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Cynthia Rand, MD, MPH Department of Pediatrics
Fitting It All In: Do Immunizations Interfere with Other Preventive Services for Adolescents? Cynthia Rand, MD, MPH Department of Pediatrics
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Disclosure Statement Speaker: Cynthia Rand, MD, MPH Dr. Rand has no relevant financial relationships or conflicts of interest to disclose. This presentation does not involve discussion of unapproved or off-label, experimental or investigational use.
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Background Multiple new vaccine recommendations for adolescents
Tdap, Meningococcal, HPV, Varicella, Influenza, Hep A Complex agenda for adolescent preventive care Bright Futures recommends counseling regarding: Risky behaviors Sexual activity/STIs Weight, healthy diet and exercise Emotional health and relationship issues In the past decade, there have been multiple new vaccine recommendations for adolescents. These include a new booster for Tdap, a new mengingococcal and HPV vaccine, a booster for varicella, a universal recommendation for influenza vaccine, as well as for hepatitis A vaccine. In addition, there is a complex agenda for adolescent preventive care. Bright Futures, which is supported by the AAP, recommends counseling regarding risky behaviors, which include not wearing a seat belt or helmet, along with use of alcohol, tobacco and other drugs, counseling about sexual activity and how to prevent sexually transmitted infections, counseling about weight, health diet and exercise, particularly now with an epidemic of obesity, as well as counseling about emotional health and relationship issues with teens. So you can see the amount of topics that are recommended at well visits are large, and we have a lot of vaccines to deliver. So we are trying to figure out how physicians can do both, and whether one competes with the other, or do they enhance one another
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Problem: complex agenda
Does giving more immunizations reduce or enhance the proportion of preventive care delivered to adolescents? Hypothesis: We hypothesize that patients who are up-to-date for immunization also have high rates of preventive counseling
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Objectives Measure up-to-date (UTD) rates of immunization
Measure the type and extent of counseling delivered at WCCs Assess whether patients who discuss more topics also have higher rates of UTD for immunization Assess how providing a vaccine at a visit effects the proportion of counseling provided
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Methods 11-13 yr old and 14-17 yr old adolescents with WCCs
11 primary care practices Pediatric, Family Medicine Urban, Suburban, Rural Upstate NY Adolescents completed survey (modified YAHCS) and chart reviews performed Mail recruitment rate 10-30%
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Methods Chart review tool Analyses
Immunizations given after age 10, counseling documented Provider and patient characteristics Analyses Descriptive statistics (immunization rates, counseling reported ) Chi-square tests compared provider/patient characteristics with UTD rates and counseling Logistic regression: relationship between proportion of counseling and UTD for immunization Linear mixed model: relationship between getting any vaccine at WCC and proportion of counseling received
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Young Adult Health Care Survey (YAHCS)
Adaption of the YAHCS, which measures: Preventive screening/counseling on risk behaviors preventing pregnancy and STIs weight, healthy diet, and exercise depression, mental health, and relationship issues Provision of care in a confidential setting Helpfulness of counseling provided Communication and experience with care
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Results: Participant Characteristics
11-13 yr olds N (%) 14-17 yr olds Gender F M 108 (52) 100 (48) 132 (55) 108 (45) Insurance Private Public Other 177 (85) 30 (14) 1 (1) 209 (87) 29 ( 12) 2 (1) Practice type Pediatrics Family Med 147 (71) 61 (29) 156 (65) 84 (35) Practice setting Suburban Urban Rural 4 (2) 57 (27) 7 (3) 77 (32)
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Vaccination Rates * * * * *p<0.001 ^ girls only Tdap 96% vs. 93%
Mening 66% vs. 82% HPV 1 38% vs. 74% HPV2 34% vs. 73% HPV3 25% vs. 67% *p<0.001 ^ girls only
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Up-to-Date Immunization Rates
Characteristic Tdap/Mening* N (%) OR (95% CI) Tdap/Mening/HPV1 (girls) Age 321 (72) 1.4 (1.2, 1.6) 110 (46) 1.96 (1.6, 2.4) Provider type Family Med Pediatric 68 (47) 253 (84) 0.2 ( ) (ref) 17 (24) 93 (56) 0.2 (0.1, 0.4) Practice setting Suburban Rural Urban 242 (80) 73 (54) 6(55) 0.6 (0.2, 2.0) 0.3 (0.1, 0.96) 89 (53) 19 (31) 2 (25) 0.6 (0.2,1.3) 0.3 (0.2, 0.6) Provider degree MD/DO NP PA 242 (74) 57 (83) 21 (42) 1.9 (0.7, 5.2) 2.5 (0.9, 7.3) 76 (47) 31 (60) 3 (14) 3.4 (0.8, 14.6) (5.5, 1.3, 22.9) Logistic regression model controlling for: insurance type, proportion counseling; GEE to accommodate clustered data structure; Provider and patient gender NS in bivariate analysis
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Percent of WCC Visits with Vaccines Given
Tdap: % Meningococcal: 15% HPV (girls only): % Hepatitis A: % Varicella: % Influenza: % Any vaccine at WCC: 37%
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Counseling Reported * * *p<0.05
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Counseling Reported * * *
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Proportion of Counseling Given
Characteristic Proportion Counseling Mean Difference (95% CI) Age 0.41 0.01 ( , 0.03) Provider type Pediatric Family Med 0.44 0.35 -- -0.16 (-0.22, -0.09) Practice setting Suburban Rural Urban 0.52 -0.26 (-0.44, -0.08) -0.18 (-0.35, ) Any vaccine at WCC Yes No 0.36 0.45 -0.06 (-0.12, -0.01) Linear mixed model with random practice effect, controlling for: insurance type Patient and provider gender NS in bivariate analysis
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Percent Agreement Chart & Patient
Topic Young teen (11-13 yrs) Older teen (14-17 yrs) Diet 71* 72* Exercise 63 70 Alcohol 50* 55* Puberty 53^ -- Friends 54^ Any vaccine received at WCC 84* 85^ Received meningoccocal 87 80^ Received tetanus 83^ 67^ Received influenza 70^ Received HPV 88^ 87^ *p<0.05, Chart more likely to report , ^p<0.05, Teen more likely to report
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Conclusions Older, urban & suburban pediatric patients more likely to be UTD for vaccines Counseling rates are not different for teens UTD or not Counseling rates on risky behaviors lower for young teens Fewer topics covered at visits where teens receive immunizations Providers over-report counseling given Teens over-report vaccines given
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Limitations WCC not taped, unable to know true bias in report/chart
Poor representation from urban practices Western NY practices, may not be generalizable
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Next Steps Examine quality (patient satisfaction) of topics covered, related to vaccines given Measure whether counseling topics covered vary with specific vaccines, number given, and vaccines refused Assess whether using patient questionnaire and template increases both counseling and immunization rates
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Recommendations Give patients all vaccines they are eligible for concomitantly Consider additional means to deliver preventive counseling websites, handouts, schools, social networking sites provider can focus on issues most relevant/important to specific teen Consider alternative means to provide vaccine counseling websites, personal health records
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Thanks! Research Team: Funding:
Phyllis Vincelli, BA CDC Cooperative Agreement Nora Peters, BA 1U01IP Stanley Schaffer, MD, MS Jonathan Klein, MD, MPH Allison Kennedy, MPH Mentor: Peter Szilagyi, MD, MPH Statisticians: Aaron Blumkin, MS Hongyue Wang, PhD
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