Parent-reported Barriers and Parental Beliefs Associated with Intentions to Obtain HPV Vaccination for Children in a Primary care Patient Population in Minnesota, USA.

Human papillomavirus (HPV) vaccine uptake among adolescents remains suboptimal in the US. The COVID-19 pandemic posed new challenges to increase HPV vaccination rates. To characterize parent-reported barriers to obtain HPV vaccination for their children and to identify psychosocial factors associated with parents' intention to vaccinate their children for HPV, we administered parent surveys between April 2020 and January 2022 during a randomized pragmatic trial assessing the impact of evidence-based implementation strategies on HPV vaccination rates for adolescent patients at six Mayo Clinic primary care practices in Southeast Minnesota. A total of 342 surveys were completed (response rate 34.1%). Analyses were focused on parents of unvaccinated children (n = 133). The survey assessed the main reason the child did not receive the HPV vaccine, parental beliefs about the vaccine, and the parent's intention to vaccinate the child for HPV in the next 12 months. Frequently reported awareness and access barriers to HPV vaccination included not knowing the child was due (17.8%) and COVID-19 related delay (11.6%). Frequently reported attitudinal barriers include the belief that the child was too young for the vaccine (17.8%) and that the vaccine is not proven to be safe (16.3%). Injunctive social norm (Adjusted-OR = 3.15, 95%CI: 1.94, 5.41) and perceived harm beliefs (Adjusted-OR = 0.58, 95%CI: 0.35, 0.94) about the HPV vaccine were positively and negatively associated with HPV vaccination intention, respectively. Our findings suggest that continued efforts to overcome parental awareness, access, and attitudinal barriers to HPV vaccination are needed and underscore the importance of utilizing evidence-based health system-level interventions.

Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection.

EXECUTIVE SUMMARY: The risk of cervical cancer (CC) among women immunosuppressed for a variety of reasons is well documented in the literature. Although there is improved organ function, quality of life and life expectancy gained through use of immunosuppressant therapy, there may be increased long-term risk of cervical neoplasia and cancer and the need for more intense screening, surveillance, and management. Although guidance for CC screening among HIV-infected women (see Table 1) has been supported by evidence from retrospective and prospective studies, recommendations for CC screening among non-HIV immunosuppressed women remains limited because quality evidence is lacking. Moreover, CC screening guidelines for HIV-infected women have changed because better treatments evolved and resulted in longer life expectancy.The objective of this report was to summarize current knowledge of CC, squamous intraepithelial lesions, and human papillomavirus (HPV) infection in non-HIV immunocompromised women to determine best practices for CC surveillance in this population and provide recommendations for screening. We evaluated those with solid organ transplant, hematopoietic stem cell transplant, and a number of autoimmune diseases.A panel of health care professionals involved in CC research and care was assembled to review and discuss existing literature on the subject and come to conclusions about screening based on available evidence and expert opinion. Literature searches were performed using key words such as CC, cervical dysplasia/squamous intraepithelial lesion, HPV, and type of immunosuppression resulting in an initial group of 346 articles. Additional publications were identified from review of citations in these articles. All generated abstracts were reviewed to identify relevant articles. Articles published within 10 years were considered priority for review. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations for screening generated from each group were largely based on expert opinion. Adherence to screening, health benefits and risks, and available clinical expertise were all considered in formulating the recommendations to the degree that information was available. RESULTS: Solid Organ Transplant: Evidence specific for renal, heart/lung, liver, and pancreas transplants show a consistent increase in risk of cervical neoplasia and invasive CC, demonstrating the importance of long-term surveillance and treatment. Reports demonstrate continued risk long after transplantation, emphasizing the need for screening throughout a woman's lifetime.Hematopoietic Stem Cell Transplant: Although there is some evidence for an increase in CC in large cohort studies of these patients, conflicting results may reflect that many patients did not survive long enough to evaluate the incidence of slow-growing or delayed-onset cancers. Furthermore, history of cervical screening or previous hysterectomy was not included in registry study analysis, possibly leading to underestimation of CC incidence rates.Genital or chronic graft versus host disease is associated with an increase in high-grade cervical neoplasia and posttransplant HPV positivity.Inflammatory Bowel Disease: There is no strong evidence to support that inflammatory bowel disease alone increases cervical neoplasia or cancer risk. In contrast, immunosuppressant therapy does seem to increase the risk, although results of observational studies are conflicting regarding which type of immunosuppressant medication increases risk. Moreover, misclassification of cases may underestimate CC risk in this population. Recently published preventive care guidelines for women with inflammatory bowel disease taking immunosuppressive therapy recommend a need for continued long-term CC screening.Systemic Lupus Erythematosus and Rheumatoid Arthritis: The risk of cervical high-grade neoplasia and cancer was higher among women with systemic lupus erythematosus than those with rheumatoid arthritis (RA), although studies were limited by size, inclusion of women with low-grade neoplasia in main outcomes, and variability of disease severity or exposure to immunosuppressants. In studies designed to look specifically at immunosuppressant use, however, there did seem to be an increase in risk, identified mostly in women with RA. Although the strength of the evidence is limited, the increase in risk is consistent across studies.Type 1 DM: There is a paucity of evidence-based reports associating type 1 DM with an increased risk of cervical neoplasia and cancer. RECOMMENDATIONS: The panel proposed that CC screening guidelines for non-HIV immunocompromised women follow either the (1) guidelines for the general population or (2) current center for disease control guidelines for HIV-infected women. The following are the summaries for each group reviewed, and more details are noted in accompanying table:Solid Organ Transplant: The transplant population reflects a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance.Hematopoietic Stem Cell Transplant: These women have a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening. A new diagnosis of genital or chronic graft versus host disease in a woman post-stem cell transplant results in a greater risk of CC than in the general population and should result in more intensive screening and surveillance.Inflammatory Bowel Disease: Women with inflammatory bowel disease being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Those women with inflammatory bowel disease not on immunosuppressive therapy are not at an increased risk and should follow screening guidelines for the general population.Systemic Lupus Erythematosus and Rheumatoid Arthritis: All women with systemic lupus erythematosus, whether on immunosuppressant therapy or not and those women with RA on immunosuppressant therapy have a greater risk of cervical neoplasia and cancer than the general population and should follow CC screening guidelines for HIV-infected women. Women with RA not on immunosuppressant therapy should follow CC screening guidelines for the general population.Type 1 Diabetes Mellitus: Because of a lack of evidence of increased risk of cervical neoplasia and cancer among women with type 1 DM, these women should follow the screening guidelines for the general population.

