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A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care
L E Rodewald1, P G Szilagyi, S G Humiston
1Department of Pediatrics, University of Rochester, Rochester, New York,USA.
Insights
Tracking with outreach significantly improved childhood immunization rates and health supervision visits, especially for vulnerable populations. This intervention proved more effective than prompting alone in ensuring timely vaccinations.
Area of Science:
- Pediatrics
- Public Health
- Health Services Research
Background:
- Childhood immunization rates remain a critical public health concern.
- Identifying effective interventions to improve vaccination coverage is essential, particularly in underserved communities.
Purpose of the Study:
- To compare the effectiveness and cost-effectiveness of two interventions: tracking with outreach and prompting to increase immunization rates.
- To assess the impact on immunization status, timeliness, primary care utilization, and screening rates.
Main Methods:
- A randomized controlled trial was conducted across nine primary care sites.
- Two interventions, tracking/outreach and provider prompting, were evaluated using a 2x2 factorial design with a control group.
- Outcomes were assessed via blinded chart abstraction in birth cohorts aged 0-12 months.
Main Results:
- Tracking with outreach significantly increased complete immunization coverage by 20 percentage points and reduced immunization delays by 63 days.
- This intervention also boosted health supervision visits and screening rates for anemia and lead exposure.
- The prompting intervention showed no significant impact due to inconsistent use and failure to vaccinate ill children.
Conclusions:
- Outreach interventions effectively improve immunization status, health supervision, and screening rates, with notable benefits for uninsured and impoverished children.
- While the cost per additional child immunized was high, it must be considered alongside significant spillover benefits.
- Further research is needed to identify effective strategies for reducing missed immunization opportunities within primary care settings.
Objective:
To compare and measure the effects and cost-effectiveness of two interventions designed to raise immunization rates.
Settings:
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:
Randomized, controlled trial, randomizing 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 abstraction.
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 resulted 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.