Effectiveness of Advance Care Planning: What Works, What Doesn't, and What Needs to Change?

An increasing recognition over the past five decades of the importance of patients' autonomy and the right to be able to choose to limit medical treatment at the end of life has led to the development of a number of documents related to advance care planning, including the advance directive, medical power of attorney, and portable orders for life-sustaining treatment (POLST). While these documents are important aspects of advance care planning, without having goals-of-care conversations, a specific plan, and necessary supports to achieve these goals, the documents alone offer a false promise. Healthcare professionals must be trained on how to have indepth goals-of-care conversations with patients and their families, and effectively document the decisions. Advance care planning needs to be viewed as a process that must continue as the patient's health status, social support system, and living environment change. Designating a healthcare representative who participates in goals-of-care conversations and can work with the healthcare team to make "just in time" decisions about care reduces the burden and stress on friends and family. In this article we discuss the strengths and limitations of advance directives, medical power of attorney forms, and POLST forms; propose concrete changes to optimize the effectiveness of each; and present a comprehensive approach to advance care planning that we hope will improve care for those nearing the end of life, and ensure that their wishes and goals to have or to limit treatment are more consistently honored.

Acute cannabis toxicity.

Objective: We describe the clinical effects of, and products associated with, acute exposures to cannabis during the early legalization period of recreational cannabis in Oregon and Alaska. Methods: This was an observational study of Oregon/Alaska Poison Center data between 4 December 2015 and 15 April 2017. A standardized data collection instrument was created for this study that captured information about cannabis product description, route of exposure, intentional vs unintentional exposure, product dose, product manufacture source, product ownership source, initial vital signs, clinical signs and symptoms, and subject disposition. Subjects were included if the Poison Center received a call about an acute exposure to cannabis from the subject, subject's family member or friend, or healthcare worker participating in the subject's care. Subjects were excluded if there was no evident exposure, the exposure was chronic, there were co-ingestants, or the subject was non-human (e.g. pet). Results: Two hundred fifty three individuals were acutely exposed to cannabis (median age 20 years; range 8 months - 96 years; 54.2% males): 71 (28.1%) children (<12 years), 42 (16.6%) adolescents (12-17 years), and 140 (55.3%) adults (≥18 years). Children were most likely to unintentionally (98.6%) ingest (97.2%) homemade (35.2%) edibles (64.8%) belonging to a family member (73.2%) and experience sedation (52.1%). Adults were most likely to intentionally (88.6%) ingest (66.4%) retail (40.0%) edibles (48.6%) and experience neuroexcitation (47.1%). Adolescents' exposures had similarities to both adult and children; they were most likely to intentionally (81.0%) ingest (50.0%) homemade (23.8%) edibles (45.2%) belonging to a friend (47.3%) and to experience either neuroexcitation (42.9%) or sedation (40.5%). Among all ages, tachycardia and neuroexcitation were more likely following inhalation exposures compared to ingestions. Eight subjects were admitted to an intensive care unit, including three patients who were intubated; one subject died. Edibles were the most common products to cause symptoms in all age groups, while concentrated products were more likely to lead to intubation, especially when ingested. Children in particular had a higher likelihood of intensive care unit admission and intubation following exposure to concentrated products. Conclusions: Neurotoxicity is common after acute cannabis exposures. Children experienced unintentional exposures, particularly within the home and occasionally with major adverse outcomes. Concentrated products such as resins and liquid concentrates were associated with greater toxicity than other cannabis products. These findings may help guide other states during the early retail cannabis legalization period.

Integrating Public Health and Health Care Strategies to Address the Opioid Epidemic: The Oregon Health Authority's Opioid Initiative.

