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Introduction Immunization education for physicians-in-training is crucial to address vaccine concerns in clinical practice. Vaccine education is not standardized across residency programs. The Collaboration for Vaccination Education and Research (CoVER) team developed an online curriculum for pediatric (Peds) and family medicine (FM) residents. Methods A cluster randomized controlled trial (RCT) was performed during the 2017–2018 academic year to evaluate the CoVER curriculum. A convenience sample of residency institutions were randomly allocated to the intervention or control group, with stratification by residency type. The intervention, the CoVER curriculum, consisted of four online modules and an in-person training guide. Control sites continued with their standard vaccine education. Pre-intervention and post-intervention surveys were emailed to residents in both groups. The primary outcomes compared between groups were changes in “vaccine knowledge,” “vaccine attitudes/hesitancy,” and “self-confidence” in immunization communication. The team assessing outcomes was unblinded to assignments. Hierarchical general linear model was used to adjust for residency type and residency year; residency site was modeled as a random effect. Results Overall, 1444 residents from 31 residency programs were eligible to participate (734 intervention, 710 control). The pre-intervention response rate was 730 (51%) and post-intervention was 526 (36%). Average knowledge scores increased from pre-intervention (control 53%; CoVER 53%) to post-intervention (control 58%; CoVER 60%). Increases in vaccine knowledge among FM residents were greater for CoVER compared to controls (p = 0.041). Vaccine hesitancy was more common among FM (23%) than Peds (10%) residents. In all three residency years, residents in the CoVER group showed greater increases in self-confidence in ability to discuss vaccines with parents/patients (p Conclusion The CoVER curriculum is an effective model to standardize immunization education of physicians-in-training. This RCT demonstrated the effectiveness of the CoVER curriculum to improve resident confidence in their ability to discuss vaccines with parents and patients.

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.

Introduction Little is known about missed opportunities (MOs) for HPV vaccination during primary care visits at which influenza vaccination is delivered. Methods We extracted electronic health records for HPV vaccine-eligible 11-to-17-year-olds. We assessed the proportion of visits during which an influenza vaccine was given and an HPV vaccine was due, but not given (i.e., MOs). Results Of 56,135 eligible visits, 57.5% represented MOs for HPV vaccination. MOs were more common at visits where an initial versus subsequent HPV vaccine dose was due (68.6% vs. 31.3%) and for acute/chronic and nurse-only visits compared to preventive visits (74.0% and 80.2% vs. 36.7%). In a multivariable model, MOs were more likely for the initial HPV dose and for non-preventive visits, but did not vary by patient sex/age. Conclusions HPV vaccine MOs were common during visits where influenza vaccine was administered. Increasing simultaneous administration of HPV and influenza vaccines could increase HPV vaccine coverage.

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system–level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

This retrospective chart review compared the length of stay (LOS) of families with limited English proficiency (LEP) versus English-speaking families seen in 3 pediatric urgent care centers (PUCCs). Visits were included for patients aged 2 months to 17 years seen between January 1, 2016, and December 31, 2016, with 1 of 5 primary diagnoses. For each LEP encounter, we randomly selected 3 English-speaking encounters within the same PUCC and diagnosis class. We compared overall LOS between LEP and English-speaking encounters. Of our entire sample, 184 (1.03%) were LEP encounters, of which 145 (78.8%) preferred Spanish. Comparing the LEP visits to 552 matched English-speaking visits, we found a significant difference in average LOS (LEP 85.5 minutes; English-speaking 76.4 minutes) and in prescriptions provided ( P = .005) but not in triaged acuity nor number of medications administered, laboratory or radiological studies, or suction treatments. This study serves as a starting point to better care for patients/families with LEP in PUCCs.

Background Adult influenza vaccination rates are low. Tailored patient reminders might raise rates. Objective Evaluate impact of a health system’s patient portal reminders: (1) tailored to patient characteristics and (2) incorporating behavioral science strategies, on influenza vaccination rates among adults. Design Pragmatic 6-arm randomized trial across a health system during the 2019–2020 influenza vaccination season. The setting was one large health system—53 adult primary care practices. Participants All adult patients who used the patient portal within 12 months, stratified by the following: young adults (18–64 years, without diabetes), older adults (≥65 years, without diabetes), and those with diabetes (≥18 years). Interventions Patients were randomized within strata to either (1) pre-commitment reminder alone (1 message, mid-October), (2) pre-commitment + loss frame messages, (3) pre-commitment + gain frame messages, (4) loss frame messages alone, (5) gain frame messages alone, or (6) standard of care control. Patients in the pre-commitment group were sent a message in mid-October, asking if they planned on getting an influenza vaccination. Patients in loss or gain frame groups were sent up to 3 portal reminders (late October, November, and December, if no documented influenza vaccination in the EHR) about importance and safety of influenza vaccine. Main Measures Receipt of 1 influenza vaccine from 10/01/2019 to 03/31/2020. Key Results 196,486 patients (145,166 young adults, 29,795 older adults, 21,525 adults with diabetes) were randomized. Influenza vaccination rates were as follows: for young adults 36.8%, for older adults 55.6%, and for diabetics 60.6%. On unadjusted and adjusted (for age, gender, insurance, race, ethnicity, and prior influenza vaccine history) analyses, influenza vaccination rates were not statistically different for any study group versus control. Conclusions Patient reminders sent by a health system’s patient portal that were tailored to patient demographics (young adults, older adults, diabetes) and that incorporated two behavioral economic messaging strategies (pre-commitment and loss/gain framing) were not effective in raising influenza vaccination rates. Trial Registration This trial was registered with ClinicalTrials.gov (NCT04110314).

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.

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.

