Alignment of substance use community benefit prioritization and service lines in US hospitals: a cross-sectional study.

BACKGROUND: Non-profit hospitals in the U.S. are required by the 2010 Patient Protection and Affordable Care Act (ACA) to conduct a community health needs assessment (CHNA) every three years and to formulate an implementation strategy in response to those needs. Hospitals often identify substance use as a need relevant to their communities in their CHNAs and then must determine whether to create strategies to address such a need within their implementation strategies. The aim of this study is to assess the relationship between a hospital's prioritization of substance use within its community benefit documents and its substance use service offerings, while considering other hospital and community characteristics. METHODS: This study of a national sample of U.S. hospitals utilizes data collected from publicly available CHNAs and implementation strategies produced by hospitals from 2018 to 2021. This cross-sectional study employs descriptive statistics and multivariable analysis to assess relationships between prioritization of substance use on hospital implementation strategies and the services offered by hospitals, with consideration of community and hospital characteristics. Hospital CHNA and strategy documents were collected and then coded to identify whether the substance use needs were prioritized by the hospital. The collected data were incorporated into a data set with secondary data sourced from the 2021 AHA Annual Survey. RESULTS: Multivariable analysis found a significant and positive relationship between the prioritization of substance use as a community need on a hospital's implementation strategy and the number of the services included in this analysis offered by the hospital. Significant and positive relationships were also identified for five service categories and for hospital size. CONCLUSIONS: The availability of service offerings is related both to a hospital's prioritization of substance use and to its size, indicating that these factors are likely inter-related regarding a hospital's sense of its ability to address substance use as a community need. Policymakers should consider why a hospital may not prioritize a need that is prevalent within their community; e.g., whether the organization believes it lacks resources to take such steps. This study also highlights the value of the assessment and implementation strategy process as a way for hospitals to engage with community needs.

Pain management: A deeper look at rural and urban nurses' perceptions and experiences.

PURPOSE: About 11.4 million individuals admitted to misusing an opioid in the past year. The purpose of this study was to determine if nurses' definitions of pain management differed by location, and to assess the challenges treating patients with pain management concerns. This study fills a gap by comparing quantitative and qualitative feedback from nurses on pain management concerns in their practice location. METHODS: Data were collected using an electronic survey emailed to licensed nurses across the United States. The mixed methods survey used multiple choice, select all that apply, and open-ended responses to gather data on nurses' perceptions of pain management. One hundred and eighty nurses completed the survey and were included in the study. Sixty-six percent practiced in an urban hospital. FINDINGS: Rural and urban nurses defined pain management as nonopioids and opioids. Seventy-one percent of urban nurses defined pain management as physical therapy compared to only 61% of rural nurses. Similarly, 62% of urban nurses identified homeopathic medicines and treatments as pain management techniques compared to 52% of rural nurses. From the qualitative data, 32% of rural nurses stated that patients with pain management concerns only want pain medications compared to 14% of urban nurses. CONCLUSIONS: Nurses have a critical position in and valuable perspective on the opioid epidemic. Rural communities are relatively disadvantaged in combatting the opioid epidemic. The finding that rural residents only want pain medication instead of alternative pain management options further challenges the country's rural health care workforce.

A qualitative understanding of nurses' challenges with pain management.

BACKGROUND: Studies have shown that providers deliver inadequate pain management, which is important since ineffective pain management can lead to patient safety concerns and negative health outcomes. There is a gap in the literature understanding the specific details of nurses' struggles treating patients who need help with pain management. METHODS: This qualitative descriptive study assessed nurses' challenges with pain management to provide a comprehensive, low-inference summary of the data. Participants were interviewed about their biggest challenges. FINDINGS: Three main themes emerged from the data: prescribing patterns, education on zero pain, and system problems. Major challenges identified in this study were understanding nurses' perceptions of pain management care delivery and the need for quality pain management education. DISCUSSION: The health community needs to raise awareness and provide more comprehensive education regarding the nurse' role in pain management.

Impact of interpersonal client-provider relationship on satisfaction with mental healthcare among the LGBTQ+ population.

BACKGROUND: Gender and sexual minorities are more likely to report unfavourable experiences with primary care. Aside from being refused care, additional challenges include stigma, discrimination, social and societal rejection, and violence. AIMS: The purpose of this study was to determine which aspects of the client-provider relationship affected perceived satisfaction with the quality of mental healthcare received. METHODS: Data was collected via electronic survey, which yielded 177 responses. Univariate and ordinal logistic regression were used to determine if a significant relationship existed between the variables of interest. RESULTS: Results indicate that clients who felt less trust for their providers, reported inadequate time spent in therapeutic encounters, and felt their providers looked down on or judged them were less satisfied with the quality of mental healthcare they received. In addition, LGBTQ+ clients who were less satisfied with the quality of care they received were significantly less confident in their ability to receive adequate future mental healthcare. CONCLUSIONS: Results of this study highlight the importance of provider awareness, attitude, and access to information regarding the mental health needs of the LGBTQ+ population because these support culturally competent care, which potentially encourages future care-seeking behaviors.

