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Increasing immunization rates among inner-city, African American children. A randomized trial of case management
D Wood1, N Halfon, C Donald-Sherbourne
1RAND, Santa Monica, CA, USA. dwood@gte.net
Insights
Case management improved infant immunization rates in inner-city African American families. However, the intervention was not cost-effective overall, highlighting the need for better targeting methods for high-risk populations.
Area of Science:
- Public Health
- Pediatrics
- Health Services Research
Background:
- Inner-city immunization rates are lower than the national average.
- Previous interventions to improve immunization in these areas have been limited.
- Targeting underserved populations remains a challenge.
Purpose of the Study:
- To evaluate the effectiveness of a case management intervention.
- To assess immunization levels in infants from African American families in inner-city Los Angeles.
- To determine the cost-effectiveness of the intervention.
Main Methods:
- Randomized controlled trial involving 419 African American infants and families.
- Case managers provided in-depth assessments and follow-up visits.
- Outcomes measured included immunization completion rates at age 1 year and cost-effectiveness.
Main Results:
- Case management increased immunization completion by 13.2% (63.8% vs. 50.6%, P=.01).
- The intervention was most effective for infants with fewer than 3 well-child visits, increasing their immunization rates by 28%.
- The intervention was not cost-effective overall ($12,022 per child), but more so for subgroups with low preventive care utilization ($4,546 per child).
Conclusions:
- Case management can effectively increase infant immunization rates in vulnerable urban populations.
- The intervention's effectiveness is pronounced in families with low healthcare engagement.
- Improved prospective identification methods, like immunization registries, are needed to optimize case management for high-risk groups.
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:
Randomized 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 subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.