Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage

BACKGROUND

Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality.

STUDY DESIGN AND METHODS

This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality.

RESULTS

Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias.

CONCLUSION

We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.

Safety and Immunogenicity of Live Viral Vaccines in a Multicenter Cohort of Pediatric Transplant Recipients

Importance

Live vaccines (measles-mumps-rubella [MMR] and varicella-zoster virus [VZV]) have not been recommended after solid organ transplant due to concern for inciting vaccine strain infection in an immunocompromised host. However, the rates of measles, mumps, and varicella are rising nationally and internationally, leaving susceptible immunocompromised children at risk for life-threating conditions.

Objective

To determine the safety and immunogenicity of live vaccines in pediatric liver and kidney transplant recipients.

Design, Setting, and Participants

This cohort study included select pediatric liver and kidney transplant recipients who had not completed their primary MMR and VZV vaccine series and/or who displayed nonprotective serum antibody levels at enrollment between January 1, 2002, and February 28, 2023. Eligibility for live vaccine was determined by individual US pediatric solid organ transplant center protocols.

Exposures

Exposure was defined as receipt of a posttransplant live vaccine. Transplant recipients received 1 to 3 doses of MMR vaccine and/or 1 to 3 doses of VZV vaccine.

Main Outcome and Measure

Safety data were collected following each vaccination, and antibody levels were obtained at 0 to 3 months and 1 year following vaccination. Comparisons were performed using Mann-Whitney U test, and factors associated with development of postvaccination protective antibodies were explored using univariate analysis.

Results

The cohort included 281 children (270 [96%] liver, 9 [3%] kidney, 2 [1%] liver-kidney recipients) from 18 centers. The median time from transplant to enrollment was 6.3 years (IQR, 3.4-11.1 years). The median age at first posttransplant vaccine was 8.9 years (IQR, 4.7-13.8 years). A total of 202 of 275 (73%) children were receiving low-level monotherapy immunosuppression at the time of vaccination. The majority of children developed protective antibodies following vaccination (107 of 149 [72%] varicella, 130 of 152 [86%] measles, 100 of 120 [83%] mumps, and 124 of 125 [99%] rubella). One year post vaccination, the majority of children who initially mounted protective antibodies maintained this protection (34 of 44 [77%] varicella, 45 of 49 [92%] measles, 35 of 42 [83%] mumps, 51 of 54 [94%] rubella). Five children developed clinical varicella, all of which resolved within 1 week. There were no cases of measles or rubella and no episodes of graft rejection within 1 month of vaccination. There was no association between antibody response and immunosuppression level at the time of vaccination.

Conclusions and Relevance

The findings suggest that live vaccinations may be safe and immunogenic after solid organ transplant in select pediatric recipients and can offer protection against circulating measles, mumps, and varicella.

Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting

OBJECTIVES

This project seeks to improve providers' practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.

DESIGN

We conduct a two-arm, controlled, mixed-methods, hybrid type II study.

SETTING

This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.

INTERVENTIONS

We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.

OUTCOME MEASURES

We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.

RESULTS

198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (-1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).

CONCLUSIONS

In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

Survey of Physician Practices, Attitudes, and Knowledge Regarding Recombinant Zoster Vaccine

BACKGROUND

Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years.

OBJECTIVE

To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions.

DESIGN

Mail and internet-based survey conducted from May through July 2020.

PARTICIPANTS

General internists and family physicians throughout the USA.

MAIN MEASURES

Survey responses.

KEY RESULTS

The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients.

CONCLUSION

Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.

Mother's Milk Messaging™: trial evaluation of app and texting for breastfeeding support

BACKGROUND

New mothers experience BF challenges but have limited evidence-based technology-enabled support.

OBJECTIVES

1) Determine if using the Mother's Milk Messaging™ app improved aspects of breastfeeding and breastfeeding rates and 2) Describe engagement as well as themes from the qualitative feedback on the app.

METHOD

Randomized Controlled Trial National sample of primiparous, singleton mothers recruited online and then randomized using stratification by language into three arms: 1) BF text messages plus app; 2) BF text messages, app and physician-moderated private Facebook (FB) group; 3) Attention control group who received injury prevention texts. Exclusive breastfeeding rates as primary outcome and knowledge/attitude, confidence, and social support as secondary outcomes. We determined engagement through analysis of app usage metrics. We conducted and content-coded interviews with participants to learn more about app usage and BF experience. Due to the nature of the intervention participants could not be blinded.

RESULTS

There were a total of 346 participants in the trial, with 227 in the Intervention (n = 154 group 1 and n = 156 group 2) and 119 in the control group. Because of minimal Facebook activity, the two intervention groups 1 and 2 were combined. There were no differences in breastfeeding exclusivity and duration. (NS). Women in the intervention arm reported significantly higher confidence with breastfeeding and perceived social support to the control group (p < .05). Greater than 80% registered the app and those that engaged with the app had higher scores with time. Mothers appreciated receiving text messages and videos with reliable information. No harm was reported in this study.

CONCLUSION

MMM increased confidence with breastfeeding and with gathering social supports. Exclusively BF was high in all participants. Mothers perceived it as useful and dependable especially the texting.

Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

BACKGROUND

Rotavirus vaccine (RV) coverage levels for US infants are <80%.

METHODS

We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age.

RESULTS

Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age.

CONCLUSIONS

US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.

US Primary Care Providers' Experiences and Practices Related to Routine Pediatric Vaccination During the COVID-19 Pandemic

OBJECTIVE

To describe, among pediatricians (Peds) and family physicians (FPs), 1) changes made to routine childhood vaccination delivery as a result of the pandemic, and 2) perceived barriers to delivering vaccinations from March 2020 through the time of the survey.

METHODS

A nationally representative survey among Peds and FPs was administered by mail or Internet in October-December 2020.

RESULTS

Response rate was 64% (579/909). For children aged 0 to 2 years, among those who vaccinated that age group prepandemic (Peds n = 265, FPs n = 222), 5% of Peds and 15% of FPs reported they had stopped vaccinating these children at any time. For children aged 4 to 6 years (Peds n=264, FPs n = 229), 19% of Peds and 17% of FPs reported they had stopped vaccinating at any time. For children aged 11-18 years (Peds n = 265, FPs n = 251), 24% of Peds and 19% of FPs reported they had stopped vaccinating at any time. Nearly all reported returning to prepandemic vaccination services at the time of the survey. Factors most frequently reported as major/moderate barriers to providing vaccinations included fewer in-person visits because patients/parents were concerned about risk of SARS-CoV-2 infection (Peds, 52%; FPs, 54%), fewer in-person visits for sports clearance (Peds, 39%; FPs, 44%), and fewer back-to-school in-person visits because some children were in virtual learning (Peds, 25%; FPs, 33%).

CONCLUSIONS

Although some physicians reported interrupting vaccination services at some point during the pandemic, the majority reported continuing to provide vaccinations throughout, with essentially all returning to prepandemic vaccination services by end of 2020.

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention

OBJECTIVES

To assess pediatricians' mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices.

STUDY DESIGN

Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ² test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting.

RESULTS

The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or "don't know" for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities.

CONCLUSIONS

Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

BACKGROUND

In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines.

OBJECTIVE

To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM.

