Provider characteristics and behaviors as predictors of immunization coverage

Primary care Providers' approaches to cervical cancer screening in Muslim females

The utilization of the Papanicolaou (Pap) test and the human papillomavirus (HPV) vaccine has significantly decreased rates of cervical cancer and related mortality. Disparities in receiving these preventive screenings are scarcely studied in Muslim females. Our study explores primary care providers' (PCP) approaches to cervical cancer screening in Muslim females. We created a cross-sectional Qualtrics survey using convenience sampling of PCPs who perform Pap tests in central Ohio. Recruitment emails were disseminated via departmental email listservs. We had 200 analyzable responses and 78% of respondents reported having Muslim patients. Bivariate analysis was used to identify predictors of providers' approaches. Providers younger than 35 years obtained a sexual history from Muslim females less frequently, family medicine providers were more likely to obtain a sexual history from Muslim females, and gynecologists were more likely to offer the HPV vaccine to Muslim females. Providers who counseled patients about Pap tests (P<0.001) and HPV modes of transmission (P<0.004) were more likely to offer cervical cancer screening for Muslim females. Our findings suggested that providers' age and specialty may be predictors of proactive cervical cancer screening and prevention in Muslim females and that there is a gap between current guidelines and preventive clinical practices regarding the HPV vaccine and transmission counseling.

A method for measuring the effect of certified electronic health record technology on childhood immunization status scores among Medicaid managed care network providers

OBJECTIVE

To provide a methodology for estimating the effect of U.S.-based Certified Electronic Health Records Technology (CEHRT) implemented by primary care physicians (PCPs) on a Healthcare Effectiveness Data and Information Set (HEDIS) measure for childhood immunization delivery.

MATERIALS AND METHODS

This study integrates multiple health care administrative data sources from 2010 through 2014, analyzed through an interrupted time series design and a hierarchical Bayesian model. We compared managed care physicians using CEHRT to propensity-score matched comparisons from network physicians who did not adopt CEHRT. Inclusion criteria for physicians using CEHRT included attesting to the Childhood Immunization Status clinical quality measure in addition to meeting "Meaningful Use" (MU) during calendar year 2013. We used a first-presence patient attribution approach to develop provider-specific immunization scores.

RESULTS

We evaluated 147 providers using CEHRT, with 147 propensity-score matched providers selected from a pool of 1253 PCPs practicing in Maryland. The estimate for change in odds of increasing immunization rates due to CEHRT was 1.2 (95% credible set, 0.88-1.73).

DISCUSSION

We created a method for estimating immunization quality scores using Bayesian modeling. Our approach required linking separate administrative data sets, constructing a propensity-score matched cohort, and using first-presence, claims-based childhood visit information for patient attribution. In the absence of integrated data sets and precise and accurate patient attribution, this is a reusable method for researchers and health system administrators to estimate the impact of health information technology on individual, provider-level, process-based, though outcomes-focused, quality measures.

CONCLUSION

This research has provided evidence for using Bayesian analysis of propensity-score matched provider populations to estimate the impact of CEHRT on outcomes-based quality measures such as childhood immunization delivery.

Choice of measures of vaccination and estimates of risk of pediatric pertussis

BACKGROUND

Vaccination uptake at the individual level can be assessed in a variety of ways, including traditional measures of being up-to-date (UTD), measures of UTD that consider dose timing, like age-appropriate vaccination, and risk reduction from individual doses. This analysis compared methods of operationalizing vaccination uptake and corresponding risk of pertussis infection.

METHODS

City-wide case-control study of children in Philadelphia aged 3 months through 6 years, between 2001 and 2013. Multiple logistic regression was used to isolate the independent effects of each measure of vaccination uptake and the corresponding relative odds of pertussis.

RESULTS

Being UTD on vaccinations was associated with a 52% reduction in risk of pertussis (OR 0.48, 95% CI: 0.34, 0.69). Evaluation of delayed receipt of vaccine versus on-time UTD yielded similar results. There was a decrease in risk of pertussis for each additional dose received with the greatest reduction in pertussis infection observed from the first (OR 0.48, 95% CI: 0.28, 0.83) and second dose (OR 0.17, 95% CI: 0.08, 0.34). Additional doses conferred minimal additional protection in this age group.

