Publications by authors named "Lori A Crane"

144 Publications

Design and Effectiveness of the Youth Engaged Strategies for Changing Adolescent Norms! (YES-CAN!) Program for Reducing Skin Cancer Risk.

J Cancer Educ 2022 Jan 7. Epub 2022 Jan 7.

Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13055 East 17th Avenue, Aurora, CO, USA.

Adolescence is a critical period for reducing skin cancer risks, yet the development of effective interventions for middle and high school youth has lagged behind those for younger children. We developed and implemented the "Youth Engaged Strategies for Changing Adolescent Norms!" (YESCAN!) program, a school-based peer leader program that uses a youth-researcher partnership approach and a project-based curriculum to support high school students in developing and delivering short narrative videos and related material about skin cancer prevention to middle school students. Participating middle and high school students completed pre- and post-program surveys assessing skin cancer attitudes, perceived norms, and behavioral intentions. Middle school students (N = 97) reported positive pre- to post-program changes in future intentions to engage in sun protection and reduce UV exposure behaviors and on numerous measures of normative beliefs and attitudes. High school students (N = 13) reported positive changes on a smaller set of behavioral intentions, normative beliefs, and attitudes. These findings add to a growing body of support for youth-participatory, peer-led approaches to adolescent risk reduction in general and to skin cancer risks specifically. The YESCAN! program fills a need for effective skin cancer prevention among adolescents, while at the same time addressing educational objectives to develop 21st Century Skills.
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http://dx.doi.org/10.1007/s13187-021-02121-zDOI Listing
January 2022

US Primary Care Providers' Experiences and Practices Related to Routine Pediatric Vaccination During the COVID-19 Pandemic.

Acad Pediatr 2021 Oct 28. Epub 2021 Oct 28.

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.

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.
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http://dx.doi.org/10.1016/j.acap.2021.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8553366PMC
October 2021

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention.

J Pediatr 2021 12 25;239:81-88.e2. Epub 2021 Aug 25.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.

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 χ 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.
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http://dx.doi.org/10.1016/j.jpeds.2021.08.036DOI Listing
December 2021

Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

Acad Pediatr 2021 Jul 10. Epub 2021 Jul 10.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (MM Cortese, JE Tate, JL St. Pierre, and MC Lindley), Atlanta, Ga.

Background: Rotavirus vaccine (RV) coverage levels for US infants are <80%.

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.
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http://dx.doi.org/10.1016/j.acap.2021.07.003DOI Listing
July 2021

Physician attitudes regarding the Advisory Committee on Immunization Practices Adult Immunization Schedule.

Vaccine 2021 06 2;39(29):3799-3802. Epub 2021 Jun 2.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

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.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.055DOI Listing
June 2021

Physician survey regarding updated PCV13 vaccine recommendations for adults ≥65 years.

J Am Geriatr Soc 2021 09 14;69(9):2612-2618. Epub 2021 May 14.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado, USA.

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.
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http://dx.doi.org/10.1111/jgs.17274DOI Listing
September 2021

Primary Care Physicians' Perspective on Pharmacists Delivering Vaccines to Adults.

J Am Board Fam Med 2021 Mar-Apr;34(2):392-397

From the Department of Pharmacy, Children's Hospital Colorado, Aurora, (CEM); Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora (LPH, STO, JRC, LAC, CG, MB, BLB, AK); Division of General Internal Medicine, Denver Health, Denver, CO (LPH); Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora (STO, JRC, MB, AK); Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora (LAC).

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 physicians' (PCPs) experiences with and attitudes about pharmacists administering vaccinations.

Methods: Internet and mail survey of PCPs representative of American College of Physicians' and American Academy of Family Physicians' 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 physicians' concerns by providing a systematic way for pharmacists and physicians to share patient vaccination histories.
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http://dx.doi.org/10.3122/jabfm.2021.02.200486DOI Listing
September 2021

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018.

J Pediatr 2021 Jul 6;234:149-157.e3. Epub 2021 Mar 6.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.

Objectives: To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time.

Study Design: We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010.

Results: Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001).

Conclusions: Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.
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http://dx.doi.org/10.1016/j.jpeds.2021.03.002DOI Listing
July 2021

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

J Gen Intern Med 2021 08 2;36(8):2283-2291. Epub 2021 Feb 2.

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.

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.
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http://dx.doi.org/10.1007/s11606-020-06456-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342675PMC
August 2021

Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians.