DESIGN

Survey conducted in October 2019-January 2020 by mail or internet based on preference.

PARTICIPANTS

Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships.

MAIN MEASURES

Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted.

KEY RESULTS

Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

Physician survey regarding updated PCV13 vaccine recommendations for adults ≥65 years

BACKGROUND

In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM).

OBJECTIVES

We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years.

DESIGN

This was done by mail and internet-based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs).

RESULTS

The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change.

CONCLUSIONS

Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted.

The potential for centralized reminder/recall to increase immunization rates: A national survey of immunization information systems (IIS) managers

Little is known about Immunization Information System (IIS) attitudes and experiences using Centralized IIS-based Reminder/Recall (CI-R/R), an effective approach to increasing immunization rates. To describe among IIS managers as it relates to CI-R/R: 1) past experiences and future plans conducting it; 2) attitudes and barriers, 3) IIS capabilities and polices that influence, and 4) factors that differentiate IIS who have and have not conducted CI-R/R. Electronic Surveys were sent to all IIS managers in July 2018 using a member listserve. Fifty-seven of 62 IIS programs contacted (92%) responded. The majority (61%) had ever conducted CI-R/R; 34% reported they were "very likely" to conduct CI-R/R within 6 months. The majority (64%) were in favor of CI-R/R. Barriers included lack of staff (78%), competing demands (76%), and cost (63%). Thirty percent reported receiving a ≥75% of immunization data via real-time electronic interfaces (HL7). Overall, 49% and 24% of jurisdictions had mandatory immunization reporting from private and public health entities for childhood and adult immunizations, respectively. Differences between IIS that ever and never performed CI-R/R, respectively, included: mandatory reporting from private and public entities for children (65% v 27%, p = 0.006), having a legal mandate for CI-R/R (50% v 19%, p = 0.02), less likely to prefer practice-based R/R to CI-R/R (68% v. 91%, p = 0.04), and not reporting having too many competing demands (29% v 67%, p = 0.007). Most IIS have conducted CI-R/R and have positive attitudes towards it. Given it effectiveness and low cost, efforts to sustain it should be considered.

Policies Among US Pediatricians for Dismissing Patients for Delaying or Refusing Vaccination

This survey study assesses US pediatrician practices and office policies in response to parents who either refuse primary vaccinations or request to spread out individual vaccines in the primary series.

Physicians' Use of Evidence-Based Strategies to Increase Adult Vaccination Uptake

INTRODUCTION

This study assesses the following among primary care physicians: (1) the use of evidence-based strategies to improve adult vaccination rates, (2) the number of strategies employed simultaneously, and (3) characteristics associated with assessing adult vaccinations at each visit.

METHODS

An internet and mail survey was administered between December 2015 and January 2016 on primary care physicians designed to be representative of the American College of Physicians and American Academy of Family Physicians memberships. Data analysis was conducted in 2019.

RESULTS

The response rate was 66% (617 of 935); 94% reported using electronic health records. Standing orders (84%) and electronic provider reminders at a visit (61%) were the most common strategies reported for influenza vaccine. Electronic provider reminders at a visit (53%) and recording a vaccination in an immunization registry (32%) were the most common strategies reported for all noninfluenza vaccines. Most physicians reported using 2 or more strategies, although this was more common for influenza (74%) than for noninfluenza (62%) vaccines. In multivariable analysis, physicians who reported assessing adult vaccinations at every patient visit were more likely to work in practices where decisions about purchasing and handling vaccines were made at a larger system level (RR=1.20, 95% CI=1.04,1.40), and they reported using electronic provider reminders (RR=1.38, 95% CI=1.15, 1.69) and standing orders (RR=1.45, 95% CI=1.21, 1.75) for all noninfluenza adult vaccines.

CONCLUSIONS

Several strategies are being used to increase adult vaccination, particularly for the influenza vaccine. Investment in implementing standing orders and electronic clinical decision support for all routine adult vaccinations could help facilitate assessment of adult vaccinations at each visit and potentially improve adult vaccination rates.

Pediatricians' Experiences With and Perceptions of the Vaccines for Children Program

BACKGROUND AND OBJECTIVES

The Vaccines for Children Program (VFC) provides vaccines for children who may not otherwise be vaccinated because of financial barriers. Pediatrician participation is crucial to the VFC's ongoing success. Our objectives were to assess, among a national sample of pediatricians, (1) VFC program participation, (2) perceived burden versus benefit of participation, and (3) knowledge and perception of a time-limited increased payment for VFC vaccine administration under the Patient Protection and Affordable Care Act.

METHODS

An electronic and mail survey was conducted from June 2017 to September 2017.

RESULTS

Response rate was 79% (372 of 471); 86% of pediatricians reported currently participating in the VFC; among those, 85% reported never having considered stopping, 10% considered it but not seriously, and 5% seriously considered it. Among those who had considered no longer participating (n = 47), the most commonly reported reasons included difficulty meeting VFC record-keeping requirements (74%), concern about action by the VFC for noncompliance (61%), and unpredictable VFC vaccine supplies (59%). Participating pediatricians rated, on a scale from -5 (high burden) to +5 (high benefit), their overall perception of the VFC: 63% reported +4 or +5, 23% reported +1 to +3, 5% reported 0, and 9% reported -1 to -5. Of pediatricians, 39% reported awareness of temporary increased payment for VFC vaccine administration. Among those, 10% reported that their practice increased the proportion of Medicaid and/or VFC-eligible patients served on the basis of this change.

CONCLUSIONS

For most pediatricians, perceived benefits of VFC participation far outweigh perceived burdens. To ensure the program's ongoing success, it will be important to monitor factors influencing provider participation.

Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

Background

Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear.

Methods and Results

We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated.

Conclusions

In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.

Primary care physician knowledge, attitudes, and diagnostic testing practices for norovirus and acute gastroenteritis

BACKGROUND

Norovirus is a leading cause of acute gastroenteritis (AGE) across the age spectrum; candidate vaccines are in clinical trials. While norovirus diagnostic testing is increasingly available, stool testing may not be performed routinely, which can hamper surveillance and burden of disease estimates. Additionally, lack of knowledge of the burden of disease may inhibit provider vaccine recommendations, which could affect coverage rates and ultimately the impact of the vaccine. Our objectives were to understand physicians' stool testing practices in outpatients with AGE, and physician knowledge of norovirus, in order to improve surveillance and prepare for vaccine introduction.

METHODS

Internet and mail survey on AGE, norovirus, and future norovirus vaccines conducted January to March 2018 among national networks of primary care pediatricians, family practice and general internal medicine physicians.

RESULTS

The response rate was 59% (820/1383). During peak AGE season, physicians estimated they ordered stool tests for a median of 15% (interquartile range: 5-33%) of their outpatients with AGE. Stool tests were reported as more often available for ova and parasites, Clostridioides difficile, and bacterial culture (>95% for all specialties) than for norovirus (6-33% across specialties); even when available, norovirus-specific tests were infrequently ordered. Most providers were unaware that norovirus is a leading cause of AGE across all age groups (Pediatricians 80%, Family Practice 86%, General Internal Medicine 89%) or that alcohol-based hand sanitizers are ineffective against norovirus (Pediatricians 51%, Family Practice 66%, General Internal Medicine 62%). Concerns cited as major barriers to implementing a future norovirus vaccine included if the vaccine is not covered by insurance (General Internal Medicine 64%, Pediatricians 67%, Family Practice 74%) and lack of adequate reimbursement for vaccination (Pediatricians 43%, General Internal Medicine 46%, Family Practice 50%). Factors that providers believed were 'not at all a barrier' or 'minor barrier' to new vaccine introduction included the belief that "my patients won't need this vaccine" (General Internal Medicine 78%, Family Practice 86%, Pediatricians 90%) and "my patients already get too many vaccines" (Family Practice 89%, General Internal Medicine 92%, Pediatricians 95%).

