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Children with severe neurological impairment and polypharmacy are exposed to anticholinergic (AC) medications that may have anticholinergic side effects, but this is understudied. Anticholinergic Cognitive Burden (ACB) scores measure total anticholinergic burden for a medication regimen, and scores ≥3 have been associated with increased morbidity and mortality in adults.We assessed the relationship between ACB scores and parent-reported anticholinergic symptoms in children.Cross-sectional study of patients one to 18 years-old with ICD-defined severe neurological impairment and polypharmacy. At routine clinical visits, total ACB scores were computed for all medications. Parent-reported AC symptoms (constipation, drowsiness, difficulty concentrating, dry mouth, or urinary problems) were assessed. Multivariable logistic regression was used to test the association between total ACB scores ≥3 for scheduled medications and the presence of AC symptoms, adjusted for age and recent acute healthcare utilization.Among 123 unique patients, 87% were prescribed AC medications. Common AC medication classes included: systemic antihistamines (64%), anxiolytics (53%), antidepressants (30%), H2 blockers (22%), and muscle relaxants (20%). Total ACB scores ≥3 were observed in 44% for scheduled medications and in 63% of patients for scheduled plus PRN medications. Total ACB scores ≥3 were significantly associated with an increased odds of ≥1 anticholinergic symptoms for scheduled medications (OR: 3.1; 95% CI: 1.4, 6.7) and for scheduled plus PRN medications (OR: 2.9; 95% CI: 1.3, 6.4).If replicated in larger populations, the association between elevated total ACB scores and anticholinergic side effects in children should prompt clinicians to consider deprescribing potentially unneeded anticholinergic medications.

Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP).We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP.We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP.The exposure was the receipt of antibiotics in the emergency department (ED).Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses.Among 523 children, 66% were5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.

Objective To describe, among pediatricians (Peds) and family physicians (FPs), 1) changes made to routine childhood vaccination delivery as a result of the pandemic, and 2) perceived barriers to delivering vaccinations from March 2020 through the time of the survey. Methods A nationally representative survey among Peds and FPs was administered by mail or Internet in October-December 2020. Results Response rate was 64% (579/909). For children aged 0–2 years, among those who vaccinated that age group pre-pandemic (Peds n=265, FPs n=222), 5% of Peds and 15% of FPs reported they had stopped vaccinating these children at any time. For children aged 4–6 years (Peds n=264, FPs n=229), 19% of Peds and 17% of FPs reported they had stopped vaccinating at any time. For children aged 11–18 years (Peds n=265, FPs n=251), 24% of Peds and 19% of FPs reported they had stopped vaccinating at any time. Nearly all reported returning to pre-pandemic vaccination services at the time of the survey. Factors most frequently reported as major/moderate barriers to providing vaccinations included fewer in-person visits because patients/parents were concerned about risk of SARS-CoV-2 infection (Peds, 52%; FPs, 54%), fewer in-person visits for sports clearance (Peds, 39%; FPs, 44%), and fewer back-to-school in-person visits because some children were in virtual learning (Peds, 25%; FPs, 33%). Conclusions Although some physicians reported interrupting vaccination services at some point during the pandemic, the majority reported continuing to provide vaccinations throughout, with essentially all returning to pre-pandemic vaccination services by end of 2020.

The Advisory Committee on Immunization Practices (ACIP) was created out of the need to formalize vaccine recommendations for the United States. Annually, ACIP delivers recommendations to the CDC director for guidance about United States vaccine use and publishes the Adult Immunization Schedule. Updated schedules feature changes to vaccine recommendations as well as changes to the schedule's usability for physicians. The objective of this study was to determine physicians' attitudes about the Adult Immunization Schedule. Surveys were administered to a sentinel physician network from October 2019 through January 2020. Physicians that responded were comfortable using the Adult Immunization Schedule, but reported confusion about some medical condition-based indications. Physicians reported a lack engagement with mobile applications, CDC Vaccine Schedules and Shots by STFM (the Society for Teachers of Family Medicine). Future work should focus on increasing clarity regarding the recommendations with medical condition-based indications and increasing knowledge of mobile applications for physicians.

PURPOSE: Studies based on administrative databases show that infant pyeloplasty is associated with minority race/ethnicity but lack clinical data that may influence treatment. Our objective was to identify clinical and demographic factors associated with pyeloplasty in infants from three large tertiary centers. METHODS: We reviewed infants with unilateral Society for Fetal Urology (SFU) grade 3-4 hydronephrosis seen at three tertiary centers from 2/1/2018-9/30/2019. Patients were excluded if > 6 months old or treated surgically prior to the initial visit. Outcomes were: pyeloplasty < age 1 year and SFU grade on most recent ultrasound (US) within the first year. Covariables included: age at the initial visit, race/ethnicity, treating site, insurance type, febrile UTI, and initial imaging findings. Univariable and multivariable analyses were performed using log-rank tests and Cox proportional hazards models, respectively. RESULTS: 197 patients met study criteria; 19.3% underwent pyeloplasty. Pyeloplasty was associated with: treating site (p=0.03), SFU 4 on initial US (p =0.001), MAG-3 (p 20 minutes (p < 0.001) in patients undergoing a MAG-3 (n=107). MAG-3 (p