Introduction: Many published accounts have shown that quality improvement (QI) initiatives within medical practice settings can increase vaccination rates. Project ECHO is a telementoring platform that uses video conferencing technology to educate and support healthcare professionals through case-based learning and brief lectures. This manuscript explores the results of a learning collaborative focused on combining QI and Project ECHO to increase human papillomavirus (HPV) vaccination rates within pediatric practices. Methods: The American Academy of Pediatrics (AAP) recruited 3 AAP chapters that then recruited individual pediatricians and their practices for participation. Participants responded to surveys regarding chapter and pediatrician experience and satisfaction. Impact on HPV immunization rates (HPV initiation, series completion, and missed opportunities to vaccinate during visits) was measured using practice reports of chart reviews to AAP’s data aggregator, which produced run charts. Results: Thirty-four pediatricians within 8 practices completed the project; 1 practice withdrew. Physicians self-reported increased confidence in communicating with vaccine-hesitant families and implementing QI activities. We analyzed practice run charts utilizing QI run chart rules and found nonrandom change towards improvement for aggregate missed opportunities to vaccinate but not for HPV vaccine initiation or series completion. Conclusions: An HPV QI learning collaborative improved participant confidence in HPV vaccine communication and QI skills and decreased missed opportunities to vaccinate. Future projects should consider a more extended project period or more frequent data collection to reduce data variability to make it easier to spot nonrandom changes.

Objective Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. Methods Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. Measures: outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. Intervention: providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. Analyses: chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. Results MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). Conclusions Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery.

Importance Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. Objectives To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. Design, Setting, and Participants From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. Interventions Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. Main Outcomes and Measures Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. Results Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (−2.4%; 95% CI, −3.5% to −1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (−6.8%; 95% CI, −9.7% to −3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. Conclusions and Relevance This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. Trial Registration ClinicalTrials.gov Identifier:NCT03599557

Objective Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals, but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. Methods Practices with at least 50 patients 11–17 years old with estimated vaccination rates less than national goals, were assigned to intervention (n = 11) and control (n = 11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013–6/30/2014 and 7/1/2014–3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015–16. Results Among the cohort of 10,861 adolescent patients, 38% were 11–13 years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9 months, the intervention sites increased HPV initiation 10.2 PP compared with 7.3 PP in control sites ( P 10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR = 2.06, 95% CI = 1.43, 2.96). Conclusions Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents. Clinical trial registry number: NCT02165722 .

Becoming a Responsible Teen (BART) is a community-based, HIV risk reduction curriculum shown to increase safer sex behaviors among African American adolescents. However, BART does not address common barriers to sexual health care access, which may limit program efficacy. We used a community-engaged adaptation process to maximize program relevance and health outcomes by incorporating a broad ecological perspective. Adolescent and staff advisory boards at a community-based organization recommended modifications (e.g., delete references to Kwanzaa, update language, localize incentives) and supported inclusion of critical on-site health services, such as sexually transmitted infection testing and condom provision. We conducted a trial of adapted BART (one session/week for 8 weeks) with 36 adolescents at two community organizations (mean age = 15.5 years, 52% female; 61% reported previous sexual intercourse). Most received on-site sexually transmitted infection testing (61%) and condoms (70%). Adolescents demonstrated significant improvements in self-efficacy for safer sexual practices (p < .02), AIDS risk knowledge (p < .001), condom knowledge (p < .001), and condom attitudes (p < .04). Adolescents and staff were satisfied with the revised curriculum and found on-site services acceptable. Based on improvements in constructs influencing behavior and the successful delivery of services essential for optimal health, future studies to assess efficacy and sustainability of the adapted curriculum appear warranted.

Objective To evaluate the effect of different modalities of centralized reminder/recall (autodialer, text, mailed reminders) on increasing childhood influenza vaccination. Study design Two simultaneous randomized clinical trials conducted from October 2017 to April 1, 2018, in New York State and Colorado. There were 61 931 children in New York (136 practices) and 23 845 children in Colorado (42 practices) who were randomized to different centralized reminder/recall modalities—4 arms in New York (autodialer, text, mailed, and no reminder control) and 3 arms in Colorado (autodialer, mailed, and no reminder control). The message content was similar across modalities. Up to 3 reminders were sent for intervention arms. The main outcome measure was receipt of ≥1 influenza vaccine. Results In New York, compared with the control arm (26.6%), postintervention influenza vaccination rates in the autodialer arm (28.0%) were 1.4 percentage points higher (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10), but the rates for text (27.6%) and mail (26.8%) arms were not different from controls. In Colorado, compared with the control arm (29.9%), postintervention influenza vaccination rates for the autodialer (32.9%) and mail (31.5%) arms were 3.0 percentage points (adjusted risk ratio, 1.08; 95% CI, 1.03-1.12) and 1.6 percentage points (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10) higher, respectively. Compared with the control arm, the incremental cost per additional vaccine delivered was $20 (New York) and $16 (Colorado) for autodialer messages. Conclusions Centralized reminder/recall for childhood influenza vaccine was most effective via autodialer, less effective via mail, and not effective via text messages. The impact of each modality was modest. Compared with no reminders, the incremental cost per additional vaccine delivered was also modest for autodialer messages. Trial registration ClinicalTrials.gov : NCT03294473 and NCT03246100 .

Background Studies have noted variations in the cost-effectiveness of school-located influenza vaccination (SLIV), but little is known about how SLIV’s cost-effectiveness may vary by targeted age group (e.g., elementary or secondary school students), or vaccine consent process (paper-based or web-based). Further, SLIV’s cost-effectiveness may be impacted by its spillover effect on practice-based vaccination; prior studies have not addressed this issue. Methods We performed a cost-effectiveness analysis on two SLIV programs in upstate New York in 2015–2016: (a) elementary school SLIV using a stepped wedge design with schools as clusters (24 suburban and 18 urban schools) and (b) secondary school SLIV using a cluster randomized trial (16 suburban and 4 urban schools). The cost-per-additionally-vaccinated child (i.e., incremental cost-effectiveness ratio (ICER)) was estimated by dividing the incremental SLIV intervention cost by the incremental effectiveness (i.e., the additional number of vaccinated students in intervention schools compared to control schools). We performed deterministic analyses, one-way sensitivity analyses, and probabilistic analyses. Results The overall effectiveness measure (proportion of children vaccinated) was 5.7 and 5.5 percentage points higher, respectively, in intervention elementary (52.8%) and secondary schools (48.2%) than grade-matched control schools. SLIV programs vaccinated a small proportion of children in intervention elementary (5.2%) and secondary schools (2.5%). In elementary and secondary schools, the ICER excluding vaccine purchase was $85.71 and $86.51 per-additionally-vaccinated-child, respectively. When additionally accounting for observed spillover impact on practice-based vaccination, the ICER decreased to $80.53 in elementary schools -- decreasing substantially in secondary schools. (to $53.40). These estimates were higher than the published practice-based vaccination cost (median = $25.50, mean = $45.48). Also, these estimates were higher than our 2009–2011 urban SLIV program mean costs ($65) due to additional costs for use of a new web-based consent system ($12.97 per-additionally-vaccinated-child) and higher project coordination costs in 2015–2016. One-way sensitivity analyses showed that ICER estimates were most sensitive to the SLIV effectiveness. Conclusions SLIV raises vaccination rates and may increase practice-based vaccination in primary care practices. While these SLIV programs are effective, to be as cost-effective as practice-based vaccination our SLIV programs would need to vaccinate more students and/or lower the costs for consent systems and project coordination. Trial Registration ClinicalTrials.gov NCT02227186 (August 25, 2014), updated NCT03137667 (May 2, 2017). Electronic supplementary material The online version of this article (10.1186/s12913-019-4228-5) contains supplementary material, which is available to authorized users.