CONCLUSIONS

Primary care physicians had few concerns regarding future norovirus vaccine introduction, but have knowledge gaps on norovirus prevalence and hand hygiene for prevention. Also, physicians infrequently order stool tests for outpatients with AGE, which limits surveillance estimates that rely on physician-ordered stool diagnostics. Closing physician knowledge gaps on norovirus burden and transmission can help support norovirus vaccine introduction.

Immunization Status at the Time of Liver Transplant in Children and Adolescents

This study characterizes the percentage of pediatric patients undergoing liver transplant who were up to date for their age on immunizations at the time of transplant and risk factors for underimmunization.

HPV Vaccine Delivery Practices by Primary Care Physicians

BACKGROUND AND OBJECTIVES

To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

METHODS

We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

RESULTS

The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) (P < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

CONCLUSIONS

Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.

Radiographic evaluation of patellar ligament length after tibial plateau leveling osteotomy in dogs

OBJECTIVE

To radiographically compare patellar ligament length (PLL) in dogs undergoing tibial plateau leveling osteotomy (TPLO) for unilateral cranial cruciate ligament rupture at preoperative, postoperative, and follow-up evaluations.

ANIMALS

105 dogs that underwent TPLO for unilateral cranial cruciate ligament rupture at a referral veterinary hospital from October 1, 2008, through November 30, 2017.

PROCEDURES

Medical records were reviewed to obtain information on dog signalment, surgical procedure, and radiographically measured PLL at preoperative, postoperative, and follow-up evaluations.

RESULTS

Dogs undergoing TPLO had a shorter PLL at the postoperative and follow-up evaluations, compared with the PLL at the preoperative evaluation. Mean ± SD overall unadjusted PLL decreased significantly by 2.3 ± 3.4% between the preoperative and postoperative evaluation and by 2.8 ± 3.9% between the preoperative and follow-up evaluation. The PLL did not differ significantly between the postoperative and follow-up evaluation; mean PLL decreased by 0.4 ± 3.8% between the postoperative and follow-up evaluation.

CONCLUSIONS AND CLINICAL RELEVANCE

The PLL was shorter after TPLO in dogs, which was similar to changes observed for humans after high tibial osteotomy procedures. Further evaluation of clinical assessments, joint mobility, ultrasonographic assessments, and kinematic results are needed to determine the relevance of the PLL and whether a decrease in ligament length results in decreased mobility and persistent lameness in dogs, as has been reported for humans.

Incidence of Hospitalization for Vaccine-Preventable Infections in Children Following Solid Organ Transplant and Associated Morbidity, Mortality, and Costs

IMPORTANCE

Pediatric transplant recipients are at risk for vaccine-preventable infections owing to immunosuppression, suboptimal response to vaccines before and after transplant, and potential underimmunization if transplant occurred early in life. However, the incidence and burden of illness from vaccine-preventable infections in this population is unknown.

OBJECTIVES

To evaluate in pediatric solid organ transplant recipients the number of hospitalizations for vaccine-preventable infections in the first 5 years after transplant and to determine the associated morbidity, mortality, and costs.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study from January 1, 2004, to December 31, 2011, with 5 years of follow-up per participant (unless they died during the study period). The participants of this multicenter study through the Pediatric Health Information System were solid organ transplant recipients who were younger than 18 years at the time of transplant. Analysis began in July 2017.

EXPOSURES

Transplant.

MAIN OUTCOMES AND MEASURES

Hospitalizations for a vaccine-preventable infection during the first 5 years after transplant were ascertained using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, clinical modification diagnosis codes. Data were collected on clinical care, outcomes, and costs during these hospitalizations.

RESULTS

Of 6980 transplant recipients identified, there were 3819 boys (54.7%), and the mean (SD) age at transplant was 8 (6.2) years. Overall, 1092 patients (15.6%) had a total of 1471 cases of vaccine-preventable infections. There were 187 of 1471 cases (12.7%) that occurred during transplant hospitalization. The case fatality rate was 1.7% for all infections. Excluding infections that occurred during transplant hospitalization (when all patients go to the intensive care unit), 213 of 1257 patients (17.0%) were hospitalized with a vaccine-preventable infection requiring intensive care. In multivariable analysis, age younger than 2 years at time of transplant and receipt of a lung, heart, intestine, or multivisceral organ were positively associated with increased risk of a hospitalization from a vaccine-preventable infection.Transplant hospitalizations complicated by vaccine-preventable infections were $120 498 more expensive (median cost) than transplant hospitalizations not complicated by vaccine-preventable infections.

CONCLUSIONS AND RELEVANCE

Hospitalization for vaccine-preventable infections occurred in more than 15% of solid organ transplant recipients in the first 5 years after transplant at a rate of up to 87 times higher than in the general population. There was significant morbidity, mortality, and costs from these infections, demonstrating the importance of immunizing all transplant candidates and recipients. Further research on improving immunization delivery, preventing nosocomial infections, and monitoring response to vaccines in the transplant population is needed.

Vaccination Practices Among Obstetrician/Gynecologists for Non-pregnant Patients

INTRODUCTION

Many non-pregnant women see obstetrician-gynecologists as their sole source of medical care, yet little is known about vaccination practices of obstetrician-gynecologists for non-pregnant patients. The objectives were to assess, among a national sample of obstetrician-gynecologists, practices related to vaccine delivery in non-pregnant patients and factors associated with stocking and administering more than three different vaccines to non-pregnant patients.

METHODS

E-mail and mail surveys were administered July-October 2015, with analyses performed during October-November 2015 and April-June 2018.

RESULTS

The response rate was 73% (353/482). Human papillomavirus (92%); influenza (82%); and tetanus, diphtheria, acellular pertussis vaccines (50%) were the vaccines most commonly assessed, with the remaining vaccines assessed by <40% of respondents. Vaccines most commonly administered by obstetrician-gynecologists to non-pregnant patients included human papillomavirus (81%); influenza (70%); and tetanus, diphtheria, acellular pertussis (54%). The remaining vaccines were administered by <30% of obstetrician-gynecologists. Factors associated with routinely administering more than three vaccines to non-pregnant patients included working in a hospital-, public health-, or university-associated clinic (RR=1.87, 95% CI=1.35, 2.58, referent to private practice); a larger practice (more than five providers; RR=1.54, 95% CI=1.05, 2.27); perceiving fewer financial barriers (RR=0.74, 95% CI=0.57, 0.96); fewer practice-associated barriers (RR=0.71, 95% CI=0.55, 0.92); and greater patient barriers (RR=1.62, 95% CI=1.33, 1.98).