J Gen Intern Med 2021 07 22;36(7):2030-2038. Epub 2021 Jan 22.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.

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 < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016-2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018-2019 influenza season, and 8% recommended LAIV.

Conclusions: Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.
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http://dx.doi.org/10.1007/s11606-020-06397-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298749PMC
July 2021

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates.

Health Serv Res 2021 04 22;56(2):193-203. Epub 2021 Jan 22.

Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA.

Objective: To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race.

Data Sources: Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files.

Study Design: Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument.

Data Collection/extraction Methods: Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011.

Principal Findings: Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses.

Conclusions: Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.
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http://dx.doi.org/10.1111/1475-6773.13627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968942PMC
April 2021

US Primary Care Physicians' Viewpoints on HPV Vaccination for Adults 27 to 45 Years.

J Am Board Fam Med 2021 Jan-Feb;34(1):162-170

From Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO (LPH, STO, LAC, JRC, MB, BLB, CG, AK); Division of General Internal Medicine, Denver Health, Denver, CO (LPH); Department of Pediatrics, Children's Hospital-Colorado, Aurora, CO (STO, JRC, MB, AK); National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA (LEM, EM, MCL); Department of Community and Behavioral Health, University of Colorado Anschutz Medical Campus, Aurora, CO (LAC).

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.
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http://dx.doi.org/10.3122/jabfm.2021.01.200408DOI Listing
August 2021

Policies Among US Pediatricians for Dismissing Patients for Delaying or Refusing Vaccination.

JAMA 2020 09;324(11):1105-1107

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora.

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http://dx.doi.org/10.1001/jama.2020.10658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492908PMC
September 2020

Physicians' Use of Evidence-Based Strategies to Increase Adult Vaccination Uptake.

Am J Prev Med 2020 09 21;59(3):e95-e103. Epub 2020 May 21.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics Children's Hospital Colorado, Aurora, Colorado.

Introduction: This study assesses the following among primary care physicians: (1) the use of evidence-based strategies to improve adult vaccination rates, (2) the number of strategies employed simultaneously, and (3) characteristics associated with assessing adult vaccinations at each visit.

Methods: An internet and mail survey was administered between December 2015 and January 2016 on primary care physicians designed to be representative of the American College of Physicians and American Academy of Family Physicians memberships. Data analysis was conducted in 2019.

Results: The response rate was 66% (617 of 935); 94% reported using electronic health records. Standing orders (84%) and electronic provider reminders at a visit (61%) were the most common strategies reported for influenza vaccine. Electronic provider reminders at a visit (53%) and recording a vaccination in an immunization registry (32%) were the most common strategies reported for all noninfluenza vaccines. Most physicians reported using 2 or more strategies, although this was more common for influenza (74%) than for noninfluenza (62%) vaccines. In multivariable analysis, physicians who reported assessing adult vaccinations at every patient visit were more likely to work in practices where decisions about purchasing and handling vaccines were made at a larger system level (RR=1.20, 95% CI=1.04,1.40), and they reported using electronic provider reminders (RR=1.38, 95% CI=1.15, 1.69) and standing orders (RR=1.45, 95% CI=1.21, 1.75) for all noninfluenza adult vaccines.

Conclusions: Several strategies are being used to increase adult vaccination, particularly for the influenza vaccine. Investment in implementing standing orders and electronic clinical decision support for all routine adult vaccinations could help facilitate assessment of adult vaccinations at each visit and potentially improve adult vaccination rates.
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http://dx.doi.org/10.1016/j.amepre.2020.03.020DOI Listing
September 2020

Use of Standing Orders for Vaccination Among Pediatricians.

Pediatrics 2020 05;145(5)

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado.

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.
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http://dx.doi.org/10.1542/peds.2019-1855DOI Listing
May 2020

Primary care physician support for harmonizing HPV vaccination recommendations across genders - United States, 2018.

Vaccine 2020 05 8;38(21):3699-3701. Epub 2020 Apr 8.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.

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.
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http://dx.doi.org/10.1016/j.vaccine.2020.03.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234803PMC
May 2020

Impact of media reports regarding influenza vaccine on obstetricians' vaccination practices.

Vaccine 2020 04 21;38(18):3474-3479. Epub 2020 Mar 21.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

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.
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http://dx.doi.org/10.1016/j.vaccine.2020.02.051DOI Listing
April 2020

Pediatricians' Experiences With and Perceptions of the Vaccines for Children Program.

Pediatrics 2020 03 21;145(3). Epub 2020 Feb 21.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado.

