Rachel Caskey

Knowledge and Early Adoption of the HPV Vaccine Among Girls and Young Women: Results of a National Survey

PURPOSE In 2006, universal human papillomavirus (HPV) vaccination of females ages 9 to 26 years became a formal recommendation, yet little is known about knowledge and adoption of this vaccine. METHODS A cross-sectional survey of females aged 13 to 26 years was drawn from a nationally representative panel, and developed and maintained by Knowledge Networks, Inc. (Menlo Park, CA). Outcome measures included: (a) knowledge about HPV and the HPV vaccine, (b) barriers to vaccine adoption, and (c) prevalence and correlates of early vaccine receipt. RESULTS Overall, 1,011 of 2,143 subjects (47%) completed the survey. Thirty percent of 13- to 17-year-olds and 9% of 18- to 26-year-olds reported receipt of at least one HPV injection. Knowledge about HPV varied; however, 5% or fewer subjects believed that the HPV vaccine precluded the need for regular cervical cancer screening or safe-sex practices. Adjusting for healthcare utilization and sources of information, vaccine receipt was more likely among 13- to 17-year-olds who reported a recent healthcare visit (adjusted odds ratio [AOR] 7.31, confidence interval [CI] 2.00-26.8) and reported discussing the HPV vaccine (AOR 4.50, CI 1.02-19.90) with a healthcare provider; and more likely among 18- to 26-year-olds who reported discussing the HPV vaccine (AOR 3.08, CI 1.21-7.80) with family or a healthcare provider (AOR 11.92, CI 2.62-54.27). CONCLUSIONS Few girls and young women believe that the HPV vaccine is protective beyond the true impact of the vaccine. Despite moderate uptake, many females at risk of acquiring HPV have not yet received the vaccine. These findings suggest the important role of both healthcare providers and parents in HPV vaccine adoption.

Early lessons learned from extramural school programs that offer HPV vaccine.

BACKGROUND There has been little evaluation of school-located vaccination programs that offer human papillomavirus (HPV) vaccine in US schools without health centers (ie, extramural programs). This article summarizes lessons learned from such programs. METHODS In July to August 2010, 5 programs were identified. Semistructured, in-depth telephone interviews were conducted with program representatives about practical aspects of planning and implementation, including configuration and effectiveness. RESULTS Most programs offered HPV vaccine as part of a broader effort to increase uptake of adolescent vaccines. Respondents stressed the importance of building partnerships with local school systems throughout all aspects of the planning and implementation phases. All programs offered HPV vaccine at no cost to students. Most did not have a mechanism to bill private insurance, and some found Medicaid reimbursements to be a challenge. Programs achieved modest rates of initiation of the 3-dose HPV vaccine series (median 10%); however, among those who initiated the series, completion rates were high (median 78%). HPV vaccine uptake was lowest for a program that offered only HPV vaccine. CONCLUSIONS Extramural programs may increase uptake of vaccines and decrease absenteeism due to noncompliance with vaccine requirements for school entry. Until extramural programs in the US receive better access to billing private insurers and Medicaid, sustainability of these programs relies on grant funding. Better integration of extramural school-located vaccine programs with existing local healthcare and other programs at schools is an area for growth.

The transition to ICD-10-CM: challenges for pediatric practice.

BACKGROUND AND OBJECTIVES: Diagnostic codes are used widely within health care for billing, quality assessment, and to measure clinical outcomes. The US health care system will transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), in October 2015. Little is known about how this transition will affect pediatric practices. The objective of this study was to examine how the transition to ICD-10-CM may result in ambiguity of clinical information and financial disruption for pediatricians. METHODS: Using a statewide data set from Illinois Medicaid specified for pediatricians, 2708 International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes were identified. Diagnosis codes were categorized into 1 of 5 categories: identity, class-to-subclass, subclass-to-class, convoluted, and no translation. The convoluted and high-cost diagnostic codes (n = 636) were analyzed for accuracy and categorized into “information loss,” “overlapping categories,” “inconsistent,” and “consistent.” Finally, reimbursement by Medicaid was calculated for each category. RESULTS: Twenty-six percent of pediatric diagnosis codes are convoluted, which represents 21% of Illinois Medicaid pediatric patient encounters and 16% of reimbursement. The diagnosis codes represented by information loss (3.6%), overlapping categories (3.2%), and inconsistent (1.2%) represent 8% of Medicaid pediatric reimbursement. CONCLUSIONS: The potential for financial disruption and administrative errors from 8% of reimbursement diagnosis codes necessitates special attention to these codes in preparing for the transition to ICD-10-CM for pediatric practices.

