A Randomized Study of Tracking With Outreach and Provider Prompting to Improve Immunization Coverage and Primary Care
Author: Rodewald- L. E.; Szilagyi- P. G.; Humiston- S. G.; Barth- R.; Kraus- R. & Raubertas- R. F.
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.
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|Added on||2 July 2015 04:58:05|
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