 months after the first was strongly and linearly associated with level of education ( p = 0.004 ) . The noncompliance rate among those with less than a grade 10 education was 50 % , grade 10 - 13 education 34 % , some college education 15 % and some university education 9 % . In the r and omized controlled trial the enhanced intervention group had twice the compliance rate of the regular intervention group ( 48 % v. 25 % ; p = 0.008 ) . Subjects with no post secondary education were highly responsive to the enhanced intervention ( relative risk 2.1 ; p = 0.02 ) compared with those with a higher level of education ( relative risk 1.0 ; p = 1.0 ) . CONCLUSION Hepatitis B vaccine recipients with lower educational levels are at increased risk of noncompliance with the second dose of vaccine but are highly responsive to telephone reminders BACKGROUND Some r and omised controlled trials ( RCTs ) done in German-speaking Europe are published in international English- language journals and others in national German- language journals . We assessed whether authors are more likely to report trials with statistically significant results in English than in German . METHODS We studied pairs of RCT reports , matched for first author and time of publication , with one report published in German and the other in English . Pairs were identified from reports round in a manual search of five leading German- language journals and from reports published by the same authors in English found on Medline .  Quality of methods and reporting were assessed with two different scales by two investigators who were unaware of authors ' identities , affiliations , and other characteristics of trial reports . Main study endpoints were selected by two investigators who were unaware of trial results . Our main outcome was the number of pairs of studies in which the levels of significance ( shown by p values ) were discordant . FINDINGS 62 eligible pairs of reports were identified but 19 ( 31 % ) were excluded because they were duplicate publications . A further three pairs ( 5 % ) were excluded because no p values were given . The remaining 40 pairs were analysed . Design characteristics and quality features were similar for reports in both language s. Only 35 % of German- language articles , compared with 62 % of English- language articles , reported significant ( p < 0.05 ) differences in the main endpoint between study and control groups ( p = 0.002 by McNemar 's test ) . Logistic regression showed that the only characteristic that predicted publication in an English- language journal was a significant result . The odds ratio for publication of trials with significant results in English was 3.75 ( 95 % CI 1.25 - 11.3 ) . INTERPRETATION Authors were more likely to publish RCTs in an English- language journal if the results were statistically significant . English language bias may , therefore , be introduced in review s and meta-analyses if they include only trials reported in English . The effort of the Cochrane Collaboration to identify as many controlled trials as possible , through the manual search of many medical journals published in different language s will help to reduce such bias A controlled prospect i ve study of an  infant immunization surveillance program  in Rhode Isl and demonstrated significant motivational effects of the program on parents of newborn infants .  Immunizations were initiated more often at the earliest appropriate age and higher overall levels of immunization with certain vaccines were obtained in the portion of the population subjected to the program than among controls . The effect was most pronounced in the lowest social class and diminished successively with increasing social rank . Costs were estimated to be $ 42 per additional child immunized . Strengths and weaknesses revealed by the study suggest that costs could be further reduced by nearly one third with but minor changes in the program , and without diminishing its effectiveness The Ohio Department of Health initiated a program of mailing an immunization reminder to the mothers of six-month-old children predicted to be at high risk of failure to receive vaccinations based on birth certificate information . The evaluation results indicated a 50 % gain in immunizations amongst children whose parents received the letter when compared with those not receiving the letter OBJECTIVE To test the effectiveness of customized , family-oriented reminder letters in activating patients to seek appropriate preventive services . DESIGN R and omized clinical trial . One group received computer-generated , customized letters explaining recommended preventive procedures for each family member . A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups . A third group ( control group ) received no letters .  SETTING A private medical centre , without university affiliation , in rural Quebec . PARTICIPANTS From 8770 patients who met study criteria , 719 families were r and omly selected . Data were available for 1971 of 1998 patients in these families . MAIN OUTCOME MEASURES The Family Received Index is the proportion of all procedures for which a family was overdue that they received . The Family End-of- study Up-to- date Index is the proportion of procedures for which the family was eligible and for which they were up-to- date at the end of the study . RESULTS The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters ( Kruskal-Wallis P = .0139 ) . Comparison of the Family End-of- study Up-to- date indices also demonstrated that families of patients sent customized letters were more likely to be up-to- date than families not sent letters ( Kruskal-Wallis P = .0054 ) . No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group . CONCLUSIONS This study demonstrates a clinical ly small but statistically significant value to customizing reminder letters Publication bias can be considered to have three stages : ( 1 ) Prepublication bias occurs in the performance of research , caused by ignorance , sloth , greed , or the double st and ard applied to clinical trials but not to clinical practice . ( 2 ) Publication bias refers to basing acceptance or rejection of a manuscript on whether it supports the treatment tested . Potentially biased review ers are of equal concern . ( 3 ) Postpublication bias occurs in publishing interpretations , review s , and meta-analyses of published clinical trials . Bias can be minimized by ( 1 ) insisting on high- quality research and thorough literature review s , ( 2 ) eliminating the double st and ard concerning peer review and informed consent applied to clinical research and practice , ( 3 ) publishing legitimate trials regardless of their results , ( 4 ) requiring peer review ers to acknowledge conflicts of interest , ( 5 ) replacing ordinary review articles with meta-analyses , and ( 6 ) requiring the authors of review s to acknowledge possible conflicts of interest The objectives of this study were to see whether , in the opinion of authors , blinding or unmasking or a combination of the two affects the quality of review s and to compare authors ' and editors ' assessment s. In a trial conducted in the British Medical Journal , 527 consecutive manuscripts were r and omized into one of three groups , and each was sent to two review ers , who were r and omized to receive a blinded or an unblinded copy of the manuscript . Review quality was assessed by two editors and the corresponding author . There was no significant difference in assessment between groups or between editors and authors . Review s recommending publication were scored more highly than those recommending rejection
BACKGROUND Immunization rates for children and adults are rising , but coverage levels have not reached national goals .
As a result of low immunization rates , vaccine-preventable diseases still occur .
In an era of increasing complexity of immunization schedules , rising expectations about the performance of primary care , and large dem and s on primary care physicians , it is important to underst and and promote interventions that work in primary care setting s to increase immunization coverage .
A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients ( e.g. , all children who should receive the measles vaccine ) , and identifying the best strategy to ensure high vaccination rates .
Strategies have focused on patient-oriented interventions ( e.g. , patient reminders ) , provider interventions , and system interventions .
One intervention strategy involves patient reminder/recall systems .