Paul M. Darden

Reasons for Not Vaccinating Adolescents: National Immunization Survey of Teens, 2008–2010

OBJECTIVE: To determine the reasons adolescents are not vaccinated for specific vaccines and how these reasons have changed over time. METHODS: We analyzed the 2008–2010 National Immunization Survey of Teens examining reasons parents do not have their teens immunized. Parents whose teens were not up to date (Not-UTD) for Tdap/Td and MCV4 were asked the main reason they were not vaccinated. Parents of female teens Not-UTD for human papillomavirus vaccine (HPV) were asked their intent to give HPV, and those unlikely to get HPV were asked the main reason why not. RESULTS: The most frequent reasons for not vaccinating were the same for Tdap/Td and MCV4, including “Not recommended” and “Not needed or not necessary.” For HPV, the most frequent reasons included those for the other vaccines as well as 4 others, including “Not sexually active” and “Safety concerns/Side effects.” “Safety concerns/Side effects” increased from 4.5% in 2008 to 7.7% in 2009 to 16.4% in 2010 and, in 2010, approaching the most common reason “Not Needed or Not Necessary” at 17.4% (95% CI: 15.7–19.1). Although parents report that health care professionals increasingly recommend all vaccines, including HPV, the intent to not vaccinate for HPV increased from 39.8% in 2008 to 43.9% in 2010 (OR for trend 1.08, 95% CI: 1.04–1.13). CONCLUSIONS: Despite doctors increasingly recommending adolescent vaccines, parents increasingly intend not to vaccinate female teens with HPV. The concern about safety of HPV grew with each year. Addressing specific and growing parental concerns about HPV will require different considerations than those for the other vaccines.

Adolescent medicine in pediatric practice: a survey of practice and training.

This study was designed to assess the relation between training in adolescent medicine, during and after residency, and self-reported practice of adolescent medicine. This is a cross-sectional study. A questionnaire was mailed to all members of the South Carolina Chapter of the American Academy of Pediatrics. After 2 mailings, 198 (83%) questionnaires were returned. Adolescent medicine training in residency was associated with more adolescent patients enrolled in a practice (P < 0.01) and more adolescent patient visits (P < 0.01) but not with an increase in perceived competence in the practice of adolescent medicine. Adolescent medicine continuing medical education was associated with seeing more adolescent patients and with increased competence in many areas, including contraceptives, suicide, and school problems (P < 0.05). Training in adolescent medicine during and after residency is associated with treating more adolescent patients. Continuing medical education also is associated with increased perceived competence in areas related to adolescents.

Evaluation of bivalent live attenuated influenza A vaccines in children 2 months to 3 years of age: safety, immunogenicity and dose-response

1126 children, 2 months to 3 years old, received a single intranasal dose of 10(4), 10(6), or 10(7) TCID50 of cold adapted (ca) A/Kawasaki/9/86 (H1N1) and A/Beijing/352/89 (H3N2) or placebo, in a double blind, placebo-controlled, safety and immunogenicity trial. No reactogenicity attributable to vaccine was demonstrated. A single bivalent 10(6) or 10(7) dose produced high rates of seroconversion to H1N1 (77%) and H3N2 (92%) in seronegative children > 6 months old; serologic responses were lower to H1N1 (P < 0.001) and H3N2 (P = 0.01) in younger infants. A single 10(6) dose of bivalent ca influenza A vaccine can be immunogenic in children, but response is age dependent.

Comparing Patients Seen in Pediatric Resident Continuity Clinics and National Ambulatory Medical Care Survey Practices: A Study From the Continuity Research Network

OBJECTIVES. The goal was to compare visit data from Continuity Research Network practices with data for a nationally representative sample of pediatric visits in practice settings from the National Ambulatory Medical Care Survey. METHODS. A cross-sectional study comparing data for Continuity Research Network practice visits during a 1-week period in 2002 with data from the 2000 National Ambulatory Medical Care Survey was performed. Continuity Research Network and National Ambulatory Medical Care Survey data were derived from 30 patient visits per practice site for patients <22 years of age, with the primary care providers being residents and practicing pediatricians, respectively. RESULTS. Eighteen Continuity Research Network practices reported on 540 visits, compared with 32 National Ambulatory Medical Care Survey physicians reporting on 792 visits. Continuity Research Network patients were more likely to be black non-Hispanic or Hispanic/Latino and to have public insurance. The top 5 reasons for visits were the same for Continuity Research Network and National Ambulatory Medical Care Survey visits, although the orders varied slightly. These 5 reasons accounted for 58% of Continuity Research Network visits and 49% of National Ambulatory Medical Care Survey visits. Continuity Research Network visits were more likely to result in patient instructions to return at a specific time (78% vs 52%). CONCLUSIONS. Residents in Continuity Research Network practices provide care to more underserved patients but evaluate problems that are similar to those observed in office practices; the Continuity Research Network practices thus provide important training experiences for residents who will serve both minority and nonminority children.

