Centers for Disease Control and Prevention.

background and objectives: Because physicians’ practices could be modified to reduce missed opportunities for human papillomavirus (HPV) vaccination, our goal was to: (1) describe self-reported practices regarding recommending the HPV vaccine; (2) estimate the frequency of parental deferral of HPV vaccination; and (3)identify characteristics associated with not discussing it. methods: A national survey among pediatricians and family physicians (FP) was conducted between October 2013 and January 2014. Using multivariable analysis, characteristics associated with not discussing HPV vaccination were examined. results: Response rates were 82% for pediatricians (364 of 442) and 56% for FP (218 of 387). For 11–12 year-old girls, 60% of pediatricians and 59% of FP strongly recommend HPV vaccine; for boys,52% and 41% ostrongly recommen. More than one-half reported ≥25% of parents deferred HPV vaccination. At the 11–12 year well visit, 84% of pediatricians and 75% of FP frequently/always discuss HPV vaccination. Compared with physicians who frequently/always discuss, those who occasionally/rarely discuss(18%) were more likely to be FP (adjusted odds ratio [aOR]: 2.0 [95% confidence interval (CI): 1.1–3.5), be male (aOR: 1.8 [95% CI: 1.1–3.1]), disagree that parents will accept HPV vaccine if discussed with other vaccines (aOR: 2.3 [95% CI: 1.3–4.2]), report that 25% to 49% (aOR: 2.8 [95% CI: 1.1–6.8]) or ≥50% (aOR: 7.8 [95% CI: 3.4–17.6]) of parents defer, and express concern about waning immunity (aOR: 3.4 [95% CI: 1.8–6.4]). conclusions: Addressing physicians’ perceptions about parental acceptance of HPV vaccine, the possible advantages of discussing HPV vaccination with other recommended vaccines, and concerns about waning immunity could lead to increased vaccination rates.

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.

Background Adults are at substantial risk for vaccine-preventable disease, but their vaccination rates remain low. Objective To assess practices for assessing vaccination status and stocking recommended vaccines, barriers to vaccination, characteristics associated with reporting financial barriers to delivering vaccines, and practices regarding vaccination by alternate vaccinators. Design Mail and Internet-based survey. Setting Survey conducted from March to June 2012. Participants General internists and family physicians throughout the United States. Measurements A financial barriers scale was created. Multivariable linear modeling for each specialty was performed to assess associations between a financial barrier score and physician and practice characteristics. Results Response rates were 79% (352 of 443) for general internists and 62% (255 of 409) for family physicians. Twenty-nine percent of general internists and 32% of family physicians reported assessing vaccination status at every visit. A minority used immunization information systems (8% and 36%, respectively). Almost all respondents reported assessing need for and stocking seasonal influenza; pneumococcal; tetanus and diphtheria; and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines. The most commonly reported barriers were financial. Characteristics significantly associated with reporting greater financial barriers included private practice setting, fewer than 5 providers in the practice, and, for general internists only, having more patients with Medicare Part D. The most commonly reported reasons for referring patients elsewhere included lack of insurance coverage for the vaccine (55% for general internists and 62% for family physicians) or inadequate reimbursement (36% and 41%, respectively). Patients were most often referred to pharmacies/retail stores and public health departments. Limitations Surveyed physicians may not be representative of all physicians. Conclusion Improving adult vaccination delivery will require increased use of evidence-based methods for vaccination delivery and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D. Primary Funding Source Centers for Disease Control and Prevention.

OBJECTIVES To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests. METHODS An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012. RESULTS The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective. CONCLUSIONS Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice.

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) (P , .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P , .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 12year-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-yearold 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.WHAT'S KNOWN ON THIS SUBJECT: Although diseases caused by human papillomavirus (HPV) are responsible for major morbidity and mortality in the United States, HPV vaccination rates remain low. Primary care physicians' current HPV vaccine delivery practices and their experiences with HPV vaccine delivery are not well described.WHAT THIS STUDY ADDS: Although most physicians recommend the HPV vaccine for patients 11 to 12 years old, many are not using a presumptive style when introducing the HPV vaccine, standing orders, or electronic alerts for HPV delivery. Most perceive that the 2-dose schedule is resulting in higher HPV completion rates.

OBJECTIVE In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended the quadrivalent human papillomavirus vaccine (HPV4) for the routine immunization schedule for 11- to 12-year-old boys. Before October 2011, HPV4 was permissively recommended for boys. We conducted a study in 2010 to provide data that could guide efforts to implement routine HPV4 immunization in boys. Our objectives were to describe primary care physicians’: 1) knowledge and attitudes about human papillomavirus (HPV)-related disease and HPV4, 2) recommendation and administration practices regarding HPV vaccine in boys compared to girls, 3) perceived barriers to HPV4 administration in boys, and 4) personal and practice characteristics associated with recommending HPV4 to boys. METHODS We conducted a mail and Internet survey in a nationally representative sample of pediatricians and family medicine physicians from July 2010 to September 2010. RESULTS The response rate was 72% (609 of 842). Most physicians thought that the routine use of HPV4 in boys was justified. Although it was permissively recommended, 33% recommended HPV4 to 11- to 12-year-old boys and recommended it more strongly to older male adolescents. The most common barriers to HPV4 administration were related to vaccine financing. Physicians who reported recommending HPV4 for 11- to 12-year-old boys were more likely to be from urban locations, perceive that HPV4 is efficacious, perceive that HPV-related disease is severe, and routinely discuss sexual health with 11- to 12-year-olds. CONCLUSIONS Although most physicians support HPV4 for boys, physician education and evidence-based tools are needed to improve implementation of a vaccination program for males in primary care settings.

Background-Risk factors for cardiovascular disease (CVD) derived from the Framingham study are widely used to guide preventive efforts. It remains unclear whether these risk factors predict CVD death in racial/ethnic minorities as well as they do in the predominately white Framingham cohorts. Methods and Results-Using linked data from the National Health and Nutrition Examination Survey III (1988 to 1994 and the National Death Index, we developed Cox proportional hazard models that predicted time to cardiovascular death separately for non-Hispanic white (NHW), non-Hispanic black (NHB), and Mexican American (MA) participants ages 40 to 80 years with no previous CVD. We compared calibration and discrimination for the 3 racial/ethnic models. We also plotted predicted 10-year CVD mortality by age for the three racial/ethnic groups while holding other risk factors constant (3437 NHW, 1854 NHB, and 1834 MA subjects met inclusion criteria).