Human papillomavirus (HPV) vaccination rates are well below the Healthy People 2020 goal of 80%. Vaccinating in settings other than primary care, such as local health departments (LHDs), may help achieve higher HPV immunization rates. We tested the effect of a quality improvement (QI) collaborative to reduce missed opportunities (MOs) for HPV vaccine in LHDs. Between 2016 and 2019, we conducted four consecutive cohorts of a virtual QI collaborative at 24 LHDs across multiple states. Participants were trained on topics including how to provide an effective recommendation for HPV vaccine, strategies to reduce MOs, and motivational interviewing. Throughout the 6-month project implementation, LHDs tested strategies to reduce MOs through Plan-Do-Study-Act cycles, performed chart reviews to identify and characterize MOs, and received feedback reports to assess progress on MOs. HPV vaccination rates were assessed pre- and post-intervention. LHDs reduced MOs for HPV vaccine in all four cohorts with aggregated data showing a 25.3 percentage point reduction in MOs. Modified Poisson regression analysis found a 44% reduction in the relative risk of missing the opportunity for an HPV vaccine at a visit (RR = 0.56, 0.46-0.68, p .001). This project shows that strategies effective in reducing MO for HPV vaccine in primary care settings are also effective in LHD settings. Training LHD staff on these strategies may help the U.S. approach national goals for HPV vaccine coverage.

IMPORTANCE: Influenza vaccination rates across the US are low. Because few practices send patient reminders for influenza vaccination, a scalable patient reminder system is needed. OBJECTIVE: To evaluate the effect of patient reminders sent via a health care system’s electronic health record patient portal on influenza vaccination rates. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, 4-arm randomized clinical trial was performed from October 1, 2018, to March 31, 2019, across the UCLA (University of California, Los Angeles) health care system. A total of 164 205 patients in 52 primary care practices who had used the patient portal within 12 months were included. INTERVENTIONS: Patients due for an influenza vaccine were sent a letter via the patient portal of the health care system reminding them about the importance of influenza vaccination, safety of the vaccine, and morbidity associated with influenza. Patients were randomized within primary care practices to 1 of 4 study groups (no reminder [n = 41 070] vs 1 reminder [n = 41 055], 2 reminders [n = 41 046], or 3 reminders [n = 41 034]). MAIN OUTCOMES AND MEASURES: The primary outcome was receipt of 1 or more influenza vaccines as documented in the electronic health record, which was supplemented with influenza vaccination data from external sources (eg, pharmacies). Secondary outcomes were influenza vaccination rates among subgroups and influenza vaccinations self-reported by patients in reply to the portal-based query as having been received elsewhere. RESULTS: A total of 164 205 patients (mean [SD] age, 46.2 [19.6] years; 95 779 [58.3%] female) were randomly allocated to 1 of the 4 study arms. In the primary analysis across all ages and not including patient self-reported vaccinations in reply to portal reminders, influenza vaccination rates were 37.5% for those receiving no reminders, 38.0% for those receiving 1 reminder (P = .008 vs no reminder), 38.2% for those receiving 2 reminders (P = .03 vs no reminder), and 38.2% for those receiving 3 reminders (P = .02 vs no reminder). In the secondary analysis not including patient self-reported vaccinations, among adults aged 18 to 64 years (vaccination rates: 32.0% in the control group, 32.8% in the 1-reminder group, 32.8% in the 2-reminder group, and 32.8% in the 3-reminder group; P = .001), male patients (vaccination rates: 37.3% vs 38.3%, 38.6%, and 38.8%; P = .001), non-Hispanic patients (vaccination rates: 37.6% vs 38.2%, 38.3%, and 38.2%; P = .004), and those who were not vaccinated in the prior 2 years (vaccination rates: 15.3% vs 15.9%, 16.3%, and 16.1%; P < .001), vaccination rates were higher in the portal reminder groups than in the control group; the findings in these 3 subgroups mirrored the findings in the entire population. When self-reported vaccinations received elsewhere were included, influenza vaccination rates were 1.4 to 2.9 percentage points higher in the portal reminder groups, with a dose-response effect (0 reminders: 15 537 [37.8%]; 1 reminder: 16 097 [39.2%]; 2 reminders: 16 426 [40.0%]; and 3 reminders: 16 714 [40.7%]; P

This article was migrated. The article was not marked as recommended. Background: Vaccine education during residency is not standardized. Little is known about resident perspectives on vaccines and ideal vaccine training. Methods: A convenience sample of pediatric and family medicine (FM) residents were surveyed using a de novo 22 question survey to understand perspectives on vaccines and current and preferred vaccine education curriculum. Responses were analyzed categorically and compared by resident year using Fisher's Exact test. Results: In October 2016, 126 residents from 9 pediatric and FM programs completed the survey. Resident respondents' training levels varied. Most were 25-29 years old and female. High familiarity with vaccines and agreeing to defer recommended vaccine(s) increased with additional years of training (p