Routine pelvic examinations: A descriptive cross-sectional survey of women's attitudes and beliefs after new guidelines.

Routine pelvic examinations have been a fundamental part of the annual female examination. The 2014 American College of Physicians (ACP) guideline recommends against routine pelvic examinations in asymptomatic, nonpregnant, average-risk women. Our aim was to evaluate women's attitudes and beliefs about pelvic examinations and how knowledge of the new guidelines contributes to attitudes and beliefs. A descriptive cross-sectional study was performed using a self-administered written survey developed through literature review and pretested and revised on the basis of staff suggestions. Nonpregnant women age≥21years presenting to outpatient clinics at Mayo Clinic in Arizona or Mayo Clinic in Rochester, Minnesota, received the survey. After being asked about pelvic examination practices and beliefs, participants were informed of the ACP guideline, to determine effect on attitudes and beliefs. Demographic characteristics and pertinent medical history questions were collected from participants. In total, 671 women who were predominantly white, married, and educated completed surveys. Participants described pelvic examinations as reassuring, and a majority believed the examinations were useful in detecting ovarian cancer (74.6%), necessary for screening for sexually transmitted infections (STIs) (71.0%), or necessary before initiating contraception (67.0%). After reading the 2014 ACP guideline, significantly fewer women planned to continue yearly pelvic examinations (P<0.001). Despite evidence to the contrary, women believed pelvic examinations were necessary for STI screening, contraception initiation, and ovarian cancer detection. After education on the ACP screening guideline, fewer women planned to continue yearly pelvic examinations.

Cervical cancer screening in Ghana, west Africa: prevalence of abnormal cytology and challenges for expanding screening.

