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OBJECTIVES: This study sought to compare the cost-effectiveness of a school-based hepatitis B vaccine delivery program with that of a vaccine delivery program associated with a network health maintenance organization (HMO). METHODS: The vaccination program enrolled 3359 sixth-grade students from 18 middle schools in Denver, Colo. Immunization status and direct and indirect program costs were compiled. The sensitivity of the outcomes was assessed by simulation methods. RESULTS: The per-dose cost-effectiveness ratio for the school-based delivery system was $31. This cost-effectiveness ratio remained stable when the model was simulated with costs that were underestimated or overestimated by 20%. In the network HMO, the direct cost per dose was $68 and the societal cost was $118 when the child's father worked full-time and the mother worked part-time. There is less than a 5% chance that the network HMO-based vaccination program could be more cost-effective than the school-based program. CONCLUSIONS: The cost per dose of the school-based program was significantly less than that of the network HMO-based program, because in the school program government-purchased vaccine was available at a lower cost and parents did not incur work-loss costs.

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Pediatricians and pediatric medical and surgical subspecialists should know their legal responsibilities to protect the privacy of identifiable patient health information. Although paper and electronic medical records have the same privacy standards, health data that are stored or transmitted electronically are vulnerable to unique security breaches. This statement describes the privacy and confidentiality needs and rights of pediatric patients and suggests appropriate security strategies to deter unauthorized access and inappropriate use of patient data. Limitations to physician liability are discussed for transferred data. Any new standards for patient privacy and confidentiality must balance the health needs of the community and the rights of the patient without compromising the ability of pediatricians to provide quality care.

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OBJECTIVE: To determine the health care resources and perceived barriers to care of families attending free vaccine fairs. DESIGN: A cross-sectional survey. SETTING: Twelve free vaccine fairs in Denver, Colorado, in 1994. PARTICIPANTS: A total of 533 consecutive parents or guardians of children receiving vaccine at the fairs. Interventions. None. MEASUREMENTS/RESULTS: Survey respondents reported that their children received regular health care through a private physician or health maintenance organization (HMO) (47%), a public clinic (20%), or a hospital-based clinic (14%); 18% had no regular site for health care. Twenty-seven percent of the families carried private insurance, although less than half of these plans covered children's vaccines: 9% were enrolled in an HMO or a preferred provider organization and 13% had Medicaid, whereas 50% had no health insurance. Families who received primary care at a private physician's office (OR: 1.7; 95% CI: 1.01-2.7) and those with no regular site for health care (OR: 2.0; 95% CI: 1.01-4.0) were more likely than those who went to a public clinic or hospital clinic to report free vaccine as the most important reason for attending a vaccine fair. Conversely, families who received well-child care at a hospital clinic were more likely to identify no appointment needed as the most important reason (OR: 2.7; 95% CI: 1. 4-5.1). Families with private health insurance (OR: 2.3; 95% CI: 1. 05-4.0) or no health insurance (OR: 2.3; 95% CI: 1.1-4.6) were more likely to identify free vaccine as the most important reason for attending a vaccine fair, whereas those enrolled in an HMO or preferred provider organization identified convenient time as the most important reason (OR: 3.2; 95% CI: 1.2-8.3). Families with Medicaid (OR: 3.2; 95% CI: 1.3-8.3) or with no insurance (OR: 2.1; 95% CI: 1.02-4.6) were more likely than were those with private insurance to identify no appointment needed as the most important reason for attending a vaccine fair. CONCLUSIONS: Most families attending free vaccine fairs have a regular source of health care. For families with private health insurance or with no health insurance, the availability of free vaccine is the major reason to bring their children to a vaccine fair, whereas for families whose insurance routinely covers the cost of childhood vaccine (HMO, Medicaid), convenience is the major determinant.

