INCREASING IMMUNIZATION RATES AMONG INNER-CITY, AFRICAN-AMERICAN CHILDREN - A RANDOMIZED TRIAL OF CASE-MANAGEMENT

Context.-Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in in ner-city areas have been largely untested. Objective.-To assess the ef fectiveness of case management in raising immunization levels among in fants of inner-city, African American families. Design.-Randomized con trolled trial with follow-up through 1 year of life. Setting.-Low-inco me areas of inner-city Los Angeles, Calif. Patients.-A representative sample of 419 African American infants and their families. Interventio ns.-In-depth assessment by case managers before infants were 6 weeks o f age, with home visits 2 weeks prior to when immunizations were sched uled and additional follow-up visits as needed. Main Outcome Measures. -Percentage of children with up-to-date immunizations at age 1 year, c haracteristics associated with improved immunization rates, and cost-e ffectiveness of case management intervention. Results.-A total of 365 newborns were followed up to age 1 year. Overall, the immunization com pletion for the case management group was 13.2 percentage points highe r 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 r eported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 p ercentage points. Although for the case management group intervention was not cost-effective ($12 022 per additional child immunized), it wa s better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. Conclusion s.-A case management intervention in the first year of life was effect ive but not cost-effective at raising immunization levels in inner-cit y, African American infants. The intervention was demonstrated to be p articularly 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 immuni zations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.