Aims were to assess the prevalence of Papanicolaou (Pap) abnormalities found with cervical cancer screening in Agogo and Nkawie, communities in the Ashanti region of Ghana, and compare the correlation between Pap readings performed at the Komfo Anokye Teaching Hospital in Kumasi, Ghana, and at the Mayo Clinic cytology laboratory in Rochester, MN. Demographic data was collected and Pap tests were performed on women recruited for screening in the communities of Agogo (n=119) and Nkawie (n=255). The Pap tests were assessed by pathology laboratory staff at Komfo Anokye Teaching Hospital and Mayo Clinic. There was a significant difference in prevalence of abnormal cytology between the sites with a rate of 12.6% in Agogo and 3.5% in Nkawie (P=0.016). Demographic differences were noted in education level (P<0.001), occupation (P<0.001), religion (P=0.002), and marital status (P<0.001). The Cohen correlation coefficient between the two pathology departments interpreting samples was 0.185, which indicates a significant degree of discordance (P<0.001). Currently Ghana does not have a national cervical cancer screening program. Identifying higher risk communities and patients as a priority for screening may be useful with limited resources. Accurate identification of Pap abnormalities is necessary to implement an effective screening program.

Increased adherence to prenatal group B streptococcal screening guidelines through a paired electronic reminder and education intervention.

The 2010 Centers for Disease Control and Prevention (CDC) update on perinatal group B streptococcal (GBS) prevention advises universal vaginal-rectal GBS screening of pregnant women in the 35th through 37th week of gestation. Because GBS colonization is transient, a test performed more than 5 weeks before delivery may not have sufficient negative predictive value to be clinically useful. Our objective was to increase rates of quality-improved, CDC-adherent GBS screening and decrease repeat screening. A reminder for maternal vaginal-rectal GBS testing was added to the physicians' electronic ordering screen, and family medicine physicians and residents were educated about screening guidelines through standardized, in-person presentations. Retrospective chart review was performed before and after these interventions. Univariate or bivariate analysis was performed for demographic factors, timing of first screen, rates of CDC-adherent screening (the newly defined quality-improved screen and the usual screen), and rates of repeat and unnecessary screens. Multivariate analysis was performed with quality-improved and usual screening as dependent variables. Bivariate analysis showed that post-intervention rates of quality-improved screening increased from 30 to 62 % (P < .001), usual screening increased from 69 to 84 % (P = .005), and repeat GBS screening decreased from 20 to 8 % (P = .007). Multivariate analysis showed increased post-intervention odds of quality-improved screening [odds ratio (OR) 3.59; 95 % CI 2.07-6.34] and usual screening (OR 2.67; 95 % CI 1.40-5.25). Low-cost, reproducible quality improvement interventions (electronic order reminder, educational sessions) have the potential to increase guideline adherence for GBS screening in pregnant women and decrease repeat screening.

Multilevel Implementation Strategies for Adolescent Human Papillomavirus Vaccine Uptake: A Cluster Randomized Clinical Trial.

Importance: Despite availability of a safe and effective vaccine, an estimated 36 500 new cancers in the US result from human papillomavirus (HPV) annually. HPV vaccine uptake falls short of national public health goals and lags other adolescent vaccines. Objective: To evaluate the individual and combined impact of 2 evidence-based interventions on HPV vaccination rates among 11- and 12-year-old children. Design, Setting, and Participants: The study team conducted a cluster randomized clinical trial with a stepped-wedge factorial design at 6 primary care practices affiliated with Mayo Clinic in southeastern Minnesota. Using block randomization to ensure balance of patient volumes across interventions, each practice was allocated to a sequence of four 12-month steps with the initial baseline step followed by 2 intermediate steps (none, 1, or both interventions) and a final step wherein all practices implemented both interventions. Each month, all eligible children who turned 11 or 12 years in the 2 months prior were identified and followed until the end of the step. Data were analyzed from April 2018 through March 2019. Participants included children who turned 11 or 12 years old and were due for a dose of the HPV vaccine. Interventions: Parents of eligible patients were mailed reminder/recalls following their child's birthdays. Health care professionals received confidential audit/feedback on their personal in-office success with HPV vaccine uptake via intra-campus mail. These 2 interventions were assessed separately and in combination. Main Outcomes and Measures: Eligible patients' receipt of any valid dose of HPV vaccine during the study step. Results: The cohort was comprised of 9242 11-year-olds (5165 [55.9%]) and 12-year-olds (4077 [44.1%]), and slightly more males (4848 [52.5%]). Parent reminder/recall resulted in 34.6% receiving a dose of HPV vaccine, health care professional audit/feedback, 30.4%, both interventions together resulted in 39.7%-all contrasted to usual care, 21.9%. Compared with usual care, the odds of HPV vaccination were higher for parent reminder/recall (odds ratio [OR], 1.56; 95% CI, 1.23-1.97) and for the combination of parent reminder/recall and health care professional audit/feedback (OR, 2.03; 95% CI, 1.44-2.85). Health care professional audit/feedback alone did not differ significantly from usual care (OR, 1.19; 95% CI, 0.94-1.51). Conclusions and Relevance: In this cluster randomized trial, the combination of parent reminder/recall and health care professional audit/feedback increased the odds of HPV vaccination compared with usual care. These findings underscore the value of simultaneous implementation of evidence-based strategies to improve HPV vaccination.