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 ( = 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.
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http://dx.doi.org/10.1542/peds.2019-1207DOI Listing
March 2020

Primary care physician knowledge, attitudes, and diagnostic testing practices for norovirus and acute gastroenteritis.

PLoS One 2020 14;15(1):e0227890. Epub 2020 Jan 14.

National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States.

Background: Norovirus is a leading cause of acute gastroenteritis (AGE) across the age spectrum; candidate vaccines are in clinical trials. While norovirus diagnostic testing is increasingly available, stool testing may not be performed routinely, which can hamper surveillance and burden of disease estimates. Additionally, lack of knowledge of the burden of disease may inhibit provider vaccine recommendations, which could affect coverage rates and ultimately the impact of the vaccine. Our objectives were to understand physicians' stool testing practices in outpatients with AGE, and physician knowledge of norovirus, in order to improve surveillance and prepare for vaccine introduction.

Methods: Internet and mail survey on AGE, norovirus, and future norovirus vaccines conducted January to March 2018 among national networks of primary care pediatricians, family practice and general internal medicine physicians.

Results: The response rate was 59% (820/1383). During peak AGE season, physicians estimated they ordered stool tests for a median of 15% (interquartile range: 5-33%) of their outpatients with AGE. Stool tests were reported as more often available for ova and parasites, Clostridioides difficile, and bacterial culture (>95% for all specialties) than for norovirus (6-33% across specialties); even when available, norovirus-specific tests were infrequently ordered. Most providers were unaware that norovirus is a leading cause of AGE across all age groups (Pediatricians 80%, Family Practice 86%, General Internal Medicine 89%) or that alcohol-based hand sanitizers are ineffective against norovirus (Pediatricians 51%, Family Practice 66%, General Internal Medicine 62%). Concerns cited as major barriers to implementing a future norovirus vaccine included if the vaccine is not covered by insurance (General Internal Medicine 64%, Pediatricians 67%, Family Practice 74%) and lack of adequate reimbursement for vaccination (Pediatricians 43%, General Internal Medicine 46%, Family Practice 50%). Factors that providers believed were 'not at all a barrier' or 'minor barrier' to new vaccine introduction included the belief that "my patients won't need this vaccine" (General Internal Medicine 78%, Family Practice 86%, Pediatricians 90%) and "my patients already get too many vaccines" (Family Practice 89%, General Internal Medicine 92%, Pediatricians 95%).

Conclusions: Primary care physicians had few concerns regarding future norovirus vaccine introduction, but have knowledge gaps on norovirus prevalence and hand hygiene for prevention. Also, physicians infrequently order stool tests for outpatients with AGE, which limits surveillance estimates that rely on physician-ordered stool diagnostics. Closing physician knowledge gaps on norovirus burden and transmission can help support norovirus vaccine introduction.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0227890PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6959576PMC
April 2020

HPV Vaccine Delivery Practices by Primary Care Physicians.

Pediatrics 2019 10 16;144(4). Epub 2019 Sep 16.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background And Objectives: To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

Methods: We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

Results: The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) ( < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine ( < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

Conclusions: Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.
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http://dx.doi.org/10.1542/peds.2019-1475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297056PMC
October 2019

Ten years of experience with herpes zoster vaccine in primary care- how attitudes and practices have changed and what it may mean for a new zoster vaccine.

Vaccine 2019 09 7;37(37):5509-5512. Epub 2019 Aug 7.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, United States.

Zoster vaccine live (ZVL [Zostavax]) has been recommended for the prevention of herpes zoster (HZ) among immunocompetent adults ≥60 years in the United States since 2008. To examine changes in healthcare providers' perceptions and practices related to HZ disease and vaccination, we administered surveys to national networks of primary care physicians in 2005, 2008, and 2016. Ten years after ZVL was first licensed, physicians were more likely to respond that they perceived HZ as a serious disease and more strongly recommended ZVL, and were less likely to report less likely to report several major barriers to HZ vaccination such as patient cost, vaccine effectiveness and competing medical concerns. Overall, physician attitudes appear to be more favorable towards zoster vaccination after a decade of availability of a HZ vaccine. The new recombinant zoster vaccine (RZV [Shingrix]) may benefit from physician's increased perception of the importance of HZ and HZ vaccination.
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http://dx.doi.org/10.1016/j.vaccine.2019.08.002DOI Listing
September 2019

Survey of Adult Influenza Vaccination Practices and Perspectives Among US Primary Care Providers (2016-2017 Influenza Season).