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OBJECTIVE: To assess the effects of an elementary school-based health center (SBHC) on access to and the use of physical and mental health services by children aged 4 to 13 years. STUDY DESIGN: A retrospective cohort analysis of parent surveys from a comparable intervention (SBHC) and a comparison of urban elementary schools. INTERVENTION: Elementary SBHC services, including preventive physical health care; the care of minor short-term illnesses, injuries, and stable ongoing medical conditions, dental screenings; and mental health counseling. PARTICIPANTS: All parents of students at both schools were asked to complete a survey. Return rates on the survey were 78.3% (570/728) and 77.0% (440/571) at the intervention and comparison schools, respectively. MAIN OUTCOME MEASURES: The use of health services, access to health services, and health service satisfaction. RESULTS: Compared with respondents at comparison schools, respondents whose children had access to an SBHC had less difficulty (P = .01) receiving physical health care for their children, ie, treatment of illnesses and injuries, immunizations, and physical examinations (odds ratio, 0.66; 95% confidence interval, 0.48-0.91). Access to an SBHC was independently and significantly related to less emergency department use (odds ratio, 0.63; 95% confidence interval, 0.40-0.99; P<.05), a greater likelihood of having had a physician's visit since the school year began (odds ratio, 1.92; 95% confidence interval, 1.39-2.65; P<.01), and a greater likelihood of having had an annual dental examination (odds ratio, 1.36; 95% confidence interval, 1.01-1.83; P<.05). Measured by a 12-item scale, respondents who reported the SBHC as their most-used health service were significantly more satisfied with their service than respondents who mostly used community clinics (z=-5.21; P<.01) or hospital clinics (z=-4.03; P<.01). CONCLUSIONS: Independent of insurance status and other confounding variables, underserved minority children with SBHC access have better health care access and use than children without SBHC access, signifying that SBHCs can be an effective component of health delivery systems for these children.

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Diminishing financial resources for school health dictate the most efficient possible deployment of the school health workforce. School nurses trained as nurse practitioners could help resolve the common problems of ready access to and appropriate use of primary care, early detection of potentially costly medical problems, and efficient use of school health staff. To determine how best to use existing resources to meet the increasingly varied and complex health care needs of children and adolescents, a pilot project was conducted in Denver from 1994 to 1996. With physician back-up and health aide support, school nurses were trained as nurse practitioners to provide in-school diagnostic and treatment services. Based on their evaluation study of this pilot project, the authors suggest ways to solve problems in role transition, including well-balanced training; clear role definition and assignment of responsibilities; appropriate back-up and mentoring support; and issues of sustaining long-term programs.

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BACKGROUND: The number of school-based health centers (SBHCs) has grown from 40 in 1985 to >900 in 1996. During the 1996-1997 school year there were 914 SBHCs, 32% of which were located in elementary schools. Despite the relatively large number of elementary SBHCs in existence, SBHCs serving elementary-aged students are not adequately represented in the literature. OBJECTIVE: To analyze physical and mental primary health care utilization in a comprehensive elementary SBHC for an underserved Hispanic population. DESIGN: Retrospective analyses of services used at an elementary SBHC during the 1995-1996 school year. We describe physical and mental health services utilization provided by SBHC staff who offered a range of primary medical and mental health services. PATIENTS: The study population was predominately Hispanic, and comprised of 811 elementary school students (grades preschool through fifth) registered for SBHC use. Analyses were conducted on 591 students who used the SBHC. RESULTS: The 591 SBHC users made 2443 visits, ranging between 1 and 54 visits/individual; mean 4 visits/student. Two thirds of visits (1638) were medical provider visits, and 33% (798) were mental health provider visits. Most students (75%) saw a medical provider exclusively, 9% saw a mental health provider exclusively, and 16% of students were seen by both. Mean duration of medical provider visits +/-SD was 15 +/- 13 minutes, mean for mental health provider visits +/-SD, 37 +/- 16 minutes. Of the 3035 diagnoses, 64% were medical and 36% were mental health diagnoses. These diagnostic frequencies are grouped as follows: acute medical (31%), health maintenance (22%), depression (10%), non-Diagnostic and Statistical Manual of Mental Disorders-IV mental health diagnoses (8%), conflict disorder/emotional disturbance (8%), chronic medical (8%), academic/learning disorder (7%), anxiety disorder (3%), and other (4%). CONCLUSIONS: High rates of SBHC utilization by this population and the range of diagnoses recorded suggest health care delivered in a comprehensive, culturally-sensitive SBHC has the potential for impacting the health and well-being of underserved elementary-aged students.