Primary Human Papillomavirus Test Uptake and Cervical Cancer Screening Trends in the Midwest, United States.

INTRODUCTION/OBJECTIVES: Despite U.S. Preventive Services Task Force and American Cancer Society endorsement of primary HPV screening, limited published data shows low uptake. PRIMARY AIM: Assess cervical cancer screening rates over time, particularly primary HPV test uptake, among patients in a midwestern practice. SECONDARY AIM: Evaluate associations between sociodemographics and screening adherence. METHODS: Cross-sectional study. Qualifying subjects and type of screening test used were identified by applying ICD-9, ICD-10, lab test, and CPT codes to the Unified Data Platform. Sociodemographics were found through the electronic health record. RESULTS: Primary HPV uptake represented <1% of annual screening from 1/2017 to 1/2022. On 1/1/2022, only 55% of 21 to 29 year old and 63% of 30 to 65 year old were up to date with screening among the studied population. For 21 to 29 year old, compared with White women, Black women were 28% less likely to be screened [RR = 0.72 (0.66-0.79)]. Compared with never-smokers, current smokers were 9% less likely to be screened [RR = 0.91 (0.87-0.96)], past smokers were 14% more likely [RR = 1.14 (1.09-1.2)]. Among 30 to 65 year old, compared with White women, Black women were 14% less likely to be screened [RR = 0.86 (0.81-0.9)]. Compared with never-smokers, current smokers were 21% less likely to be screened [RR = 0.79 (0.77-0.81)], past smokers were 6% less likely [RR = 0.94 (0.92-0.95)]. Jointly considering race, ethnicity, smoking status, Charlson score, and rurality, findings were similar for 21 to 29 year old; Black women were screened less than White women [RR = 0.73 (0.67-0.79)]; current smokers [RR = 0.9 (0.85-0.94)] and past smokers [RR = 1.12 (1.06-1.17)] were screened less than never smokers. For 30 to 65 year old, Black women were screened less than White women [RR = 0.83 (0.79-0.88)]; current smokers [RR = 0.8 (0.78-0.81)] and past smokers [RR = 0.95 (0.93-0.96)] were screened less than never smokers. CONCLUSIONS: Screening rates remained below the Healthy People 2030 goal of 79.2% over time, particularly for younger Black women and current smokers, with minimal use of primary HPV screening.

Primary human papillomavirus testing by clinician- versus self-collection: Awareness and acceptance among cervical cancer screening-eligible women.