Are Patient-Held Vaccination Records Associated With Improved Vaccination Coverage Rates?

OBJECTIVE: The goal was to determine whether patient-held vaccination records improve vaccination rates. METHODS: The public-use files of the 2004–2006 National Immunization Survey, a national, validated survey of households with children 19 to 35 months of age, were used. The main outcome was up-to-date (UTD) vaccination status (4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus vaccine, 3 poliovirus vaccine, 1 measles vaccine, 3 Haemophilus influenza type B vaccine, and 3 hepatitis B vaccine doses), and the main predictor was the use of a vaccination record. Control variables were race/ethnicity, maternal education, poverty status, language, number of children in the home, state of residence, and number of health care providers. RESULTS: Overall, 80.8% of children were UTD, and 40.8% of children had vaccination records. Children with vaccination records were more likely to be UTD (83.9% vs 78.6%; P < .0001). The largest effects associated with vaccination records were seen for children with multiple providers, comparing with and without a vaccination record (82.8% vs 71.9%; P < .0001), those with low maternal education, (81.6% vs 72.9%; P < .0001), and those with ≥4 children in the household, (76% vs 69.6%; P < .004). Logistic regression predicting UTD status and controlling for race/ethnicity, maternal education, poverty level, language, number of children in the home, and number of vaccine providers revealed the vaccination record to be associated with a 62% increase in the odds of UTD status (odds ratio: 1.62 [95% confidence interval: 1.49–1.77]). CONCLUSIONS: Use of patient-held vaccination records is an easily implemented strategy that is associated with increased immunization rates. A greater effect was seen in groups at risk for underimmunization. Methods to incorporate and to ensure effective use of these records should be implemented.

Potential Cost Savings of Decreased Emergency Department Visits Through Increased Continuity in a Pediatric Medical Home

PURPOSE To determine the potential cost savings of decreased emergency department (ED) visits resulting from increased continuity of care provided in a pediatric medical home. METHODS An economic modeling study comparing the cost of ED visits associated with average continuity of care versus the cost of ED visits associated with a 10% point increase in continuity was performed. This models premise is that increased continuity will decrease care in the ED. Parameters of the model included average continuity of care and expected use of the ED by pediatric patients as well as the relationship between these two variables. Parameters were estimated from the literature. Average continuity, as measured by the Continuity of Care Index by Bice and Boxerman, was determined to be 40%. Average ED use was estimated to be 0.68 visits/child per year. Continuity of care was stratified into low, medium, and high levels. The Medical University of South Carolinas ED charges were used. An average pediatric practice was estimated to contain 2000 patients. RESULTS Two hypothetical practices of 2000 patients each were created to represent pediatric medical homes: practice 1 received 40% continuity and practice 2 received 50%. The models outcome was measured in terms of expected ED charges per practice averted over a 1-year period. Increasing continuity of care by 10% points yielded a decline in expected ED visits from 1362 to 1290 per practice: 19,905 US dollars was saved. CONCLUSION Continuity of care can yield many benefits, including cost savings from decreased charges associated with less frequent ED use.