CONTEXT: Oregon is experiencing an opioid overdose epidemic, similar to the United States as a whole. To address this crisis, the Oregon Health Authority (OHA) implemented a strategic Opioid Initiative, convening stakeholders and integrating public health and health care system activities across sectors. Recent data indicate progress: from 2015 to 2016, Oregon had the sharpest decline in prescription opioid overdose deaths of any state. PROGRAM: The Opioid Initiative, launched in 2015, focuses on integrating efforts to improve patient care and safety, and population health, by increasing access to nonopioid pain treatment, supporting medication-assisted treatment and naloxone access for people taking opioids, decreasing opioid prescribing, and using data to inform policies and interventions. IMPLEMENTATION: Four OHA projects highlight the integration: (1) a Medicaid Coordinated Care Organization Performance Improvement Project focused on decreasing risky opioid prescribing; (2) Health Evidence Review Commission guidelines that set coverage standards for opioid and nonopioid back pain treatments for Medicaid recipients; (3) statewide opioid prescribing guidelines; and (4) an opioid data dashboard. Each project involves a partnership between governmental public health, public and private health care systems, and external stakeholders. PROGRESS: From 2015 to 2017, the number of Oregonians on 90 or more Morphine Equivalent Doses (MEDs) decreased by 37%, from 11.1 per 1000 residents quarterly to 7.0 per 1000 residents quarterly. Prescription opioid overdose deaths decreased 20% from 4.5 per 100 000 in 2015 to 3.6 per 100 000 in 2016. Within the Medicaid population, the percentage of clients on 120 or more MEDs for 30 consecutive days decreased 27%, from 2.3% in December 2015 to 1.6% in September 2017. DISCUSSION: Oregon's integrated approach to address the opioid crisis spans public health and health care systems, engages key stakeholders, and uses data and evidence to inform policies. The progress to date is promising and may assist other states seeking to identify effective strategies to decrease opioid prescribing, misuse, and overdose.

Chlamydia Retesting Among Safety-Net Clinic Patients: Infertility Prevention Project.

BACKGROUND: Due to high reinfection rates, the Centers for Disease Control and Prevention (CDC) recommend retesting everyone diagnosed with chlamydia after treatment. However, retesting rates are often low, and research on retesting is limited. METHODS: Infertility Prevention Project (IPP) was a national chlamydia screening and treatment project in the United States. We completed a retrospective longitudinal analysis using IPP testing data from 8,266 women with at least 1 positive test result from 2010 to 2013. We calculated the proportion of women retested 2-12 months after a chlamydia diagnosis and used Cox proportional hazards models to explore associated factors. RESULTS: Only 32% of women had evidence of retesting by 12 months of follow-up. Being younger (multivariate hazard ratio [mHR]: 0.96; 95% confidence interval [CI]: 0.95-0.96), black (mHR: 1.29; 95% CI: 1.12-1.50), or attending a county sexually transmitted diseases (STD; mHR: 1.91; 95% CI: 1.68-2.17), county family planning (mHR: 1.53; 95% CI: 1.39-1.69), or school-based (mHR: 2.34; 95% CI: 2.07-2.65) clinic relative to a nonprofit community health clinic were associated with increased retesting rates. CONCLUSIONS: Less than one-third of women are retested. Our results show that some clinic settings may have systematic differences which facilitate retesting, such as use of automated reminders, closed patient populations, and makeup of patient populations. Investigation of clinical environments through site visits and further data analyses may be keys to improving retesting rates.

Heavy precipitation as a risk factor for shigellosis among homeless persons during an outbreak - Oregon, 2015-2016.

OBJECTIVES: Shigella species are the third most common cause of bacterial gastroenteritis in the United States. During a Shigella sonnei outbreak in Oregon from July 2015 through June 2016, Shigella cases spread among homeless persons with onset of the wettest rainy season on record. METHODS: We conducted time series analyses using Poisson regression to determine if a temporal association between precipitation and shigellosis incidence existed. Models were stratified by housing status. RESULTS: Among 105 infections identified, 45 (43%) occurred in homeless persons. With increasing precipitation, cases increased among homeless persons (relative risk [RR] = 1.36 per inch of precipitation during the exposure period; 95% confidence interval [CI] = 1.17-1.59), but not among housed persons (RR = 1.04; 95% CI 0.86-1.25). CONCLUSIONS: Heavy precipitation likely contributed to shigellosis transmission among homeless persons during this outbreak. When heavy precipitation is forecast, organizations working with homeless persons could consider taking proactive measures to mitigate spread of enteric infections.

Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate.

