The delivery of immunizations and other preventive services in private practices. Increasing immunization rates among inner-city, African American children. A randomized trial of case management. Effect of 2 urban emergency department immunization programs on childhood immunization rates. The immunization of children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC). The impact of different strategies. Effect of the vaccines for children program on inner-city neighborhood physicians. 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 Patient-Specific Reminder Letters and Pediatric Well-Child-Care Show Rates Effect of emergency department immunizations on immunization rates and subsequent primary care visits. The effect of patient education on pediatric immunization rates. School health nurse interventions to increase immunisation uptake in school entrants. Immunization status as determined by patients' hand-held cards vs medical records. Is an emergency department visit a marker for undervaccination and missed vaccination opportunities among children who have access to primary care? Computer reminders improve on-time immunization rates. Improving The Immunization Coverage Of Children Less Than 7 Years Old In A Family Practice Residency Evaluation of telephoned computer-generated reminders to improve immunization coverage at inner-city clinics. Reducing missed opportunities for immunizations. Easier said than done. Rubella susceptibility in inner-city adolescents: the effect of a school immunization law. The impact of the standards for pediatric immunization practices on vaccination coverage levels. Evaluation of registered nurses follow-up on the reported immunization status of children attending child care centres. Computer-generated recall letters for underimmunized children: how cost-effective? A program to immunize hospitalized preschool-aged children: evaluation and impact. Incentives and motivators in school-based hepatitis B vaccination programs. The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from Pediatric Research in Office Settings. Methodological issues in determining rates of childhood immunization in office practice. A study from pediatric research in office settings (PROS). Effectiveness of a mailed reminder on the immunization levels of infants at high risk of failure to complete immunizations.
OBJECTIVES To measure the proportion of children cared for in private practice s who are fully immunized and have been screened for anemia , tuberculosis ( TB ) , and lead poisoning by 2 years of age . DESIGN Cross-sectional chart review . SETTING Fifteen private pediatric practice s in central North Carolina ( 11 chosen r and omly ) . PATIENTS One thous and thirty-two r and omly selected 2-year-old children . MAIN OUTCOME MEASURES Proportion of children immunized and screened  for anemia , TB and lead poisoning by 24 months of age and immunization and screening rates of the practice s. RESULTS Sixty-one percent of the children were fully immunized at 24 months of age ; the rates among practice s varied widely ( 38 % to 82 % ) . Sixty-eight percent of the children had been screened for anemia , 57 % had been screened for TB , and 3 % had been screened for lead poisoning . Physicians overestimated the proportions of fully immunized children in their practice s by an average of 10 % ( range , -3 % to 17 % ) . The median number of well child visits by 2 years of age was 5 ( range , 0 to 14 ) , and only 19 % of the entire sample made 8 or more well child visits , the number recommended by the American Academy of Pediatrics in the first 18 months of life . The numbers of well child and non-well child visits were the strongest predictors of complete immunization . Practice characteristics associated with being fully immunized included the use of preventive services prompting sheets ( eg , flow sheets ) in the medical records , not seeing the same physician for all well child care , and having nurses review patients ' immunization status during their visits to the office . CONCLUSIONS Underimmunization and inadequate screening are significant problems in private pediatric practice s in North Carolina . Physicians are unaware of the rates of underimmunization in their offices 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 Emergency departments ( EDs ) are recommended as sites for immunizing children . However , there is little information about the effect of ED immunization programs on immunization rates . OBJECTIVES To assess the ability of 2 ED immunization programs to vaccinate children and to measure the effect of the programs on immunization rates after the ED visit and 6 months later . DESIGN A prospect i ve cohort study . Emergency department patients were screened for immunization status , and vaccinations were offered to patients who either were documented to be eligible or were eligible by age and had no documented records . A systematic , sequential sample of those accepting vaccinations ( study patients ) was compared with a systematic , sequential sample of those not vaccinated ( control subjects ) . Telephone interviews and medical record review s were performed 6 months after the ED visit to verify date s of immunizations . Results were weighted to reflect the sampling frames of patients screened by the 2 programs . SETTING Two EDs in New York City ( in Manhattan and the Bronx ) and the surrounding primary care