Reminders, alerting patients to the need for vaccines that will be due in the future, and recall messages, informing patients about vaccines that are overdue, have been shown to improve immunization rates for children and adolescents in numerous systematic reviews. Therefore, reminder and recall interventions (R/R) are recommended by the Task Force on Community Preventive Services for increasing immunization rates on the basis of strong evidence. R/R messages can be delivered by mail (letter or postcard), via personal or auto-dialer phone calls, by text or e-mail or via patient-portals and can simply be alerts to action or can include educational material with the aim of motivating patients to seek vaccination. R/R has also been shown to be a relatively low-cost intervention with high cost-effectiveness compared with other recommended strategies. However, although R/R as a strategy is consistently effective and cost-effective overall, there is wide variation in the impact of R/R by 1) modality of how it is delivered, 2) the targeted vaccine, 3) the age group, and 4) whether the R/R is conducted centrally by a health system or Immunization Information System or by individual practices. This narrative review summarizes the literature about effectiveness of R/R within each of these categories. We also discuss limitations of R/R, with a focus on the potential impact of parental vaccine hesitancy in blunting its effectiveness and problems with data integrity, on which R/R relies. We also discuss challenges to sustaining R/R efforts, including potential methods of funding for R/R efforts.

Verbally rich interactions beginning in early infancy are critical to future vocabulary development. We explored the effectiveness of introducing finger puppets in the primary care setting to support caregiver-infant interactions. The intervention cohort was given a puppet at 2 months, with high dosage defined as using the puppet daily in the first 2 weeks. At 6 months, a usual care cohort was enrolled, and outcome measures were collected for all participants. For the intervention, 92% (n = 70) of those eligible participated, and 80% (n = 56) completed the 6-month visit. For usual care, 78% (n = 60) of those eligible participated. In per-protocol analysis, overall cognitive stimulation (StimQ-I) ( P = .04) and Parental Involvement in Developmental Advance subscale ( P = .03) scores were higher for the high-dosage group (28.68, 5.16) than those for the low-dosage (24.81, 4.48) and usual care (24.15, 3.98) groups. Finger puppets may provide a low-cost and scalable way to support early language and child development.

INTRODUCTION Vaccine hesitancy contributes to outbreaks of preventable disease worldwide. The Vaccine Hesitancy Scale (VHS), developed by the international WHO SAGE Working Group, has been validated previously for measuring hesitancy towards childhood vaccines; some psychometric properties were suboptimal. METHODS We collected data using large, nationally-representative samples of parents in the U.S. We adapted the VHS items, and additional hesitancy items, to assess hesitancy towards influenza and HPV vaccines in addition to routine childhood vaccines. We then used exploratory and confirmatory factor analysis to identify latent constructs and create modified scales for childhood (VHS-child), influenza (VHS-flu) and HPV (VHS-HPV) vaccines with improved psychometric properties. Finally, we compared hesitancy scores on the VHS-child, VHS-flu, and VHS-HPV, to self-reported receipt of each vaccine category, and compared subscale scores to assess whether drivers of hesitancy differed by vaccine category. RESULTS 2052 parents of children

Introduction The purpose of this study was to understand pediatric urologists' perceived role of patient characteristics on discussions about treatment of infants with suspected UPJ obstruction. Methods We conducted semi-structured interviews with pediatric urologists from three geographically diverse sites. Interview domains included: clinical indications for surgery, discussions with parents, and consideration of parent socioeconomic factors. Transcribed data and field notes were analyzed using a team-based, inductive grounded theory approach. Results Thirteen physicians were interviewed. Physicians reported a standardized approach to discussions to facilitate parental understanding. While they did not report overt consideration of demographics, they tailored discussions based on educational and cultural background and language barriers. Physicians also reported that concerns about risk of loss to follow up contributed to their treatment recommendations. Most physicians recognized that the lack of clear data often led to use of personal experience to guide recommendations. Conclusion Physicians recognize a gap in data to guide surgical decisions and utilize personal experience to augment this gap. They also recognize the influence of educational and language barriers on discussions with families and consider risk of loss to follow up when making recommendations, suggesting an implicit consideration of demographics. These findings suggest that development of evidence-based guidelines may reduce treatment variations. Level of Evidence Not applicable (qualitative research study written in compliance with COREQ guidelines).

Introduction: Since 2009, pharmacists in all 50 states have been authorized to provide vaccinations to adults. The objective of this study was to assess primary care physicians9 (PCPs) experiences with and attitudes about pharmacists administering vaccinations. Methods: Internet and mail survey of PCPs representative of American College of Physicians9 and American Academy of Family Physicians9 memberships. Results: Response rate was 69% (642/926). Ninety-eight percent of respondents agreed (79% “Strongly,” 19% “Somewhat”) that it is their responsibility to assure their adult patients receive recommended vaccinations. Most respondents agreed that pharmacists either did not have access to patient medical information (33% “Strongly,” 45% “Somewhat”) or did not have adequate vaccination history (33% “Strongly,” 41% “Somewhat”). The majority also agreed that pharmacists did not inform them when vaccinations were given (35% “Strongly,” 39% “Somewhat”) and did not enter vaccinations administered into immunization information systems (IISs) (20% “Strongly,” 37% “Somewhat”). However, 83% agreed (31% “Strongly,” 52% “Somewhat”) that it is helpful to have pharmacists share the role of vaccinating adults. Conclusions: PCPs have mixed feelings about pharmacists delivering vaccines. Universal use of IISs by pharmacists could partially address physicians9 concerns by providing a systematic way for pharmacists and physicians to share patient vaccination histories.