BACKGROUND AND OBJECTIVES: Human papillomavirus (HPV) vaccination rates lag behind vaccination rates for other adolescent vaccines; a bundled intervention may improve HPV vaccination rates. Our objective is to evaluate the impact of quality improvement (QI) training plus a bundled practice-based intervention (provider prompts plus communication skills training plus performance feedback) on improving HPV vaccinations in pediatric resident continuity clinics. METHODS: Staff and providers in 8 resident clinics participated in a 12-month QI study. The intervention included training to strengthen provider communication about the HPV vaccine. Clinics also implemented provider prompts, received monthly performance feedback, and participated in learning collaborative calls. The primary outcome measure was eligible visits with vaccination divided by vaccine-eligible visits (captured HPV vaccination opportunities). Practices performed chart audits that were fed into monthly performance feedback on captured HPV vaccination opportunities. We used conditional logistic regression (conditioning on practice) to assess captured vaccination opportunities, with the time period of the study (before and after the QI intervention) as the independent variable. RESULTS: Overall, captured opportunities for HPV vaccination increased by 16.4 percentage points, from 46.9% to 63.3%. Special cause was demonstrated by centerline shift, with 8 consecutive points above the preintervention mean. On adjusted analyses, patients were more likely to receive a vaccine during, versus before, the intervention (odds ratio: 1.87; 95% confidence interval: 1.54–2.28). Captured HPV vaccination rates improved at both well-child and other visits (by 11.7 and 13.0 percentage points, respectively). CONCLUSIONS: A bundled intervention of provider prompts and training in communication skills plus performance feedback increased captured opportunities for HPV vaccination.

Background Only half of US schoolchildren receive influenza vaccine. School-located influenza vaccination (SLIV) might raise vaccination rates but conducting flu vaccine clinics at schools is challenging to implement. We compared 2 school-based programs designed to raise influenza vaccination rates: parent reminder/educational messages sent to parents from schools which is a low-intensity intervention vs the combination of reminder/educational messages plus SLIV clinics which is a high-intensity intervention. Methods We assigned 36 schools (6 school districts, 2 per group) to 3 groups: (1) control, ie, no SLIV and no parent reminder/education, (2) parent reminder/education emailed by schools, and (3) parent reminder/education plus SLIV clinics. Some schools had SLIV clinics in prior years. Health department nurses conducted SLIV clinics. Results Among 24,832 children at 36 schools, vaccination rates were control (51.3%), parent reminder/education-only (41.2%), and reminder/education + SLIV (58.7%). On multivariate analyses which controlled for vaccination in prior seasons, children in reminder/education + SLIV schools had higher vaccination rates (OR 1.27, 95% CI 1.10-1.47), but children in reminder/education-only schools had lower rates (OR 0.87, 95% CI 0.75-1.00) than children in control schools. Conclusions Parent reminder/education combined with SLIV clinics raise vaccination rates, but parent reminder/education alone does not.

Purpose We evaluated a managed care organization (MCO)–generated text message reminder–recall system designed to improve human papillomavirus (HPV) vaccination coverage. Methods We conducted a randomized controlled trial of text reminder–recall for parents of 3,812 publicly insured adolescents aged 11–16 years with no prior HPV vaccinations who were enrolled in a single MCO and were patients at one of 39 primary care practices. We determined the rate of HPV receipt for intervention versus control with the Kaplan–Meier failure function and determined hazard ratios using a clustered stratified Cox model, clustering on primary care provider and stratified on practice. We examined results for all subjects, and for those with a valid phone number, stratified by age group (11–13 years and 14–16 years) and gender. A post hoc analysis included all subjects and controlled for age and gender. Results HPV dose 1 vaccination rates were not significantly different when all participants were included, but for the subset of parents (54%) able to receive messages, HPV dose 1 rates were 13% for the control group and 16% for the intervention group; hazard ratio, 1.3 (95% confidence interval, 1.0–1.6; p = .04), when controlling for age and gender. There were no significant findings in the analysis stratified by age and gender. Conclusions MCO-based text reminders are feasible and have a modest effect on HPV dose 1 vaccination rates for those parents able to receive text messages with valid phone numbers in the MCO database. Future studies should examine a similar intervention for those parents who already accepted the first HPV vaccine dose.

Objective Adolescent immunization rates are suboptimal. Experts recommend provider prompts at health care visits to improve rates. We assessed the impact of either electronic health record (EHR) or nurse- or staff-initiated provider prompts on adolescent immunization rates. Methods We conducted a randomized controlled trial, allocating practices in 1 of 2 practice-based research networks (PBRN) to provider prompts or standard-of-care control. Ten primary care practices participated, 5 intervention and 5 controls, each matched in pairs on urban, suburban, or rural location and practice type (pediatric or family medicine), from a PBRN in Greater Rochester, New York (GR-PBRN); and 12 practices, 6 intervention, 6 controls, similarly matched, from a national pediatric continuity clinic PBRN (CORNET). The study period was 1 year per practice, ranging from June 2011 to January 2013. Study participants were adolescents 11 to 17 years attending these 22 practices; random sample of chart reviews per practice for baseline and postintervention year to assess immunization rates (n = 7,040 total chart reviews for adolescents with >1 visit in a period). The intervention was an EHR prompt (4 GR-PBRN and 5 CORNET practice pairs) (alert) that appeared on providers' computer screens at all office visits, indicating the specific immunizations that adolescents were recommended to receive. Staff prompts (1 GR-PBRN pair and 1 CORNET pair) in the form of a reminder sheet was placed on the provider's desk in the exam room indicating the vaccines due. We compared immunization rates, stratified by PBRN, for routine vaccines (meningococcus, pertussis, human papillomavirus, influenza) at study beginning and end. Results Intervention and control practices within each PBRN were similar at baseline for demographics and immunization rates. Immunization rates at the study end for adolescents who were behind on immunizations at study initiation were not significantly different for intervention versus control practices for any vaccine or combination of vaccines. Results were similar for each PBRN and also when only EHR-based prompts was assessed. For example, at study end, 3-dose human papillomavirus vaccination rates for GR-PBRN intervention versus control practices were 51% versus 53% (adjusted odds ratio 0.96; 95% confidence interval 0.64–1.34); CORNET intervention versus control rates were 50% versus 42% (adjusted odds ratio 1.06; 95% confidence interval 0.68–1.88). Conclusions and Relevance: In both a local and national setting, provider prompts failed to improve adolescent immunization rates. More rigorous practice-based changes are needed.