Randomized Multicenter Trial Documenting the Efficacy and Safety of a Lactose-Free and a Lactose-Containing Formula for Term Infants

OBJECTIVE To evaluate the efficacy and safety of a new lactose-free infant formula. DESIGN Randomized, prospective, double-blind, controlled, outpatient, multicenter, parallel 12-week trial. SETTING Ambulatory-care facilities of the participating centers. SUBJECTS 137 healthy term infants (approximately 7 days old at the time of study enrollment). INTERVENTION Healthy term infants, whose mothers had decided not to breast-feed, were randomly assigned 1 of the 2 study formulas. MAIN OUTCOME MEASURES Weight, length, and occipitofrontal circumference measurements were obtained at baseline and when the infant was 2, 4, 8, and 12 weeks old. Formula acceptance and tolerance were also assessed at weeks 2, 4, 8, and 12. Serum albumin concentration, creatirune level, and blood urea nitrogen were determined at baseline and week 12. Adverse events were assessed throughout the study. STATISTICAL ANALYSES PERFORMED Each baseline anthropometric and laboratory variable was analyzed for comparability between groups using the Student t test and was also analyzed using a repeated-measures analysis of variance method. Covariance analysis was applied to the final laboratory data using the respective baseline data as covariates. Decisions about equality of mean responses to formula effects were based on the .05 level of significance in all cases. RESULTS One hundred four infants completed the study. No significant differences between the 2 formula groups were noted for any of the growth and blood parameters. APPLICATIONS This new formula is an effective and safe lactose-free nutrition alternative for infants who require such a diet.

Obesity Prevalence in Low-Income Preschool Children in Oklahoma

Objective. To determine the prevalence of overweight and obesity in low-income preschool children in Oklahoma and to identify potential race/ethnic disparities. Methods. Subjects included 39 151 children aged 2 to 4 years who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in 2009. Body mass index percentiles were calculated from the child’s height, weight, sex, and age. Results. In 2009, 30.7% of Oklahoma’s children in WIC were overweight, including 13.7% obese. Disparities by race/ethnicity were greatest for obese children: prevalence was 18.8% for American Indians (odds ratio [OR] = 1.8, confidence interval [CI] = 1.54-2.03) and 17.2% for Hispanics (OR = 1.6, CI = 1.52-1.73) compared with 11.8% for non-Hispanic whites, whereas African Americans were less obese (OR = 0.9, CI = 0.79-0.98). Conclusion. Obesity rates in low-income Oklahoma children are highest among American Indians and Hispanic children. Interventions aimed at these high-risk groups need to be explored.

Time in continuity clinic as a predictor of continuity of care for pediatric residents.

Objective. In 1996, the Residency Review Committee–Pediatrics recommended doubling time in continuity clinic to 2 half days per week. It has yet to be demonstrated that increased time in clinic yields greater continuity of care. The objective of this study was to determine whether increasing the number of half days spent in clinic improves continuity of care for residents. Methods. We reviewed computerized encounter records for all Medical University of South Carolina pediatric residents from 1982 to 1998. Depending on the year and the resident’s training level, house staff spent varying amounts of time in continuity clinic. Time in clinic was estimated from grants and materials generated in the residency program. We calculated continuity of care from the resident’s perspective for each individual resident per year using the Continuity for Physician (PHY) formula. Results. Continuity for 488 resident-years (200 residents) was evaluated. Residents spent from 10% to 30% of their time per year in clinic. Mean PHY was 57% (interns), 62% (second-year residents), and 52% (third-year residents). The correlation coefficient (R) between PHY and percentage of time in clinic was .22. In multivariable modeling, percentage of time in clinic, training level, and year predicted continuity. An increase of 1 half day in clinic was associated with an 11% increase in physician continuity. When analyses were limited to sick visits, R improved to .58. The effect size remained 11%. However, training level and academic year were no longer significant. Conclusion. Increasing time spent in clinic improves continuity and may indeed enhance the quality of this fundamental experience.

Impact of a physician recommendation

HPV vaccination has failed to achieve uptake comparable to the other adolescent-specific vaccines. Gargano et al. conducted a survey of parents of adolescents in a single Georgia county and found uptake similar to national surveys. They also found among the most commonly cited reasons for receiving vaccines a recommendation from a health care provider and among the most commonly cited reasons for not getting any of the adolescent vaccines were concerns for adverse effects. Of note, they found that the recommendation for any one vaccine had a positive effect on the uptake of other vaccines. Their findings of the importance of provider recommendations matched findings from other studies of adolescent vaccines, infant vaccines, and adult vaccines. This is despite flaws in their study including a very poor response rate (effectively 4.5%) of those surveyed and in their reporting including a lack of details of survey methods. Local surveys of vaccination have much to offer the national and local discussion about immunization delivery and how delivery should be optimized, but such surveys should use standardized approaches as well as pursue more comprehensive investigations at the local level to address the nuances national complex-cluster surveys cannot.