BACKGROUND: In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology “shared clinical decision-making” (SDM) into recommendations for two adult vaccines. OBJECTIVE: To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM. DESIGN: Survey conducted in October 2019–January 2020 by mail or internet based on preference. PARTICIPANTS: Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships. MAIN MEASURES: Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of “not knowing how to implement SDM” conducted. KEY RESULTS: Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as “recommended” and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15–1.81)] and females [1.28 (1.02–1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

BACKGROUND: Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years. OBJECTIVE: We sought to examine family physicians’ (FPs) and general internal medicine physicians’ (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016–2017 and 2018–2019 influenza seasons. DESIGN: E-mail and mail surveys conducted February–March 2017, January–February 2019. PARTICIPANTS: Nationally representative samples of FPs and GIMs. MAIN MEASURES: Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019). KEY RESULTS: Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% “almost always/always” recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults

Introduction: In June 2019, the Advisory Committee on Immunization Practices (ACIP) recommended shared clinical decision making (SCDM) regarding human papillomavirus (HPV) vaccination for adults 27 to 45 years. Our objectives were to assess among primary care physicians 1) recent practice regarding HPV vaccination for adults 27 to 45 years, 2) knowledge of HPV and the new SCDM recommendation, and 3) attitudes toward and anticipated effect of the new SCDM recommendation. Methods: From October to December 2019, we administered an Internet and mail survey to national networks of 494 general internist (GIM) and 474 family physician (FP) members of the American College of Physicians and American Academy of Family Physicians, respectively. Results: Response rate was 64% (617/968; GIM, 57%; FP, 71%). Fifty-eight percent were aware of the new ACIP recommendation; 42% had recommended HPV vaccination to adults 27 to 45 years, but most had administered HPV vaccine to very few of these patients (73% to 0% and 22% to 1 to 3). Fifty-five percent and 63% were unaware that HPV vaccination does not prevent progression of existing HPV-related cancers or infections, respectively and 57% were not sure what to emphasize when having a SCDM conversation about HPV vaccination. A majority reported they will be more likely recommend HPV vaccination to adults in the 27-to-45-year age range as a result of the new recommendation. Conclusions: Physicians are interested in recommending HPV vaccination for adults age 27 to 45 years despite ACIP not routinely recommending it in this age range. The majority need more education about the optimal use of HPV vaccine in this age group.

Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years.To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions.Mail and internet-based survey conducted from May through July 2020.General internists and family physicians throughout the USA.Survey responses.The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients.Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.

Objectives To use electronic health record data from the first 2 hours of care to derive and validate a model to predict hypotensive septic shock in children with infection. Design Derivation-validation study using an existing registry. Setting Six emergency care sites within a regional pediatric healthcare system. Three datasets of unique visits were designated:1)training set (five sites, April 1, 2013, to December 31, 2016),2)temporal test set (five sites, January 1, 2017, to June 30, 2018), and3)geographic test set (sixth site, April 1, 2013, to June 30, 2018). Patients Patients in whom clinicians were concerned about serious infection from 60 days to 18 years were included; those with septic shock in the first 2 hours were excluded. There were 2,318 included visits; 197 developed septic shock (8.5%). Interventions Lasso with 10-fold cross-validation was used for variable selection; logistic regression was then used to construct a model from those variables in the training set. Variables were derived from electronic health record data known in the first 2 hours, including vital signs, medical history, demographics, and laboratory information. Test characteristics at two thresholds were evaluated: 1) optimizing sensitivity and specificity and 2) set to 90% sensitivity. Measurements and main results Septic shock was defined as systolic hypotension and vasoactive use or greater than or equal to 30 mL/kg isotonic crystalloid administration in the first 24 hours. A model was created using 20 predictors, with an area under the receiver operating curve in the training set of 0.85 (0.82-0.88); 0.83 (0.78-0.89) in the temporal test set and 0.83 (0.60-1.00) in the geographic test set. Sensitivity and specificity varied based on cutpoint; when sensitivity in the training set was set to 90% (83-94%), specificity was 62% (60-65%). Conclusions This model predicted risk of septic shock in children with suspected infection 2 hours after arrival, a critical timepoint for emergent treatment and transfer decisions. Varied cutpoints could be used to customize sensitivity to clinical context.

Background While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination. Methods In April 2019, we surveyed families with adolescents 11–17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal. Results 2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent’s health-care provider’s recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal. Conclusions HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.

Background In 2017, three media stories regarding influenza vaccine may have impacted obstetricians’ (OB) influenza vaccination practices: reports of reduced influenza vaccine effectiveness, a severe influenza season, and a possible increased risk of miscarriage among pregnant women receiving 2009 H1N1 vaccine in the 1st trimester who had received H1N1 vaccine the previous season (later disproven). Objective Describe OB’s: (1) awareness of; (2) attitudes and experiences related to; and (3) reported alterations in practice as a result of these reports. Methods A survey among a nationally representative sample of OBs April to June 2018. Results Response rate was 65% (302/468). 88% of OBs were “very aware” of the severe season, 74% of lower effectiveness, and 25% of the miscarriage study (47% “completely unaware” of miscarriage study). Among those aware, 58%, 57%, and 16% reported ≥10% of pregnant patients initiated discussions about the severe season, lower effectiveness, and miscarriage study, respectively. Most (83%) agreed reports about increased severity increased their enthusiasm for recommending influenza vaccine; fewer agreed reports about the miscarriage study (18%) and lower vaccine effectiveness (12%) decreased their enthusiasm for recommending influenza vaccine. Providers were more likely to initiate discussion with patients about increased severity of the season than the other reports. However, 35% agreed the miscarriage study reports increased their concerns about influenza vaccine safety; 18% (n = 48) reported changing the way they recommended influenza vaccine. Of those, 17 (6% of all respondents) reported not recommending influenza vaccine to women during the 1st trimester and 26 (10% of all respondents) recommended it but were willing to delay until the 2nd trimester. Conclusions During a season in which media stories could have influenced OB influenza vaccination behaviors in different directions, reports underscoring importance of influenza vaccine may have had more impact on OBs’ recommendations than reports questioning vaccine safety or effectiveness.

Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics.In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains.Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals.Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

To assess measles experience, practice, and knowledge by pediatricians in the context of resurgent US outbreaks in 2018-2019.A nationally representative network of pediatricians were surveyed by email and mail from January to April 2020.The response rate was 67% (297 of 444). In the 3 years preceding the survey, 52% of the respondents reported awareness of measles cases in/near their community. Most thought that media reports about recent measles outbreaks had decreased delay/refusal of measles, mumps, and rubella (MMR) vaccine (6% "greatly decreased"; 66% "moderately decreased"). More than 60% of the pediatricians responded correctly for 6 of 9 true/false measles knowledge items. Less than 50% responded correctly for 3 true/false items, including statements about pretravel MMR recommendations for a preschooler and measles isolation precautions. The most common resources that the pediatricians would "sometimes" or "often/always" consult for measles information were those from the American Academy of Pediatrics (72%), a state or local public health department (70%), and the Centers for Disease Control and Prevention (63%). More than 90% of the pediatricians reported correct clinical practice for MMR vaccination of a 9-month-old before international travel. More than one-third of the respondents did not have a plan for measles exposures in their clinic. Pediatricians aware of measles cases in/near their community in the previous 3 years and those working in a hospital/clinic or Health Maintenance Organization setting were more likely to have a plan for measles exposures.During this time of heightened risk for measles outbreaks, there are opportunities to strengthen the knowledge and implementation of measles pretravel vaccination and infection prevention and control recommendations among pediatricians.

Importance Parents of children with severe neurological impairment (SNI) manage complex medication regimens (CMRs) at home, and clinicians can help support parents and simplify CMRs. Objective To measure the complexity and potentially modifiable aspects of CMRs using the Medication Regimen Complexity Index (MRCI) and to examine the association between MRCI scores and subsequent acute visits. Design, Setting, and Participants This cross-sectional study was conducted between April 1, 2019, and December 31, 2020, at a single-center, large, hospital-based, complex care clinic. Participants were children with SNI aged 1 to 18 years and 5 or more prescribed medications. Exposure Home medication regimen complexity was assessed using MRCI scores. The total MRCI score is composed of 3 subscores (dosage form, dose frequency, and specialized instructions). Main Outcomes and Measures Patient-level counts of subscore characteristics and additional safety variables (total doses per day, high-alert medications, and potential drug-drug interactions) were analyzed by MRCI score groups (low, medium, and high score tertiles). Associations between MRCI score groups and acute visits were tested using Poisson regression, adjusted for age, complex chronic conditions, and recent health care use. Results Of 123 patients, 73 (59.3%) were male with a median (interquartile range [IQR]) age of 9 (5-13) years. The median (IQR) MRCI scores were 46 (35-61 [range, 8-139]) overall, 29 (24-35) for the low MRCI group, 46 (42-50) for the medium MRCI group, and 69 (61-78) for the high MRCI group. The median (IQR) counts for the subscores were 6 (4-7) dosage forms per patient, 7 (5-9) dose frequencies per patient, and 5 (4-8) instructions per patient, with counts increasing significantly across higher MRCI groups. Similar trends occurred for total daily doses (median [IQR], 31 [20-45] doses), high-alert medications (median [IQR], 3 [1-5] medications), and potential drug-drug interactions (median [IQR], 3 [0-6] interactions). Incidence rate ratios of 30-day acute visits were 1.26 times greater (95% CI, 0.57-2.78) in the medium MRCI group vs the low MRCI group and 2.42 times greater (95% CI, 1.10-5.35) in the high MRCI group vs the low MRCI group. Conclusions and Relevance Higher MRCI scores were associated with multiple dose frequencies, complicated by different dosage forms and instructions, and associated with subsequent acute visits. These findings suggest that clinical interventions to manage CMRs could target various aspects of these regimens, such as the simplification of dosing schedules.