CONCLUSION

Examining vaccination status by individual doses may offer improved predictive capacity for identifying children at risk for pertussis infection compared to the traditional UTD measure.

Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting

A physician's recommendation is the most effective published method of motivating HPV vaccination initiation. The emergency department (ED) is the 'public health safety net', and often the only access to care for underserved populations. Recommendation of the HPV vaccine in the ED is a potential avenue to improve vaccination rates among sub-populations who do not have access to routine medical care. We assessed willingness of EM physicians to recommend the vaccine, target high-risk women, and disclose perceived barriers to vaccination in the ED. A cross sectional study using an 11-item survey, was used to assess physician attitudes toward recommending the HPV vaccine in an ED setting to age eligible patients. 67.4% stated they would recommend the vaccine, 23.9% were neutral, and 8.7% would not recommend the vaccine to age eligible patients in the ED. 41% noted lack of adequate reimbursement for vaccination as a barrier to vaccination in the ED (P<0.05). Physicians were comfortable targeting women at high risk for cervical cancer for vaccination (P<0.05). EM physicians are comfortable targeting high-risk women for HPV vaccination in an ED setting. Support of EM physicians in the national effort to improve HPV vaccine uptake is an important step in eradicating a largely preventable yet lethal cancer.

Physicians' human papillomavirus vaccine recommendations, 2009 and 2011

BACKGROUND

Physician recommendation is a key predictor of human papillomavirus (HPV) vaccine uptake. Understanding factors associated with recommendation is important for efforts to increase current suboptimal vaccine uptake.

PURPOSE

This study aimed to examine physician recommendations to vaccinate female patients aged 11-26 years, in 2009 and 2011, at 3 and 5 years postvaccine licensure, respectively. A second aim was to identify trends in factors associated with vaccine recommendation for ages 11 and 12 years.

METHODS

Nationally representative samples of physicians practicing family medicine, pediatrics, and obstetrics and gynecology were randomly selected from the American Medical Association Physician Masterfile (n=1538 in 2009, n=1541 in 2011). A mailed survey asked physicians about patient and clinical practice characteristics; immunization support; and frequency of HPV vaccine recommendation ("always" ≥75% of the time vs other). Analyses were conducted in 2012.

RESULTS

Completed surveys were received from 1013 eligible physicians (68% response rate) in 2009 and 928 (63%) in 2011. The proportion of physicians who reported always recommending HPV vaccine increased significantly from 2009 to 2011 for patients aged 11 or 12 years (35% vs 40%, respectively; p=0.03), but not for patients aged 13-17 years (53% vs 55%; p=0.28) or 18-26 years (50% vs 52%; p=0.52). Physician specialty, age, and perceived issues/barriers to vaccination were associated with vaccine recommendation for patients aged 11 or 12 in both years.

CONCLUSIONS

Results suggest a modest increase in recommendations for HPV vaccination of girls aged 11 or 12 years over a 2-year period; however, recommendations remain suboptimal for all age groups despite national recommendations for universal immunization.

Are Recent Medical Graduates More Skeptical of Vaccines?

Rates of delay and refusal of recommended childhood vaccines are increasing in many U.S. communities. Children's health care providers have a strong influence on parents' knowledge, attitudes, and beliefs about vaccines. Provider attitudes towards immunizations vary and affect their immunization advocacy. One factor that may contribute to this variability is their familiarity with vaccine-preventable diseases and their sequelae. The purpose of this study was to investigate the association of health care provider year of graduation with vaccines and vaccine-preventable disease beliefs. We conducted a cross sectional survey in 2005 of primary care providers identified by parents of children whose children were fully vaccinated or exempt from one or more school immunization requirements. We examined the association of provider graduation cohort (5 years) with beliefs on immunization, disease susceptibility, disease severity, vaccine safety, and vaccine efficacy. Surveys were completed by 551 providers (84.3% response rate). More recent health care provider graduates had 15% decreased odds of believing vaccines are efficacious compared to graduates from a previous 5 year period; had lower odds of believing that many commonly used childhood vaccines were safe; and 3.7% of recent graduates believed that immunizations do more harm than good. Recent health care provider graduates have a perception of the risk-benefit balance of immunization, which differs from that of their older counterparts. This change has the potential to be reflected in their immunization advocacy and affect parental attitudes.

Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review

BACKGROUND

The Summit of Independent European Vaccination Experts (SIEVE) recommended in 2007 that efforts be made to improve healthcare workers' knowledge and beliefs about vaccines, and their attitudes towards them, to increase vaccination coverage. The aim of the study was to compile and analyze the areas of disagreement in the existing evidence about the relationship between healthcare workers' knowledge, beliefs and attitudes about vaccines and their intentions to vaccinate the populations they serve.

METHODS

We conducted a systematic search in four electronic databases for studies published in any of seven different languages between February 1998 and June 2009. We included studies conducted in developed countries that used statistical methods to relate or associate the variables included in our research question. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of the studies and extracted their relevant characteristics. The data were descriptively analyzed.

RESULTS

Of the 2354 references identified in the initial search, 15 studies met the inclusion criteria. The diversity in the study designs and in the methods used to measure the variables made it impossible to integrate the results, and each study had to be assessed individually. All the studies found an association in the direction postulated by the SIEVE experts: among healthcare workers, higher awareness, beliefs that are more aligned with scientific evidence and more favorable attitudes toward vaccination were associated with greater intentions to vaccinate. All the studies included were cross-sectional; thus, no causal relationship between the variables was established.

CONCLUSION

The results suggest that interventions aimed at improving healthcare workers' knowledge, beliefs and attitudes about vaccines should be encouraged, and their impact on vaccination coverage should be assessed.

A national survey about human papillomavirus vaccination: what we didn't ask, but physicians wanted us to know

STUDY OBJECTIVE

The current study presents findings from a qualitative examination of free text comments from a national survey of U.S. physicians on human papillomavirus vaccine recommendation beliefs and practices. Qualitative analyses of free text physician responses may offer a more complete and physician-driven description of influences on human papillomavirus vaccine recommendation.

DESIGN AND PARTICIPANTS

In 2009, a survey assessing physicians' knowledge, attitudes, and human papillomavirus vaccination practices was conducted among a national sample of U.S. physicians practicing Family Medicine, Pediatrics, or Obstetrics/Gynecology (response rate 67.8%). Qualitative comments were analyzed using a Grounded Theory approach.

RESULTS

Of 1008 completed surveys, 112 participants provided comments, which were organized into three primary HPV vaccine-related themes: (a) comments about cost of the vaccine, (b) comments about institutional policies and procedures, and (c) physicians' personal views and one secondary theme related to survey methodology: the parent study's use of an upfront cash incentive. Many comments pertained to issues that were queried in the closed-end survey items; however, some comments provided insight into understudied areas (e.g., physician attitudes regarding survey methodology).

CONCLUSION

Physician respondents used the free text space to reemphasize issues that were most important to them and to offer insight about aspects of the vaccine and the survey process.

Differences in pediatric drug information sources used by general versus subspecialist pediatricians

OBJECTIVE

To describe pediatric labeling information needs and sources of general and subspecialist pediatricians. Study design. Self-administered questionnaire of Fellows of the American Academy of Pediatrics (AAP).

RESULTS

The response rate was 48%. Top sources used by pediatricians to obtain pediatric labeling information were journals (86%), pediatric dosage books (84%), AAP News (77%), drug representatives (65%), and PDA-based databases (35%). Generalists were more likely than subspecialists to use AAP News (82% vs 60%; P < .001) and drug representatives (72% vs 41%; P < .001) to obtain prescribing information. Both groups reported that it was most important to have additional prescribing information for mental health and cardiovascular medications.

CONCLUSIONS

Despite differences in the methods used to obtain pediatric labeling information, generalist and subspecialist pediatricians both prioritized mental health and cardiovascular medications as needing additional prescribing information. Interventions to effectively disseminate new or revised pediatric labeling information to pediatricians should consider using methods identified in this study.

Paediatricians knowledge, attitudes, and practices regarding immunizations for infants in Italy

Background

The purpose of this study was to investigate whether paediatricians have appropriate knowledge, attitudes, and behaviours regarding vaccinations for infants in Italy.