Twenty years ago, Oregon voters approved the Death With Dignity Act, making Oregon the first state in the United States to allow physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. This report summarizes the experience in Oregon, including the numbers and types of participating patients and providers. These data should inform the ongoing policy debate as additional jurisdictions consider such legislation.

Surveillance of Extrapulmonary Nontuberculous Mycobacteria Infections, Oregon, USA, 2007-2012.

Limited data are available describing extrapulmonary nontuberculous mycobacteria (NTM) infections in the general population. We describe results from statewide population-based laboratory surveillance in Oregon, USA, during 2007-2012. We defined a case of extrapulmonary NTM infection as >1 isolate from skin/soft tissue, disseminated sites, lymph node, joint, or other sites. The annual incidence of extrapulmonary NTM infection (other than Mycobacterium gordonae) was stable, averaging 1.5 cases/100,000 population. Median age of the 334 patients was 51 years, and 53% of patients were female. Half of cases were caused by M. avium complex, but rapid-growing NTM species accounted for one third of cases. Most extrapulmonary NTM infections are skin/soft tissue. Compared with pulmonary NTM infection, more extrapulmonary infections are caused by rapid-growing NTM species. the designation of NTM as a reportable disease in Oregon in 2014 will result in better detection of changes in the incidence and patterns of disease in the future.

Case Finding Using Syndromic Surveillance Data During an Outbreak of Shiga Toxin-Producing Escherichia coli O26 Infections, Oregon, 2015.

Shiga toxin-producing Escherichia coli (STEC) causes an estimated 265 000 infections in the United States annually. Of emerging non-O157:H7 STEC serotypes, O26 is the most commonly recognized. During an outbreak of STEC O26 in Oregon in 2015, we used syndromic surveillance data to supplement case finding by laboratory reporting. From 157 records retrieved by querying syndromic surveillance data, we detected 4 confirmed and 5 suspected cases. However, none of the suspected cases were confirmed by stool culture, and by the time that the data were being analyzed, the confirmed cases were already known to investigators. Syndromic surveillance data can potentially supplement case finding during outbreaks of foodborne disease. To be an effective case-finding strategy, timely completion of all steps, including collecting specimens from suspected cases, should be performed in real time.

Electronic Cigarettes as an Introductory Tobacco Product Among Eighth and 11th Grade Tobacco Users - Oregon, 2015.

During 2011-2015, increased electronic cigarette (e-cigarette) and hookah use offset declines in cigarette and other tobacco product use among youths (persons aged <18 years) (1). Limited information exists about which tobacco product introduced youths to tobacco product use. Patterns of first use of e-cigarettes among Oregon youths who were tobacco users were assessed in the Oregon Healthy Teens 2015 survey, a cross-sectional survey of eighth and 11th grade students in Oregon. Respondents were asked, "The very first time you used any tobacco or vaping product, which type of product did you use?" Among students who had ever used any tobacco product (ever users), e-cigarettes were the most common introductory tobacco product reported by both eighth (43.5%) and 11th (34.4%) grade students. Among students who used a tobacco product for ≥1 day during the past 30 days (current users), e-cigarettes were the most common introductory tobacco product reported by eighth grade students (44.4%) and the second most common introductory tobacco product reported by 11th grade students (31.0%). Introductory use of e-cigarettes was commonly reported among youths in Oregon who were ever or current tobacco users, underscoring the importance of proven interventions to prevent all forms of tobacco use among youths (2,3).

Long-Term Outcomes in a Population-based Cohort with Respiratory Nontuberculous Mycobacteria Isolation.