CONCLUSIONS

Human papillomavirus; influenza; and tetanus, diphtheria, acellular pertussis vaccines are the only vaccines routinely assessed and administered to non-pregnant patients by most obstetrician-gynecologists. Given their role as the sole source of care for many women, obstetrician-gynecologists could make a positive impact on the vaccination status of their non-pregnant patients.

Primary care physicians' perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adults

BACKGROUND

Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine.

METHODS

We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs.

RESULTS

The response rate was 67% (620/930). Forty-nine percent of respondents (n = 303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n = 317), 73% and 57% responded that in patients ≥ 50 years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%).

CONCLUSIONS

Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.

Primary care physicians' experience with zoster vaccine live (ZVL) and awareness and attitudes regarding the new recombinant zoster vaccine (RZV)

BACKGROUND

The Advisory Committee on Immunization Practices (ACIP) has routinely recommended zoster vaccine live (ZVL) for adults  ≥60 since 2008; only 33% of eligible adults received it by 2016. A recombinant zoster vaccine (RZV) was licensed in 2017 and ACIP recommended in January 2018. Our objectives were to assess among primary care physicians (1) practices and attitudes regarding ZVL and (2) awareness of RZV.

METHODS

We administered an Internet and mail survey from July to September 2016 to national networks of 953 primary care physicians.

RESULTS

Response rate was 65% (603/923). Ninety-three % of physicians recommended ZVL to adults ≥60, but fewer recommended it to adults ≥60 with a prior history of zoster (88%), adults > 85 (62%) and adults ≥60 on low-dose methotrexate (42%). Several physicians recommended ZVL in ways that are not recommended by ACIP including to adults 50-59 (50%), adults ≥60 with HIV (33%), and adults ≥60 on high dose prednisone (≥20 mg/day) (27%). Nineteen percent of physicians stocked and administered ZVL and did not refer patients elsewhere for vaccination, 37% did not stock and only referred patients to receive it, and 44% both stocked/administered and referred elsewhere. Twenty-three % (n = 115) of physicians who had ever administered ZVL in the office (n = 490) had stopped, citing primarily financial issues (90%). Only 5% were 'very aware' of RZV.

CONCLUSIONS

Physicians report not recommending ZVL to certain ACIP-recommended groups, but report recommending it to some groups for which the vaccine should be avoided. Implementation of recommendations for RZV will need to consider financial barriers and the complex patchwork of office-based and pharmacy delivery ZVL has encountered.

Vaccine financing and billing in practices serving adult patients: A follow-up survey

BACKGROUND

Financial concerns are often cited by physicians as a barrier to administering routinely recommended vaccines to adults. The purpose of this study was to assess perceived payments and profit from administering recommended adult vaccines and vaccine purchasing practices among general internal medicine (GIM) and family medicine (FM) practices in the United States.

METHODS

We conducted an interviewer-administered survey from January-June 2014 of practices stratified by specialty (FM or GIM), affiliation (standalone or ≥ 2 practice sites), and level of financial decision-making (independent or larger system level) in FM and GIM practices that responded to a previous survey on adult vaccine financing and provided contact information for follow-up. Practice personnel identified as knowledgeable about vaccine financing and billing responded to questions about payments relative to vaccine purchase price and payment for vaccine administration, perceived profit on vaccination, claim denial, and utilization of various purchasing strategies for private vaccine stocks. Survey items on payment and perceived profit were assessed for various public and private payer types. Descriptive statistics were calculated and responses compared by physician specialty, practice affiliation, and level of financial decision-making.

RESULTS

Of 242 practices approached, 43% (n = 104) completed the survey. Reported payment levels and perceived profit varied by payer type. Only for preferred provider organizations did a plurality of respondents report profiting on adult vaccination services. Over half of respondents reported losing money vaccinating adult Medicaid beneficiaries. One-quarter to one-third of respondents reported not knowing about Medicare Part D payment levels for vaccine purchase and vaccine administration, respectively. Few respondents reported negotiating with manufacturers or insurance plans on vaccine purchase prices or payments for vaccination.

CONCLUSIONS

Practices vaccinating adults may benefit from education and technical assistance related to vaccine financing and billing and greater use of purchasing strategies to decrease upfront vaccine cost.

Adoption of Serogroup B Meningococcal Vaccine Recommendations

: media-1vid110.1542/5799875076001PEDS-VA_2018-0344Video Abstract BACKGROUND AND OBJECTIVES: In 2015, the Advisory Committee on Immunization Practices recommended that 16- to 23-year-olds may be vaccinated with the serogroup B meningococcal (MenB) vaccine on the basis of individual clinical decision-making (Category B). We assessed the following among US pediatricians and family physicians (FPs): (1) practices regarding MenB vaccine delivery, (2) factors influencing a decision to recommend the MenB vaccine, and (3) factors associated with discussing the MenB vaccine.

METHODS

We surveyed a nationally representative sample of pediatricians and FPs via e-mail and Internet from October 2016 to December 2016.

RESULTS

The response rate was 72% (660 of 916). During routine visits, 51% of pediatricians and 31% of FPs reported always or often discussing MenB vaccine. Among those who discussed often or always, 91% recommended vaccination; among those who never or rarely discussed, 11% recommended. We found that 73% of pediatricians and 41% of FPs currently administered the MenB vaccine. Although many providers reported not knowing about factors influencing recommendation decisions, MenB disease outbreaks (89%), disease incidence (62%), and effectiveness (52%), safety (48%), and duration of protection of MenB vaccine (39%) increased the likelihood of recommendation, whereas the Category B recommendation (45%) decreased likelihood. Those somewhat or not at all aware of the MenB vaccine (risk ratio 0.32 [95% confidence interval 0.25-0.41]) and those practicing in a health maintenance organization (0.39 [0.18-0.87]) were less likely, whereas those aware of disease outbreaks in their state (1.25 [1.08-1.45]) were more likely to discuss MenB vaccine.

CONCLUSIONS

Primary care physicians have significant gaps in knowledge about MenB disease and the MenB vaccine, and this appears to be a major driver of the decision not to discuss the vaccines.

A method for achieving high response rates in national surveys of U.S. primary care physicians

Physician questionnaires are commonly used in health services research; however, many survey studies are limited by low response rate. We describe the effectiveness of a method to maximize survey response without using incentives, the effectiveness of survey reminders over time, and differences in response rates based on survey mode and primary care specialty. As part of a study to assess vaccine policy issues, 13 separate surveys were conducted by internet and mail over the period of 2008 to 2013. Surveys were conducted among pre-recruited networks of pediatricians, family physicians and general internists. Each network was active for 2 years and responded to 3–6 surveys. Physicians who indicated preference to respond through an online survey received up to 9 e-mailed requests to complete the questionnaire and up to 2 mailed questionnaires. Physicians who chose to respond by mail received up to 3 mailed questionnaires and a reminder postcard. For 6 of the 13 surveys conducted over the 6 year period, an additional mailing using a hand-addressed envelope was mailed to non-responders at the end of the usual protocol. Effectiveness of survey methods was measured by response rates. The overall response rates varied from 66‒83%. Response rates declined 17 percentage-points on average between the first and last surveys administered within each physician network. The internet group consistently had higher response rates than the mail group (74% vs. 62% on average). An additional mailing in a hand-written envelope boosted the final response rate by 11 percentage-points. Self-selection of survey mode, multiple reminders, and hand-written envelopes are effective methods for maximizing response rates in physician surveys.