Methods

A random sample of 500 paediatricians received a self-administered anonymous questionnaire covering demographic and professional characteristics; knowledge about the mandatory, recommended, and not indicated vaccinations for infants; attitudes about vaccinations for infants; behaviour regarding current administration or willingness to administer mandatory or recommended vaccinations for infants and immunization education programs of the parents.

Results

Only 42.3% paediatricians knew all recommended vaccinations for infants and this knowledge was significantly higher in females, in those who worked a higher number of hours for week, and in those who use guidelines for immunization practice. Only 10.3% had a very favourable attitude towards the utility of the recommended vaccinations for infants and this was significantly higher in those who administered recommended vaccinations for infants. A large proportion (82.7%) of paediatricians routinely informed the parents about the recommended vaccinations for infants and this appropriate behaviour was significantly higher among younger, in those with a higher number of years in practice, and in those who administered the recommended vaccinations for infants.

Conclusion

Training and educational interventions are needed in order to improve knowledge, attitudes, and behaviours regarding vaccinations for infants among paediatricians.

Support for universal childhood vaccination against influenza among private pediatric clinics and public health departments in Georgia

Recently, it has been recommended that all persons 6 months to 18 years be vaccinated annually against influenza. To assess support for this universal recommendation leading up to its implementation, a cross-sectional survey of healthcare workers at private pediatric clinics (N = 44) and public health departments (N = 75) was conducted. The survey, conducted in the state of Georgia during 2005-2006, asked about (a) support for universal childhood vaccination against influenza, (b) general and influenza-specific immunization practices in 2004-2005, and (c) types of assistance needed to implement a universal childhood recommendation. Our response rate was 70 percent for private clinics and 71 percent for public health departments. The majority of providers supported universal childhood vaccination against influenza; agreement was especially pronounced at public health departments. Public health departments employed more nurses and were more likely to have a policy of vaccinating parents along with their children; private clinics were more likely to use patient reminders or add extra hours during the influenza vaccination season. Respondents from both types of clinics indicated they would need multiple forms of assistance to implement a universal recommendation for childhood vaccination against influenza. Given the strong support for universal vaccination among healthcare workers at public health departments, these facilities may be instrumental for reaching the large number of children recently added to the recommendations. However, these facilities will need multiple forms of assistance.

Physicians who do and do not recommend children get all vaccinations

The objectives of this study were to determine (1) the proportion of physicians who do and do not recommend that children receive all available vaccines and (2) physician characteristics, attitudes, and behaviors associated with not recommending children receive all vaccines. A self-administered, cross-sectional electronic survey of physicians was conducted in 2005. Analyses were restricted to pediatricians (n = 250) and family practitioners (n = 484) who indicated they see at least five pediatric patients per week. A total of 1,935 surveys were distributed, and 1,251 (65%) physicians responded. Eleven percent of the physicians included in the analysis did not recommend to parents that children receive all available vaccines. Compared with physicians who recommended all vaccines for children, physicians who did not were more likely to be family practitioners versus pediatricians (OR = 2.9, CI = 1.4-5.8), agree or be neutral versus disagree that they have some concerns about childhood immunization safety (OR = 3.1, CI = 1.8-5.2), and have <or= 3 versus >or= 8 physicians in their practice (OR = 2.0, CI = 1.1-3.7). We conclude that physician characteristics and concerns about childhood immunizations are associated with not recommending all childhood vaccines. Further investigation of physicians' concerns about vaccine safety is needed to improve health communications directed toward health care providers.

Private Pediatric Clinic Characteristics Associated with Influenza Immunization Efforts in the State of Georgia: A Pilot Evaluation

The Advisory Committee on Immunization Practices (ACIP) recently recommended that all children 6 months to 18 years be vaccinated annually against influenza. Because pediatricians will be critical for implementing this recommendation, we assessed the characteristics of immunization providers associated with the greatest efforts to vaccinate children against influenza. Using a cross-sectional survey of 35 private pediatric clinics in Georgia, we found that adding extra hours for immunization during the influenza vaccination season and having a policy of allowing six or more vaccines to be delivered at one appointment were characteristics associated with a greater intent to vaccinate children in the 2004-2005 influenza vaccination season. Most respondents indicated that for their clinic to implement a universal childhood vaccination policy it would be important to have a formal recommendation from the ACIP and American Academy of Pediatrics, and to be assured that they could receive credits or refunds for unused vaccine.