Background Vaccine-preventable infections result in significant morbidity, mortality, and costs in pediatric transplant recipients. However, at the time of transplant, less than 20% of children are up-to-date for age-appropriate immunizations that could prevent these diseases. Smartphone apps have the potential to increase immunization rates through their ability to provide vaccine education, send vaccine reminders, and facilitate communication between parents and a multidisciplinary medical group. Objective The aim of this study was to describe the development of a smartphone app, Immunize PediatricTransplant, to promote pretransplant immunization and to report on app functionality and usability when applied to the target population. Methods We used a mixed methods study design guided by the Mobile Health Agile Development and Evaluation Lifecycle. We first completed a formative research including semistructured interviews with transplant stakeholders (12 primary care physicians, 40 parents or guardians of transplant recipients, 11 transplant nurse coordinators, and 19 transplant subspecialists) to explore the acceptability of an immunization app to be used in the pretransplant period. Based on these findings, CANImmunize Inc developed the Immunize PediatricTransplant app. We next held 2 focus group discussions with 5-6 transplant stakeholders/group (n=11; 5 parents of transplant recipients, 2 primary care physicians, 2 transplant nurse coordinators, and 2 transplant subspecialists) to receive feedback on the app. After the app modifications were made, alpha testing was conducted on the functional prototype. We then implemented beta testing with 12 stakeholders (6 parents of transplant recipients, 2 primary care doctors, 2 transplant nurse coordinators, and 2 transplant subspecialists) to refine the app through an iterative process. Finally, the stakeholders completed the user version of the Mobile Application Rating Scale (uMARS) to assess the functionality and quality of the app. Results A new Android- and Apple-compatible app, Immunize PediatricTransplant, was developed to improve immunization delivery in the pretransplant period. The app contains information about vaccine use in the pretransplant period, houses a complete immunization record for each child, includes a communication tool for parents and care providers, and sends automated reminders to parents and care providers when immunizations are due. During usability testing, the stakeholders were able to enter a mock vaccine record containing 16 vaccines in an average of 8.1 minutes (SD 1.8) with 87% accuracy. The stakeholders rated engagement, functionality, aesthetics, and information quality of the app as 4.2/5, 4.5/5, 4.6/5, and 4.8/5, respectively. All participants reported that they would recommend this app to families and care teams with a child awaiting solid organ transplant. Conclusions Through a systematic, user-centered, agile, iterative approach, the Immunize PediatricTransplant app was developed to improve immunization delivery in the pretransplant period. The app tested well with end users. Further testing and agile development among patients awaiting transplant are needed to understand real-world acceptability and effectiveness in improving immunization rates in children awaiting transplant.

In the United States, human papillomavirus (HPV) catch-up vaccination has been nationally recommended for women and men of different ages. We surveyed national networks of primary care physicians specializing in family medicine, pediatrics, and internal medicine to assess attitudes about HPV vaccination. Of 785 physicians, 730 (93.0%), were in favor of a change to harmonize the recommended catch-up vaccination age across genders; the most commonly cited reason was to simplify the immunization schedule (97.9%). After considering these and other data, the Advisory Committee on Immunization Practices updated national policy to recommend catch-up vaccination for all persons through age 26 years.

Centralized reminder/recall (C-R/R) is an evidence-based strategy for increasing vaccination rates that uses a population-level database such as a state immunization information system (IIS) to send notifications across large geographic areas. IISs are usually based in state public health departments, which could initiate C-R/R. While C-R/R is a promising strategy, the factors influencing its initiation and sustainment are not clear. Utilizing qualitative content analysis methodology and interviews with key stakeholders involved in or knowledgeable about C-R/R, we examined the characteristics of these initiatives and factors influencing their success. We identified and spoke with managers and senior leaders across IISs, health plans, health systems, pharmaceutical companies, and advocacy organizations and focused especially on C-R/R activities within IISs. Several considerations were determined important to C-R/R success: decision-making, stakeholder buy-in, partnerships, funding, data and technology, evaluation, and message content. Salient barriers were costs and lack of funding, poor contact data quality (i.e. telephone number, home address), and messaging that is either overly broad or too specific. Pertinent facilitators of C-R/R included notifying health providers in advance of an initiative, conducting a rigorous post-reminder/recall evaluation, and engaging a range of partners. Partnerships were important to stakeholders for multiple reasons including technical assistance, resource sharing, and sharing of best practices. Overall, our results illustrate the many opportunities to advance C-R/R through further collaboration within and across public health departments and potentially via public-private partnerships.

Many non-pregnant women see obstetrician-gynecologists as their sole source of medical care, yet little is known about vaccination practices of obstetrician-gynecologists for non-pregnant patients. The objectives were to assess, among a national sample of obstetrician-gynecologists, practices related to vaccine delivery in non-pregnant patients and factors associated with stocking and administering more than three different vaccines to non-pregnant patients.E-mail and mail surveys were administered July-October 2015, with analyses performed during October-November 2015 and April-June 2018.The response rate was 73% (353/482). Human papillomavirus (92%); influenza (82%); and tetanus, diphtheria, acellular pertussis vaccines (50%) were the vaccines most commonly assessed, with the remaining vaccines assessed by40% of respondents. Vaccines most commonly administered by obstetrician-gynecologists to non-pregnant patients included human papillomavirus (81%); influenza (70%); and tetanus, diphtheria, acellular pertussis (54%). The remaining vaccines were administered by30% of obstetrician-gynecologists. Factors associated with routinely administering more than three vaccines to non-pregnant patients included working in a hospital-, public health-, or university-associated clinic (RR=1.87, 95% CI=1.35, 2.58, referent to private practice); a larger practice (more than five providers; RR=1.54, 95% CI=1.05, 2.27); perceiving fewer financial barriers (RR=0.74, 95% CI=0.57, 0.96); fewer practice-associated barriers (RR=0.71, 95% CI=0.55, 0.92); and greater patient barriers (RR=1.62, 95% CI=1.33, 1.98).Human papillomavirus; influenza; and tetanus, diphtheria, acellular pertussis vaccines are the only vaccines routinely assessed and administered to non-pregnant patients by most obstetrician-gynecologists. Given their role as the sole source of care for many women, obstetrician-gynecologists could make a positive impact on the vaccination status of their non-pregnant patients.