RATIONALE: The natural history of nontuberculous mycobacteria (NTM) respiratory infection in the general population is poorly understood. OBJECTIVES: To describe the long-term clinical, microbiologic, and radiographic outcomes of patients with respiratory NTM isolates. METHODS: We previously identified a population-based cohort of patients with respiratory NTM isolation during 2005-2006 and categorized patients as cases or noncases using the American Thoracic Society/Infectious Diseases Society of America pulmonary NTM disease criteria at that time. During 2014-2015, we reviewed medical charts of patients alive on January 1, 2007. Outcomes of interest were the proportion of baseline noncases who later met case criteria and the proportions of patients with culture conversion or findings consistent with persistent disease at least 2-5 years and at least 5 years after first isolation. We defined disease persistence radiographically as infiltrate, nodules, or cavities and microbiologically as a positive respiratory mycobacterial culture. We used logistic regression to evaluate factors associated with evidence of persistence. RESULTS: The study included 172 patients (62% of 278 eligible); those not included either refused consent (n = 47) or were not located (n = 56). One hundred two (59%) included patients met case criteria at baseline. Mycobacterium avium complex was commonly isolated among baseline cases (n = 91 [89%]) and noncases (n = 52 [74%]). Overall, 57 (55%) baseline cases had died, as compared with 43 (61%) noncases (P = 0.47). Among baseline noncases, only four (5.7%) later met case criteria. Overall, 55 (54%) baseline cases and 6 (9%) noncases initiated NTM treatment. Among cases, cultures were converted in 25 (64.1%) treated versus 4 (40%) untreated patients (P = 0.04). Of 89 cases alive 2 years after isolation, 61 (69%) had additional radiography, and 35 (39%) had respiratory cultures. Of these individuals, 54 (89%) had radiographic evidence and 17 (49%) had microbiologic evidence of disease persistence. At 5 years after first isolation these figures were 36 (82%) and 13 (54%), respectively. Women were more likely to have persistent radiographic findings and microbiologic persistence, and patients with chronic obstructive pulmonary disease were less likely to have microbiologic persistence. CONCLUSIONS: In the general population, follow-up beyond 2 years of patients with respiratory NTM isolation is limited. Among those with additional evaluations, at least half of individuals have persistent positive cultures or radiographic findings consistent with NTM at least 2 years after isolation.

Mortality after Respiratory Isolation of Nontuberculous Mycobacteria. A Comparison of Patients Who Did and Did Not Meet Disease Criteria.

RATIONALE: The mortality of patients with respiratory tract isolates of nontuberculous mycobacteria (NTM) and their risk factors for death are not well described. OBJECTIVES: To determine age-adjusted mortality rates for patients with respiratory NTM isolates and their causes of death and to examine whether American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) diagnostic criteria identify those at higher risk of death after NTM isolation. METHODS: We linked vital records registries with a previously identified Oregon population-based cohort of patients with NTM respiratory isolation. We excluded patients with Mycobacterium gordonae (n = 33) and those who died (n = 21) at the time of first isolation. We calculated 5-year age-adjusted mortality rates. We used Kaplan-Meier and Cox proportional hazards analysis to examine the association of ATS/IDSA criteria and other risk factors with death. RESULTS: Of 368 subjects with respiratory NTM isolates in 2005-2006, 316 were included in the survival analysis. Most (84%) of their cultures isolated Mycobacterium avium complex. 35.1% died in the 5 years following respiratory isolation. Five-year age-adjusted mortality rates were slightly higher for those meeting (28.7/1,000) versus not meeting (23.4/1,000) ATS/IDSA criteria. In multivariate analysis, older age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.04-1.07) and lung cancer (aHR, 2.77; 95% CI, 1.51-5.07) were associated with an increased risk of death. A trend was noted between meeting ATS/IDSA criteria and subsequent death (aHR, 1.37; 95% CI, 0.95-1.97). Among cases, male sex, older age, and immunosuppressive therapy use were independent risk factors for death. CONCLUSIONS: In the State of Oregon, patients with NTM respiratory isolates have high mortality, regardless of whether they meet ATS/IDSA criteria for pulmonary NTM disease. Most patients die as a result of causes other than NTM infection.

On the Reportability of Nontuberculous Mycobacterial Disease to Public Health Authorities.

