Sean T. O'Leary

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.

Parental Choice of Recall Method for HPV Vaccination: A Pragmatic Trial.

OBJECTIVES: Completion rates for the human papillomavirus vaccine (HPV) series among adolescents remain low. Effectiveness of recall with parents choosing the method (preference-based recall) for increasing HPV series completion is unstudied. Within a cluster-randomized trial, we examined effectiveness of preference-based recall compared with usual care for increasing series completion and the association of recall choices with completion. METHODS: All Kaiser Permanente Colorado pediatric practices (n = 7) were randomized to intervention (n = 4) or control (n = 3) by using covariate-constrained randomization. From January to June 2013, parents at intervention practices whose adolescents received HPV 1 were asked the recall method they preferred for subsequent doses and if they also wanted their child reminded. Completion rates were assessed 1 year after HPV 1. RESULTS: At intervention practices, 374 (43%) of 867 patients were enrolled; 39% preferred text, 18% e-mail, 9% auto-dialer, and 34% 2-methods; 19% chose to have adolescent also recalled. Intervention adolescents were more likely to complete (63% vs 38%) than were controls (adjusted risk ratio 1.47 [1.38–1.57]) and less likely to be late in completing the series (45% vs 57%, P = .02). Rates of completion were similar between different recall methods, but significantly higher for those preferring e-mail and phone compared withother methods (90% vs 60%. P = .008). Completion rates were similar for adolescents who also received recalls (62%) versus those who did not (63%). CONCLUSIONS: Preference-based recall was effective in increasing HPV series completion rates, with point estimates substantially higher than for most published studies of reminder/recall.

Parents’ perceptions of provider communication regarding adolescent vaccines

ABSTRACT Strong provider recommendations for adolescent vaccines are critical for achieving high vaccination levels. However, little is known about parents’ preferred provider communication strategies for adolescent vaccines in general, and for human papillomavirus (HPV) vaccines specifically. We performed a cross-sectional survey of 800 parents of 9-14 year olds in April 2014 to assess current adolescent vaccine communication practices by providers, parents’ preferred HPV vaccine-specific communication strategies, and the association of these two outcomes with experiential, attitudinal and demographic characteristics. Among the 356 parents in the study (response rate 48%), HPV vaccines were reported as less likely to have been “very strongly” recommended by their adolescent’s provider (39%) than other adolescent-targeted vaccines (45%-59%, <0.05 for all comparisons). Receiving a very strong recommendation for HPV vaccines was associated with a higher likelihood of vaccine receipt (71% versus 39%, p<0.001), or among those not yet vaccinated, increased likelihood of positive vaccination intentions (82% vs. 60%, p = 0.015). Nearly all parents (87%) reported that, if available, they would use a website providing personalized HPV vaccine-related materials before their adolescent’s next check-up, and other technology-based communications were also endorsed by the majority of parents. From these data we conclude that parents received weaker recommendations for HPV vaccines than other adolescent vaccines, and that most parents want additional HPV vaccine-related materials, preferably delivered using a variety of technology-based modalities which is not their providers’ current practice.

School-Based Health Centers as Patient-Centered Medical Homes

OBJECTIVE: School-based health centers (SBHCs) have been suggested as possible patient-centered medical homes. Our objectives were to determine, in a low-income, urban population, adolescents’ reasons for visiting SBHCs and the value parents place on SBHC services, and adolescents’ and parents’ assessment of how well SBHCs fulfill criteria for a medical home as defined by the American Academy of Pediatrics. METHODS: A cross-sectional, mailed survey of a random sample of 495 adolescent SBHC users and 497 parents of SBHC users from 10 SBHCs in Denver, CO from May to October 2012. Eligible adolescents were registered in an SBHC with ≥1 visit during the 2011 to 2012 school year. RESULTS: Response rates were 40% (198/495) among adolescents and 36% (181/497) among parents. The top 3 reasons for visits were for illness (78%), vaccines (69%), and sexual health education (63%). Factors reported as very important by >75% of parents in the decision to enroll their adolescent in an SBHC included clinic offering sick or injury visits, sports physicals, and vaccinations. More than 70% of adolescents gave favorable responses (always or usually, excellent or good) to questions about American Academy of Pediatrics medical home criteria (accessibility, continuity, comprehensiveness, family-centeredness, coordination, and compassion). Most parents (83%) reported that they could always or usually trust the SBHC provider to take good care of their child; 82% were satisfied with provider-to-provider communication. CONCLUSIONS: In a low-income urban population, SBHCs met criteria of a medical home from adolescents’ and parents’ perspectives. Policymakers and communities should recognize that SBHCs play an important role in the medical community, especially for underserved adolescents.

Effectiveness and Cost of Bidirectional Text Messaging for Adolescent Vaccines and Well Care.