offices . PATIENTS Children ( aged 0 - 6 years ) screened for immunization status by the ED immunization program during a 10-week period ; these included 210 children from the Manhattan ED ( 106 vaccinated in the ED ) and 274 children from the Bronx ED ( 129 vaccinated in the ED ) . INTERVENTION Emergency department immunizations . MAIN OUTCOME MEASURES Proportion of patients ( vaccinated , not vaccinated , and ED population ) up-to- date for immunizations ( 1 ) at the time of the ED visit , ( 2 ) 1 day later , and ( 3 ) 6 months later . RESULTS Two thirds of the patients in each ED had Medicaid , and one tenth were uninsured . At the time of the ED visit , 20 % of the vaccinated children in each ED were actually up-to- date and were unnecessarily vaccinated ; 74 % ( Manhattan ED ) and 72 % ( Bronx ED ) of the not vaccinated children were up-to- date ( the remainder were later determined to have been eligible for vaccinations ) . One day after the ED visit , and 6 months later , the immunization rates of the vaccinated and not vaccinated children were similar . The results of the weighted analysis were as follows : for the entire ED population screened for immunization status , compared with up-to- date rates at the time of the ED visit , rates 1 day later were 11 % ( Manhattan ED ) and 8 % ( Bronx ED ) higher in each ED ( P < .05 ) ; and rates 6 months later were the same in the Manhattan ED and 10 % lower in the Bronx ED ( P < .01 ) . Eighteen percent of all children screened for immunization status were vaccinated ; 10 to 15 children were screened and 2 to 4 children were vaccinated per 8-hour ED shift . CONCLUSIONS This ED immunization program temporarily improved the immunization rates of the ED population , but substantial personnel time was required to achieve these small gains . Urban ED immunization programs are unlikely to be cost-effective OBJECTIVE To assess the impact of different interventions to increase measles vaccination coverage among preschool children enrolled in the Special Supplemental Food Program for Women , Infants , and Children ( WIC ) . DESIGN Public health intervention trial . SETTING Six volunteer WIC sites in New York City . STUDY PARTICIPANTS Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30 , 1991 , who were eligible for measles vaccination . INTERVENTIONS Two WIC sites were assigned at r and om to one of three immunization strategies : ( 1 ) escort : child was escorted to a nearby pediatric clinic for immunization ; ( 2 ) voucher incentive : the family returned monthly , rather than every 2 months , to pick up WIC food vouchers until the child was immunized ; or ( 3 ) referral : the family was passively referred for immunization . MAIN OUTCOME MEASURE Proportion of eligible children receiving measles vaccination . RESULTS Of children eligible for measles immunization , 74 % ( 618/836 ) were immunized . Children at escort sites were 5.5 times ( relative risk [ RR ] = 5.5 ; 95 % confidence interval [ CI ] , 3.7 to 8.1 ) and those at voucher incentive sites were 2.9 times ( RR = 2.9 ; 95 % CI , 1.9 to 4.5 ) more likely to be immunized than children at referral sites . Children were immunized more rapidly at escort sites ( median , 14 days ) and voucher incentive sites ( median , 26 days ) than at referral sites ( median , 45 days ; P < .001 ) . CONCLUSIONS Both escort and voucher incentive models result ed in more children being immunized more rapidly than passive referral . Because of ease of administration , voucher incentives may be a more suitable immunization intervention for use at WIC sites , with addition of escort where feasible OBJECTIVE To determine the probable effect of the  Vaccines for Children ( VFC ) program on immunization coverage . DESIGN Preintervention and postintervention study design , with data collected before and after enrollment in the VFC program . SETTING Twenty-three inner-city neighborhood physicians ' offices in New York City . PARTICIPANTS In 1993 , 30 physicians were r and omly selected from 8 neighborhoods with the highest proportions of Medicaid-eligible individuals in New York City . In 1995 - 1996 , the 30 physicians were contacted again . Twenty-three agreed to an interview and medical record review . Within each office , the medical records of children aged 3 to 35 months , with at least 3 visits in a 3-month or longer period , were r and omly selected . Medical record review s were conducted for 173 eligible children in 1993 and 528 in 1995 - 1996 . INTERVENTIONS The VFC program was implemented in October 1994 . The administration fee increased from $ 2 to $ 17.85 ; physicians received vaccines free . MAIN OUTCOME MEASURES Up-to- date status for immunizations and lead and tuberculosis screening ; percentage of visits that are missed opportunities to immunize ; and percentage of visits that were well-child visits . Up-to- date status , missed opportunities to immunize , and well-child visits were compared across time using chi 2 analysis , corrected for the use of cluster sampling . RESULTS Up-to- date status changed significantly before and alter enrollment in the VFC program ( P < .05 ) for all immunizations and for lead and tuberculosis screening . For the diphtheria toxoid , tetanus toxoid , and pertussis vaccine , oral poliovirus vaccine , and measles , mumps , and rubella vaccine combined , coverage increased from 17.9 % to 42.2 % , up by 24.3 percentage points ( P < .05 ) . Missed opportunities to immunize did not change , but well-child visits increased from 15.0 % to 21.6 % ( P < .05 ) . Physicians generally attributed performance improvements to the VFC program and not to other competing hypotheses . CONCLUSIONS The VFC program seems to be responsible for an increase in immunization rates among these physicians 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 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 BACKGROUND The St and ards for Pediatric Immunization Practice s recommend the routine use of emergency department ( ED ) encounters for screening the immunization status of children and , if indicated , immunizing them . OBJECTIVE To test the hypothesis that ED immunizations will improve immunization rates without decreasing subsequent primary care visits . DESIGN A r and omized controlled trial of 2 interventions . Children ( aged 6 - 36 months ) ( n = 1835 ) were enrolled in the study in the ED ; informed consent was obtained from their parents . They were r and omized into 1 of 3 groups : ( 1 ) the control group ( n = 614 ) , in which no intervention was undertaken ; ( 2 ) the letter group ( n = 610 ) , in which a letter to the primary care physician was written indicating the child 's estimated likelihood of being underimmunized ; and ( 3 ) the ED vaccination group ( n = 611 ) , in which , based on a decision rule , those likely to be underimmunized were offered immunizations in the ED . After r and omization , parents were interviewed in the ED using a decision rule to estimate the likelihood of the child being underimmunized . One year after enrollment in the study , the medical records of the children at their primary care sites were review ed to determine the immunization status of the children and primary care use patterns . SETTING An urban ED and 54 primary care sites in Monroe County , New York . RESULTS The mean age of the participants was 17.9 months . Medical record review -verified underimmunization rates at the time of the ED visit were 33 % , 31 % , and 28 % for the control , letter , and ED vaccination groups , respectively . The demographic characteristics and baseline immunization rates were not different among study groups . According to the decision rule , 248 children ( 41 % ) in the ED vaccination group were likely to be underimmunized . Parents of these 248 children were offered immunizations for their children ; 117 ( 47 % ) accepted , and their children were immunized ( with 230 separate immunizations ) . One month after the ED visits , the underimmunization rates of the study groups were 31 % , 28 % ( P = .40 compared with the control group ) , and 23 % ( P = .002 ) . One year later , these rates were 28 % , 25 % ( P = .20 ) , and 25 % ( P = .20 ) . No clinical ly meaningful differences were present at either of these times . One year after the ED visit , no differences in the rates of primary care use were found among groups . CONCLUSIONS This study provides evidence that the immunization of children in this ED was ineffective at raising their immunization rates ; primary care attendance was also unaltered . Major obstacles were as follows : ( 1 ) an inability to ascertain accurately the immunization status in the ED and ( 2 ) a high rate of parental refusal to accept immunizations in the ED . The st and ards should be modified to de-emphasize the ED as a routine immunization site for children with access to primary care . Efforts and re sources should be directed toward strengthening the primary care system and tracking immunization status 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 OBJECTIVE To determine whether patients ' h and -held  immunization  cards provide accurate assessment s of immunization status when compared with their corresponding medical records . SETTING Urban hospital emergency department immunization program . DESIGN Comparison of 2 criterion st and ards . PATIENTS Children aged 4 months to 6 years who presented consecutively with their immunization cards and received routine care in the hospital 's pediatric clinic . SELECTION Of 673 eligible patients seen in the immunization program from November 1992 to October 1993 , 140 were r and omly selected for comparison of immunization card and medical record immunization date s ; in addition , all 123 eligible patients seen between August and October 1994 were selected . Of the total of 263 children , medical records for 257 ( 98 % ) were available for review . The date s of diphtheria-tetanus-pertussis , polio , measles-mumps-rubella , and Haemophilus influenzae type b immunization from immunization cards and medical records were recorded , as were patient age , sex , and ethnicity . Immunization card-medical record immunization date pairs were compared . Each immunization card and medical record was categorized as up to date , due for immunization , or delayed 2 months or more for any immunization at the time of the visit . RESULTS In 218 ( 85 % ) of 257 cases , the immunization card and medical record immunization date s were identical ( McNemar test , P = .63 ) . The immunization card and medical record agreed that patients were due for immunization in 91 cases and agreed that patients were not due for immunization in 138 cases ( kappa = 0.77 ; 95 % confidence interval , 0.70 - 0.85 ) . The immunization card and medical record agreed that patients were delayed for 1 or more