Immunization Practices of U.S. Obstetrician/Gynecologists for Pregnant Patients

INTRODUCTION

U.S. obstetrician/gynecologists play a critical role as vaccinators of pregnant women. However, little is known about their current immunization practices. Thus, study objectives were to determine (1) practices related to assessment of vaccination status and vaccine delivery for pregnant patients; (2) barriers to stocking and administering vaccines; and (3) factors associated with administering both influenza and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines.

METHODS

An e-mail and mail survey among a national sample of obstetrician/gynecologists conducted July-October 2015 (analysis August 2016-August 2017).

RESULTS

The response rate was 73.2% (353/482). Among obstetrician/gynecologists caring for pregnant women (n=324), vaccination status was most commonly assessed for influenza (97%), Tdap (92%), and measles, mumps, and rubella vaccines (88%). Vaccines most commonly administered included influenza (85%) and Tdap (76%). Few respondents reported administering other vaccines to pregnant patients. More physicians reported using standing orders for influenza (66%) than Tdap (39%). Other evidence-based strategies for increasing vaccine uptake were less frequently used (electronic decision support, 42%; immunization information system to record [13%] or assess vaccination status [11%]; reminder/recall, 7%). Barriers most commonly reported were provider financial barriers, yet provider attitudinal barriers were rare. Providers who administered both influenza and Tdap vaccines were more likely to be female, perceive fewer financial and practice barriers, less likely to be in private practice, and perceive more patient barriers.

CONCLUSIONS

Although most obstetrician/gynecologists administer some vaccines to pregnant women, the focus remains on influenza and Tdap. Financial barriers and infrequent use of evidence-based strategies for increasing vaccination uptake may be hindering delivery of a broader complement of adult vaccines in obstetrician/gynecologist offices.

Knowledge and Attitudes Regarding Category B ACIP Recommendations Among Primary Care Providers for Children

OBJECTIVE

In 2015, the Advisory Committee on Immunization Practices (ACIP) made a category B recommendation for use of serogroup B meningococcal (MenB) vaccines, meaning individual clinical decision-making should guide recommendations. This was the first use of a category B recommendation pertaining to a large population and the first such recommendation for adolescents. As part of a survey regarding MenB vaccine, our objectives were to assess among pediatricians (Peds) and family physicians (FPs) nationally: 1) knowledge of the meaning of category A versus B recommendations and insurance coverage implications, and 2) attitudes about category A and B recommendations.

METHODS

We surveyed a nationally representative sample of Peds and FPs via e-mail and mail from October to December 2016.

RESULTS

The response rate was 72% (660 of 916). Although >80% correctly identified the definition of a category A recommendation, only 24% were correct about the definition for category B. Fifty-five percent did not know that private insurance would pay for vaccines recommended as category B, and 51% did not know that category B-recommended vaccines would be covered by the Vaccines for Children program. Fifty-nine percent found it difficult to explain category B recommendations to patients; 22% thought ACIP should not make category B recommendations; and 39% were in favor of category B recommendations because they provide leeway in decision-making.

CONCLUSIONS

For category B recommendations to be useful in guiding practice, primary care clinicians will need to have a better understanding of their meaning, their implications for insurance payment, and guidance on how to discuss them with parents and patients.

Physician Knowledge and Attitudes About Hepatitis A and Current Practices Regarding Hepatitis A Vaccination Delivery

OBJECTIVE

To assess physicians': 1) knowledge and attitudes about hepatitis A disease and hepatitis A (HepA) vaccine, 2) child care and school HepA vaccine mandates, 3) practices related to HepA vaccine delivery, 4) factors associated with strongly recommending HepA vaccine to all 1- to 2-year-olds, and 5) feasibility of implementing HepA catch-up vaccination at health maintenance visits.

METHODS

A national survey was conducted among representative networks of pediatricians and family medicine physicians (FMs) from March to June, 2014 via e-mail or mail on the basis of provider preference.

RESULTS

Response rates were 81% (356 of 440) among pediatricians and 75% (348 of 464) among FMs. Less than 50% correctly identified that hepatitis A virus (HAV) infection is usually asymptomatic in young children and that morbidity from HAV disease increases with age. Ninety-two percent of pediatricians and 59% of FMs strongly recommend HepA vaccine for all 1- to 2-year-olds. In addition to practice specialty, belief that HepA vaccine is required for kindergarten enrollment was the most robust predictor of strong physician recommendation.

CONCLUSIONS

Gaps in knowledge regarding HAV infection and hepatitis A recommendations and lack of a strong recommendation for routine HepA vaccination of young children among FMs likely contribute to suboptimal coverage. Closing knowledge gaps and addressing barriers that prevent all physicians from strongly recommending HepA vaccine to 1- to 2-year-olds could help increase HepA vaccine coverage and ultimately improve population protection against HAV infection.

Hospitalizations for Respiratory Syncytial Virus and Vaccine-Preventable Infections in the First 2 Years After Pediatric Liver Transplant

OBJECTIVES

To examine in liver transplant recipients at centers participating in the Pediatric Health Information System dataset the number of hospitalizations for respiratory syncytial virus (RSV) and vaccine-preventable infections (VPIs) in the first 2 years after transplantation, morbidity and mortality associated with these hospitalizations, and costs associated with these hospitalizations.

STUDY DESIGN

A retrospective cohort study of patients <18 years of age who underwent liver transplantation at a Pediatric Health Information System center between January 1, 2004, and December 31, 2012. Hospitalizations for RSV/VPIs during the first 2 years post-transplant were ascertained using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were collected on clinical care, outcomes, and costs during these hospitalizations.

RESULTS

There were 2554 liver transplant recipients identified; 415 patients (16.3%) had 544 cases of RSV/VPIs. RSV, rotavirus, and influenza were the most common infections resulting in hospitalization. Ninety-two patients (3.6%) had RSV/VPI during their transplant hospitalization. Transplant hospitalizations complicated by RSV/VPI were longer (44 days vs. 21 days; P < .001), had higher rejection rates (37% vs. 26%; P = .02), and were more expensive ($259 697 vs. $190 860; P < .001). Multivariate analyses identified age <2 years at transplant (P < .001) and multivisceral recipient (P = .04) as predictors of a hospitalization for RSV.

CONCLUSIONS

VPIs occurred in 1 of 6 liver transplant recipients in the first 2 years post-transplant, a significantly higher rate than in the general pediatric population. These hospitalizations had substantial morbidity, mortality, and costs, demonstrating the importance of vaccinating patients before transplantation.

Use of Immunization Information Systems in Primary Care

INTRODUCTION

Immunization information systems (IISs) are highly effective for increasing vaccination rates but information about how primary care physicians use them is limited.

METHODS

Pediatricians, family physicians (FPs), and general internists (GIMs) were surveyed by e-mail and mail from January 2015 to April 2015 from all states with an existing IIS. Providers were recruited to be representative of national provider organization memberships. Multivariable log binomial regression examined factors associated with IIS use (October 2015-April 2016).