Postpartum mothers' attitudes, knowledge, and trust regarding vaccination

OBJECTIVE

To examine attitudes and knowledge about vaccinations in postpartum mothers.

METHODS

This cross-sectional study collected data via written survey to postpartum mothers in a large teaching hospital in Connecticut. We used multivariable analysis to identify mothers who were less trusting with regard to vaccines.

RESULTS

Of 228 mothers who participated in the study, 29% of mothers worried about vaccinating their infants: 23% were worried the vaccines would not work, 11% were worried the doctor would give the wrong vaccine, and 8% worried that "they" are experimenting when they give vaccines. Mothers reported that the most important reasons to vaccinate were to prevent disease in the baby (74%) and in society (11%). Knowledge about vaccination was poor; e.g., 33% correctly matched chicken pox with varicella vaccine. Mothers who were planning to breastfeed (P=.01), were primiparous (P=.01), or had an income<$40,000 but did not receive support from the women, infants, and children (WIC) program were less trusting with regard to vaccines (P=.03). Although 70% wanted information about vaccines during pregnancy, only 18% reported receiving such information during prenatal care.

CONCLUSION

Although the majority of infants receive vaccines, their mothers have concerns and would like to receive immunization information earlier. Mothers who are primiparous, have low family incomes but do not qualify for the WIC program, or are breastfeeding may need special attention to develop a trusting relationship around vaccination. Mothers would benefit from additional knowledge regarding the risks and benefits of vaccines particularly during prenatal care.

Factors Influencing Pediatricians' Intention to Recommend Human Papillomavirus Vaccines

OBJECTIVES

The objectives of this qualitative study were to describe the range of pediatricians' attitudes about human papillomavirus (HPV) vaccines and to explore factors influencing their intention to recommend HPV vaccines, extending the findings of previous quantitative studies.

METHODS

A diverse sample of pediatricians participated in semistructured individual interviews to assess attitudes and intentions regarding HPV immunization. Framework analysis was used for qualitative analysis.

RESULTS

The mean age of the 31 participants was 47 years, 17 (55%) were female, 9 (29%) were black, and 4 (13%) were Latino. The efficacy, safety, and potential health impact of vaccination were the primary factors driving participants' decisions about recommending HPV vaccines. Perceived benefits of HPV vaccination included prevention of HPV-related disease and the opportunity to educate adolescents. Perceived barriers included anticipated parental beliefs (eg, parental denial that their child would be at risk) and provider beliefs (eg, reluctance to discuss sexuality with preadolescents). Participants reported high intention to recommend HPV vaccines overall, but intention varied according to patient age, patient gender, and HPV vaccine type. The primary reasons underlying this variation included perceptions about the health impact of vaccination and relevance of HPV vaccines to the provider's patients. The main factors driving intention to recommend HPV vaccines included knowledge, personal and professional characteristics, office procedures, vaccine cost and reimbursement, parental factors, and specific attitudes about HPV vaccination.

CONCLUSIONS

These findings provide a framework for understanding pediatricians' decisions to recommend HPV vaccines and may be used to guide the design of interventions to maximize vaccine recommendations.

The impact of DTaP-IPV-HB vaccine on use of health services for young infants

BACKGROUND

In 2003, a pentavalent vaccine (diphtheria, tetanus and acellular pertussis, injectable polio and hepatitis B) was introduced into the childhood vaccination schedule. A premarketing study showed a higher incidence of fever than with the vaccines administered separately. Because fevers in young infants prompt medical evaluations, this study examines the impact of this vaccine (DTaP-IPV-HB) on subsequent use of health services.