Drugs Associated with Adverse Events in Children and Adolescents

To describe the suspected medications, types of reactions, and outcomes of adverse events (AEs) most commonly reported to the United States Food and Drug Administration (FDA) in children by age group.

A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned

BACKGROUND Many adolescents underutilize preventive services and are underimmunized. METHODS To promote medical homes and increase immunization rates, we conceptualized and implemented a 3-year, 8-school pilot school-located vaccination collaborative program. We sought community, parent, and school nurse input the year prior to implementation. We selected schools with predominantly Medicaid-enrolled or Medicaid-eligible students to receive Vaccines For Children stock vaccines. Nurses employed by a mass immunizer delivered these vaccines at participating schools 3 times a year. RESULTS Over 3 years, we delivered approximately 1800 vaccines at schools. School administrators, health centers, and neighboring private physicians generally welcomed the program. Parents did not express overt concerns about school-located vaccination. School nurses were not able to participate because of multiple school assignments. Obtaining parental consent via backpack mail was an inefficient process, and classroom incentives did not increase consent form return rate. The influenza vaccine had the most prolific uptake. The optimal time for administering vaccines was during regular school hours. CONCLUSIONS Although school-located vaccination for adolescents is feasible, this is a paradigm shift for community members and thus accompanies challenges in implementation. High principal or school personnel turnover led to a consequent lack of institutional memory. It was difficult to communicate directly with parents. Because we were uncertain about the proportion of parents who received consent forms, we are exploring Internet-based and back-to-school registration options for making the consent form distribution and return process more rigorous. Securing an immunization champion at each school helped the immunization processes. Identifying a financially sustainable school-located vaccination model is critical for national expansion of school-located vaccination.

Challenges to School-Located Vaccination: Lessons Learned

School-located vaccination (SLV) has a long history in the United States and has successfully contributed to lower morbidity and mortality due to vaccine-preventable diseases.1 Historically, SLV efforts, which tended to be single-vaccine programs intended to provide catch-up immunization to a defined school-age cohort or were implemented in response to an outbreak, were unfunded, funded by local health department, or were funded by industry or federal grants. The growing palette of vaccines recommended for routine use in adolescents along with limited success of office-based adolescent immunization create a compelling argument for the creation of financially sustainable SLV programs. An arguably significant barrier to both office-based and school-located adolescent immunization is the modest reimbursement rates afforded to immunizers. Because the immunization promotion and consent process is expensive, these costs must be reduced to a minimum to reach financial viability. Although there are challenges to creating a financially sustainable SLV program coordinated by an academic medical center, (AMC), the ability of AMCs to bill private and public insurers, the nonprofit status of medical centers, the allowances for faculty for academic pursuit, and the substantial infrastructure already present make AMCs a potentially practical site for the administration of SLV programs. Alternatively, as health departments throughout the nation continue to explore methods for billing private insurance, we may find health departments to be uniquely suited for coordinating the administration and billing of these services.

Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers

Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.

HPV vaccine acceptance among adolescent males and their parents in two suburban pediatric practices.

