Effect of emergency department immunizations on immunization rates and subsequent primary care visits
L. E. Rodewald, P. G. Szilagyi, S. G. Humiston, R. F. Raubertas, S. Wassilak, K. J. Roghmann and C. B. Hall
Department of Pediatrics, University of Rochester, NY, USA. lar9@nipl.em.cdc.gov
BACKGROUND: The Standards for Pediatric Immunization Practices recommend
the routine use of emergency department (ED) encounters for screening the
immunization status of children and, if indicated, immunizing them.
OBJECTIVE: To test the hypothesis that ED immunizations will improve
immunization rates without decreasing subsequent primary care visits.
DESIGN: A randomized controlled trial of 2 interventions. Children (aged
6-36 months) (n = 1835) were enrolled in the study in the ED; informed
consent was obtained from their parents. They were randomized into 1 of 3
groups: (1) the control group (n = 614), in which no intervention was
undertaken; (2) the letter group (n = 610), in which a letter to the
primary care physician was written indicating the child's estimated
likelihood of being underimmunized; and (3) the ED vaccination group (n =
611), in which, based on a decision rule, those likely to be underimmunized
were offered immunizations in the ED. After randomization, parents were
interviewed in the ED using a decision rule to estimate the likelihood of
the child being underimmunized. One year after enrollment in the study, the
medical records of the children at their primary care sites were reviewed
to determine the immunization status of the children and primary care use
patterns. SETTING: An urban ED and 54 primary care sites in Monroe County,
New York. RESULTS: The mean age of the participants was 17.9 months.
Medical record review-verified underimmunization rates at the time of the
ED visit were 33%, 31%, and 28% for the control, letter, and ED vaccination
groups, respectively. The demographic characteristics and baseline
immunization rates were not different among study groups. According to the
decision rule, 248 children (41%) in the ED vaccination group were likely
to be underimmunized. Parents of these 248 children were offered
immunizations for their children; 117 (47%) accepted, and their children
were immunized (with 230 separate immunizations). One month after the ED
visits, the underimmunization rates of the study groups were 31%, 28% (P =
.40 compared with the control group), and 23% (P = .002). One year later,
these rates were 28%, 25% (P = .20), and 25% (P = .20). No clinically
meaningful differences were present at either of these times. One year
after the ED visit, no differences in the rates of primary care use were
found among groups. CONCLUSIONS: This study provides evidence that the
immunization of children in this ED was ineffective at raising their
immunization rates; primary care attendance was also unaltered. Major
obstacles were as follows: (1) an inability to ascertain accurately the
immunization status in the ED and (2) a high rate of parental refusal to
accept immunizations in the ED. The standards should be modified to
de-emphasize the ED as a routine immunization site for children with access
to primary care. Efforts and resources should be directed toward
strengthening the primary care system and tracking immunization status.
