Stephen Berman

A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Otitis media, hearing loss, and language learning: Controversies and current research

ABSTRACT. This article reviews research on the possible linkage of otitis media with effusion (OME) to childrens hearing and development, identifies gaps, and directions for research, and discusses implications for healthcare practices. About half of children with an episode of OME experience a mild hearing loss while about 5-10% of children have moderate hearing loss. Recent prospective and randomized clinical trials suggest none to very small negative associations of OME to childrens later language development. Based on both retrospective and prospective longitudinal studies, associations between OME and perceiving speech in noise and tasks that require equal binaural hearing have been reported but have not been adequately studied with regard to functional outcomes. Thus, on average, for typically developing children, OME may not be a substantial risk factor for later speech and language development or academic achievement. However, these conclusions should be interpreted cautiously, since most of these studies used OME rather than hearing loss as the independent variable (although hearing loss rather than OME is hypothesized to affect language development) and many studies did not control for important confounding variables such as socioeconomic status (SES).

Influenza Among Healthy Young Children: Changes in Parental Attitudes and Predictors of Immunization During the 2003 to 2004 Influenza Season

BACKGROUND. In Colorado, the 2003 to 2004 influenza season was unusually early and severe and received substantial media attention. OBJECTIVES. Among parents of healthy young children, to determine how parental knowledge and attitudes regarding influenza infection and immunization changed during the 2003 to 2004 influenza season and to identify factors predictive of influenza immunization. METHODS. The study was conducted in 5 metropolitan Denver pediatric practices. A total of 839 healthy children age 6 to 21 months and their parents were randomly selected for participation. Parents were surveyed by telephone before (August 18 to October 7, 2003) and after (March 31 to June 10, 2004) the influenza season. RESULTS. Among 828 eligible parents, 472 (57%) completed the preseason survey; 316 (67%) of these parents subsequently completed the postseason survey. All analyses were performed for the 316 subjects who completed both preseason and postseason surveys. Compared with their attitudes before the influenza season, 48% of parents interviewed after the season viewed their child as more susceptible to influenza, 58% viewed influenza infections as more severe, and 66% perceived fewer risks associated with influenza vaccine. Ninety-five percent of parents reported hearing in the media about Colorado’s influenza outbreak, and having heard about the outbreak in the media was associated with viewing influenza infections as more severe. A total of 258 parents (82%) immunized their child against influenza. In multivariate analyses, positive predictors of immunization included a physician recommendation for immunization and a preseason to postseason increase in the perception that immunization was the social norm. Negative predictors of immunization included high perceived barriers to immunization, less parental education, and preseason intention not to immunize. CONCLUSIONS. Parent attitudes about influenza infection and immunization changed substantially during the 2003 to 2004 influenza season, with changes favoring increased parental acceptance of influenza vaccination for young children. During an intensively publicized influenza outbreak, a physician recommendation of vaccination was an important predictor of influenza immunization.

Increased Rates of Morbidity, Mortality, and Charges for Hospitalized Children With Public or No Health Insurance as Compared With Children With Private Insurance in Colorado and the United States

BACKGROUND. There has been a gradual decrease in the proportion of children covered by private health insurance in Colorado and the United States with a commensurate increase in those with public insurance or having no insurance which may impact access to care and outcomes. OBJECTIVE. The purpose of this work was to determine whether children with public or no health insurance have differences in hospital admission rates, morbidity, mortality, and/or charges that might be improved if standards of primary care comparable to those of children with private insurance could be achieved. METHODS. We conducted a retrospective comparison of hospitalization-related outcomes for children <18 years of age in Colorado from 1995–2003 and in the United States in 2000. Population-based rates for hospital admission were determined stratified by age, race/ethnicity, disease grouping, and health insurance status. RESULTS. Compared with those with private insurance, children in Colorado and the United States with public or no insurance have significantly higher rates of total hospital admission, as well as admission for chronic illness, asthma, diabetes, vaccine-preventable disease, psychiatric disease, and ruptured appendix. These children have higher mortality rates, higher severity of illness, are more likely to be admitted through the emergency department and have significantly higher hospital charges per insured child. Higher hospitalization rates occur in children who are nonwhite and/or Hispanic and those who are younger. If children with public or no health insurance in the United States in 2000 had the same hospitalization outcomes as children with private insurance,

Misperceptions About Influenza Vaccination Among Parents of Healthy Young Children

5.3 billion in hospital charges could have been saved. CONCLUSIONS. There is an opportunity to achieve improved health outcomes and decreased hospitalization costs for children with public or no health insurance if private insurance standards of health care could be achieved for all US children.

Implementation of universal influenza immunization recommendations for healthy young children : Results of a randomized, controlled trial with registry-based recall

A survey was administered to 828 parents from metropolitan Denver, Colorado, and 57% responded. Of the respondents, 47% thought their child was unlikely to contract influenza, 70% thought influenza vaccine could cause influenza, and 21% considered influenza vaccination unsafe for a 1-year-old child. The influenza immunization rate in children of surveyed parents was 71%. In multivariate analyses, the perception that influenza vaccination was the social norm was positively associated with immunization (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.03-1.69), and anticipating immunization barriers was negatively associated with immunization (OR, 0.68; 95% CI, 0.49-0.95). Parents of young children hold a number of misperceptions about influenza disease and vaccination. Despite this, high immunization rates are achievable in this population.

Respiratory rate: measurement of variability over time and accuracy at different counting periods.

