human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To measure the proportion of children cared for in private practice s who are fully immunized and have been screened for anemia , tuberculosis ( TB ) , and lead poisoning by 2 years of age . DESIGN Cross-sectional chart review . SETTING Fifteen private pediatric practice s in central North Carolina ( 11 chosen r and omly ) . PATIENTS One thous and thirty-two r and omly selected 2-year-old children . MAIN OUTCOME MEASURES Proportion of children immunized and screened  for anemia , TB and lead poisoning by 24 months of age and immunization and screening rates of the practice s. RESULTS Sixty-one percent of the children were fully immunized at 24 months of age ; the rates among practice s varied widely ( 38 % to 82 % ) . Sixty-eight percent of the children had been screened for anemia , 57 % had been screened for TB , and 3 % had been screened for lead poisoning . Physicians overestimated the proportions of fully immunized children in their practice s by an average of 10 % ( range , -3 % to 17 % ) . The median number of well child visits by 2 years of age was 5 ( range , 0 to 14 ) , and only 19 % of the entire sample made 8 or more well child visits , the number recommended by the American Academy of Pediatrics in the first 18 months of life . The numbers of well child and non-well child visits were the strongest predictors of complete immunization . Practice characteristics associated with being fully immunized included the use of preventive services prompting sheets ( eg , flow sheets ) in the medical records , not seeing the same physician for all well child care , and having nurses review patients ' immunization status during their visits to the office . CONCLUSIONS Underimmunization and inadequate screening are significant problems in private pediatric practice s in North Carolina . Physicians are unaware of the rates of underimmunization in their offices 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 R and omized 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 sub population s that do not access well-child care ; however , currently there are no means to identify these groups prospect ively . For case management to be a useful tool to raise immunizations levels among high-risk population s , better methods of tracking and targeting , such as immunization registries , need to be developed BACKGROUND Emergency departments ( EDs ) are recommended as sites for immunizing children . However , there is little information about the effect of ED immunization programs on immunization rates . OBJECTIVES To assess the ability of 2 ED immunization programs to vaccinate children and to measure the effect of the programs on immunization rates after the ED visit and 6 months later . DESIGN A prospect i ve cohort study . Emergency department patients were screened for immunization status , and vaccinations were offered to patients who either were documented to be eligible or were eligible by age and had no documented records . A systematic , sequential sample of those accepting vaccinations ( study patients ) was compared with a systematic , sequential sample of those not vaccinated ( control subjects ) . Telephone interviews and medical record review s were performed 6 months after the ED visit to verify date s of immunizations . Results were weighted to reflect the sampling frames of patients screened by the 2 programs . SETTING Two EDs in New York City ( in Manhattan and the Bronx ) and the surrounding primary care offices . PATIENTS Children ( aged 0 - 6 years ) screened for immunization status by the ED immunization program during a 10-week period ; these included 210 children from the Manhattan ED ( 106 vaccinated in the ED ) and 274 children from the Bronx ED ( 129 vaccinated in the ED ) . INTERVENTION Emergency department immunizations . MAIN OUTCOME MEASURES Proportion of patients ( vaccinated , not vaccinated , and ED population ) up-to- date for immunizations ( 1 ) at the time of the ED visit , ( 2 ) 1 day later , and ( 3 ) 6 months later . RESULTS Two thirds of the patients in each ED had Medicaid , and one tenth were uninsured . At the time of the ED visit , 20 % of the vaccinated children in each ED were actually up-to- date and were unnecessarily vaccinated ; 74 % ( Manhattan ED ) and 72 % ( Bronx ED ) of the not vaccinated children were up-to- date ( the remainder were later determined to have been eligible for vaccinations ) . One day after the ED visit , and 6 months later , the immunization rates of the vaccinated and not vaccinated children were similar . The results of the weighted analysis were as follows : for the entire ED