RESULTS

Response rates among pediatricians, FPs, and GIMs, respectively, were 75% (325/435), 68% (310/459), and 63% (272/431). A proportion of pediatricians (5%), FPs (14%), and GIMs (48%) did not know there was a state/local IIS; 81%, 72%, and 27% reported using an IIS (p<0.0001). Among those who used IISs, 64% of pediatricians, 61% of FPs, and 22% of GIMs thought the IIS could tell them a patient's immunization needs; 22%, 29%, and 51% did not know. The most frequently reported major barriers to use included the IIS not updating the electronic medical record (29%, 28%, 35%) and lack of ability to submit data electronically (22%, 27%, 31%). Factors associated with lower IIS use included FP (adjusted risk ratio=0.85; 95% CI=0.75, 0.97) or GIM (adjusted risk ratio=0.33; 95% CI=0.25, 0.42) versus pediatric specialty and older versus younger provider age (adjusted risk ratio=0.96; 95 CI%=0.94, 0.98).

CONCLUSIONS

There are substantial gaps in knowledge of IIS capabilities, especially among GIMs; barriers to interoperability between IISs and electronic medical records affect all specialties. Closing these gaps may increase use of proven IIS functions including decision support and reminder/recall.

Financing of Vaccine Delivery in Primary Care Practices

OBJECTIVE

Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances.

METHODS

A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices.

RESULTS

The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51-4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded 'yes,' and 24% of Ped and 26% of FM practices responded 'no, but have seriously considered.'

CONCLUSIONS

Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

Primary care physicians' perspective on financial issues and adult immunization in the Era of the Affordable Care Act

BACKGROUND

Financial barriers to adult vaccination are poorly understood. Our objectives were to assess among general internists (GIM) and family physicians (FP) shortly after Affordable Care Act (ACA) implementation: (1) proportion of adult patients deferring or refusing vaccines because of cost and frequency of physicians not recommending vaccines for financial reasons; (2) satisfaction with reimbursement for vaccine purchase and administration by payer type; (3) knowledge of Medicare coverage of vaccines; and (4) awareness of vaccine-specific provisions of the ACA.

METHODS

We administered an Internet and mail survey from June to October 2013 to national networks of 438 GIMs and 401 FPs.

RESULTS

Response rates were 72% (317/438) for GIM and 59% (236/401) for FP. Among physicians who routinely recommended vaccines, up to 24% of GIM and 30% of FP reported adult patients defer or refuse certain vaccines for financial reasons most of the time. Physicians reported not recommending vaccines because they thought the patient's insurance would not cover it (35%) or the patient could be vaccinated more affordably elsewhere (38%). Among physicians who saw patients with this insurance, dissatisfaction ('very dissatisfied') was highest for payments received from Medicaid (16% vaccine purchase, 14% vaccine administration) and Medicare Part B (11% vaccine purchase, 11% vaccine administration). Depending on the vaccine, 36-71% reported not knowing how Medicare covered the vaccine. Thirty-seven percent were 'not at all aware' and 19% were 'a little aware' of vaccine-specific provisions of the ACA.

CONCLUSIONS

Patients are refusing and physicians are not recommending adult vaccinations for financial reasons. Increased knowledge of private and public insurance coverage for adult vaccinations might position physicians to be more likely to recommend vaccines and better enable them to refer patients to other vaccine providers when a particular vaccine or vaccines are not offered in the practice.

Immunization practices among pediatric transplant hepatologists

Vaccination of pediatric liver transplant candidates and recipients represents an opportunity to decrease infectious complications following transplant. Although vaccine recommendations exist, studies have shown that many transplant candidates and recipients are under-immunized. The goals of this study were to assess among pediatric transplant hepatologists: (i) current immunization practices before and after transplantation, (ii) involvement of an ID physician in the transplant evaluation, and (iii) perceptions about vaccine safety and barriers to immunization. An 80-item e-mail survey of pediatric transplant hepatologists at centers in the United States and Canada participating in the SPLIT consortium was conducted from December 2014 to March 2015. The overall response rate was 80% (73/91), representing 97% (32/33) of SPLIT centers. Fifty percent of programs routinely involved an ID physician in the transplant evaluation. Administration of palivizumab was routinely considered by 48% of hepatologists pre-transplant and by 41% post-transplant. Live vaccines were recommended by 26% of hepatologists after transplant. About 10% of hepatologists reported concern that live vaccines after transplant could induce rejection. There is wide variation in immunization practices among transplant hepatologists. Specific evidence-based protocols are needed to guide immunization practices in transplant candidates and recipients.

Physician Attitudes Toward Adult Vaccines and Other Preventive Practices, United States, 2012

OBJECTIVES

We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits.

METHODS

We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians.

RESULTS

We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month.

CONCLUSIONS

Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

Primary Care Physicians' Perspectives About HPV Vaccine

BACKGROUND AND OBJECTIVES

Because physicians' practices could be modified to reduce missed opportunities for human papillomavirus (HPV) vaccination, our goal was to: (1) describe self-reported practices regarding recommending the HPV vaccine; (2) estimate the frequency of parental deferral of HPV vaccination; and (3)identify characteristics associated with not discussing it.

METHODS

A national survey among pediatricians and family physicians (FP) was conducted between October 2013 and January 2014. Using multivariable analysis, characteristics associated with not discussing HPV vaccination were examined.

RESULTS

Response rates were 82% for pediatricians (364 of 442) and 56% for FP (218 of 387). For 11-12 year-old girls, 60% of pediatricians and 59% of FP strongly recommend HPV vaccine; for boys,52% and 41% ostrongly recommen. More than one-half reported ≥25% of parents deferred HPV vaccination. At the 11-12 year well visit, 84% of pediatricians and 75% of FP frequently/always discuss HPV vaccination. Compared with physicians who frequently/always discuss , those who occasionally/rarely discuss(18%) were more likely to be FP (adjusted odds ratio [aOR]: 2.0 [95% confidence interval (CI): 1.1-3.5), be male (aOR: 1.8 [95% CI: 1.1-3.1]), disagree that parents will accept HPV vaccine if discussed with other vaccines (aOR: 2.3 [95% CI: 1.3-4.2]), report that 25% to 49% (aOR: 2.8 [95% CI: 1.1-6.8]) or ≥50% (aOR: 7.8 [95% CI: 3.4-17.6]) of parents defer, and express concern about waning immunity (aOR: 3.4 [95% CI: 1.8-6.4]).

CONCLUSIONS

Addressing physicians' perceptions about parental acceptance of HPV vaccine, the possible advantages of discussing HPV vaccination with other recommended vaccines, and concerns about waning immunity could lead to increased vaccination rates.

Provider Attitudes Regarding Vaccine Tracking Systems in Pediatric Practices

OBJECTIVE

To assess among US pediatricians' systems for tracking vaccine administration and inventory and attitudes about these systems; and attitudes regarding and perceived barriers to adoption of a 2-dimensional bar code systems.

METHODS

Internet and mail survey of a nationally representative network of pediatricians between September 2011 and January 2012.