OBJECTIVE This study aimed to determine the prevalence of Chlamydia trachomatis, Neisseria gonorrheae, and Trichomonas vaginalis and to describe factors associated with sexually transmitted infection (STI) in a pediatric emergency department (ED). METHODS Adolescents aged 14 to 19 years presenting to a Midwestern pediatric ED were asked to provide urine for STI testing and complete a survey about previous sexual activity (PSA), high-risk behaviors, demographics, and visit reason (reproductive: genitourinary complaints, abdominal pain, or a female with vomiting). Comparisons between subgroups were analyzed using Χ test. RESULTS Among 200 subjects (64% of approached), mean age was 15.6 years; 63% were female. Eleven subjects (6%; 95% confidence interval, 2.3-8.7) tested positive for 1 or more STIs: 10 for C. trachomatis (one denied PSA), 3 for T. vaginalis (all coinfected with C. trachomatis), and 1 for N. gonorrheae. Half reported PSA; of these, 71% reported 1 or more high-risk behaviors, most commonly first sex before the age of 15 years (51%) and no condom at last sex (42%). Among those with PSA and nonreproductive visit (n = 73), 11.0% had 1 or more STIs (95% confidence interval, 3.4-18.1). Two factors were associated with greater likelihood of positive STI test result, namely, reporting PSA versus no PSA (10% vs 1%, P = 0.005) and last sex within 1 month or less versus more than 1 month (20% vs 0%, P = 0.001). In this sample, none of the following characteristics were associated with STI: insurance, race, high-risk behaviors, age, or ED visit reason. CONCLUSIONS Approximately 1 in 10 sexually active adolescent ED patients without reproductive complaints had 1 or more STIs. This suggests the need for strategies to increase STI testing for this population.

OBJECTIVE: Although emergency department (ED) visits offer an opportunity to deliver brief behavioral interventions to improve health, provision of ED-based interventions targeting adolescent sexual health is uncommon. The objectives for this study were to evaluate the feasibility and preliminary effects of a novel sexual health service intervention for adolescents. METHODS: In this cross-sectional feasibility study, sexually active patients aged 14 to 19 years presenting to a Midwestern pediatric ED were recruited to receive an intervention to improve sexual health. The intervention, based on motivational interviewing (MI), included agenda setting, exploration of behaviors, a decisional balance exercise, tailored feedback, and provision of personalized health services (including condoms, prescription for emergency contraception, urine testing for Chlamydia trachomatis and Neisseria gonorrheae, and referral to the hospital-affiliated adolescent clinic). Data were collected before and after intervention administration and at a 3-month follow-up telephone interview. Surveys assessed sexual risk behaviors, satisfaction with the intervention, health care use, and demographics. Feasibility criteria were (1) subject-rated interventionist fidelity to MI principles (Likert scale 1 [strongly agree] to 4 [strongly disagree]), (2) subject satisfaction (Likert scale 1 [not at all] to 5 [very]), and (3) session duration (minutes, recorded by the interventionist). A secondary outcome was the proportion of subjects who completed at least 1 health service. Services provided at the adolescent clinic were determined by an electronic medical record review. Comparisons of responses between sex subgroups were analyzed using Χ test. RESULTS: From August to November 2012, 69 adolescents were approached, 66 (96%) completed the screening survey, and 24 (37%) reported previous sexual activity. Of those, 20 (83%) agreed to participate. The mean (SD) age was 16.2 (1.4) years; 60% were female. Most (78%) reported that the interventionist maintained high fidelity to MI principles and most (80%) were very satisfied with the intervention. Mean (SD) intervention length was 15.7 (2.2) minutes. Most subjects (65%) accepted 1 or more health services, including 42% who completed clinic follow-up. In the ED or the referral clinic, the following services were provided to the subjects: condoms (n = 11), emergency contraception prescription (n = 5), C. trachomatis/N. gonorrheae testing (n = 4), hormonal birth control provision (n = 2), and human immunodeficiency virus testing (n = 3). Fifteen subjects (75%) were reached for the 3-month follow-up, and condom use was maintained by 67% of those reporting sexual activity. CONCLUSIONS: This study demonstrated the feasibility and potential utility of an MI-based service navigation intervention to connect youth with point-of-care services as well as resources for ongoing sexual health needs. Language: en

Background Influenza vaccination rates among children are low and novel strategies are needed to raise coverage. We measured the impact of school-located influenza vaccination (SLIV) on coverage, examined whether SLIV substitutes for practice-based influenza vaccination (“substitution”), and estimated whether a second year of experience with SLIV increases its impact. Methods We implemented a stepped wedge study design with schools as clusters. In Year 1, we randomly allocated schools to SLIV or control. In Year 2, all schools performed SLIV. We used emails (suburban schools) or backpack fliers (both urban and suburban schools) to notify parents, and offered web-based (suburban) or paper-based vaccination (urban) consent forms. Local health department nurses administered SLIV vaccinations and billed insurers. We analyzed state immunization registry data to measure influenza vaccination rates. Results 42 schools (38,078 children) participated over 2 years. Overall vaccination rates were 5 and 7 percentage points higher among SLIV- school children versus control-school children in suburban (aOR 1.36, 95% CI 1.25–1.49 in Years 1–2 SLIV vs. Year 1 control schools) and urban schools (aOR 1.22, 95% CI 1.10–1.36), respectively, adjusting for prior year’s vaccination and other covariates. While no substitution occurred among children attending suburban schools, some substitution occurred among children attending urban schools, although overall vaccination rates were still higher in urban schools due to SLIV. Compared to an initial year of SLIV, more children were vaccinated in a second year of SLIV at urban (8.3% vs. 6.8%, aOR 1.24, 95% CI 1.04–1.47) but not suburban schools (3.5% vs. 2.7%, aOR 1.24, 95% CI 0.98–1.57). Conclusions In this stepped wedge trial, SLIV increased overall influenza vaccination rates in suburban and urban schools. Some substitution for primary care vaccination occurred in urban settings. A second year of SLIV expanded its reach slightly in urban schools.