OBJECTIVES: Primary human papillomavirus (HPV) testing by clinician-collection is endorsed by U.S. guideline organizations for cervical cancer screening, but uptake remains low and insights into patients' understanding are limited. This study aims to primarily address patient awareness of primary HPV screening by clinician-collection and acceptance of primary HPV screening by clinician- and self-collection, and secondarily assess factors associated with awareness and acceptance. SETTING: Primary care practices affiliated with an academic medical center. METHODS: A cross-sectional survey study of screening-eligible women aged 30-65 years was conducted to assess awareness and acceptability of primary HPV screening. We analyzed bivariate associations of respondent characteristics with awareness of primary HPV screening by clinician-collection, willingness to have clinician- or self-collected primary HPV testing, and reasons for self-collection preference. RESULTS: Respondents (n = 351; response rate = 23.4%) reported cervical cancer screening adherence of 82.8% but awareness of clinician-collected primary HPV as an option was low (18.9%) and only associated with HPV testing with recent screening (p = 0.003). After reviewing a description of primary HPV screening, willingness for clinician-collected (81.8%) or home self-collected (76.1%) HPV testing was high, if recommended by a provider. Acceptability of clinician-collected HPV testing was associated with higher income (p = 0.009) and for self-collection was associated with higher income (p = 0.002) and higher education (p = 0.02). Higher education was associated with reporting self-collection as easier than clinic-collection (p = 0.02). Women expected self-collection to be more convenient (94%), less embarrassing (85%), easier (85%), and less painful (81%) than clinician-collection. CONCLUSIONS: Educational interventions are needed to address low awareness about the current clinician-collected primary HPV screening option and to prepare for anticipated federal licensure of self-collection kits. Informing women about self-collection allows them to recognize benefits which could address screening barriers.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management.

BACKGROUND: Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self-assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment. METHODS: We retrospectively reviewed 1,110 adult primary care patients with the diagnosis of major depressive disorder enrolled in a CCM program and evaluated those with PDS (defined as patient health questionnaire-9score ≥10) 6 months after enrollment. RESULTS: At baseline, an increased depression severity, worsening symptoms of generalized anxiety, an abnormal screening on the mood disorder questionnaire (MDQ) and the diagnosis of recurrent episode of depression were independent predictors of PDS. A patient with severe, recurrent depression, an abnormal MDQ screen, and severe anxiety at baseline had a predicted 42.1% probability of PDS at 6 months. In contrast, a patient with a moderate, first episode of depression, normal MDQ screen, and no anxiety symptoms had a low probability of PDS at 6.6%. CONCLUSIONS: This study identified several patient self-assessment scores and clinical diagnosis that markedly predicted the probability of PDS 6 months after diagnosis and enrollment into CCM. Knowledge of these high-risk attributes should alert the clinician to monitor select patients more closely and consider altering therapy appropriately.

Outcomes in women age 40 years and older with cytologically benign endometrial cells.

OBJECTIVE: We sought to estimate cytologically benign endometrial cell (CBEC)-associated endometrial hyperplasia and cancer rates, and describe clinical and histologic outcomes. STUDY DESIGN: Medical records of women age >40 years with CBEC in 2005 through 2010 were reviewed for clinical characteristics; assessment with endometrial biopsy, ultrasound, or hysteroscopy; and consequent outcomes. RESULTS: Of 658 women, 281 (42.7%) were assessed: 39.4% of 330 premenopausal, and 46.0% of 328 postmenopausal women. Among these, cancer rate was 3.6% and differed between premenopausal (0.8%) and postmenopausal (6.0%) women (P = .019). Hyperplasia rate was similar in premenopausal (3.9%) and postmenopausal (3.3%) women. Of 20 assessed women with endometrial pathology, 4 (1 premenopausal) women with cancer and 4 (2 premenopausal) women with hyperplasia had no abnormal bleeding. CONCLUSION: Cancer was more common in postmenopausal women with assessed CBEC while hyperplasia was comparably distributed between premenopausal and postmenopausal women. Findings support CBEC assessment regardless of menopausal status or abnormal bleeding.

Extensive scarring alopecia and widespread rash.

This patient's nonadherence to treatment and lack of precautionary steps exacerbated this condition.

Awareness and Support of Clinician- and Patient-Collected Human Papillomavirus Testing for Cervical Cancer Screening Among Primary Care Clinicians.