immunizations in 51 cases and agreed that patients were not delayed in 187 cases ( kappa = 0.79 ; 95 % confidence interval , 0.71 - 0.88 ) . CONCLUSION The h and -held immunization card is a suitable alternative to the medical record when the need for immunization is assessed or when rates of immunization delay in population s are determined The purpose of this study was to determine : ( 1 ) whether preschool-age patients who utilize the emergency department ( ED ) are undervaccinated compared with patients having the same primary care provider and ( 2 ) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups . This retrospective cohort study involved two groups : 583 ED patients , aged 4 to 48 months , who had primary care providers ; and 583 control subjects r and omly selected from primary care sites and matched according to date of birth and primary care site . The major outcome variable was the point prevalence of undervaccination , defined as more than 60 days past due for a vaccine at the time of the ED visit , and for control subjects , at the time of their matched patient 's ED visit . Demographic variables , vaccination history , presence of chronic illness , and office utilization history were abstract ed from office charts . The mean age of all patients was 20.0 months . Emergency department patients were more likely to be boys ( 61 % vs 50 % ) and had more chronic illness , but did not differ racially from those in the control group . Primary care sites included a hospital-based clinic ( n = 137 ) , neighborhood health centers ( n = 172 ) , and private practice s ( n = 274 ) . The undervaccination rates by primary provider type were for ( 1 ) hospital clinic ED patients 21.1 % , control subjects 19.7 % ; ( 2 ) neighborhood health center ED patients 29.1 % , control subjects 22.7 % ; and ( 3 ) private practice ED patients 26.6 % , control subjects 14.9 % . Overall , the odds ratio of ED patients ' being undervaccinated compared with control subjects was 1.8 ( 95 % confidence interval 1.3 to 2.5 ) . ( ABSTRACT TRUNCATED AT 250 WORDS 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 Background : This prospect i ve cohort study was design ed to evaluate the effectiveness of mail and telephone contact with parents  as a means to improve the immunization coverage of children less than 7 years old in a family practice residency clinic . Methods : Immunization records for 519 children enrolled in an outpatient clinic were review ed and up date d. Children whose immunizations were current ( 55 ) were excluded , which left 464 children whose immunizations were more than 1 month behind for their age groups . A r and om sample of one-half of these children ( 231 ) were mailed a postcard listing the immunizations that they required to be up to date . The mailing was followed up with telephone contact , when necessary , to prompt compliance . The other one-half of the children were not contacted and served as the control group . Immunizations provided to the two groups were compared 6 months after the initial mailing . Results : Before the initiation of the study , only 10.6 percent of the infants and children in the practice had their immunizations completed or were up to date . There were 124 immunizations given to 49 children in the intervention group compared with 84 immunizations to 33 children in the control ( P<0.047 ) . Thirty-four children were brought up to date in the control group compared with 17 in the intervention cohort ( P<0.011 ) . Conclusions : Direct mail reminders and telephone contact with parents of children who were behind in their immunizations were effective methods to encourage compliance . The increased number of immunizations received by the children in the intervention group was overshadowed by the poor coverage of the entire practice , a highly mobile and predominately indigent group . Additional interventions are urgently needed to improve immunization levels in infants and children 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 BACKGROUND Missed opportunities for immunizations are associated with underimmunization of preschool-age children . Practice policies limiting immunizations to scheduled preventive visits and guidelines requiring legal guardians to sign consent forms for vaccinations are 2 factors contributing to missed opportunities . However , methods to change these policies have not been sufficiently evaluated . OBJECTIVE To measure the effectiveness of ( 1 ) changing practice policies to incorporate the new national st and ard to screen and vaccinate eligible children at all office visits and ( 2 ) eliminating legal guardian signature requirements . DESIGN A r and omized controlled trial of 2 interventions : ( 1 ) changing practice policy and routine to have office nurses screen for immunization status at all visits , attach immunization reminder cards to medical charts for eligible patients , and have providers vaccinate eligible children ( " no missed opportunities " intervention ) and ( 2 ) changing practice guidelines to allow vaccinations without a legal guardian 's signature . The first intervention was performed at both sites ; the second only at the neighborhood health center ( NHC ) . SETTING A Pediatric Continuity Clinic in a teaching hospital ( hereafter referred to as Clinic ) , and an NHC . PATIENTS Enrolled in the trial were 1005 Clinic patients and 983 NHC patients , 0 to 2 years of age . MAIN OUTCOME MEASURES Missed opportunity rates , immunization rates , and rates of preventive services . RESULTS Eliminating the requirement for a legal guardian 's signature had no effect on any of the outcome measures . The no missed opportunities intervention was partially effective .  