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To the Editor: Dr Kerpelman and colleagues¹ found that monetary sanctions increased the rate of age-appropriate immunization for children in Georgia, although they provide little information to explain these findings. By contrast, we² found that such incentives did not increase the vaccination rate for children in Maryland, which we attributed to inconsistent state policies, faulty implementation, and a flawed conceptual framework that ignored the role of providers on influencing vaccination rates.

Numerous studies have shown that children's immunization coverage reflects a complex interaction of parental behavior, access to care, and provider behavior.³ However, Kerpelman et al assumed that only parental behavior was important and did not measure missed opportunities, health care visits, or practice characteristics. In our study, we found no change in preventive health care visits and a small decrease in missed opportunities that did not lead to increased vaccination rates.

The Preschool Immunization Project (PIP) that Kerpelman et . . . [Full Text of this Article]

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