Nontuberculous mycobacteria (NTM) are environmental pathogens that are an increasingly common cause of pulmonary and extrapulmonary disease. Electronic laboratory-based reporting is a straightforward mechanism for identifying NTM infections and for monitoring trends in disease. Oregon was the first state to make NTM reportable, although at this time the reporting requirement is limited to extrapulmonary infection. This has assisted authorities in detecting outbreaks and healthcare-related infections. However, further consideration should be given to the reportability of pulmonary NTM disease. Pulmonary NTM disease is more common than tuberculosis in the United States and is of emerging public health concern. Although the direct public health action that would be triggered by a pulmonary NTM disease report is not clear, without surveillance, public health is missing an opportunity to better understand pulmonary NTM disease trends and reasons for its increasing recognition within our population. We believe state health authorities should conduct surveillance for pulmonary NTM, either by mandating reporting of laboratory isolates or by other mechanisms as we have done in Oregon.

Notes from the Field: Shigellosis Outbreak Among Men Who Have Sex with Men and Homeless Persons - Oregon, 2015-2016.

In July 2015, Shigella sonnei infections with a specific pulsed-field gel electrophoresis (PFGE) pattern linked to a multistate outbreak were recognized among men who have sex with men (MSM) in the Portland metropolitan area, and an outbreak investigation was initiated. During November 2015, isolates with PFGE patterns indistinguishable from the outbreak strain were identified in cases reported in four women, none of whom had epidemiologic links to other affected persons; however, three reported homelessness. In the ensuing months, additional S. sonnei infections were reported among homeless persons in the Portland area.

Early Syphilis Among Men Who Have Sex with Men in the US Pacific Northwest, 2008-2013: Clinical Management and Implications for Prevention.

Substantial increases in syphilis during 2008-2013 were reported in the US Pacific Northwest state of Oregon, especially among men who have sex with men (MSM). The authors aimed to characterize the ongoing epidemic and identify possible gaps in clinical management of early syphilis (primary, secondary, and latent syphilis ≤1 year) among MSM in Multnomah County, Oregon to inform public health efforts. Administrative databases were used to examine trends in case characteristics during 2008-2013. Medical records were abstracted for cases occurring in 2013 to assess diagnosis, treatment, and screening practices. Early syphilis among MSM increased from 21 cases in 2008 to 229 in 2013. The majority of cases occurred in HIV-infected patients (range: 55.6%-69.2%) diagnosed with secondary syphilis (range: 36.2%-52.4%). In 2013, 119 (51.9%) cases were diagnosed in public sector medical settings and 110 (48.0%) in private sector settings. Over 80% of HIV-infected patients with syphilis were in HIV care. Although treatment was adequate and timely among all providers, management differed by provider type. Among HIV-infected patients, a larger proportion diagnosed by public HIV providers than private providers were tested for syphilis at least once in the previous 12 months (89.6% vs. 40.0%; p < 0.001). The characteristics of MSM diagnosed with early syphilis in Multnomah County remained largely unchanged during 2008-2013. Syphilis control measures were well established, but early syphilis among MSM continued to increase. The results suggest a need to improve syphilis screening among private clinics, but few gaps in clinical management were identified.

A case-control study evaluating the role of internet meet-up sites and mobile telephone applications in influencing a syphilis outbreak: Multnomah County, Oregon, USA 2014.

OBJECTIVES: Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis. METHODS: Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression. RESULTS: Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p<0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p<0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9). CONCLUSIONS: Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals.

Female Inmates with Diabetes: Results from Changes in a Prison Food Environment.

OBJECTIVE: The prevalence of diabetes among Oregon prison inmates has increased by 50% in the last 5 years. The Healthy Food Access Project (HFAP) was implemented in the minimum-security facility at the Oregon Coffee Creek Correctional Facility to reduce the risk of chronic disease (including diabetes) and improve nutrition among female prison inmates. The intervention reduced the menu from 3,000 to 2,200 calories per day and provided nutrition education. We evaluated the effectiveness of HFAP on female inmates with diabetes on two outcomes: the effect of the reduced calorie menu on glycemic control and other biometric measures, and the calories purchased from commissary foods. METHOD: We conducted a quasiexperimental study among all female inmates with diabetes living at the prison on August 28, 2013. Exposed inmates resided in the minimum-security facility for a minimum of 90 days after August 1, 2012 (when a reduced calorie menu was implemented); unexposed inmates resided primarily or exclusively in the medium-security facility. Medical chart abstractions were conducted to collect biometric data and mixed effects models described the differences in biometric trends between exposed and unexposed participants. Commissary receipts were collected to measure calories purchased. RESULTS: Of the 63 female inmates with diabetes, 24 were exposed to the intervention and 39 were unexposed. Exposed inmates reduced their hemoglobin A1c levels by 0.04 percentage points per month compared with 0.01 percentage points per month among unexposed inmates. Changes in body mass index depended on the amount of time they had served at the prison. Participants purchased an average of 1,094 calories from the commissary per day. Exposed inmates did not purchase more calories from the commissary after HFAP implementation. CONCLUSION: Exposure to HFAP supported modest improvement in glycemic control among female inmates with diabetes, and inmates exposed to HFAP did not purchase more calories from the commissary.