population screened for immunization status , compared with up-to- date rates at the time of the ED visit , rates 1 day later were 11 % ( Manhattan ED ) and 8 % ( Bronx ED ) higher in each ED ( P < .05 ) ; and rates 6 months later were the same in the Manhattan ED and 10 % lower in the Bronx ED ( P < .01 ) . Eighteen percent of all children screened for immunization status were vaccinated ; 10 to 15 children were screened and 2 to 4 children were vaccinated per 8-hour ED shift . CONCLUSIONS This ED immunization program temporarily improved the immunization rates of the ED population , but substantial personnel time was required to achieve these small gains . Urban ED immunization programs are unlikely to be cost-effective OBJECTIVE To assess the impact of different interventions to increase measles vaccination coverage among preschool children enrolled in the Special Supplemental Food Program for Women , Infants , and Children ( WIC ) . DESIGN Public health intervention trial . SETTING Six volunteer WIC sites in New York City . STUDY PARTICIPANTS Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30 , 1991 , who were eligible for measles vaccination . INTERVENTIONS Two WIC sites were assigned at r and om to one of three immunization strategies : ( 1 ) escort : child was escorted to a nearby pediatric clinic for immunization ; ( 2 ) voucher incentive : the family returned monthly , rather than every 2 months , to pick up WIC food vouchers until the child was immunized ; or ( 3 ) referral : the family was passively referred for immunization . MAIN OUTCOME MEASURE Proportion of eligible children receiving measles vaccination . RESULTS Of children eligible for measles immunization , 74 % ( 618/836 ) were immunized . Children at escort sites were 5.5 times ( relative risk [ RR ] = 5.5 ; 95 % confidence interval [ CI ] , 3.7 to 8.1 ) and those at voucher incentive sites were 2.9 times ( RR = 2.9 ; 95 % CI , 1.9 to 4.5 ) more likely to be immunized than children at referral sites . Children were immunized more rapidly at escort sites ( median , 14 days ) and voucher incentive sites ( median , 26 days ) than at referral sites ( median , 45 days ; P < .001 ) . CONCLUSIONS Both escort and voucher incentive models result ed in more children being immunized more rapidly than passive referral . Because of ease of administration , voucher incentives may be a more suitable immunization intervention for use at WIC sites , with addition of escort where feasible OBJECTIVE To determine the probable effect of the  Vaccines for Children ( VFC ) program on immunization coverage . DESIGN Preintervention and postintervention study design , with data collected before and after enrollment in the VFC program . SETTING Twenty-three inner-city neighborhood physicians ' offices in New York City . PARTICIPANTS In 1993 , 30 physicians were r and omly selected from 8 neighborhoods with the highest proportions of Medicaid-eligible individuals in New York City . In 1995 - 1996 , the 30 physicians were contacted again . Twenty-three agreed to an interview and medical record review . Within each office , the medical records of children aged 3 to 35 months , with at least 3 visits in a 3-month or longer period , were r and omly selected . Medical record review s were conducted for 173 eligible children in 1993 and 528 in 1995 - 1996 . INTERVENTIONS The VFC program was implemented in October 1994 . The administration fee increased from $ 2 to $ 17.85 ; physicians received vaccines free . MAIN OUTCOME MEASURES Up-to- date status for immunizations and lead and tuberculosis screening ; percentage of visits that are missed opportunities to immunize ; and percentage of visits that were well-child visits . Up-to- date status , missed opportunities to immunize , and well-child visits were compared across time using chi 2 analysis , corrected for the use of cluster sampling . RESULTS Up-to- date status changed significantly before and alter enrollment in the VFC program ( P < .05 ) for all immunizations and for lead and tuberculosis screening . For the diphtheria toxoid , tetanus toxoid , and pertussis vaccine , oral poliovirus vaccine , and measles , mumps , and rubella vaccine combined , coverage increased from 17.9 % to 42.2 % , up by 24.3 percentage points ( P < .05 ) . Missed opportunities to immunize did not change , but well-child visits increased from 15.0 % to 21.6 % ( P < .05 ) . Physicians generally attributed performance improvements to the VFC program and not to other competing hypotheses . CONCLUSIONS The VFC program seems to be responsible for an increase in immunization rates among these physicians We evaluated the relative impact