RESULTS

The response rate was 71% (288 of 408). The most common methods for recording vaccine information were manual entry into an electronic (52%) or paper (27%) record; 76% recorded information in ≥2 places. Physicians reported ordering vaccine on the basis of seasonal increases in demand (55%), paper-based inventory (52%), or when stock looks low (47%); 79% reported it was time consuming to track inventory and 24% reported their practices frequently run out of vaccines. Among those participating in an immunization information system, 29% transmitted data by automatic uploads and 58% entered data manually. Physicians agreed that bar codes could facilitate tracking of vaccine inventory (96%), would improve patient safety (96%), would be more reliable and accurate than current systems (93%), and could improve the efficiency of vaccine administration (90%). Barriers to adoption of a bar code system included need for software (52%), information technology support (42%), and computer equipment (33%). The total cost at which >50% reported they would definitely or probably adopt a bar code system was between $1000 and $4999.

CONCLUSIONS

Most pediatricians report using inefficient systems for tracking vaccine administration and inventory and recognize multiple potential benefits of incorporating vaccine bar coding into their practice. To facilitate adoption, costs will need to be contained and technological barriers addressed.

Understanding how different recruitment strategies impact parent engagement with an iPad-based intervention to provide personalized information about adolescent vaccines

PURPOSE

Inadequate provider time for addressing parents' questions and concerns about adolescent vaccines is a barrier to vaccine utilization. We sought to determine how different recruitment strategies impact the degree of engagement with an intervention that provided this information via an iPad placed in a clinical setting.

METHODS

We provided to three pediatric practices in the Denver area the "Teen VaxScene" web site that generates individually customized information for parents about adolescent vaccines. Three recruitment strategies were assessed for their impact on parental use of the intervention as follows: passive recruitment using posters to advertise a "kiosk" version of the intervention; posters plus a $10 incentive for using the kiosk; and posters plus a $10 incentive plus decoupling the iPad from the kiosks to enable "roving." We assessed the engagement with the intervention at multiple levels including log in, consent, and completion of a baseline survey and viewing individually tailored web pages. Surveys were used to assess barriers to using the intervention.

RESULTS

During the 14-month study period, 693 people had contact with the iPad, 199 consented, and 48 completed the survey to enable creation of tailored content; and 42 used the tailored site. Five times as many parents (n = 40) consented to participation during the 2 months when the intervention was "roving" than during the 10-month "passive" recruitment period. Engagement with the tailored material was low, with most users viewing only the "table of contents" pages. Utilizers and nonutilizers of the intervention had similar demographic characteristics.

CONCLUSIONS

Enabling the iPad to "rove" in the clinic greatly increased the proportion of parents consenting to use the intervention. However, meaningful engagement with the material was low. Further research is needed to understand the most effective and time efficient ways to provide vaccine-related educational information to parents of adolescents.

Physician response to parental requests to spread out the recommended vaccine schedule

OBJECTIVES

To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests.

METHODS

An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012.

RESULTS

The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥ 10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective.

CONCLUSIONS

Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice.

Vaccine financing from the perspective of primary care physicians

OBJECTIVES

Because of high purchase costs of newer vaccines, financial risk to private vaccination providers has increased. We assessed among pediatricians and family physicians satisfaction with insurance payment for vaccine purchase and administration by payer type, the proportion who have considered discontinuing provision of all childhood vaccines for financial reasons, and strategies used for handling uncertainty about insurance coverage when new vaccines first become available.

METHODS

A national survey among private pediatricians and family physicians April to September 2011.

RESULTS

Response rates were 69% (190/277) for pediatricians and 70% (181/260) for family physicians. Level of dissatisfaction varied significantly by payer type for payment for vaccine administration (Medicaid, 63%; Children's Health Insurance Program, 56%; managed care organizations, 48%; preferred provider organizations, 38%; fee for service, 37%; P < .001), but not for payment for vaccine purchase (health maintenance organization or managed care organization, 52%; Child Health Insurance Program, 47%; preferred provider organization, 45%; fee for service, 41%; P = .11). Ten percent of physicians had seriously considered discontinuing providing all childhood vaccines to privately insured patients because of cost issues. The most commonly used strategy for handling uncertainty about insurance coverage for new vaccines was to inform parents that they may be billed for the vaccine; 67% of physicians reported using 3 or more strategies to handle this uncertainty.

CONCLUSIONS

Many primary care physicians are dissatisfied with payment for vaccine purchase and administration from third-party payers, particularly public insurance for vaccine administration. Physicians report a variety of strategies for dealing with the uncertainty of insurance coverage for new vaccines.

U.S. physicians' perspective of adult vaccine delivery

BACKGROUND

Adults are at substantial risk for vaccine-preventable disease, but their vaccination rates remain low.

OBJECTIVE

To assess practices for assessing vaccination status and stocking recommended vaccines, barriers to vaccination, characteristics associated with reporting financial barriers to delivering vaccines, and practices regarding vaccination by alternate vaccinators.

DESIGN

Mail and Internet-based survey.

SETTING

Survey conducted from March to June 2012.

PARTICIPANTS

General internists and family physicians throughout the United States.

MEASUREMENTS

A financial barriers scale was created. Multivariable linear modeling for each specialty was performed to assess associations between a financial barrier score and physician and practice characteristics.

RESULTS

Response rates were 79% (352 of 443) for general internists and 62% (255 of 409) for family physicians. Twenty-nine percent of general internists and 32% of family physicians reported assessing vaccination status at every visit. A minority used immunization information systems (8% and 36%, respectively). Almost all respondents reported assessing need for and stocking seasonal influenza; pneumococcal; tetanus and diphtheria; and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines. The most commonly reported barriers were financial. Characteristics significantly associated with reporting greater financial barriers included private practice setting, fewer than 5 providers in the practice, and, for general internists only, having more patients with Medicare Part D. The most commonly reported reasons for referring patients elsewhere included lack of insurance coverage for the vaccine (55% for general internists and 62% for family physicians) or inadequate reimbursement (36% and 41%, respectively). Patients were most often referred to pharmacies/retail stores and public health departments.

LIMITATIONS

Surveyed physicians may not be representative of all physicians.

CONCLUSION

Improving adult vaccination delivery will require increased use of evidence-based methods for vaccination delivery and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study

Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STIs). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the postrelease period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately two weeks (baseline) and three months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fisher's exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p < 0.01) and 5% of men and 8% of women reported unprotected anal sex (p = 0.51). Being younger (OR for each decade increase 0.48, 95% CI = 0.29-0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR = 4.74, 95% CI = 1.01-22.17 and OR = 3.98, 95% CI = 1.41-11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR = 24.00, 95% CI = 5.15-111.81 and OR = 3.49, 95% CI = 1.20-10.18, respectively) was associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p = 0.005), and female gender (OR = 4.42, 95% CI = 1.79-10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR = 3.64, 95% CI = 1.34-9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the postrelease period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing, and treatment.

Adoption of rotavirus vaccine by U.S. physicians: progress and challenges

BACKGROUND

Pentavalent rotavirus vaccine (RV5) was recommended for routine use in 2006 followed by monovalent rotavirus vaccine (RV1) in 2008.

PURPOSE

To describe, among a U.S. sample of pediatricians (n=289 respondents) and family medicine physicians (n=243 respondents), (1) current practices regarding rotavirus vaccine (RV) and barriers to use with comparison to a 2007 survey and (2) knowledge of recent safety concerns regarding RV1 and their impact on its use.

METHODS

A mail and Internet survey was conducted with the physicians, from November 2010 to January 2011; analyses were conducted March-September 2011.