Population-based Incidence of Pulmonary Nontuberculous Mycobacterial Disease in Oregon 2007 to 2012.

RATIONALE: Pulmonary nontuberculous mycobacteria (NTM) disease is a chronic, nonreportable illness, making it difficult to monitor. Although recent studies suggest an increasing prevalence of NTM disease in the United States, the incidence and temporal trends are unknown. OBJECTIVES: To describe incident cases and calculate the incidence and temporal trends of pulmonary NTM disease in Oregon. METHODS: We contacted all laboratories performing mycobacterial cultures on Oregon residents and collected demographic and specimen information for patients with NTM isolated during 2007 to 2012. We defined a case of pulmonary NTM disease using the 2007 American Thoracic Society/Infectious Disease Society of America microbiologic criteria. We used similar state-wide mycobacterial laboratory data from 2005 to 2006 to exclude prevalent cases from our calculations. We calculated annual pulmonary NTM disease incidence within Oregon during 2007 to 2012, described cases demographically and microbiologically, and evaluated incidence trends over time using a Poisson model. MEASUREMENTS AND MAIN RESULTS: We identified 1,146 incident pulmonary NTM cases in Oregon residents from 2007 to 2012. The median age was 69 years (range, 0.9-97 yr). Cases were more likely female (56%), but among patients less than 60 years old, disease was more common in male subjects (54%). Most (86%) were Mycobacterium avium/intracellulare cases; 68 (6%) were Mycobacterium abscessus/chelonae cases. Although not statistically significant, incidence increased from 4.8/100,000 in 2007 to 5.6/100,000 in 2012 (P for trend, 0.21). Incidence increased with age, to more than 25/100,000 in patients 80 years of age or older. CONCLUSIONS: This is the first population-based estimate of pulmonary NTM disease incidence in a region within the United States. In Oregon, disease incidence rose slightly during 2007 to 2012, and although more common in female individuals overall, disease was more common among male individuals less than 60 years of age.

Influenza vaccination of pregnant women: attitudes and behaviors of Oregon physician prenatal care providers.

In spite of increased risk of influenza complications during pregnancy, only half of US pregnant women get influenza vaccination. We surveyed physician prenatal care providers in Oregon to assess their knowledge and behaviors regarding vaccination of pregnant women. From September through November 2011, a state-wide survey was mailed to a simple random sample (n = 1,114) of Oregon obstetricians and family physicians. The response rate was 44.5 %. Of 496 survey respondents, 187 (37.7 %) had provided prenatal care within the last 12 months. Of these, 88.5 % reported that they routinely recommended influenza vaccine to healthy pregnant patients. No significant differences in vaccine recommendation were found by specialty, practice location, number of providers in their practice, physician gender or years in practice. In multivariable regression analysis, routinely recommending influenza vaccine was significantly associated with younger physician age [adjusted odds ratio (AOR) 2.01, 95 % confidence interval (CI) 1.29-3.13] and greater number of pregnant patients seen per week (AOR 1.95, 95 % CI 1.25-3.06). Among rural physicians, fewer obstetricians (90.3 %) than family physicians (98.5 %) had vaccine-appropriate storage units (p = 0.001). Most physician prenatal care providers understand the importance of influenza vaccination during pregnancy. To increase influenza vaccine coverage among pregnant women, it will be necessary to identify and address patient barriers to receiving influenza vaccination during pregnancy.