Background. An Advisory Committee on Immunization Practices policy of encouraging influenza vaccination for healthy 6- to 23-month-old children was in effect during the 2003–2004 influenza season, which was unusually severe in Colorado. We collaborated with 5 pediatric practices to attempt universal influenza immunization in this age group. Objectives. The objectives were (1) to assess the maximal influenza immunization rates that could be achieved for healthy young children in private practice settings, (2) to evaluate the efficacy of registry-based reminder/recall for influenza vaccination, and (3) to describe methods used by private practices to implement the recommendations. Methods. The study was conducted in 5 private pediatric practices in Denver, Colorado, with a common billing system and immunization registry. Although recommendations by the Advisory Committee on Immunization Practices included children who were 6 to 23 months of age at any point during the influenza season, our practices chose not to recall children 22 to 23 months of age, because they would have become >24 months of age during the study period. Therefore, our study population consisted of all healthy children 6 to 21 months of age from the 5 practices (N = 5193), who were randomized to intervention groups (n = 2595) that received up to 3 reminder/recall letters or to control groups (n = 2598) that received usual care. The primary outcome was receipt of ≥1 influenza immunization, as noted either in the immunization registry or in billing data. Results. Immunization rates for ≥1 dose of influenza vaccine for the intervention groups in the 5 practices were 75.9%, 75.4%, 68.1%, 55.6%, and 44.3% at the end of the season. Overall, 62.4% of children in the intervention groups and 58.0% of children in the control groups were immunized (4.4% absolute difference), with absolute differences, compared with control values, ranging from 1.0% to 9.1% according to practice. However, before intensive media coverage of the influenza outbreak began (November 15, 2003), absolute differences, compared with control values, ranged from 5.1% to 15.3% and were 9.6% overall. Before November 15, significant effects of recall were seen for children in the intervention groups, in both the 12- to 21-month age category (10.4% increase over control) and the 6- to 11-month category (8.1% increase over control); at the end of the season, however, significant effects of recall were seen only for the older age group (6.2% increase over control). The rates of receipt of 2 vaccine doses ≥1 month apart for eligible children ranged from 21% to 48% among the practices. Four of the 5 practices held influenza immunization clinics during office hours, evenings, or weekends, and these clinics achieved higher coverage rates. Conclusions. These results demonstrated that, in an epidemic influenza year, private practices were able to immunize the majority of 6- to 21-month-old children in a timely manner. Although media coverage regarding the epidemic blunted the effect of registry-based recall, recall was effective in increasing rates early in the epidemic, especially for children between 1 and 2 years of age. The practices that achieved the highest immunization rates were proactive in planning influenza clinics to handle the extra volume of immunizations required.

Total Parenteral Nutrition via Multilumen Catheters Does Not Increase the Risk of Catheter-Related Sepsis: A Randomized, Prospective Study

The respiratory rates/minute of 97 children were monitored every 10-15 minutes over one hour, by an observer and by pneumogram, at which times two 30 second and one 60 second counts were obtained. The children were under 5 years of age with lower respiratory tract infections (n = 20), upper respiratory tract infections (n = 34), or controls without acute respiratory infection (n = 43). The difference between respiratory rate count determined simultaneously by observation and pneumogram in relation to their mean count was analysed for the 60 second counting period, 30 plus 30 second period, and the 30 second period doubled. The mean difference for the 60 second period was 1.79, for the 30 plus 30 second period 1.42, and for the 30 second period doubled 1.72. The variability between respiratory rate counts determined by observation and pneumogram was significantly lower in counts obtained when the subject was sleeping and higher when agitated compared with obtaining a count when the subject was awake and calm or feeding. The variability was also significantly lower in subjects with lower respiratory tract infections compared with those with upper respiratory tract infections and control subjects without respiratory symptoms. In the same patient, over the one hour, 50% of the 60 second counts varied by up to 14 breaths/minute and 75% by up to 21 breaths/minute. The least variability was seen in children with a lower respiratory tract infection, who tended to maintain their rapid breathing in contrast to those with an upper respiratory tract infection and controls without respiratory symptoms. About 10% of initial 30 second counts, 12% of 60 second, and 16% of initial and repeat 30 second attempts to obtain accurate counts failed. Failures occurred more frequently in children <2 months of age and those agitated. The data from this study suggest that one minutes counting either at a stretch or in two blocks of 30 second intervals is better than counting the respiratory rate for 30 seconds, when the child is either awake and calm or when asleep.

Cost of Vaccine Administration Among Pediatric Practices

The purpose of this study was to determine in a randomized, prospective manner whether administration of total parenteral nutrition (TPN) via multilumen catheters increases the risk of catheter-related sepsis (CRS). All patients receiving hyperalimentation during a 24-month period were randomized to receive either a double-lumen catheter (DLC) or a triple-lumen catheter (TLC). A total of 101 catheters were placed in 79 patients, of which 49 were DLCs and 52 were TLCs. The patients with DLCs received a total of 784 days of TPN, whereas patients with TLCs received a total of 754 days of TPN. CRS was associated with one (2.0%) of the 49 DLCs vs. one (1.9%) of the 52 TLCs. In comparison, the rate of CRS associated with single-lumen catheters (historical control) at our institution was 1.4% (P > .90). We conclude that the use of multilumen catheters in TPN therapy does not result in an increased risk of CRS.

Continuous twice daily or once daily amoxicillin prophylaxis compared with placebo for children with recurrent acute otitis media

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations. METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by ≥2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments. RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged