Increased immunization rates among inner-city, African-American children: a randomized trial of case management

Case management to increase childhood immunization rates in inner-city black families may be modestly effective and very expensive. Poor and minority children are less likely to be fully immunized. Researchers randomly assigned 419 infants and their families to receive home visits and support by case managers, or just printed information on vaccination (the control group). About 64% of children receiving case management completed first-year immunizations, compared to 50.6% of children in the control group. Case management cost $12,022 for each additional child who became fully-immunized.
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 Angles 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 visit 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 ($12 022 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.