OBJECTIVE: To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care (WCC) among adolescents. METHODS: We included all adolescents needing a recommended adolescent vaccine (n = 4587) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practices. Adolescents were randomized to intervention (n = 2228) or control (n = 2359). Parents in the intervention group received up to 3 personalized short messaging services with response options 1 (clinic will call to schedule), 2 (parent will call clinic), or STOP (no further short messaging service). Primary outcomes included completion of all needed services, WCC only, all needed vaccinations, any vaccination, and missed opportunity for vaccination. RESULTS: Intervention patients were more likely to complete all needed services (risk ratio [RR] 1.31, 95% confidence interval [CI] 1.12–1.53), all needed vaccinations (RR 1.29, 95% CI 1.12–1.50), and any vaccination (RR 1.36, 95% CI 1.20–1.54). Seventy-five percent of control patients had a missed opportunity versus 69% of intervention (P = .002). There was not a significant difference for WCC visits. Responding that the clinic should call to schedule (“1”) was associated with the highest effect size for completion of all needed services (RR 1.89, 95% CI 1.41–2.54). Net cost ranged from

Influenza and Pertussis Vaccination Among Pregnant Women and Their Infants' Close Contacts: Reported Practices and Attitudes.

855 to

Adoption of Rotavirus Vaccine by U.S. Physicians Progress and Challenges

3394 per practice. CONCLUSIONS: Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services, especially among parents who responded they desired a call from the practice.

Timing of Adolescent Meningococcal Conjugate Vaccination Attitudes and Practices of Pediatricians and Family Medicine Physicians

Background: Our objectives were to describe the receipt of influenza and tetanus-diphtheria-acellular pertussis (Tdap) vaccines among postpartum women and their close contacts and the factors associated with cocooning. Methods: A survey between February 2013 and April 2013 of 613 postpartum women from 9 obstetrics practices assessed vaccine receipt among respondents and close contacts, demographics and 5 domains of health beliefs (benefits, barriers, susceptibility, severity and social norms). Multivariable models assessed the association of these factors with Tdap or influenza ”cocooning,” defined as the mother plus at least 1 close contact of her newborn receiving the vaccine. Results: The response rate was 45%; 61% of mothers reported that they and at least 1 close contact of their newborn had received influenza vaccine, and 67% reported this for Tdap. Infants whose mothers received influenza vaccine had a mean of 2.8 close contacts who also received influenza vaccine versus a mean of 0.9 contacts for infants whose mothers did not receive influenza vaccine (P < 0.0001). Infants whose mothers received Tdap vaccine had an average of 2.4 contacts who also received it versus 0.8 for infants whose mothers did not receive Tdap (P < 0.0001). Factors associated with influenza and Tdap cocooning included obstetrician recommendation, high perceived benefits, low perceived barriers and perceived susceptibility to disease. For Tdap, race/ethnicity was associated with cocooning (Hispanic/Latino, adjusted odds ratio 0.26, 95% confidence interval: 0.10–0.64 referent to White). Conclusion: Maternal vaccination and obstetrician recommendation are associated with infant cocooning. Interventions to increase cocooning of infants should focus on encouraging strong provider recommendations, increasing maternal knowledge of disease risk and addressing identified barriers. Reasons for possible racial/ethnic differences should be further explored.

Evidence-based vaccination strategies in obstetrics and gynecology settings: Current practices and methods for assessment.

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.

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings.

BACKGROUND The meningococcal conjugate vaccine (MCV4) was recommended for those aged 11-18 years in 2005. Initial supply issues led to an emphasis on immunizing older adolescents. When supply improved in 2007, routine immunization was recommended for those aged 11-12 years. PURPOSE Among a U.S. sample of pediatricians and family medicine physicians, describe (1) recommendation and administration practices for MCV4; (2) preferences regarding MCV4 administration; and (3) attitudes and characteristics associated with recommendation for those aged >12 years. METHODS A mail and Internet survey in a nationally representative sample of physicians was conducted between December 2009 and March 2010. Analysis was conducted between March 2010 and October 2010, including a multivariable analysis to examine factors associated with deferring MCV4 to ages >12 years. RESULTS Response rates were 88% (pediatricians 367/419) and 63% (family medicine physicians 268/423). In all, 95% of pediatricians and 73% of family medicine physicians reported administering MCV4 routinely to those aged 11-18 years (p<0.0001); 83% (pediatricians) and 45% (family medicine physicians) reported strongly recommending MCV4 for those aged 11-12 years (p<0.0001); 27% (pediatricians) and 40% (family medicine physicians) preferred to administer MCV4 to those aged >12 years (p<0.0001). Compared with those who strongly recommend for those aged 11-12 years, physicians who do not regularly stock MCV4, family medicine physicians, and physicians concerned about waning immunity were more likely to defer their recommendation, whereas physicians practicing in the Northeast and those with more Latino patients were less likely to defer. CONCLUSIONS Most pediatricians and family medicine physicians administer MCV4, but many, especially family medicine physicians and those concerned about waning immunity, defer their recommendation for MCV4 to patients aged >12 years.