of four procedures design ed to encourage parents to obtain immunizations for their children . In a public health setting , the families of 1,133 immunization-deficient preschool children were r and omly assigned to six conditions : ( a ) a general prompt ; ( b ) a more client-specific prompt ; ( c ) a specific prompt and increased public health clinic access ; ( d ) a specific prompt and monetary incentives ; ( e ) contact control ; and ( f ) no contact control . All interventions , except the general prompt , produced some evidence of improvement when compared with the control groups . The monetary incentive group revealed the largest effect , followed by the increased access group , specific prompt group , and general prompt group , respectively . The data suggest that relatively powerful and immediate effects on preschoolers ' clinic attendance for immunization may be produced by monetary incentives in conjunction with client-specific prompts . However , client-specific prompts alone appear to be the most cost-effective of the interventions Objective . To compare and measure the effects and cost-effectiveness of two interventions design ed to raise immunization rates . Setting s. Nine primary care sites serving impoverished and middle-class children . Subjects . Complete birth cohorts ( ages 0 to 12 months ; n = 3015 ) from these sites . Interventions . Two 18-month duration interventions : 1 ) tracking with outreach [ tracking/outreach ] to bring underimmunized children to their primary care provider office , and 2 ) a primary care provider office policy change to identify and reduce missed immunization opportunities ( prompting ) . Design . R and omized , controlled trial , r and omizing within sites using a two-by-two factorial design . Subjects were allocated to one of four study groups : control , prompting only , tracking/outreach only , and combined prompting with tracking/outreach . Outcomes were obtained by blinded chart abstract ion . Measures . Immunization status for age ; number of days of delay in immunization ; primary care utilization ; and rates of screening for occult disease . Results . Out of 3015 subjects , 274 subjects ( 9 % ) transferred out of the participating sites or had incomplete charts and were excluded . The 2741 ( 91 % ) remaining subjects were assessed . At bas 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To measure the proportion of children cared for in private practice s who are fully immunized and have been screened for anemia , tuberculosis ( TB ) , and lead poisoning by 2 years of age . DESIGN Cross-sectional chart review . SETTING Fifteen private pediatric practice s in central North Carolina ( 11 chosen r and omly ) . PATIENTS One thous and thirty-two r and omly selected 2-year-old children . MAIN OUTCOME MEASURES Proportion of children immunized and screened  for anemia , TB and lead poisoning by 24 months of age and immunization and screening rates of the practice s. RESULTS Sixty-one percent of the children were fully immunized at 24 months of age ; the rates among practice s varied widely ( 38 % to 82 % ) . Sixty-eight percent of the children had been screened for anemia , 57 % had been screened for TB , and 3 % had been screened for lead poisoning . Physicians overestimated the proportions of fully immunized children in their practice s by an average of 10 % ( range , -3 % to 17 % ) . The median number of well child visits by 2 years of age was 5 ( range , 0 to 14 ) , and only 19 % of the entire sample made 8 or more well child visits , the number recommended by the American Academy of Pediatrics in the first 18 months of life . The numbers of well child and non-well child visits were the strongest predictors of complete immunization . Practice characteristics associated with being fully immunized included the use of preventive services prompting sheets ( eg , flow sheets ) in the medical records , not seeing the same physician for all well child care , and having nurses review patients ' immunization status during their visits to the office . CONCLUSIONS Underimmunization and inadequate screening are significant problems in private pediatric practice s in North Carolina . Physicians are unaware of the rates of underimmunization in their offices 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 R and omized 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 sub population s that do not access well-child care ; however , currently there are no means to identify these groups prospect ively . For case management to be a useful tool to raise immunizations levels among high-risk population s , better methods of tracking and targeting , such as