The vaccines for children program. Policies, satisfaction, and vaccine delivery.

OBJECTIVES: Characterize the Vaccines for Children (VFC) programs in Minnesota and Pennsylvania, assess providers' satisfaction with each state's program, and examine changes in doses administered in the public sector since implementation of the VFC. METHODS: Primary care providers participating in the VFC in Minnesota and Pennsylvania were surveyed. Doses administered were based on data from the National Immunization Survey. Outcome measures included satisfaction, ease of use of VFC, doses of immunizations administered through public health departments, and overall immunization coverage for the two states. RESULTS: Most participating providers in each state (80% to 94%) reported overall satisfaction with the VFC. Pennsylvania physicians were less satisfied with quarterly ordering of immunizations than were Minnesota providers with monthly ordering (56% vs 80%, p<0.05). The most common recommendation was to reduce paperwork. Doses administered in the public sector declined in Minnesota from approximately 146,000 in 1994 to 65,400 in 1999, and in Pennsylvania from approximately 250,000 to 79,300 during the same period. CONCLUSIONS: The VFC appears to increase the numbers of poor and uninsured children who receive necessary childhood immunizations within their medical homes. Providers are generally satisfied with the program.

Cardiovascular mortality--the hidden peril of heat waves.

OBJECTIVE: Define the mortality associated with extremely hot weather during the 04 July through 14 July, 1993 heat wave that struck the northeastern United States. METHODS: DESIGN--A rapid field assessment was used to compare mortality occurring during the heat wave to mortality occurring during a period in which there was no heat wave using copies of death certificates. The findings of the rapid field assessment were validated, and it was determined whether increases in mortality occurred in other metropolitan east-coast counties also affected by the heat wave, by reviewing computerized mortality files. SETTING--Information was collected on all deaths occurring in Baltimore City, Maryland; Baltimore County, Maryland; Essex County, New Jersey; Newcastle County, Delaware; and Philadelphia County, Pennsylvania; during these specified study periods: 08-18 June (comparison period) and 06-16 July (heat wave study period), 1993. MAIN OUTCOME MEASURES--Ratios for total mortality, cause-specific mortality, and variables such as age, sex, race, residence, and day and place of death, that were available from death certificates were calculated. RESULTS: From the rapid field assessment, the following were observed: a 26% increase in total mortality and a 98% increase in cardiovascular mortality associated with the heat wave in Philadelphia. Data from the computerized mortality files showed an increase in total mortality in four of five counties examined and an increase in cardiovascular mortality in all five counties. The risk for death for those dying from cardiovascular disease increased significantly for people older than 64 years, for both sexes, and all races. CONCLUSION: As initially indicated by the Philadelphia Medical Examiner, there was excess mortality associated with a heat wave in Philadelphia. All other nearby counties examined also experienced excess mortality associated with the heat wave, although this excess was not recognized by the local health officials. The true impact of a heat wave that causes excess preventable mortality must be appropriately and rapidly ascertained. Using a national standard to certify a death as heat-related will provide the needed information rapidly so that public health resources can be more effectively allocated and mobilized to prevent further heat-related illnesses and death.

Effect of the Vaccines for Children program on physician referral of children to public vaccine clinics: a pre-post comparison.

OBJECTIVE: Started in late 1994, the Vaccines for Children (VFC) program is a major entitlement program that provides states with free vaccines for disadvantaged children. Some evaluation studies have been conducted, but they do not include individually matched pre-post comparisons of physician responses. This project studied the effect of the VFC on the physician likelihood of referring children to public vaccine clinics for immunizations. DESIGN: In 1999, trained personnel conducted a survey of a cohort of physicians who previously participated in surveys on barriers to childhood vaccination conducted before VFC implementation. Responses were matched, and pre- versus post-VFC comparisons were made. SETTING AND PARTICIPANTS: Minnesota and Pennsylvania primary care physicians selected by stratified random sampling and initially studied in 1990 to 1991 and 1993, respectively. MAIN OUTCOME MEASURES: Likelihood of referral of a child to a public vaccine clinic. RESULTS: On a scale of 0 to 10, physician likelihood of referring an uninsured child decreased by a mean of 1.9 (95% confidence interval: 1.2-2.5) from pre- to post-VFC. Two fifths (45%) of physicians reported that the VFC decreased the number of referrals from their practice to public vaccine clinics and 50% gave intermediate responses. Among physicians who participate in VFC, only 9% were likely to refer a Medicaid-insured child in contrast to 44% of those not participating. CONCLUSIONS: Physicians' reported referral and likelihood of referring Medicaid-insured and uninsured children has decreased because of VFC in Minnesota and Pennsylvania.vaccination/economics, vaccination/legislation and jurisprudence, immunization programs/economics, immunization programs/utilization, vaccines/economics, Medicaid/economics, national health programs United States, child health services.