RESULTS

Response rates were 70% (289/410) for pediatricians and 61% (243/401) for family medicine physicians; routine administration of RV was reported by 95% of pediatricians and 65% of family medicine physicians (2007: 85% and 45%). Almost all barriers to use of RV had decreased compared to 2007. For pediatricians and family medicine physicians, respectively, 94% and 70% were aware of the temporary suspension of RV1 due to presence of porcine circovirus; 49% and 45%, respectively, were aware of the addition to RV1 labeling regarding a possible increased risk of intussusception. Among physicians aware of the safety issues, <5% reported stopping giving RV as a result. After reading information about porcine circovirus, 35% of pediatricians and 59% of family medicine physicians reported it had increased their own concerns about the safety of RV; and 31% and 60%, respectively, reported this regarding intussusception.

CONCLUSIONS

The acceptance of RV has increased, and barriers to use have decreased. Among physicians, recent safety questions about RV1 have not affected use of RV, although they have raised safety concerns.

HPV vaccination of boys in primary care practices

OBJECTIVE

In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended the quadrivalent human papillomavirus vaccine (HPV4) for the routine immunization schedule for 11- to 12-year-old boys. Before October 2011, HPV4 was permissively recommended for boys. We conducted a study in 2010 to provide data that could guide efforts to implement routine HPV4 immunization in boys. Our objectives were to describe primary care physicians': 1) knowledge and attitudes about human papillomavirus (HPV)-related disease and HPV4, 2) recommendation and administration practices regarding HPV vaccine in boys compared to girls, 3) perceived barriers to HPV4 administration in boys, and 4) personal and practice characteristics associated with recommending HPV4 to boys.

METHODS

We conducted a mail and Internet survey in a nationally representative sample of pediatricians and family medicine physicians from July 2010 to September 2010.

RESULTS

The response rate was 72% (609 of 842). Most physicians thought that the routine use of HPV4 in boys was justified. Although it was permissively recommended, 33% recommended HPV4 to 11- to 12-year-old boys and recommended it more strongly to older male adolescents. The most common barriers to HPV4 administration were related to vaccine financing. Physicians who reported recommending HPV4 for 11- to 12-year-old boys were more likely to be from urban locations, perceive that HPV4 is efficacious, perceive that HPV-related disease is severe, and routinely discuss sexual health with 11- to 12-year-olds.

CONCLUSIONS

Although most physicians support HPV4 for boys, physician education and evidence-based tools are needed to improve implementation of a vaccination program for males in primary care settings.

Simultaneous control of diabetes mellitus, hypertension, and hyperlipidemia in 2 health systems

BACKGROUND

Many individuals with diabetes mellitus, hypertension, and hyperlipidemia have difficulty achieving control of all 3 conditions. We assessed the incidence and duration of simultaneous control of hyperglycemia, blood pressure, and low-density lipoprotein cholesterol in patients from 2 health care systems in Colorado.

METHODS AND RESULTS

We performed a retrospective cohort study of adults at Denver Health and Kaiser Permanente Colorado with diabetes mellitus, hypertension, and hyperlipidemia from 2000 through 2008. Over a median of 4.0 and 4.4 years, 16% and 30% of individuals at Denver Health and Kaiser Permanente achieved the primary outcome (simultaneous control with a glycosylated hemoglobin (HbA(1c)) <7.0%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL), respectively. With less strict goals (HbA(1c) <8.0%, blood pressure <140/90 mm Hg, and low-density lipoprotein cholesterol <130 mg/dL), 44% and 70% of individuals at Denver Health and Kaiser Permanente achieved simultaneous control. Sociodemographic characteristics (increasing age, white ethnicity), and the presence of cardiovascular disease or other comorbidities were significantly but not strongly predictive of achieving simultaneous control in multivariable models. Simultaneous control was less likely as severity of the underlying conditions increased, and more likely as medication adherence increased.

CONCLUSIONS

Simultaneous control of diabetes mellitus, hypertension, and hyperlipidemia was uncommon and generally transient. Less stringent goals had a relatively large effect on the proportion achieving simultaneous control. Individuals who simultaneously achieve multiple treatment goals may provide insight into self-care strategies for individuals with comorbid health conditions.

Reducing clinical inertia in hypertension treatment: a pragmatic randomized controlled trial

Clinical inertia is a major contributor to poor blood pressure (BP) control. The authors tested the effectiveness of an intervention targeting physician, patient, and office system factors with regard to outcomes of clinical inertia and BP control. A total of 591 adult primary care patients with elevated BP (mean systolic BP ≥ 140 mm Hg or mean diastolic BP ≥ 90 mm Hg) were randomized to intervention or usual care. An outreach coordinator raised patient and provider awareness of unmet BP goals, arranged BP-focused primary care clinic visits, and furnished providers with treatment decision support. The intervention reduced clinical inertia (-29% vs -11%, P=.001). Nonetheless, change in BP did not differ between intervention and usual care (-10.1/-4.1 mm Hg vs -9.1/-4.5 mm Hg, P=.50 and 0.71 for systolic and diastolic BP, respectively). Future primary care-focused interventions might benefit from the use of specific medication titration protocols, treatment adherence support, and more sustained patient follow-up visits.

Influenza vaccine delivery delays from the perspective of primary care physicians

BACKGROUND

The effects of delayed influenza vaccine delivery on primary practices are currently unknown.

PURPOSE

To describe, among primary care physicians nationally regarding the 2006-2007 influenza season: (1) how physicians defined influenza vaccine delay; (2) the extent of reported vaccine delays; and (3) the perceived effects of vaccine delays.

METHODS

Between March and June 2007, a total of 1268 primary care physicians nationally were surveyed.

RESULTS

Survey response was 74% (n=940). The majority of physicians (79%) defined "influenza vaccine delay" as not receiving vaccine by November 1. Fifty-three percent reported a vaccine delay. Providers reported the following as effects of delays: reduced satisfaction of patients or parents in the practice (72%); decreased percentage in their practice who received the vaccination (65%); disruption of scheduling influenza clinics (55%); increased referral of patients elsewhere for vaccination (55%); and negative financial impact caused by unused vaccine (46%). Those who reported experiencing delays more often reported not meeting demand for vaccine (adjusted risk ratio [ARR]=1.83, 95% CI=1.64, 2.07); that grocery stores, retail outlets, or pharmacies had vaccine before their practices did (ARR=1.82, 95% CI=1.53, 2.26); not receiving all vaccine that was ordered (ARR=1.19, 95% CI=1.06, 1.36); and having leftover vaccine (ARR=1.17, 95% CI=1.04, 1.32).

CONCLUSIONS

During the 2006-2007 influenza season, a non-shortage season, the majority of respondents reported experiencing an influenza vaccine delivery delay. Experiencing a delay was thought to decrease vaccination use, increase referrals elsewhere, and have a negative financial impact on practices. Delayed delivery of influenza vaccine is disruptive for primary care practices, and it consequently may affect vaccination coverage.

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure

OBJECTIVES

The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients.

METHODS

In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians.

RESULTS

Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P<.001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P<.001; family physicians: 50% and 86%, respectively; P<.001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07-1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66-2.81]).

CONCLUSIONS

Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.