METHODS

We compared use of health services among 6- to 10-week-old infants receiving DTaP-IPV-HB (n = 1776) with a historical control receiving the prior schedule (n = 2162) at an inner-city practice network. Data sources included a hospital immunization registry and medical records. Outcome measures were visits to the emergency department and ambulatory practices, fever, tests, antibiotics and hospitalizations. Outcomes were stratified by age (<8, 8-10 weeks) and days since vaccination (3, 7).

RESULTS

Infants vaccinated with DTaP-IPV-HB were more likely to visit the ED (1.2% versus 0.6%, P = 0.03) and receive tests (47.6% versus 8.3%, P = 0.03) within 3 days of vaccination compared with the controls. Multivariate analysis showed infants vaccinated with DTaP-IPV-HB had a 7-fold increased risk of receiving a full sepsis workup and a 3-fold increased risk of receiving antibiotics within 7 days of vaccination. Medical evaluations decreased over time after implementation of the DTaP-IPV-HB vaccine. Concurrently, the rate of vaccination for infants <8 weeks markedly dropped.

CONCLUSIONS

The DTaP-IPV-HB vaccine was associated with increased use of health services in the emergency department, but these associations lessened over time. These findings reveal a conflict between the obligation of timely and efficient vaccination with the medical management of febrile young infants.

Volume matters: physician practice characteristics and immunization coverage among young children insured through a universal health plan

OBJECTIVES

We studied the association between immunization coverage for a cohort of 2-year-old children covered by a universal health insurance plan and pediatric provider and other health services characteristics.

METHODS

We assembled a cohort of 101,570 infants born in urban areas in Ontario, Canada, between July 1, 1997, and June 31, 1998. Children were considered to have up-to-date (UTD) immunization coverage if they had > or =5 immunizations by 2 years of age, ie, the recommended 3 doses and 1 booster of diphtheria-polio-tetanus-pertussis/Haemophilus influenzae type b vaccine and 1 dose of measles-mumps-rubella vaccine. Provider practice characteristics were derived from outpatient billing records, and 1996 census data were used to derive neighborhood income quintiles. The association between UTD immunization status and provider characteristics was assessed with multilevel regression models, controlling for patient characteristics.

RESULTS

Overall, the rate of complete UTD immunization coverage was low (66.3%) despite a large number of primary care visits (median: 19 visits). Children whose usual provider had a low volume of pediatric primary care were less than one half as likely to be UTD. Other factors associated with not being UTD included very low continuity of care, low continuity of care, and usual provider in practice for <5 years. With adjustment for patient and provider characteristics, there was no difference in immunization coverage for general practitioners versus pediatricians. Children from low-income neighborhoods were less likely to be UTD.

CONCLUSIONS

Despite universal access to primary care services, rates of complete immunization coverage among 2-year-old children in Ontario are low. Because visit rates are high, primary care reform should include interventions directed at provider immunization practices to reduce missed opportunities.

Status of Quality Improvement Activities to Improve Immunization Practices and Delivery

The Centers for Disease Control and Prevention convened a symposium on 22-23 October 2003 to bring together investigators and stakeholders working to apply the quality improvement (QI) approaches to immunization delivery in individual medical practices. The goal was to identify effective program components and further development of model programs. A call for projects was widely disseminated; of 61 submissions received, eight projects were selected. Three of the eight programs used the "train the trainer" approach, three used site-specific training, one used a "practice collaborative" approach, and one employed the use of tracking and outreach workers to effect change. At the symposium, invited experts reviewed each program. Common program features that appeared effective included involvement of a variety of staff within the office environment, collection and review of site-specific performance measurements to identify gaps in delivery, periodic monitoring of performance measurement to revise interventions and maintain the improvements, and provision of formal continuing education credits. While research is needed on ways to promote and integrate QI into practices, it is likely that a variety of QI strategies will be shown to be effective, depending on the clinical settings. The field will benefit from standardized outcome measures, cost analysis, and evaluation, so comparisons can be made among different programs.

Attitudes about human papillomavirus vaccine among family physicians

STUDY OBJECTIVE

Human papillomavirus (HPV) vaccines will soon be available for clinical use, and the effectiveness of vaccine delivery programs will depend largely upon whether providers recommend the vaccine. The objectives of this study were to examine family physicians' attitudes about HPV immunization and to identify predictors of intention to recommend immunization.