Venipuncture, including peripheral intravenous catheter (IV) placement, is the leading cause of procedural pain in pediatric hospitals and emergency departments (EDs). Needle-free Jet Injection of Lidocaine Device (NJILD; J-Tip) has been demonstrated to be superior to other topical anesthetics in controlling IV-related pain. The rapid action and cost-effectiveness make it suitable for ED use. However, J-Tip was used with only 11% of IV placements at our ED. Our objectives were to: 1) use a quality improvement (QI) intervention to increase …

We aimed to evaluate the effect of school-located influenza vaccination (SLIV) on adolescents' influenza vaccination rates.In 2015-2016, we performed a cluster-randomized trial of adolescent SLIV in middle/high schools. We selected 10 pairs of schools (identical grades within pairs) and randomly allocated schools within pairs to SLIV or usual care control. At eight suburban SLIV schools, we sent parents e-mail notifications about upcoming SLIV clinics and promoted online immunization consent. At two urban SLIV schools, we sent parents (via student backpack fliers) paper immunization consent forms and information about SLIV. E-mails were unavailable at these schools. Local health department nurses administered nasal or injectable influenza vaccine at dedicated SLIV clinics and billed insurers. We compared influenza vaccination rates at SLIV versus control schools using school directories to identify the student sample in each school. We used the state immunization registry to determine receipt of influenza vaccination.The final sample comprised 17,650 students enrolled in the 20 schools. Adolescents at suburban SLIV schools had higher overall influenza vaccination rates than did adolescents at control schools (51% vs. 46%, p .001; adjusted odds ratio = 1.27, 95% confidence interval 1.18-1.38, controlling for vaccination during the prior two seasons). No effect of SLIV was noted among urbanschools on multivariate analysis. SLIV did not substitute for vaccinations in primary care or other settings; in suburban settings, SLIV was associated with increased vaccinations in primary care or other settings (adjusted odds ratio = 1.10, 95% confidence interval 1.02-1.19).SLIV in this community increased influenza vaccination rates among adolescents attending suburban schools.

To report the results of an intervention using the 4 Pillars™ Practice Transformation Program (4 Pillars™ Program) to increase adolescent vaccinations including human papillomavirus vaccine (HPV) and influenza vaccines, which remain underutilized in this population.Eleven pediatric and family medicine practices, previously control sites from a randomized controlled cluster trial, with ≥50 adolescent patients participated. The 4 Pillars™ Program was the foundation of the intervention. De-identified demographic, office visit and vaccination data were derived from electronic medical record extractions for patients whose date of birth was 4/1/1997 to 4/1/2004 (ages 11-17years at baseline). Vaccination rates for HPV, influenza, tetanus-pertussis-diphtheria (Tdap) and meningococcal (MenACWY) vaccines were determined for all eligible patients pre- and post intervention (i.e., vaccination rates on 4/1/2015 and 4/30/2016).Among 9473 patients ages 11-17years at baseline (4/1/2015), mean pre-intervention vaccination rates for HPV initiation and completion, meningococcal, Tdap and influenza vaccines were below national levels. Rates increased significantly post intervention (P0.001) for HPV initiation which increased 17.1 percentage points (PP) from 51.4%; HPV completion increased 14.8PP from 30.7%, meningococcal vaccine uptake increased 16.6PP from 79.1%, Tdap vaccine uptake increased 14.6PP from 76.9%. Influenza vaccine uptake did not increase significantly (2.3PP from 40.1%). In the regression using generalized estimating equations, odds of vaccination were higher for younger, non-white adolescents for all vaccines; being in a smaller practice decreased the odds of Tdap vaccination but increased the odds of influenza vaccination.Clinically and statistically significant improvements in HPV series initiation and completion, and meningococcal and Tdap vaccinations were observed in primary care practices implementing the 4 Pillars™ Practice Transformation Program. Clinical Trial Registry Number: NCT02165722.

Patient navigation is increasingly employed to guide patients through cancer treatment. We assessed the elements of navigation that promoted patients’ involvement in treatment among patients with breast and colorectal cancer that participated in a navigation study. We conducted qualitative analysis of 28 audiotaped and transcribed semi-structured interviews of navigated and unnavigated cancer patients. Themes included feeling emotionally and cognitively overwhelmed and desire for a strong patient-navigator partnership. Both participants who were navigated and those who were not felt that navigation did or could help address their emotional, informational, and communicational needs. The benefits of logistical support were cited less often. Findings underscore the salience of personal relationships between patients and navigators in meeting patients’ emotional and informational needs.

Background Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. Purpose Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. Design In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. Setting/participants Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). Intervention After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. Main outcome measures Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009–2010) and Year 2 (2010–2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. Results Results are shown for 2009–2010 and 2010–2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% ( p p p p Conclusions Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. Trial Registry ClinicalTrials.govNCT01224301

This article was migrated. The article was marked as recommended. Vaccine education for pediatric and family medicine residents is inadequate. Implementation of evidence-based instructional design methods for medical education is understudied. We conducted four focus groups with residents who had completed a novel immunization curriculum to explore their satisfaction with design, content and impact on confidence. Data were analyzed using thematic content analysis. Overall satisfaction with the curriculum was high. Residents valued the interactive design and content, reported improvement in confidence in discussing vaccines with parents, and shared recommendations for future iterations of the modules. Technical challenges were reported with the learning management system. Medical education modules developed using best practices in instructional design were well-liked by trainees and future modules should be developed using these principles.