Study patients had slightly fewer missed opportunities than control patients at each site : ( 0.60 vs 0.90 per patient per year at the Clinic , P = .01 ; 1.1 vs 1.3 per patient per year at the NHC , P = .02 ) . For study group patients , immunization reminder cards were attached to medical charts in only one third of vaccine-eligible visits ; when attached , they markedly increased vaccination by providers ( odds ratio for vaccinating at a visit was 6.9 comparing visits when immunization reminder cards were attached vs not attached ) . However , at the end of the study , immunization rates were similar for study and control groups at each site . The number of undervaccinated days was slightly lower for the no missed opportunities study group at the Clinic than for the control group ( 56 days vs 77 days , P < .001 ) , but they were similar for both groups at the NHC . There were no differences in rates of preventive visits or screening tests between study and control groups . CONCLUSIONS The interventions evaluated to reduce missed opportunities did not increase immunization rates . The key problem was failure to screen for immunization status at all visits . More effective interventions will be needed to overcome barriers within busy primary care practice s to substantially reduce missed opportunities In order to improve the immune status of girls in our medical clinic , we conducted a prospect i ve sero-survey to identify susceptibles and developed a system for vaccinating non-immune girls . Over an 18-month period , 481 inner-city adolescents were screened . Susceptibility rate defined by a titer less than 1:8 was 12 per cent and did not differ significantly with regard to age or race . Nine months into the study period , the State of Wisconsin enacted a " no immunization-no school " law . The susceptibility rate dropped from 22 per cent prior to the enactment of the law , to 5 per cent after . Of the 60 girls identified as susceptible , 54 ( 90 per cent ) kept their follow up appointments for vaccinations . Enforced state immunization laws appear to be effective in lowering rubella susceptibility 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 The purpose of this study was to evaluate whether follow-up by nurses increased the reported rate of correctly immunized preschoolers in child care centres ( CCCs ) . Records from 14 r and omly selected CCCs from the Hamilton-Wentworth area ( n = 514 records ) were assessed for the number of correctly immunized preschoolers by two nurses operating in different centres . The nurses advised the centres about all incomplete records and reminded parents to up date their child 's immunization status . One nurse revisited all her assigned centres two to five weeks later . Both nurses returned to the CCCs to reevaluate the records two to eight months after the initial contact . 382 records were available for the second review ( 25 % drop out rate ) . The reported rates increased significantly for all immunizations . There was no difference when the follow-up intervention was greater . This study suggests that monitoring records improves the completeness of the records in CCCs ; 19.9 % of child records were up date d ( 76 of 382 ) . In 3.4 % of cases ( 13 of 382 ) , the children received immunizations that had been previously missed 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 During a school-based vaccination program , incentives and education were offered to help motivate students to participate . Each student at all schools in the program received scholastic credit for returning a signed form , material rewards for receiving each vaccine dose , and free attendance at a social event after completing the vaccine series . In two of four schools , classes received a reward if every student in the classroom returned a signed form within five days : in these schools , 91 % and 98 % of students returned signed forms within five days , compared to 82 % and 85 % , respectively , in the two schools without this peer incentive . Approximately half the students receiving the peer incentive reported that it played a motivating role , whereas 60 % cited wanting to be protected . Few students named individual rewards as motivators . Although peer incentives appeared effective in encouraging some students to return parent consent or refusal forms , the desire to be protected may have been a stronger motivator OBJECTIVES To determine the relative impact of parental characteristics , provider behavior , and the provision of free vaccines through state-sponsored vaccine volume programs ( VVPs ) on the immunization status of children followed by private pediatricians . STUDY DESIGN Retrospective and cross-sectional surveys of immunization data . SETTING The offices of 15 private pediatricians , from 11 states , who were members of the Pediatric Research in Office Setting s network . Seven of these physicians used vaccines provided through VVPs .  