Is underimmunization a marker for insufficient utilization of preventive and primary care?

L. E. Rodewald, P. G. Szilagyi, T. Shiuh, S. G. Humiston, C. LeBaron and C. B. Hall
Department of Pediatrics, University of Rochester, NY, USA.

OBJECTIVE: To test the hypothesis that the underimmunization of young children is a marker for the lack of preventive and acute primary care. SETTING: Primary care center serving an impoverished population (90% Medicaid). DESIGN: Historical cohort study (N = 1178) of children aged 12 to 30 months that determined each child's immunization status, anemia, tuberculosis, and lead screening status; and office utilization history. Screening delay was defined as missing a recommended screening by more than 3 months past the standard screening age. RESULTS: Thirty-four percent of the population were underimmunized at 12 months of age. Compared with fully immunized children, these children were at greater risk for screening delay: anemia, 38% vs 5% (risk ratio [RR], 7.5; 95% confidence interval [CI], 5.4 to 10.4); tuberculosis, 76% vs 44% (RR, 1.7; CI, 1.6 to 1.9); and lead, 69% vs 33% (RR, 2.1; CI, 1.9 to 2.4). These RRs increased with greater immunization delay. Compared with fully immunized children, the underimmunized group made 47% fewer preventive health visits (2.5 vs 4.7 visits per infant per year, P < .001) and 43% fewer illness visits (2.5 vs 4.4, P < .001) and had 50% more missed appointments (2.1 vs 1.4, P < .001). Logistic regression, predicting anemia screening delay at 12 months of age, showed that underimmunization had an effect independent of utilization, with an odds ratio of 7.7 (CI, 5.2 to 12.0). CONCLUSION: Underimmunization was a powerful, independent marker for inadequate health supervision in this population. IMPLICATIONS: The current emphasis on immunizations has the benefit of targeting children at risk of lack of preventive and acute care. Improving immunization rates may have the potential to improve other aspects of primary care if immunization provision is not uncoupled from primary care.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Impact of Immunization at Sick Visits on Well-Child Care
Fiks et al.
Pediatrics 2008;121:898-905.
ABSTRACT | FULL TEXT  

Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook?
Broder et al.
Pediatrics 2008;121:S25-S34.
ABSTRACT | FULL TEXT  

Impact of Clinical Alerts Within an Electronic Health Record on Routine Childhood Immunization in an Urban Pediatric Population
Fiks et al.
Pediatrics 2007;120:707-714.
ABSTRACT | FULL TEXT  

National Health Care Visit Patterns of Adolescents: Implications for Delivery of New Adolescent Vaccines
Rand et al.
Arch Pediatr Adolesc Med 2007;161:252-259.
ABSTRACT | FULL TEXT  

Effects of Maternal and Provider Characteristics on Up-to-Date Immunization Status of Children Aged 19 to 35 Months
Kim et al.
Am. J. Public Health 2007;97:259-266.
ABSTRACT | FULL TEXT  

Parental Satisfaction With Early Pediatric Care and Immunization of Young Children: The Mediating Role of Age-Appropriate Well-Child Care Utilization
Schempf et al.
Arch Pediatr Adolesc Med 2007;161:50-56.
ABSTRACT | FULL TEXT  

Associations between childhood vaccination coverage, insurance type, and breaks in health insurance coverage.
Smith et al.
Pediatrics 2006;117:1972-1978.
ABSTRACT | FULL TEXT  

Volume Matters: Physician Practice Characteristics and Immunization Coverage Among Young Children Insured Through a Universal Health Plan
Guttmann et al.
Pediatrics 2006;117:595-602.
ABSTRACT | FULL TEXT  

Effect of Telephone Reminder/Recall on Adolescent Immunization and Preventive Visits: Results From a Randomized Clinical Trial
Szilagyi et al.
Arch Pediatr Adolesc Med 2006;160:157-163.
ABSTRACT | FULL TEXT  

The Association Between Having a Medical Home and Vaccination Coverage Among Children Eligible for the Vaccines for Children Program
Smith et al.
Pediatrics 2005;116:130-139.
ABSTRACT | FULL TEXT  

Timeliness of Childhood Vaccinations in the United States: Days Undervaccinated and Number of Vaccines Delayed
Luman et al.
JAMA 2005;293:1204-1211.
ABSTRACT | FULL TEXT  

On-Time Immunization Rates Among Children Who Enter Chicago Public Schools
Dominguez et al.
Pediatrics 2004;114:e741-e747.
ABSTRACT | FULL TEXT  