immunization registries , need to be developed BACKGROUND Emergency departments ( EDs ) are recommended as sites for immunizing children . However , there is little information about the effect of ED immunization programs on immunization rates . OBJECTIVES To assess the ability of 2 ED immunization programs to vaccinate children and to measure the effect of the programs on immunization rates after the ED visit and 6 months later . DESIGN A prospect i ve cohort study . Emergency department patients were screened for immunization status , and vaccinations were offered to patients who either were documented to be eligible or were eligible by age and had no documented records . A systematic , sequential sample of those accepting vaccinations ( study patients ) was compared with a systematic , sequential sample of those not vaccinated ( control subjects ) . Telephone interviews and medical record review s were performed 6 months after the ED visit to verify date s of immunizations . Results were weighted to reflect the sampling frames of patients screened by the 2 programs . SETTING Two EDs in New York City ( in Manhattan and the Bronx ) and the surrounding primary care offices . PATIENTS Children ( aged 0 - 6 years ) screened for immunization status by the ED immunization program during a 10-week period ; these included 210 children from the Manhattan ED ( 106 vaccinated in the ED ) and 274 children from the Bronx ED ( 129 vaccinated in the ED ) . INTERVENTION Emergency department immunizations . MAIN OUTCOME MEASURES Proportion of patients ( vaccinated , not vaccinated , and ED population ) up-to- date for immunizations ( 1 ) at the time of the ED visit , ( 2 ) 1 day later , and ( 3 ) 6 months later . RESULTS Two thirds of the patients in each ED had Medicaid , and one tenth were uninsured . At the time of the ED visit , 20 % of the vaccinated children in each ED were actually up-to- date and were unnecessarily vaccinated ; 74 % ( Manhattan ED ) and 72 % ( Bronx ED ) of the not vaccinated children were up-to- date ( the remainder were later determined to have been eligible for vaccinations ) . One day after the ED visit , and 6 months later , the immunization rates of the vaccinated and not vaccinated children were similar . The results of the weighted analysis were as follows : for the entire ED population screened for immunization status , compared with up-to- date rates at the time of the ED visit , rates 1 day later were 11 % ( Manhattan ED ) and 8 % ( Bronx ED ) higher in each ED ( P < .05 ) ; and rates 6 months later were the same in the Manhattan ED and 10 % lower in the Bronx ED ( P < .01 ) . Eighteen percent of all children screened for immunization status were vaccinated ; 10 to 15 children were screened and 2 to 4 children were vaccinated per 8-hour ED shift . CONCLUSIONS This ED immunization program temporarily improved the immunization rates of the ED population , but substantial personnel time was required to achieve these small gains . Urban ED immunization programs are unlikely to be cost-effective OBJECTIVE To assess the impact of different interventions to increase measles vaccination coverage among preschool children enrolled in the Special Supplemental Food Program for Women , Infants , and Children ( WIC ) . DESIGN Public health intervention trial . SETTING Six volunteer WIC sites in New York City . STUDY PARTICIPANTS Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30 , 1991 , who were eligible for measles vaccination . INTERVENTIONS Two WIC sites were assigned at r and om to one of three immunization strategies : ( 1 ) escort : child was escorted to a nearby pediatric clinic for immunization ; ( 2 ) voucher incentive : the family returned monthly , rather than every 2 months , to pick up WIC food vouchers until the child was immunized ; or ( 3 ) referral : the family was passively referred for immunization . MAIN OUTCOME MEASURE Proportion of eligible children receiving measles vaccination . RESULTS Of children eligible for measles immunization , 74 % ( 618/836 ) were immunized . Children at escort sites were 5.5 times ( relative risk [ RR ] = 5.5 ; 95 % confidence interval [ CI ] , 3.7 to 8.1 ) and those at voucher incentive sites were 2.9 times ( RR = 2.9 ; 95 % CI , 1.9 to 4.5 ) more likely to be immunized than children at referral sites . Children were immunized more rapidly at escort sites ( median , 14 days ) and voucher incentive sites ( median , 26 days ) than at referral sites ( median , 45 days ; P < .001 ) . CONCLUSIONS Both escort and voucher incentive models result ed in more children being immunized more rapidly than passive referral . Because of ease of administration , voucher incentives may be a more suitable immunization intervention for use at WIC sites , with addition of escort where feasible OBJECTIVE To determine the probable effect of the  Vaccines for Children ( VFC ) program on immunization coverage . DESIGN Preintervention and postintervention study design , with data collected before and after enrollment in the VFC program . SETTING Twenty-three inner-city neighborhood physicians ' offices in New York City . PARTICIPANTS In 1993 , 30 physicians were r and omly selected from 8 neighborhoods with the highest proportions of Medicaid-eligible individuals in New York City . In 1995 - 1996 , the 30 physicians were contacted again . Twenty-three agreed to an interview and medical record review . Within each office , the medical records of children aged 3 to 35 months , with at least 3 visits in a 3-month or longer period , were r and omly selected . Medical record review s were conducted for 173 eligible children in 1993 and 528 in 1995 - 1996 . INTERVENTIONS The VFC program was implemented in October 1994 . The administration fee increased from $ 2 to $ 17.85 ; physicians received vaccines free . MAIN OUTCOME MEASURES Up-to- date status for immunizations and lead and tuberculosis screening ; percentage of visits that are missed opportunities to immunize ; and percentage of visits that were well-child visits . Up-to- date status , missed opportunities to immunize , and well-child visits were compared across time using chi 2 analysis , corrected for the use of cluster sampling . RESULTS Up-to- date status changed significantly before and alter enrollment in the VFC program ( P < .05 ) for all immunizations and for lead and tuberculosis screening . For the diphtheria toxoid , tetanus toxoid , and pertussis vaccine , oral poliovirus vaccine , and measles , mumps , and rubella vaccine combined , coverage increased from 17.9 % to 42.2 % , up by 24.3 percentage points ( P < .05 ) . Missed opportunities to immunize did not change , but well-child visits increased from 15.0 % to 21.6 % ( P < .05 ) . Physicians generally attributed performance improvements to the VFC program and not to other competing hypotheses . CONCLUSIONS The VFC program seems to be responsible for an increase in immunization rates among these physicians We evaluated the relative impact of four procedures design ed to encourage parents to obtain immunizations for their children . In a public health setting , the families of 1,133 immunization-deficient preschool children were r and omly assigned to six conditions : ( a ) a general prompt ; ( b ) a more client-specific prompt ; ( c ) a specific prompt and increased public health clinic access ; ( d ) a specific prompt and monetary incentives ; ( e ) contact control ; and ( f ) no contact control . All interventions , except the general prompt , produced some evidence of improvement when compared with the control groups . The monetary incentive group revealed the largest effect , followed by the increased access group , specific prompt group , and general prompt group , respectively . The data suggest that relatively powerful and immediate effects on preschoolers ' clinic attendance for immunization may be produced by monetary incentives in conjunction with client-specific prompts . However , client-specific prompts alone appear to be the most cost-effective of the interventions Objective . To compare and measure the effects and cost-effectiveness of two interventions design ed to raise immunization rates . Setting s. Nine primary care sites serving impoverished and middle-class children . Subjects . Complete birth cohorts ( ages 0 to 12 months ; n = 3015 ) from these sites . Interventions . Two 18-month duration interventions : 1 ) tracking with outreach [ tracking/outreach ] to bring underimmunized children to their primary care provider office , and 2 ) a primary care provider office policy change to identify and reduce missed immunization opportunities ( prompting ) . Design . R and omized , controlled trial , r and omizing within sites using a two-by-two factorial design . Subjects were allocated to one of four study groups : control , prompting only , tracking/outreach only , and combined prompting with tracking/outreach . Outcomes were obtained by blinded chart abstract ion . Measures . Immunization status for age ; number of days of delay in immunization ; primary care utilization ; and rates of screening for occult disease . Results . Out of 3015 subjects , 274 subjects ( 9 % ) transferred out of the participating sites or had incomplete charts and were excluded . The 2741 ( 91 % ) remaining subjects were assessed . At bas 
    Output:
    