Background: Cervical cancer screening has shifted toward human papillomavirus (HPV)-based testing, but uptake of primary HPV screening in the United States is unknown and previous studies highlight delays in clinician adoption of guideline updates. Methods: We conducted a cross-sectional electronic survey of primary care clinicians (n = 252; response rate = 30.9%) assessing awareness and support of primary HPV screening. We assessed factors for association with past use of HPV testing and support of clinician- and patient-collected HPV testing individually using Fisher's exact test and jointly using Firth's logistic regression. Results: Most clinicians (79%) were familiar with one or more primary HPV screening guidelines. Support for clinician-collected (89%) and patient-collected (82%) HPV testing was high, but only 34.5% reported prior use. Guideline familiarity was positively associated with HPV testing in practice (p = 0.0001). Support of clinician-collected testing was positively associated with more years in practice (p = 0.03), internal (vs. family) medicine specialty (p = 0.03), and guideline familiarity (p ≤ 0.0001). Male clinicians more frequently supported patient collection for patients overdue for screening (p = 0.013). Physicians more frequently than advanced practice providers (APPs) supported patient collection for screening-adherent women (p = 0.021). Multivariable analysis showed those unfamiliar with guidelines were less likely to have used HPV testing [odds ratio, OR: 0.10 (0.03-0.32)] or to support clinician-collected HPV testing [OR: 0.16 (0.07-0.37)]. APPs were less likely than physicians to support patient-collected HPV testing among screening-adherent women [OR: 0.42 (0.20-0.87)]. Conclusions: We observed high levels of guideline awareness and clinician support for primary HPV testing, despite relatively low use. This merits further exploration to inform future interventions to increase uptake.

Socioeconomic disadvantage and human papillomavirus (HPV) vaccination uptake.

IMPORTANCE: Despite availability of safe and effective human papillomavirus (HPV) vaccines, vaccination uptake remains low in the U.S. Research examining the impact of neighborhood socioeconomic status on HPV vaccination may help target interventions. OBJECTIVE: To examine the association between area deprivation and HPV vaccine initiation and completion. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study of individuals aged 11-18 years residing in the upper Midwest region. Receipt of HPV vaccination was examined over a three-year follow-up period (01/01/2016-12/31/2018). MAIN OUTCOMES AND MEASURES: Outcomes of interest were initiation and completion of HPV vaccination. Demographic data were collected from the Rochester Epidemiology Project (REP). Area-level socioeconomic disadvantage was measured by calculating an Area Deprivation Index (ADI) score for each person, a measure of socioeconomic disadvantage derived from American Community Survey data. Multivariable mixed effect Cox proportional hazards models were used to examine the association of ADI quartiles (Q1-Q4) with HPV vaccine series initiation and completion, given initiation. RESULTS: Individuals residing in census block groups with higher deprivation had significantly lower likelihood of HPV vaccine initiation (Q2: HR = 0.91, 0.84-0.99 Q3: HR = 0.83, 0.76-0.90; Q4: HR = 0.84, 0.74-0.96) relative to those in the least-deprived block groups (Q1). Similarly, those living in block groups with higher deprivation had significantly lower likelihood of completion (Q2: HR = 0.91, 0.86-0.97; Q3: HR = 0.87, 0.81-0.94; Q4: HR = 0.82, 0.74-0.92) compared to individuals in the least-deprived block groups (Q1). CONCLUSIONS AND RELEVANCE: Lower probability of both HPV vaccine-series initiation and completion were observed in areas with greater deprivation. Our results can inform allocation of resources to increase HPV vaccination rates in our primary care practice and provide an example of leveraging public data to inform similar efforts across diverse health systems.

A Comparison of Perceived Lifetime Breast Cancer Risk to Calculated Lifetime Risk Using the Gail Risk Assessment Tool.

Background: Understanding the accuracy of a woman's perceived breast cancer risk can enhance shared decision-making about breast cancer screening through provider and patient discussion. We aim to report and compare women's perceived lifetime breast cancer risk to calculated lifetime breast cancer risk. Methods: Women presenting to Mayo Clinic in Arizona and Minnesota in July 2016 completed a survey assessing their perceived breast cancer risk. Lifetime Gail risk scores were calculated from questions pertaining to health history and were then compared with perceived breast cancer risk. Results: A total of 550 predominantly white, married, and well-educated (≥college) women completed surveys. Using lifetime Gail risk scores, 5.6% were classified as high risk (>20% lifetime risk), 7.7% were classified as intermediate risk (15%-20%), and 86.6% were classified as average risk (<15%). Of the 27 women who were classified as high risk, 18 (66.7%) underestimated their risk and of the 37 women who were intermediate risk, 12 (32.4%) underestimated risk. Women more likely to underestimate their risk had a reported history of an abnormal mammogram and at least one or more relative with a history of breast cancer. Surveyed women tended to overestimate risk 4.3 (130/30) times as often as they underestimated risk. Conclusion: In a group of predominantly white, educated, and married cohort of women, there was a large portion of women in the elevated risk groups who underestimated risk. Specific aspects of medical history were associated with underestimation including a history of abnormal mammogram and family history of breast cancer. Overall, in our sample, more women overestimated than underestimated risk.