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OBJECTIVES: To determine the prevalence of elevated blood lead levels and to evaluate the accuracy of a lead screening questionnaire in a western United States urban inner-city pediatric population. DESIGN: A convenience sample of children between the ages of 6 months and 6 years seen for a well-child visit were enrolled. Venous blood lead levels were measured and a lead screening questionnaire was completed. SETTING: The primary care clinics of the 10 community health centers of the city and county of Denver, Colorado. Approximately 85% of children receiving services are below the 150% poverty level and 54% are insured through the state's Medicaid program. SUBJECTS: A total of 2978 children seen for a well-child visit from February 1993 to January 1994. MAIN OUTCOME MEASURES: The prevalence of elevated blood lead levels and the operating characteristics of both the Centers for Disease Control and Prevention lead screening questionnaire and the complete questionnaire used in Denver, using venous blood lead levels as the criterion standard. RESULTS: The mean blood lead level was 0.20 mumol/L (4.19 micrograms/dL). Eighty-five children had blood lead levels of 0.48 mumol/L (10 micrograms/dL), representing 2.9% of the study group (95% confidence interval [CI], 2.3-3.5). Only 0.3% of the cohort had blood lead levels greater than 0.96 mumol/L (20 micrograms/dL). The sensitivity, specificity, and positive predictive value of the Centers for Disease Control and Prevention questionnaire was 57%, 51%, and 3%, respectively. The sensitivity, specificity, and positive predictive value of the complete questionnaire was 59.7%, 36%, and 2.6%, respectively. The marginal cost of identifying a child with a blood lead level greater than 0.96 mumol/L (20 micrograms/dL) was $4925. CONCLUSIONS: Few of the low-income children in this study had blood lead levels greater than 0.48 mumol/L (10 micrograms/dL). The questionnaire did little better than chance at predicting the presence or absence of elevated blood lead levels and cannot replace a blood lead level test for childhood lead screening in this community.

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OBJECTIVES: 1) To examine a wide range of potential risk factors for delayed childhood immunization against measles, mumps, and rubella and 2) to determine the parental response to proposed solutions regarding the problem of delayed childhood immunization. DESIGN: A case-control study in which subjects had (controls) or had not (cases) received measles, mumps, and rubella vaccine (MMR) by 2 years of age. Parents of subjects were also surveyed to find out whether they thought selected proposals to improve immunization rates would be successful. RESULTS: Maternal education of high school or less at the time of the child's birth, more than or equal to two moves between birth and age 2, maternal age < 21 years of age at the time of the child's birth, more than or equal to two older siblings, participation in The Special Supplemental Food Program for Women, Infants, and Children (WIC), participation in the federal food stamp program, and incorrect knowledge of the recommended age for MMR significantly elevated the odds ratio (OR) for delayed immunization. At least two older siblings (OR = 3.2), maternal age < 21 years of age at the time of the child's birth (OR = 2.8), and incorrect knowledge of the recommended age for MMR (OR = 2.7) remained significant risk factors in a multivariate logistic regression model. Insurance status and cost factors were not significant risk factors for delayed immunization. Parents though that reminders for immunization and a central record system would have made obtaining immunizations easier. CONCLUSIONS: Based on our findings of the importance of immunization knowledge and demographic characteristics as risk factors for delayed immunization, we suggest that a message (the recommended age for immunizations) and a target group for that message (families who move frequently, have older children, and are headed by younger parents) be evaluated as an intervention to improve immunization rates.

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OBJECTIVE: To determine the percentage of patients in a large pediatric practice in compliance with national recommendations regarding immunizations and well-child care visits. RESEARCH DESIGN: Chart review. Point estimates with 95% confidence intervals were determined for reviewed charts in compliance with recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and schedule of well-child care visits, screening, and anticipatory guidance recommended by the American Academy of Pediatrics (AAP). SETTING: A large, multisite urban public pediatric practice. PATIENTS: Three hundred eighty-six infants and children (aged 0 to 60 months) who had a total of 7595 patient visits. SELECTION PROCEDURE: A random sample of charts. RESULTS: There was a large discrepancy in compliance for patients aged 0 to 23 months in ACIP-recommended immunizations (90.5% +/- 3.9%) vs AAP-recommended well-child care visits (37.6% +/- 6.4%) and for patients aged 24 to 60 months in ACIP-recommended immunizations (87.8% +/- 5.1%) vs AAP-recommended well-child care visits (31.0% +/- 7.1%). CONCLUSIONS: The data suggest that immunization alone does not ensure that children will receive all aspects of preventive care, raising questions about the practicality of the current AAP recommendations for preventive pediatric health care.

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