Abstract
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.