DESIGN

Cross-sectional survey instrument assessing provider and practice characteristics, knowledge about HPV, attitudes about HPV vaccination, and intention to administer two hypothetical HPV vaccines.

PARTICIPANTS

Surveys were mailed to a national random sample of 1,000 American Academy of Family Physicians (AAFP) members.

MAIN OUTCOME MEASURE

Intention to administer two hypothetical HPV vaccines (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to boys and girls of different ages.

RESULTS

One hundred fifty-five surveys (15.5%) were returned and 145 were used in the final sample. Participants reported higher intention to recommend both hypothetical HPV vaccines to girls vs. boys (P < 0.0001) and to older vs. younger adolescents (P < 0.0001). They were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine to boys and girls (P < 0.001). Variables independently associated with intention (P < 0.05) included: female gender of provider, knowledge about HPV, belief that organizations such as the AAFP would endorse vaccination, and fewer perceived barriers to vaccination.

CONCLUSIONS

Female gender, knowledge about HPV, and attitudes about vaccination were independently associated with family physicians' intention to recommend HPV vaccines. Vaccination initiatives directed toward family physicians should focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination.

Pediatricians' intention to administer human papillomavirus vaccine: the role of practice characteristics, knowledge, and attitudes

PURPOSE

The objective of this study was to examine pediatrician characteristics and attitudes associated with intention to recommend two hypothetical human papillomavirus (HPV) vaccines.

METHODS

A survey instrument mailed to a random sample of 1000 pediatricians assessed provider characteristics, HPV knowledge, and attitudes about HPV vaccination. Intention to administer each of two HPV vaccines types (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to girls and boys of three different ages (11, 14, and 17 years) was assessed. Linear mixed modeling for repeated measures and multivariable linear regression models were performed to identify variables associated with intention to recommend vaccination.

RESULTS

The mean age of participants (n = 513) was 42 years and 57% were female. Participants were more likely to recommend vaccination to girls vs. boys and older vs. younger children, and were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine (p < .0001). Variables independently associated with intention to recommend a cervical cancer/genital wart vaccine were: higher estimate of the percentage of sexually active adolescents in one's practice (beta .084, p = .002), number of young adolescents seen weekly (beta 1.300, p = .015), higher HPV knowledge (beta 1.079, p = .015), likelihood of following the recommendations of important individuals and organizations regarding immunization (beta .834, p = .001), and fewer perceived barriers to immunization (beta -.203, p = .001).

CONCLUSIONS

Vaccination initiatives directed toward pediatricians that focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination, may facilitate adherence to emerging national immunization guidelines.

Preventive counseling at adolescent ambulatory visits

PURPOSE

To evaluate factors that independently predict counseling for diet, exercise, sexually transmitted diseases (STDs), pregnancy, smoking, and injuries at adolescent well visits, and compare these rates to the frequency of counseling at adolescent acute visits.

METHODS

The 1997-2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys were combined for patients aged 11-21 years. Acute visits were identified by ICD-9 code for: sexual health, obesity, asthma, injury, and well care. Bivariate analyses were used to determine differences in relevant counseling provided at acute visits compared with well visits. Logistic regression was used to assess factors that predict counseling on each of the above topics at well adolescent visits.

RESULTS

Of 23,378 adolescent ambulatory visits, 1508 (6.5%) were for well care. Only 0.8% of visits were for obesity, 3.7% for sexual health, 2.6% for asthma, and 13% for injuries. Counseling was more frequent at acute than well visits for diet (72% vs. 28%), exercise (52% vs. 23%), human immunodeficiency virus/sexually transmitted diseases (HIV/STD; 14% vs. 6.2%), and family planning (FP) (24% vs. 10%), (all p values < .05). Pediatric clinicians were more likely than other specialists to provide counseling for diet (OR 2.3), HIV/STD (OR 2.7), FP (OR 2.9), tobacco use (OR 2.8), and injury prevention (OR 4.7). Blacks received less exercise counseling than Whites (OR 0.4), and counseling about sensitive issues (STDs, family planning) occurred more often in older adolescents (OR 1.3).