To describe 1) obstetrician-gynecologists' (ob-gyns') perceptions of the frequency of vaccine refusal among pregnant patients and perceived reasons for refusal and 2) ob-gyns' strategies used when encountering vaccine refusal and perceived effectiveness of those strategies.We conducted an email and mail survey among a nationally representative network of ob-gyns from March 2016 to June 2016.The response rate was 69% (331/477). Health care providers perceived that pregnant women more commonly refused influenza vaccine than tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine: 62% of respondents reported 10% or greater of pregnant women they care for in a typical month refused influenza vaccine compared with 32% reporting this for Tdap vaccine. The most commonly reported reasons for vaccine refusal were patients' belief that influenza vaccine makes them sick (48%), belief they are unlikely to get a vaccine-preventable disease (38%), general worries about vaccines (32%), desire to maintain a natural pregnancy (31%), and concern that their child could develop autism as a result of maternal vaccination (25%). The most commonly reported strategies ob-gyns used to address refusal were stating that it is safe to receive vaccines in pregnancy (96%), explaining that not getting the vaccine puts the fetus or newborn at risk (90%), or that not getting the vaccine puts the pregnant woman's health at risk (84%). The strategy perceived as most effective was stating that not getting vaccinated puts the fetus or newborn at risk.Ob-gyns perceive vaccine refusal among pregnant women as common and refusal of influenza vaccine as more common than refusal of Tdap vaccine. Emphasizing the risk of disease to the fetus or newborn may be an effective strategy to increase vaccine uptake.

Background In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM). Objectives We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years. Design This was done by mail and internet-based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs). Results The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change. Conclusions Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted.

Background Rotavirus vaccine (RV) coverage levels for US infants are Methods We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age. Results Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age. Conclusions US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.

Objectives To assess pediatricians’ mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices. Study design Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ2 test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting. Results The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or “don’t know” for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities. Conclusions Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.

Purpose Centralized reminder/recall (C-R/R) using Immunization Information Systems has been effective in increasing childhood immunization rates. Previously, C-R/R using autodialer for human papillomavirus (HPV) vaccine did not raise rates. We assessed C-R/R for HPV vaccine using other modalities and focused on younger adolescents. Methods We conducted a three-arm pragmatic RCT in randomly sampled primary care practices in Colorado (n = 88) and New York (n = 136), proportionate to where adolescents received care. We randomized, within practices, adolescents aged 11-14 years who had not completed the HPV vaccination series to receive C-R/R using different modalities (Colorado: autodialer, mail, or control; New York: autodialer, text, or control). Up to two reminders were sent in intervention arms for each dose needed between 2/2017 and 12/2018. Results In Colorado, no significant differences were found for series initiation (31.3% control, 31.1% autodial, 31.8% mail), with slight improvement for series completion in the autodialer arm (29.7% control, 31.1% autodialer, p = .04) but not the mail arm (30.9%, p = .06). No significant differences were found in New York for series initiation (24.1% for all arms) or completion (17.1% control, 16.9% autodial, 17.9% text). Adjusted analyses showed higher completion rates for the autodialer arm in Colorado but not for other arms. In Colorado, C-R/R reduced time to series completion by around 2 months. Cost per adolescent was $1.81 for mail; under $.40 for all other modalities. Conclusions C-R/R has less benefit for raising HPV vaccination rates than other studies have noted for childhood immunizations, although it may quicken series completion at little cost.

Objective: Health misinformation on social media threatens public health. One question that could lend insight into how and through whom misinformation spreads is whether certain people are susceptible to many types of health misinformation, regardless of the health topic at hand. This study provided an initial answer to this question and also tested four hypotheses concerning the psychosocial attributes of people who are susceptible to health misinformation: (1) deficits in knowledge or skill, (2) preexisting attitudes, (3) trust in health care and/or science, and (4) cognitive miserliness. Method: Participants in a national U.S. survey (N = 923) rated the perceived accuracy and influence of true and false social media posts about statin medications, cancer treatment, and the Human Papilloma Virus (HPV) vaccine and then responded to individual difference and demographic questions. Results: Perceived accuracy of health misinformation was strongly correlated across statins, cancer, and the HPV vaccine (rs ≥ .70), indicating that individuals who are susceptible to misinformation about one of these topics are very likely to believe misinformation about the other topics as well. Misinformation susceptibility across all three topics was most strongly predicted by lower educational attainment and health literacy, distrust in the health care system, and positive attitudes toward alternative medicine. Conclusions: A person who is susceptible to online misinformation about one health topic may be susceptible to many types of health misinformation. Individuals who were more susceptible to health misinformation had less education and health literacy, less health care trust, and more positive attitudes toward alternative medicine. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Little is known about Immunization Information System (IIS) attitudes and experiences using Centralized IIS-based Reminder/Recall (CI-R/R), an effective approach to increasing immunization rates. To describe among IIS managers as it relates to CI-R/R: 1) past experiences and future plans conducting it; 2) attitudes and barriers, 3) IIS capabilities and polices that influence, and 4) factors that differentiate IIS who have and have not conducted CI-R/R. Electronic Surveys were sent to all IIS managers in July 2018 using a member listserve. Fifty-seven of 62 IIS programs contacted (92%) responded. The majority (61%) had ever conducted CI-R/R; 34% reported they were “very likely” to conduct CI-R/R within 6 months. The majority (64%) were in favor of CI-R/R. Barriers included lack of staff (78%), competing demands (76%), and cost (63%). Thirty percent reported receiving a ≥75% of immunization data via real-time electronic interfaces (HL7). Overall, 49% and 24% of jurisdictions had mandatory immunization reporting from private and public health entities for childhood and adult immunizations, respectively. Differences between IIS that ever and never performed CI-R/R, respectively, included: mandatory reporting from private and public entities for children (65% v 27%, p = 0.006), having a legal mandate for CI-R/R (50% v 19%, p = 0.02), less likely to prefer practice-based R/R to CI-R/R (68% v. 91%, p = 0.04), and not reporting having too many competing demands (29% v 67%, p = 0.007). Most IIS have conducted CI-R/R and have positive attitudes towards it. Given it effectiveness and low cost, efforts to sustain it should be considered.