J Gen Intern Med 2019 10 19;34(10):2167-2175. Epub 2019 Jul 19.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 13123 East 16th Ave, Box 055, Aurora, CO, 80045, USA.

Background: Seasonal influenza vaccination is recommended for all adults; however, little is known about how primary care physicians can communicate effectively with patients about influenza vaccination.

Objective: To assess among general internal medicine (GIM) and family physicians (FP) regarding adult influenza vaccination: (1) recommendation and administration practices, (2) barriers to discussing and perceived reasons for patient refusal, and (3) factors associated with physician self-efficacy in convincing patients to be vaccinated.

Design: Email and mail survey conducted in February-March 2017 PARTICIPANTS: Nationally representative sample of GIM and FP MAIN MEASURES: Factor analysis was used to group similar items for multivariable analysis of barriers and strategies associated with high physician self-efficacy about convincing patients to be vaccinated (defined as disagreeing that they could do nothing to change resistant patients' minds).

Key Results: Response rate was 67% (620/930). Ninety-eight percent always/almost always recommended influenza vaccine to adults ≥ 65 years, 90% for adults 50-64 years, and 75% for adults 19-49 years. Standing orders (76%) and electronic alerts (64%) were the most commonly used practice-based immunization strategies. Frequently reported barriers to discussing vaccination were other health issues taking precedence (41%), time (29%), and feeling they were unlikely to change patients' minds (24%). Fifty-eight percent of physicians reported high self-efficacy about convincing patients to be vaccinated; these providers reported fewer patient belief barriers contributing to vaccine refusal (RR = 0.93 per item; 95% CI (0.89-0.98); Cronbach's α = 0.70), were more likely to report using both fact- (1.08/item; (1.03-1.14); 0.66) and personal experience-based (1.07/item; (1.003-1.15); 0.65) communication strategies, and were more likely to work in practices using patient reminders for influenza vaccine (1.32; (1.16-1.50)).

Conclusions: Physicians identified barriers to successfully communicating about adult influenza vaccination but few effective strategies to counter them. Interventions to promote self-efficacy in communication and under-utilized practice-based immunization strategies are needed.
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http://dx.doi.org/10.1007/s11606-019-05164-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816593PMC
October 2019

The high costs of cheap tanning: pricing and promotional practices of indoor tanning facilities in six cities in the United States.

J Public Health Policy 2019 Dec;40(4):448-458

Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.

Few studies have investigated pricing and promotional practices used by the indoor tanning industry, despite their potential to promote indoor UV tanning-a well-established risk factor for melanoma skin cancer. Posing as potential customers, we telephoned 94 indoor tanning businesses in six United States (U.S.) cities and requested pricing information. The price of a single tanning session ranged from $0 to $23, and was lower at facilities that offered indoor tanning as a secondary service (mean $4.82 and free in 35%) than at tanning salons (mean $16.45). Session prices in salons could be as low as $1.50 with daily use of an unlimited monthly plan. Free indoor tanning, monthly packages, and memberships encourage increased use. Policies that limit free indoor tanning or that restrict pricing and advertising for indoor tanning exist in several places in the U.S. and Europe. Future research should evaluate whether those policies are effective in reducing indoor tanning.
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http://dx.doi.org/10.1057/s41271-019-00175-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900455PMC
December 2019

Vaccination Practices Among Obstetrician/Gynecologists for Non-pregnant Patients.

Am J Prev Med 2019 03;56(3):429-436

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado.

Introduction: 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.

Methods: E-mail and mail surveys were administered July-October 2015, with analyses performed during October-November 2015 and April-June 2018.

Results: 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 by <40% 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 by <30% 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).

Conclusions: 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.
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http://dx.doi.org/10.1016/j.amepre.2018.10.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383792PMC
March 2019

Primary care physicians' perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adults.

Vaccine 2019 01 28;37(4):565-570. Epub 2018 Dec 28.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

Background: Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine.

Methods: We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs.

Results: The response rate was 67% (620/930). Forty-nine percent of respondents (n = 303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n = 317), 73% and 57% responded that in patients ≥ 50 years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%).

Conclusions: Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.
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http://dx.doi.org/10.1016/j.vaccine.2018.12.031DOI Listing
January 2019

Obstetrician-Gynecologists' Strategies to Address Vaccine Refusal Among Pregnant Women.