Predictors of patient comfort and adherence with less frequent cervical cancer screening.

BACKGROUND: The Papanicolaou (Pap) test is an effective, well-accepted screening tool that has led to a decrease in cervical cancer incidence and mortality. Updated evidence-based cervical cancer screening guidelines support less frequent testing in low-risk patients but have met resistance from providers and patients. AIMS: To assess patient knowledge about cervical cancer screening and attitudes toward recommendations for less frequent testing. METHODS: A hard copy of an eight-question survey was distributed to 389 women aged 30-64 years at two primary care clinics in Rochester, Minnesota, over a six-week period. RESULTS: The survey response rate was 86.8%. Of the 280 women who responded to a survey question about the cause of cervical cancer, 212 (75.7%) identified human papillomavirus (HPV) as the cause. Multivariable logistic regression analysis showed that this knowledge was not associated with feeling comfortable with a recommendation for less frequent testing or with support for less frequent testing. The only significant predictor of patient comfort and adherence with a two- to three-year Pap testing interval was the patient's belief about whether a Pap test was needed annually or every two or three years. CONCLUSIONS: Patient belief about Pap testing frequency was the strongest predictor of attitude toward less frequent Pap testing and was not based on knowledge of HPV. Future studies should explore why some patients continue to expect annual testing and identify interventions to help providers elicit and change patients' expectations about cervical cancer screening.

How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation.

Vaccine hesitancy occurs throughout the world and can result in poor vaccine uptake and vaccine-preventable disease-outbreaks. Vaccine hesitancy dates back to the days of Edward Jenner and the smallpox vaccine. It persists despite the preponderance of evidence supporting vaccine safety and effectiveness. Studies show even among parents of well-vaccinated children that 15-35% of those parents are vaccine-hesitant. Studies have failed to show the efficacy of educational interventions, and, indeed, a number of studies of educational interventions show a contrarian effect leaving the vaccine-hesitant more entrenched in their views. Still dozens of studies support health care provider recommendation as a major factor in achieving high rates of vaccine uptake. Furthermore, studies find those recommendations perceived as stronger are more effective than those perceived as weaker. What makes for a stronger recommendation? Several observational studies indicate that presumptive, announcement language as contrasted with participatory, conversational language makes for a stronger more effective recommendation. Several trials now demonstrate that health care providers and practices can implement this language and obtain higher vaccination uptake. The authors recommend the practice be adopted as a routine practice in the clinical setting for all vaccinations.

Association of Primary Care Team Composition and Clinician Burnout in a Primary Care Practice Network.

OBJECTIVE: To determine the relationship of the emotional exhaustion domain of burnout with care team composition in a Midwestern primary care practice network. PARTICIPANTS AND METHODS: We studied 420 family medicine clinicians (253 physicians and 167 nurse practitioners/physician assistants [NP/PAs]) within a large integrated health system throughout 59 Midwestern communities. The observational cross-sectional study utilized a single-question clinician self-assessment of the emotional exhaustion domain of burnout on a scale of 0 (never) to 6 (daily) conducted between March 1 and April 2, 2018, and administrative data collected between January 1, 2017, and December 31, 2017. We used a multivariable linear mixed model for data analysis, adjusted for clinical- and team-level factors, including clinician sex, panel size and complexity, clinician type (physician or NP/PA), clinician full-time equivalent (FTE), total care team panel size, and number of clinicians on the care team. RESULTS: Among 217 survey respondents (51.7%), the median frequency of the emotional exhaustion domain of burnout was once per week. Adjusted analyses revealed that a greater proportion of physician FTE on the care team was associated with a lower emotional exhaustion domain of burnout among individual clinicians (P=.05). Female clinicians had a higher emotional exhaustion domain of burnout than male clinicians (P=.05). None of the other variables in the model were associated with emotional exhaustion. CONCLUSION: Primary care teams containing both physicians and NP/PAs had lower levels of emotional exhaustion with increasing proportion of physician FTE. More work is needed to explore what other variables may be associated with burnout in primary care team-based practices.