Key Points Question In children with severe neurological impairment (SNI) who cannot self-report, can comprehensive parent-reported symptom assessments inform medication use? Findings In this cross-sectional study of 100 children with SNI and polypharmacy, parents reported that children experienced multiple concurrent high-distress symptoms, notably irritability (65.0%), insomnia (55.0%), and pain (54.0%). Although higher symptom burdens were associated with increasing polypharmacy, opportunities existed to optimize pharmacotherapy; for example, among 54.0% of children with pain, only 61.0% were prescribed an analgesic. Meaning Comprehensive parent-reported symptom data paired with medication data could help clinicians identify targets for personalized symptom management, including underrecognized or undertreated symptoms., This cross-sectional study examines whether higher global symptom scores are associated with use of more medications and assesses associations between specific symptoms and medications among children with severe neurological impairment., Importance Children with severe neurological impairment (SNI) often take multiple medications to treat problematic symptoms. However, for children who cannot self-report symptoms, no system exists to assess multiple symptoms and their association with medication use. Objectives To assess the prevalence of 28 distinct symptoms, test whether higher global symptom scores (GSS) were associated with use of more medications, and assess the associations between specific symptoms and medications. Design, Setting, and Participants This cross-sectional study was conducted between April 1, 2019, and December 31, 2019, using structured parent-reported symptom data paired with clinical and pharmacy data, at a single-center, large, hospital-based special health care needs clinic. Participants included children aged 1 to 18 years with SNI and 5 or more prescribed medications. Data analysis was performed from April to June 2020. Exposure During routine clinical visits, parent-reported symptoms were collected using the validated 28-symptom Memorial Symptom Assessment Scale (MSAS) and merged with clinical and pharmacy data. Main Outcomes and Measures Symptom prevalence, counts, and GSS (scored 0-100, with 100 being the worst) were calculated, and the association of GSS with medications was examined. To evaluate associations between symptom-medication pairs, the proportion of patients with a symptom who used a medication class or specific medication was calculated. Results Of 100 patients, 55.0% were boys, the median (interquartile range [IQR]) age was 9 (5-12) years, 62.0% had 3 or more complex chronic conditions, 76.0% took 10 or more medications, and none were able to complete the MSAS themselves. Parents reported a median (IQR) of 7 (4-10) concurrent active symptoms. The median (IQR) GSS was 12.1 (5.4-20.8) (range, 0.0-41.2) and the GSS was 9.8 points (95% CI, 5.5-14.1 points) higher for those with worse recent health than usual. Irritability (65.0%), insomnia (55.0%), and pain (54.0%) were the most prevalent symptoms. Each 10-point GSS increase was associated with 12% (95% CI, 4%-19%) higher medication counts, adjusted for age and complex chronic condition count. Among the 54.0% of children with reported pain, 61.0% were prescribed an analgesic. Conclusions and Relevance These findings suggest that children with SNI reportedly experience substantial symptom burdens and that higher symptom scores are associated with increased medication use. Paired symptom-medication data may help clinicians identify targets for personalized symptom management, including underrecognized or undertreated symptoms.

This cross-sectional study evaluates whether the Parent-Reported Outcomes of Symptoms system identifies more symptoms than clinicians do among children with severe neurological impairment.

This survey study assesses US pediatrician practices and office policies in response to parents who either refuse primary vaccinations or request to spread out individual vaccines in the primary series.

Objectives To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pre-transplant immunization rates. Study design Semi-structured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver and kidney transplant recipients at three geographically diverse large pediatric transplant centers in the United States. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was utilized to identify themes. Results Stakeholders participated in 30-60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pre-transplant immunizations, (2) lack of communication, coordination and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations and (5) differences between organ type in prioritization and completion of pre-transplant immunization. Conclusions There are multiple factors that contribute to low immunization rates amongst pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