Childhood Immunization Rates Before and After the Implementation of Medicaid Managed Care
Kirschke et al.
Arch Pediatr Adolesc Med 2004;158:230-235.
ABSTRACT | FULL TEXT  

Strategies to Improve Immunization Rates and Well-Child Care in a Disadvantaged Population: A Cluster Randomized Controlled Trial
Hambidge et al.
Arch Pediatr Adolesc Med 2004;158:162-169.
ABSTRACT | FULL TEXT  

Accuracy of Parental Reporting of Immunization
AbdelSalam and Sokal
CLIN PEDIATR 2004;43:83-85.
ABSTRACT  

Immunization Coverage of Vulnerable Children: A Comparison of Health Center and National Rates
Schempf et al.
Med Care Res Rev 2003;60:85-100.
ABSTRACT  

Timeliness of Childhood Immunizations
Luman et al.
Pediatrics 2002;110:935-939.
ABSTRACT | FULL TEXT  

Improving the Health of Infants on Medicaid by Collocating Special Supplemental Nutrition Clinics With Managed Care Provider Sites
Kendal et al.
Am. J. Public Health 2002;92:399-403.
ABSTRACT | FULL TEXT  

Parental Perceptions of Well-Child Care Visits in an Inner-city Clinic
Busey et al.
Arch Pediatr Adolesc Med 2002;156:62-66.
ABSTRACT | FULL TEXT  

Prevalence and Predictors of Immunization Among Inner-City Infants: A Birth Cohort Study
Brenner et al.
Pediatrics 2001;108:661-670.
ABSTRACT | FULL TEXT  

Effects of Medicaid Managed Care on Quality: Childhood Immunizations
Alessandrini et al.
Pediatrics 2001;107:1335-1342.
ABSTRACT | FULL TEXT  

Effect of Patient Reminder/Recall Interventions on Immunization Rates: A Review
Szilagyi et al.
JAMA 2000;284:1820-1827.
ABSTRACT | FULL TEXT  

Quality of Care and Use of the Medical Home in a State-Funded Capitated Primary Care Plan For Low-Income Children
Kempe et al.
Pediatrics 2000;105:1020-1028.
ABSTRACT | FULL TEXT  

The Impact of a Pediatric Medical Home on Immunization Coverage
Ortega et al.
CLIN PEDIATR 2000;39:89-96.
ABSTRACT  

Immunization Outreach in an Inner-City Housing Development: Reminder-Recall on Foot
Goldstein et al.
Pediatrics 1999;104:69e-69.
ABSTRACT | FULL TEXT  

How Much Time Is Spent on Well-Child Care and Vaccinations?
LeBaron et al.
Arch Pediatr Adolesc Med 1999;153:1154-1159.
ABSTRACT | FULL TEXT  

The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care
Hillman et al.
Pediatrics 1999;104:931-935.
ABSTRACT | FULL TEXT  

Immunization Levels Among Premature and Low-Birth-Weight Infants and Risk Factors for Delayed Up-to-Date Immunization Status
Davis et al.
JAMA 1999;282:547-553.
ABSTRACT | FULL TEXT  

Vaccines for Children Program, United States, 1997
Santoli et al.
Pediatrics 1999;104:15e-15.
ABSTRACT | FULL TEXT  

Influences on the Receipt of Well-child Visits in the First Two Years of Life
Freed et al.
Pediatrics 1999;103:864-869.
ABSTRACT | FULL TEXT  

Immunization Performance Measurement in a Changing Immunization Environment
Rodewald et al.
Pediatrics 1999;103:889-897.
ABSTRACT | FULL TEXT  

Use of a Structured Encounter Form to Improve Well-Child Care Documentation
Madlon-Kay
Arch Fam Med 1998;7:480-483.
ABSTRACT | FULL TEXT  

Population-Based Study of the Adequacy of Well-Child Care Services: A Rural County's Report Card
Gadomski et al.
Arch Pediatr Adolesc Med 1998;152:745-748.
ABSTRACT | FULL TEXT  

Anemia and Elevated Lead Levels in Underimmunized Inner-city Children
Adams et al.
Pediatrics 1998;101 :e6-e6.
ABSTRACT | FULL TEXT  

Increasing Immunization: A Medicaid Managed Care Model
Browngoehl et al.
Pediatrics 1997;99:e4-e4.
ABSTRACT | FULL TEXT