An innovative housing-related measure for individual socioeconomic status and human papillomavirus vaccination coverage: A population-based cross-sectional study.

BACKGROUND: Human papillomavirus (HPV) is a known cause of anogenital (eg, cervical) and oropharyngeal cancers. Despite availability of effective HPV vaccines, US vaccination-completion rates remain low. Evidence is conflicting regarding the association of socioeconomic status (SES) and HPV vaccination rates. We assessed the association between SES, defined by an individual validated Housing-based Index of Socioeconomic Status (HOUSES), and HPV vaccination status. METHODS: We conducted a cross-sectional study of children/adolescents 9-17 years as of December 31, 2016, living in southeastern Minnesota by using a health-record linkage system to identify study-eligible children/adolescents, vaccination dates, and home addresses matched to HOUSES data. We analyzed the relationship between HPV vaccination status and HOUSES using multivariable Poisson regression models stratifying by age, sex, race, ethnicity, and county. RESULTS: Of 20,087 study-eligible children/adolescents, 19,363 (96.4%) were geocoded and HOUSES measures determined. In this cohort, 57.9% did not receive HPV vaccination, 15.8% initiated (only), and 26.3% completed the series. HPV vaccination-initiation and completion rates increased over higher SES HOUSES quartiles (P < .001). Rates of HPV vaccination initiation versus unvaccinated increased across HOUSES quartiles in multivariable analysis adjusted for age, sex, race, ethnicity, and county (1st quartile, referent; 2nd quartile, 0.97 [0.87-1.09]; 3rd quartile, 1.05 [0.94-1.17]; 4th quartile, 1.15 [1.03-1.28]; test for trend, P = .002). HOUSES was a stronger predictor of HPV vaccination completion versus unvaccinated (1st quartile referent; 2nd quartile, 1.06 [0.96-1.16]; 3rd quartile, 1.12 [1.03-1.23]; 4th quartile, 1.32 [1.21-1.44]; test for trend, P < .001). Significant interactions were shown for HPV vaccination initiation by HOUSES for sex (P = .009) and age (P = .006). CONCLUSION: The study showed disparities in HPV vaccination by SES, with the highest HOUSES quartiles associated with increased rates of initiating and even greater likelihood of completing the series. HOUSES data may be used to target and tailor HPV vaccination interventions to undervaccinated populations.

Trends Over Time in Pap and Pap-HPV Cotesting for Cervical Cancer Screening.

BACKGROUND: In 2012, updated cervical cancer screening recommendations were released with consensus on Papanicolaou (Pap) testing every 3 years for women age 21-65 years or Pap-human papillomavirus (HPV) cotesting at 5-year intervals for women age 30-65 years. Primary study aims: Assess current use of Pap-HPV cotesting and describe local population trends over time in Pap and Pap-HPV cotesting. Secondary aim: Assess sociodemographic factors correlating with screening. METHODS: We assessed Rochester Epidemiology Project data for Pap and Pap-HPV cotesting among women age 16 years and older living in Olmsted County, Minnesota, yearly from 2005 (study population n = 47,203) through 2016 (study population n = 49,510). We calculated 3-year (Pap) and 5-year (Pap-HPV) moving prevalence rates of screening as proportion of eligible population. Multivariable logistic regression was used to assess factors potentially associated with screening. RESULTS: In 2016, 64.6% of 27,418 eligible 30- to 65-year-old women were up to date with cervical cancer screening; 60.8% had received Pap-HPV cotest screening. Significant declines in Pap completion rates over time were observed in all age groups, including an unexpected decline in 21- to 29-year-old women. Coincident with decreasing Pap screening rates, Pap-HPV cotesting significantly increased among women age 30-65 years, from 10.0% in 2007 to 60.8% in 2016. CONCLUSIONS: This suggests increasing adoption of 2012 screening recommendations in the 30- to 65-year-old population. However, decline in Pap screening among 21- to 29-year-old women is concerning. Disparities by race, ethnicity, smoking status, and comorbidity level were observed. Results suggest need for multilevel patient and clinician interventions to increase cervical cancer screening adherence.