CONCLUSIONS

Despite recommendations, more counseling occurs at acute rather than well visits, and still does not reach all those adolescents in need. There remains much room for improvement in physicians' adherence to national guidelines for adolescent care.

Physician reimbursement levels and adherence to American Academy of Pediatrics well-visit and immunization recommendations

BACKGROUND

There is concern that commercial health insurance reimbursement levels for immunizations and well-child visits may not be meeting the delivery and practice overhead costs within some areas of the country. There is also concern that insufficient physician reimbursement levels may negatively affect the quality of children's health care.

OBJECTIVE

We examined the relationships between commercial health insurance reimbursement levels to physicians for pediatric services and rates of immunization and well visits for children and adolescents.

DESIGN

Quality of care was measured by examining state-level immunization and well-visit rates for 2002, which were obtained from the National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS). Reimbursement data were obtained from the American Academy of Pediatrics Medical Cost Model. Variations in the child and adolescent HEDIS measures were examined as a function of physician reimbursement levels for pediatric services across states. HEDIS data were available for a total of 32 states. Partial correlations controlled for pediatrician concentration, as collected from the US Bureau of the Census and the American Medical Association Physician Masterfile data.

RESULTS

Compliance with HEDIS immunization rates for all recommended vaccines was 60% for children and 24% for adolescents. By excluding the varicella vaccine, these rates increased to 70% for children and 44% for adolescents. Adherence rates for well visits were also higher for infants (60%) and children (59%) than for adolescents (34%). Physician reimbursement levels for pediatric services varied from 16.88 dollars per member per month to 32.06 dollars per member per month across states. Statistically significant positive correlations for reimbursement levels were found for 8 of the 16 HEDIS measures examined. Correlations with reimbursement levels were found for childhood immunizations (r = 0.42), infant well visits (r = 0.44), childhood well visits (r = 0.46), and adolescent well visits (r = 0.42). Reimbursement levels were especially strongly related to the rates of adolescent varicella vaccination (r = 0.53). When partial correlations were examined to control for pediatrician concentration, the correlations were reduced by 0.09 on average, suggesting that pediatrician supply may serve as an intermediary of the reimbursement relationship.

CONCLUSIONS

Immunization and well-visit rates for infants, children, and adolescents were positively linked with physician reimbursement rates for those services. Although methodologic limitations suggest caution when interpreting these findings, more attention should be given to physician reimbursement levels as a possible predictor of immunization and well-visit rates as measures of quality of care and to the importance of reimbursement levels for pediatrician recruitment.

Parental vaccine safety concerns. The experiences of pediatricians and family physicians

OBJECTIVES

Recently several concerns regarding vaccine safety have received significant media attention. Primary care physicians are the most common interface for parents with the immunization delivery system and are likely to have the greatest opportunity for exposure and experience with parental vaccine safety concerns.

METHODS

Mail survey study of a national random sample of 750 pediatricians (PDs) and 750 family physicians (FPs) was conducted in 2000. Outcome variables of primary interest included the number of parental vaccine refusals in the past year, frequency of specific parent vaccine safety concerns, and actions taken by physicians when parents refused a vaccine. Chi-square analysis was used to determine the significance of the association of each outcome variable of interest with physician specialty, frequency of vaccine refusal, and the demographic variables. Multivariate analysis explored the potential for independent predictors of physicians who experienced increases in vaccine refusal.

RESULTS

The response rate was 70%. Overall, 93% of PDs and 60% of FPs reported at least one parental vaccine refusal in their practice in the past year. PDs also were more likely than FPs to report an increase in the number of vaccine refusals over the past year (18% v 8%, p =0.01), while FPs were more likely to report a decrease in vaccine refusals over the same time period (18% v 11%; p <0.5). PDs were more likely than FPs to provide additional information regarding vaccines to parents who refused vaccines and/or to discuss the issue at later visits. The most common concerns of parents were related to short-term reactions and pain from multiple injections.

CONCLUSIONS

While almost all PDs and most FPs experienced at least one vaccine refusal from parents in the past year, far fewer physicians of both specialties observed an increase in their occurrence. Physicians must work to be consistently well informed of both the benefits of immunization as well as the issues of parental concern regarding vaccine safety.