BACKGROUND AND OBJECTIVES: The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health, yet there is limited current national data on prevalence of hesitancy among US parents. Among a nationally representative sample of US parents, we aimed to (1) assess and compare prevalence of hesitancy and factors driving hesitancy for routine childhood and influenza vaccination and (2) examine associations between sociodemographic characteristics and hesitancy for routine childhood or influenza vaccination. METHODS: In February 2019, we surveyed families with children using the largest online panel generating representative US samples. After weighting, we assessed hesitancy using a modified 5-point Vaccine Hesitancy Scale and labeled parents as hesitant if they scored >3. RESULTS: A total of 2176 of 4445 parents sampled completed the survey (response rate 49%). Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines; 12% strongly and 27% somewhat agreed they had concerns about serious side effects of both routine childhood and influenza vaccines. A total of 70% strongly agreed that routine childhood vaccines are effective versus 26% for influenza vaccine (P < .001). In multivariable models, an educational level lower than a bachelor’s degree and household income CONCLUSIONS: Almost 1 in 15 US parents are hesitant about routine childhood vaccines, whereas >1 in 4 are hesitant about influenza vaccine. Furthermore, 1 in 8 parents are concerned about vaccine safety for both routine childhood and influenza vaccines, and only 1 in 4 believe influenza vaccine is effective. Vaccine hesitancy, particularly for influenza vaccine, is prevalent in the United States.

OBJECTIVES: Standing orders are an effective way to increase vaccination rates, yet little is known about how pediatricians use this strategy for childhood immunizations. We assessed current use of, barriers to using, and factors associated with use of standing orders for vaccination among pediatricians. METHODS: Internet and mail survey from June 2017 to September 2017 among a nationally representative sample of pediatricians. In the principal component analysis of barrier items, we identified 2 factors: physician responsibility and concerns about office processes. A multivariable analysis that included barrier scales and physician and/or practice characteristics was used to identify factors associated with use of standing orders. RESULTS: The response rate was 79% (372 of 471); 59% of respondents reported using standing orders. The most commonly identified barriers among nonusers were concern that patients may mistakenly receive the wrong vaccine (68%), concern that patients prefer to speak with the physician about a vaccine before receiving it (62%), and belief that it is important for the physician to be the person who recommends a vaccine to patients (57%). These 3 items also made up the physician responsibility barrier factor. Respondents with higher physician responsibility scores were less likely to use standing orders (risk ratio: 0.59 [95% confidence interval: 0.53–0.66] per point increase). System-level decision-making about vaccines, suburban or rural location, and lower concerns about office processes scores were each associated with use of standing orders in the bivariate, but not the multivariable, analysis. CONCLUSIONS: Among pediatricians, use of standing orders for vaccination is far from universal. Interventions to increase use of standing orders should address physicians’ attitudinal barriers as well as organizational factors.

BACKGROUND AND OBJECTIVES: The Vaccines for Children Program (VFC) provides vaccines for children who may not otherwise be vaccinated because of financial barriers. Pediatrician participation is crucial to the VFC’s ongoing success. Our objectives were to assess, among a national sample of pediatricians, (1) VFC program participation, (2) perceived burden versus benefit of participation, and (3) knowledge and perception of a time-limited increased payment for VFC vaccine administration under the Patient Protection and Affordable Care Act. METHODS: An electronic and mail survey was conducted from June 2017 to September 2017. RESULTS: Response rate was 79% (372 of 471); 86% of pediatricians reported currently participating in the VFC; among those, 85% reported never having considered stopping, 10% considered it but not seriously, and 5% seriously considered it. Among those who had considered no longer participating (n = 47), the most commonly reported reasons included difficulty meeting VFC record-keeping requirements (74%), concern about action by the VFC for noncompliance (61%), and unpredictable VFC vaccine supplies (59%). Participating pediatricians rated, on a scale from −5 (high burden) to +5 (high benefit), their overall perception of the VFC: 63% reported +4 or +5, 23% reported +1 to +3, 5% reported 0, and 9% reported −1 to −5. Of pediatricians, 39% reported awareness of temporary increased payment for VFC vaccine administration. Among those, 10% reported that their practice increased the proportion of Medicaid and/or VFC-eligible patients served on the basis of this change. CONCLUSIONS: For most pediatricians, perceived benefits of VFC participation far outweigh perceived burdens. To ensure the program’s ongoing success, it will be important to monitor factors influencing provider participation.

OBJECTIVE: Childhood influenza vaccination rates remain suboptimal. Provider perceptions on strategies to achieve universal vaccination are needed. We assessed the perceptions and attitudes of primary care providers across 2 states regarding 2 strategies to potentially bolster rates: centralized reminder/recall (C-R/R), such as reminder/recall (R/R) notices from state immunization registries, and influenza vaccination by complementary community vaccinators (CCVs), such as retail pharmacies, schools, and health departments. METHODS: We sent a mailed survey to a representative sample of providers across Colorado and New York. Questions addressed R/R activities for influenza vaccine, preferences and attitudes about the health department sending C-R/R notices for influenza vaccine, and attitudes about CCVs. Bivariate analyses assessed provider perceptions and compared perceptions by state. RESULTS: The overall response rate was 56% (n = 590/1052). Twenty-two percent of providers in Colorado and 33% in New York performed practice-based R/R for all patients during the 2015–16 influenza season. Eighty-one percent of providers in both states preferred the health department or had no preference for who sent C-R/R notices for influenza vaccine to their patients; most preferred to include their practice names on C-R/R messages. Many providers in both Colorado (75%) and New York (46%, P < .001) agreed that their patients like the option of having CCVs where children can receive influenza vaccine. Some providers expressed concerns regarding potential loss of income and/or difficulty documenting receipt of influenza vaccine at CCVs. CONCLUSIONS: Most providers support C-R/R, and many support CCVs to increase influenza vaccination rates. Collaborations between traditional primary care providers and CCVs might boost coverage.