1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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%

7. 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

8. 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

9. 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)

10. 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

11. 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

12. Percent of WCC Visits with Vaccines Given
Tdap: %
Meningococcal: 15%
HPV (girls only): %
Hepatitis A: %
Varicella: %
Influenza: %
Any vaccine at WCC: 37%

13. Counseling Reported * *
*p<0.05

14. Counseling Reported * * *

15. 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

16. 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

17. 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

18. Limitations WCC not taped, unable to know true bias in report/chart
Poor representation from urban practices
Western NY practices, may not be generalizable

19. 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

20. 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

21. 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