PURPOSE To measure HPV vaccine acceptance among unvaccinated adolescent males and parents and correlate acceptance with knowledge, awareness, and personal experience. METHODS Adolescent males ages 11-21 years old and their parents completed questionnaires measuring attitudes and knowledge about HPV vaccination and personal experience. Acceptance was defined as wanting the vaccine and conditional acceptance as wanting the vaccine if it would protect against genital warts or cervical cancer. RESULTS Adolescent (n=154) and parent (n=121) vaccine acceptance was low (16% and 34%, respectively); however, conditional acceptance was higher. While adolescents had similar conditional acceptance for a vaccine against genital warts and cervical cancer, parents reported higher conditional acceptance for protection against genital warts. Independent predictors of acceptance included personal experience and demographic variables. CONCLUSIONS HPV vaccine acceptance among adolescents and parents was low. Conditional acceptance levels highlight the importance of education about a few important benefits of HPV vaccination, which may increase vaccination rates.

HPV vaccine: Less is more

Vaccines have a long history of preventing diseases that otherise would result in substantial healthcare and societal costs but ntil recently have not been recognized as an important means of ancer prevention. Meanwhile, human papillomavirus (HPV) has ecome the most common sexually transmitted infection worldide and is the causal mediator for nearly all cervical neoplasias n females, anal cancers in both males and females and a growng number of head and neck cancers in both males and females 1–3]. Consequently HPV-related disease is growing in the U.S. and revention is critical to avoiding a substantial future burden of HPVelated cancer. We believe that current clinical practice is impeding ppropriate vaccination rates and consequently we are proposing change in strategy. There is strong and consistent evidence that vaccination against PV is effective at preventing cervical precancerous lesions, is costffective, and is safe [4,5]. Vaccination has both individual benefits prevent HPV-related disease) and broader external public benets (decreasing disease burden and associated health care costs) nd the Advisory Committee on Immunization Practices (ACIP) curently recommends universal HPV vaccination of adolescent and oung adults, with an emphasis on vaccination at 11–12-years of ge. However, despite this recommendation, only 60% of teenage emale and 42% of teenage males in the U.S. initiate vaccination received at least one dose); and only 40% of teenage females and 2% of teenage males have completed the three dose HPV vaccine eries [6]. Nonetheless, vaccination rates for other adolescent vacines are much higher with 88% of teenagers receiving the tetanus, iphtheria, and acellular pertussis (Tdap) vaccine, and 79% receiv-

Emergency department-based care transitions for pediatric patients: A systematic review

CONTEXT: Successful care transitions between emergency departments (EDs) and outpatient settings have implications for quality, safety, and cost of care. OBJECTIVE: To investigate the effectiveness of ED-based care transition interventions in achieving outpatient follow-up among pediatric patients. DATA SOURCES: Medline, Embase, CINAHL, Cochrane Library, trial registers, and reference lists of relevant articles. STUDY SELECTION AND DATA EXTRACTION: Eligible studies included randomized controlled trials of ED-based care transition interventions involving pediatric patients (aged ≤18 years). Study selection, data extraction, and risk of bias assessment were performed in duplicate and independent manner. Study results were pooled for meta-analysis by using a random effects model. RESULTS: Sixteen randomized controlled trials, comprising 3760 patients, were included in the study. Most interventions were single-site (n = 14), multicomponent (n = 12), and focused on patients with asthma (n = 8). Pooling data from 10 studies (n = 1965 patients) found moderate-quality evidence for a relative increase of 29% in outpatient follow-up with interventions compared with routine care (odds ratio, 1.58 [95% confidence interval, 1.08–2.31]). Successful interventions included structured telephone reminders, educational counseling on follow-up, and appointment scheduling assistance. There was low-quality evidence when pooling data from 5 studies (n = 1609 participants) that exhibited little or no beneficial effect of interventions on ED readmissions (risk ratio, 1.02 [95% confidence interval, 0.91–1.15]). LIMITATIONS: All studies were conducted in urban US hospitals which makes generalization of the results to rural settings and other countries difficult. CONCLUSIONS: ED-based care transition interventions are effective in increasing follow-up but do not seem to reduce ED readmissions. Further research is required to investigate the mechanisms that affect the success of these interventions.