OBJECTIVES: The objective of this study was to describe sexual health behaviors as well as prior use of and preferences for sexual health services among adolescents in the pediatric emergency department (ED). METHODS: In this cross-sectional study subjects aged 14 to 19 years who presented to an urban or suburban ED from a single Midwestern hospital system completed a written survey. The survey included questions on previous sexual activity high-risk behaviors (first sex before age 15 years no condom at last sex substance use at last sex >3 partners in past 3 months and >4 lifetime partners) and sexual health service use and preferences. Comparisons of responses between subgroups were analyzed using chi2 test. Multiple logistic regression was used to identify factors associated with high-risk behaviors. Care preferences were scored using a 4-point Likert scale; mean scores were ranked. RESULTS: Subjects included 306 adolescents (85% of approached). The mean age was 15.5 years. Almost half (45%) reported previous sexual activity and of those 63% reported 1 or more high-risk behaviors (most commonly first sex before age 15 years [43%] and no condom at last sex [29%]). Almost all wanted to prevent pregnancy but only one third received birth control counseling before sexual debut and 14% reported no contraception at last sex. Younger age was associated with 1 or more high-risk behaviors (odds ratio 3.7; confidence interval 1.39-9.84). Preferences for care included caring knowledgeable providers and low/no cost. CONCLUSIONS: Because of high prevalence of high-risk behaviors among adolescents presenting in the ED strategies should be developed to link these patients to comprehensive sexual health care.

During influenza season, acute respiratory illness due to influenza is difficult to distinguish from other influenza-like illnesses, but testing should be reserved for situations when timely results will influence management or infection control measures. Immunization status and timing of disease onset notwithstanding, a neuraminidase inhibitor should be offered immediately for certain high-risk children; neuraminidase inhibitor treatment should be considered if shorter illness is warranted or an at-risk sibling may be protected. Antipyretics and cough control may be useful. Immunization with an age-appropriate dose of an inactivated influenza vaccine is the cornerstone of prevention for health care personnel and our patients.

BACKGROUND AND OBJECTIVE: Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement–related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months. METHODS: We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis. RESULTS: JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ21degrees of freedom = 0.33, P = .56), with no significant difference in the success at IV placement. CONCLUSIONS: We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

OBJECTIVE: Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children. METHODS: We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014–2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control). Parents of children at SLIV schools were sent information and vaccination consent forms via e-mail, backpack fliers, or both (depending on school preferences) regarding school vaccine clinics. Health department nurses conducted vaccine clinics and billed insurers. For all children registered at SLIV/control schools, we compared receipt of influenza vaccination anywhere (primary outcome). RESULTS: The 44 schools served 19 776 eligible children in 2014–2015. Children in SLIV schools had higher influenza vaccination rates than children in control schools county-wide (54.1% vs 47.4%, P < .001) and in suburban (61.9% vs 53.6%, P < .001) and urban schools (43.9% vs 39.2%; P < .001). Multivariate analyses (controlling for age, grade, vaccination in previous season) confirmed bivariate findings. Among parents who consented for SLIV, nearly half of those notified by backpack fliers and four-fifths of those notified by e-mail consented online. In suburban districts, SLIV did not substitute for primary care influenza vaccination. In urban schools, some substitution occurred. CONCLUSIONS: SLIV raised seasonal influenza vaccination rates county-wide and in both suburban and urban settings. SLIV did not substitute for primary care vaccinations in suburban settings where pediatricians often preorder influenza vaccine but did substitute somewhat in urban settings.

Background: There is limited high-quality evidence about the impact of patient navigation (PN) on outcomes for patients with diagnosed cancer. Methods: We pooled data from two sites from the national Patient Navigation Research Program. Patients (n = 438) with newly diagnosed breast (n = 353) or colorectal cancer (n = 85) were randomized to PN or usual care. Trained lay navigators met with patients randomized to PN to help them assess treatment barriers and identify resources to overcome barriers. We used intent-to-treat analysis to assess time to completion of primary treatment, psychologic distress (impact of events scale), and satisfaction (patient satisfaction with cancer-related care) within 3 months after initiation of cancer treatment. Results: The sample was predominantly middle-aged (mean age = 57) and female (90%); 44% were race-ethnic minorities (44%), 46% reported lower education levels, 18% were uninsured, and 9% reported a non-English primary language. The randomized groups were comparable in baseline characteristics. Primary analysis showed no statistically significant group differences in time to completion of primary cancer treatment, satisfaction with cancer-related care, or psychologic distress. Subgroup analysis showed that socially disadvantaged patients (i.e., uninsured, low English proficiency, and non-English primary language) who received PN reported higher satisfaction than those receiving usual care (all P < 0.05). Navigated patients living alone reported greater distress than those receiving usual care. Conclusions: Although the primary analysis showed no overall benefit, the subgroup analysis suggests that PN may improve satisfaction with care for certain disadvantaged individuals. Impact: PN for cancer patients may not necessarily reduce treatment time nor distress. Cancer Epidemiol Biomarkers Prev; 21(10); 1673–81. ©2012 AACR.

Objective. We evaluated the association between parents' beliefs about vaccines, their decision to delay or refuse vaccines for their children, and vaccination coverage of children at aged 24 months. Methods. We used data from 11,206 parents of children aged 24–35 months at the time of the 2009 National Immunization Survey interview and determined their vaccination status at aged 24 months. Data included parents' reports of delay and/or refusal of vaccine doses, psychosocial factors suggested by the Health Belief Model, and provider-reported up-to-date vaccination status. Results. In 2009, approximately 60.2% of parents with children aged 24–35 months neither delayed nor refused vaccines, 25.8% only delayed, 8.2% only refused, and 5.8% both delayed and refused vaccines. Compared with parents who neither delayed nor refused vaccines, parents who delayed and refused vaccines were significantly less likely to believe that vaccines are necessary to protect the health of children (70.1% vs. 96.2%), that their child might get a disease if they aren't vaccinated (71.0% vs. 90.0%), and that vaccines are safe (50.4% vs. 84.9%). Children of parents who delayed and refused also had significantly lower vaccination coverage for nine of the 10 recommended childhood vaccines including diphtheria-tetanus-acellular pertussis (65.3% vs. 85.2%), polio (76.9% vs. 93.8%), and measles-mumps-rubella (68.4% vs. 92.5%). After adjusting for sociodemographic differences, we found that parents who were less likely to agree that vaccines are necessary to protect the health of children, to believe that their child might get a disease if they aren't vaccinated, or to believe that vaccines are safe had significantly lower coverage for all 10 childhood vaccines. Conclusions. Parents who delayed and refused vaccine doses were more likely to have vaccine safety concerns and perceive fewer benefits associated with vaccines. Guidelines published by the American Academy of Pediatrics may assist providers in responding to parents who may delay or refuse vaccines.