Obstet Gynecol 2019 01;133(1):40-47

Adult and Child Consortium for Health Outcomes Research and Delivery Science, the Department of Pediatrics, and the Department of Community and Behavioral Health, University of Colorado Anschutz Medical Campus, and Children's Hospital Colorado, Aurora, Colorado; the American College of Obstetricians and Gynecologists, Washington, DC; the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and the Division of General Internal Medicine, Denver Health, Denver, Colorado.

Objective: 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.

Methods: We conducted an email and mail survey among a nationally representative network of ob-gyns from March 2016 to June 2016.

Results: 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.

Conclusion: 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.
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http://dx.doi.org/10.1097/AOG.0000000000003005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411050PMC
January 2019

Primary care physicians' experience with zoster vaccine live (ZVL) and awareness and attitudes regarding the new recombinant zoster vaccine (RZV).

Vaccine 2018 11 26;36(48):7408-7414. Epub 2018 Oct 26.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

Background: The Advisory Committee on Immunization Practices (ACIP) has routinely recommended zoster vaccine live (ZVL) for adults  ≥60 since 2008; only 33% of eligible adults received it by 2016. A recombinant zoster vaccine (RZV) was licensed in 2017 and ACIP recommended in January 2018. Our objectives were to assess among primary care physicians (1) practices and attitudes regarding ZVL and (2) awareness of RZV.

Methods: We administered an Internet and mail survey from July to September 2016 to national networks of 953 primary care physicians.

Results: Response rate was 65% (603/923). Ninety-three % of physicians recommended ZVL to adults ≥60, but fewer recommended it to adults ≥60 with a prior history of zoster (88%), adults > 85 (62%) and adults ≥60 on low-dose methotrexate (42%). Several physicians recommended ZVL in ways that are not recommended by ACIP including to adults 50-59 (50%), adults ≥60 with HIV (33%), and adults ≥60 on high dose prednisone (≥20 mg/day) (27%). Nineteen percent of physicians stocked and administered ZVL and did not refer patients elsewhere for vaccination, 37% did not stock and only referred patients to receive it, and 44% both stocked/administered and referred elsewhere. Twenty-three % (n = 115) of physicians who had ever administered ZVL in the office (n = 490) had stopped, citing primarily financial issues (90%). Only 5% were 'very aware' of RZV.

Conclusions: Physicians report not recommending ZVL to certain ACIP-recommended groups, but report recommending it to some groups for which the vaccine should be avoided. Implementation of recommendations for RZV will need to consider financial barriers and the complex patchwork of office-based and pharmacy delivery ZVL has encountered.
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http://dx.doi.org/10.1016/j.vaccine.2018.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324734PMC
November 2018

Trajectories of Nevus Development From Age 3 to 16 Years in the Colorado Kids Sun Care Program Cohort.

JAMA Dermatol 2018 11;154(11):1272-1280

Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora.

Importance: Nevi are a risk factor for melanoma and other forms of skin cancer, and many of the same factors confer risk for both. Understanding childhood nevus development may provide clues to possible causes and prevention of melanoma.

Objectives: To describe nevus acquisition from the ages of 3 to 16 years among white youths and evaluate variation by sex, Hispanic ethnicity, and body sites that are chronically vs intermittently exposed to the sun.

Design, Setting, And Participants: This annual longitudinal observational cohort study of nevus development was conducted between June 1, 2001, and October 31, 2014, among 1085 Colorado youths. Data analysis was conducted between February 1, 2015, and August 31, 2017.

Main Outcomes And Measures: Total nevus counts on all body sites and on sites chronically and intermittently exposed to the sun separately.

Results: A total of 557 girls and 528 boys (150 [13.8%] Hispanic participants) born in 1998 were included in this study. Median total body nevus counts increased linearly among non-Hispanic white boys and girls between the age of 3 years (boys, 6.31; 95% CI, 5.66-7.03; and girls, 6.61; 95% CI, 5.96-7.33) and the age of 16 years (boys, 81.30; 95% CI, 75.95-87.03; and girls, 77.58; 95% CI, 72.68-82.81). Median total body nevus counts were lower among Hispanic white children (boys aged 16 years, 51.45; 95% CI, 44.01-60.15; and girls aged 16 years, 53.75; 95% CI, 45.40-63.62) compared with non-Hispanic white children, but they followed a largely linear trend that varied by sex. Nevus counts on body sites chronically exposed to the sun increased over time but leveled off by the age of 16 years. Nevus counts on sites intermittently exposed to the sun followed a strong linear pattern through the age of 16 years. Hispanic white boys and girls had similar nevus counts on sites intermittently exposed to the sun through the age of 10 years, but increases thereafter were steeper for girls, with nevus counts surpassing those of boys aged 11 to 16 years.

Conclusions And Relevance: Youths are at risk for nevus development beginning in early childhood and continuing through midadolescence. Patterns of nevus acquisition differ between boys and girls, Hispanic and non-Hispanic white youths, and body sites that are chronically exposed to the sun and body sites that are intermittently exposed to the sun. Exposure to UV light during this period should be reduced, particularly on body sites intermittently exposed to the sun, where nevi accumulate through midadolescence in all children. Increased attention to sun protection appears to be merited for boys, in general, because they accumulated more nevi overall, and for girls, specifically, during the adolescent years.
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http://dx.doi.org/10.1001/jamadermatol.2018.3027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248123PMC
November 2018

A method for achieving high response rates in national surveys of U.S. primary care physicians.

PLoS One 2018 23;13(8):e0202755. Epub 2018 Aug 23.

Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States of America.

Physician questionnaires are commonly used in health services research; however, many survey studies are limited by low response rate. We describe the effectiveness of a method to maximize survey response without using incentives, the effectiveness of survey reminders over time, and differences in response rates based on survey mode and primary care specialty. As part of a study to assess vaccine policy issues, 13 separate surveys were conducted by internet and mail over the period of 2008 to 2013. Surveys were conducted among pre-recruited networks of pediatricians, family physicians and general internists. Each network was active for 2 years and responded to 3-6 surveys. Physicians who indicated preference to respond through an online survey received up to 9 e-mailed requests to complete the questionnaire and up to 2 mailed questionnaires. Physicians who chose to respond by mail received up to 3 mailed questionnaires and a reminder postcard. For 6 of the 13 surveys conducted over the 6 year period, an additional mailing using a hand-addressed envelope was mailed to non-responders at the end of the usual protocol. Effectiveness of survey methods was measured by response rates. The overall response rates varied from 66‒83%. Response rates declined 17 percentage-points on average between the first and last surveys administered within each physician network. The internet group consistently had higher response rates than the mail group (74% vs. 62% on average). An additional mailing in a hand-written envelope boosted the final response rate by 11 percentage-points. Self-selection of survey mode, multiple reminders, and hand-written envelopes are effective methods for maximizing response rates in physician surveys.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202755PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107210PMC
February 2019

Adoption of Serogroup B Meningococcal Vaccine Recommendations.

Pediatrics 2018 09 20;142(3). Epub 2018 Aug 20.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and.

: media-1vid110.1542/5799875076001PEDS-VA_2018-0344 BACKGROUND AND OBJECTIVES: In 2015, the Advisory Committee on Immunization Practices recommended that 16- to 23-year-olds may be vaccinated with the serogroup B meningococcal (MenB) vaccine on the basis of individual clinical decision-making (Category B). We assessed the following among US pediatricians and family physicians (FPs): (1) practices regarding MenB vaccine delivery, (2) factors influencing a decision to recommend the MenB vaccine, and (3) factors associated with discussing the MenB vaccine.

Methods: We surveyed a nationally representative sample of pediatricians and FPs via e-mail and Internet from October 2016 to December 2016.

Results: The response rate was 72% (660 of 916). During routine visits, 51% of pediatricians and 31% of FPs reported always or often discussing MenB vaccine. Among those who discussed often or always, 91% recommended vaccination; among those who never or rarely discussed, 11% recommended. We found that 73% of pediatricians and 41% of FPs currently administered the MenB vaccine. Although many providers reported not knowing about factors influencing recommendation decisions, MenB disease outbreaks (89%), disease incidence (62%), and effectiveness (52%), safety (48%), and duration of protection of MenB vaccine (39%) increased the likelihood of recommendation, whereas the Category B recommendation (45%) decreased likelihood. Those somewhat or not at all aware of the MenB vaccine (risk ratio 0.32 [95% confidence interval 0.25-0.41]) and those practicing in a health maintenance organization (0.39 [0.18-0.87]) were less likely, whereas those aware of disease outbreaks in their state (1.25 [1.08-1.45]) were more likely to discuss MenB vaccine.

Conclusions: Primary care physicians have significant gaps in knowledge about MenB disease and the MenB vaccine, and this appears to be a major driver of the decision not to discuss the vaccines.
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http://dx.doi.org/10.1542/peds.2018-0344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200322PMC
September 2018
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