PATIENTS Children 2 to 3 years old followed by the participating physicians . METHODS The immunization status of children was assessed from two separate sample s. For sample 1 , immunization data were abstract ed from the medical records of 60 consecutive eligible children seen in each office . Parents of the selected children indicated the method of payment for immunizations and the education levels of the mothers . Because this cross-sectional survey might have over sample d frequent health care users , a retrospective chart review of up to 75 r and omly selected children in each pediatrician 's practice was also conducted ( sample 2 ) . Additional data were collected from the parents of children in sample 2 by telephone interviews . For both sample s , patients were considered to be fully immunized if they had received four diphtheria-tetanus-pertussis/diphtheria-tetanus vaccines , three oral poliovirus/inactivated poliovirus vaccines , and one measles-mumps-rubella vaccine before their second birthdays . Before collecting vaccination data , pediatricians completed a survey detailing their immunization beliefs and practice s. Logistic regression was used to identify factors that were independently associated with a child being fully immunized . RESULTS For sample 1 , 81.7 % of the 857 children surveyed were fully immunized . Practitioner-specific immunization rates varied widely , ranging from 51 % to 97 % . The immunization rate of children who received vaccines provided by VVPs was similar to that of children whose immunizations were not provided by VVPs ( 81.2 % vs 82.2 % ; odds ratio [ OR ] for a VVP as a predictor for being fully immunized , 0.94 , 95 % confidence interval [ CI ] , 0.66 to 1.32 ) . In addition , parents who paid for immunizations out of pocket were as likely to have fully immunized children as those who had little or no out-of-pocket expenditures for vaccines ( OR , 1.13 ; 95 % CI , 0.75 to 1.13 ) . In the logistic model , only individual pediatrician and size of the metropolitan area in which the pediatrician 's practice was located were significant predictors of a child 's immunization status . The results from sample 2 were similar ; 82.1 % of the 772 surveyed patients were fully immunized . With sample 2 , individual pediatrician and age of the child at the time of the survey were the only predictors of immunization status . The OR of a VVP as a predictor of a child being fully immunized was 1.37 ( 95 % CI , 0.65 to 2.90 ) . CONCLUSIONS Individual provider behavior may be the most important determinant of the immunization status of children followed by private pediatricians . In our sample s , the effect of parental characteristics was limited . State-sponsored VVPs were not associated with higher immunization rates , perhaps because cost of vaccines did not seem to be a significant barrier to immunization in this population OBJECTIVE To compare 3 methods for measuring pediatric office immunization rates . DESIGN Retrospective and prospect i ve cross-sectional surveys . PATIENTS Children 2 and 3 years old from 15 pediatric practice s in 11 states . METHODS Immunization rates were determined for each practice using 3 methods . The Consecutive method used data from the practice 's medical records of patients seen consecutively in the office ; the Chart method used data from r and omly selected practice medical records ; and the Active method ( reference st and ard ) used a combination of medical record data with a telephone interview to collect additional immunization data and current patient status , using data only on current patients . Analyses were based on a mean of 57 , 62 , and 51 ( Consecutive , Chart , and Active method , respectively ) patients per practice . Patients were considered fully immunized if they had received 4 doses of DTP/DT vaccine , 3 doses of OPV/IPV , and 1 dose of MMR vaccine by their second birthday Comparisons were made using the paired t test . RESULTS The mean immunization rate by method was Consecutive , 81.5 % ( range , 51%-97 % ) ; Chart , 71.6 % ( range , 42%-94 % ) ; and Active , 79.6 % ( range , 53%-96 % ) . Within a given practice , the differences between methods varied considerably ( 0 to 28 percentage points ) . The mean difference from the reference st and ard Active method was 8 percentage points ( P < .001 ) for the Chart method and -1.9 percentage points ( P = .36 ) for the Consecutive method . The largest difference was between the Consecutive and Chart methods ( mean difference , 9.9 percentage points ; P = .003 ) . Practitioners uniformly found the Consecutive method easiest to implement . CONCLUSIONS Practice -specific immunization rates are one of the few objective measures of the quality of preventive pediatric care . Pediatric practice s monitoring their immunization rates should consider using the Consecutive method , a simple , acceptable , and valid measure of practice immunization rate 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 The measurement of performance in the delivery of recommended  vaccinations for children is used frequently as a marker for quality of care and as an outcome for studies of interventions to improve immunization coverage levels .
The critical element of immunization performance measurement is the determination of immunization status .
This method ologic review 1 ) discusses immunization status as a measure of quality of primary care for children , 2 ) describes immunization status measures used in immunization intervention studies , and 3 ) examines selected technical issues of immunization status measurement .