1. Anne F. Brayer, MD* 2. Sharon G. Humiston, MD, MPH* 1. *Associate Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine and Pediatrics, University of Rochester, Rochester, NY. After completing this article, readers should be able to: 1. Describe the epidemiology of meningococcal disease, including predisposing host and environmental factors. 2. Recognize early and key clinical features of meningococcal meningitis and severe meningococcal sepsis. 3. Know current treatment guidelines for invasive meningococcal disease. 4. Identify the most common complications and prognosis for meningococcal disease. 5. Be familiar with current vaccination recommendations in the United States. Neisseria meningitidis remains a serious bacterial threat to the well-being of children. Since the introduction of immunization against Haemophilus influenzae and Streptococcus pneumoniae, the risk of serious illness from these organisms has decreased sharply among immunized children, and it is hoped that widespread use of meningococcal conjugate vaccine will lead to the same outcome. The meningococcus causes a variety of disease entities, but this review focuses primarily on its two major manifestations: severe meningococcal septicemia (SMS), sometimes confusingly called “meningococcemia,” and meningococcal meningitis (MM). ### Prevalence Annually, meningococcal disease has affected as many as 3,000 people in the United States. Although outbreaks of illness tend to receive major media attention, fewer than 5% of cases occur during outbreaks. The prevalence of the asymptomatic carrier state varies from less than 2% in children younger than 2 years of age to as high as 10% to 40% among adolescents and young adults. The highest carrier prevalence is among those living in close quarters, such as college students and military recruits. Based on data from the United States Active Bacterial Core Surveillance sites, the estimated average annual incidence of meningococcal disease is 0.53 cases per 100,000 population, with the annual incidence decreasing from 0.92 per 100,000 population in 1998 to 0.33 cases …

Health and health care disparities related to cancer are a major public health problem in the United States. Providing care that is truly patient-centered could address disparities in cancer screening and follow-up through better alignment between patient needs and health care resources available to address those needs. Key health care reforms offer promise for doing so.

Background Healthcare provider immunization education is vital to accurately address concerns regarding vaccines, but such training is not standardized across residency programs. To assess educational needs and develop a vaccine curriculum for pediatric (Peds) and family medicine (FM) residents, the Collaboration for Vaccination Education and Research (CoVER) was established. There is a need to identify knowledge, attitudes, and hesitancy regarding vaccines among residents. Methods In July 2017, an anonymous 30-item survey was sent to residents from 26 US institutions participating in CoVER. Items included (1) vaccine knowledge, (2) attitudes toward vaccines, (3) resident vaccine hesitancy, and (4) demographics. Differences in proportions were calculated using Fisher’s Exact test while the Kruskal–Wallis test was used to compare continuous outcomes. Results Of 1,447 residents invited, 746 completed the survey (52% response rate). Among participants, 12 were excluded due to inability to determine residency type and or year. The final cohort consisted of 734 residents (Table 1). Knowledge (Figure 1): Percent correct increased with residency year from PGY1 to PGY4 (49%, [95% CI 47–51]; 64% [95% CI 58–70]; test for trend P < 0.001). Compared with FM residents, Peds residents were more likely to answer knowledge questions correctly (56%; 49%; P < 0.001). Attitudes (Table 2): Confidence in communicating with parents increased with training (P < 0.001) but confidence in vaccination did not. Hesitancy (Figure 2): Three percent of residents (n = 21) self-reported as vaccine hesitant. They were more likely to be FM (75%, P < 0.001). Residents were more likely to delay a vaccine in someone without a medical contraindication with increased year of training (P < 0.001). Conclusion This initial assessment of the residents’ knowledge, attitudes and hesitancy shows that despite increasing knowledge with training, vaccine confidence was unaffected. It was surprising to find hesitancy among residents, highlighting the need for further vaccine education. Future steps include evaluation of a vaccine education curriculum in residency training to increase confidence in the benefits of vaccination. Disclosures B. Pahud, Pfizer Foundation: Grant Investigator, Research grant. GlaxoSmithKline: Investigator, Salary. Alios Biopharma/Janssen: Investigator, Salary. Pfizer: Consultant, Consulting fee and Speaker honorarium. Sequirus: Consultant, Consulting fee. Sanofi Pasteur: Consultant, Consulting fee. B. R. Lee, PCORI: Grant Investigator, Research grant. KCALSI: Grant Investigator, Research grant. Merck: Investigator, Salary. D. Middleton, Merck: Scientific Advisor, Consulting fee. Pfizer: Scientific Advisor, Consulting fee. GlaxoSmithKline: Scientific Advisor, Consulting fee. Sanofi Pasteur: Scientific Advisor, Consulting fee.

OBJECTIVES: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006–2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years. METHODS: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural). We adjusted these data to obtain national estimates of the total practice cost (in 2006 dollars) for providing 1 influenza vaccination to children aged 6 months to 18 years. RESULTS: Among all respondents, the median total cost per vaccination was $28.62 (interquartile range: $18.67–45.28). The median component costs were as follows: clinical personnel labor costs, $2.01; nonclinical personnel labor costs, $7.96; all other (overhead) costs, $10.43. Vaccine purchase costs averaged $8.22. Smaller practices and urban practices had higher costs than larger or suburban practices. With the assumption of vaccine administration reimbursement for all Vaccines for Children (VFC)-eligible children at the current Medicaid median of $8.40, the financial loss across all US pediatric practices through delivery of VFC vaccines would be $98 million if one third of children received influenza vaccine. CONCLUSION: The total cost for pediatric practices to provide influenza vaccination is high, varies according to practice characteristics, and exceeds the average VFC reimbursement.