Access to Health Care in Appalachia: Perception and Reality.

Introduction: Health disparities such as cancer and diabetes are well documented in Appalachia. These disparities contribute to health status, and by many indicators, Appalachian people are less healthy than those who live in other parts of the country. Access to health care is one factor that contributes to health disparities. Access to care is complex and involves both intrinsic and extrinsic aspects, including satisfaction with quality of care. This research sought to compare Appalachian to non-Appalachian communities in terms of perceptions of access to care. Methods: We implemented a statewide survey to quantify perceptions of multiple components of access to care, including satisfaction with quality of care. We compared survey results to quantitative data from the County Health Rankings to document consistency with perceptions of access to care. We used chi-square analysis to compare Appalachian with non-Appalachian respondents. Results: More than 600 people completed the survey. Results of the survey identify significant differences between Appalachian and non-Appalachian residents' perceptions of access to care and their satisfaction with health care. Specifically, Appalachian residents are less satisfied with convenience, information, quality, and courtesy of health care. They perceive providers relying on stereotypes when communicating with patients. Implications: Examining and documenting perceptions of health care is important because it could lead to improving access by focusing on cultural competency in addition to more resource intensive strategies. Health disparities in Appalachia might be minimized by being more compassionate and understanding of people who live here.

Expanding the Population Health Workforce: Strategic Priorities of Hospital Organizations in the United States.

The role of hospital contributions to population health is a topic increasingly worthy of attention in the years since the Affordable Care Act. To explore how hospitals themselves consider their role as population health leaders, the authors analyzed data from the 2015 American Hospital Association Annual Population Health Survey, which asks organizations about which strategic priorities should be expanded in order to strengthen their organization's population health workforce. Descriptive statistics for the study sample of 1418 hospitals show that physicians were the most commonly ranked priority, followed by behavioral health professionals. Using multivariate analysis, the professional roles identified were grouped into 5 categories: behavioral health, clinical, data collection, business functions, and social supports and services. Doing so revealed that different types of hospitals were more likely to identify different types of roles as more important. Larger hospitals were more likely than others to identify behavioral health and clinical roles. For-profit hospitals were less likely to prioritize data collection and social determinants than their nonprofit peers. These findings provide important insight for public health professionals regarding the staffing priorities of hospitals within their communities. Many population health programs may not be moving beyond traditional clinical expertise to engage the upstream determinants of health in their communities.

Patient Characteristics Affect Discharge Status for Opioid-related Infective Endocarditis.

BACKGROUND: Opioid overdoses have increased dramatically in the last 20 years, but secondary complications, such as infective endocarditis (IE) are also on the rise. OBJECTIVE: The objective of this study was to understand the effect that opioid-related IE has on hospitals across the US and to understand the disposition of patients after treatment for IE, particularly in regard to insurance status and type. RESEARCH DESIGN: Secondary data analysis of the publicly-available 2015 Nationwide Inpatient Sample (NIS) was used to assess opioid-related IE based on patient and hospital characteristics. Bivariate and logistic regression was calculated to determine significance between the outcome variable (IE) and other covariates. SUBJECTS: The 2015 NIS data contained 7,153,989 weighted observations with 5760 (0.02%) incidences of opioid-related IE. MEASURES: The NIS dataset represents a 20% stratified sample of all US hospitalizations across all payors in a given year. Opioid-related IE was the outcome variable measured through ICD-9 and ICD-10 codes, and the independent variables included the patient's age, sex, primary payer, household income, discharge status, length of stay, and transfer status, and the hospital's size, ownership, region, and location with teaching status. RESULTS: Routine discharge was the top discharge status across all payors, except Medicare. Nearly 26% of self-pay patients were discharged against medical advice. Logistic regression results indicate that patients who are younger, uninsured, have increased condition severity, have longer lengths of stay, and are discharged against medical advice or transferred to a short-term hospital or other health facility experienced significantly higher odds of opioid-related IE admissions as compared with all other admissions. The only significant hospital characteristic was region. CONCLUSIONS: The fact that patient disposition varied across different payors suggests that hospitals are missing opportunities to engage the most vulnerable patients with IE. Given the long-term care required by this condition, hospitals are well-positioned to participate in interventions to initiate substance abuse treatment and help patients navigate outpatient substance abuse treatment options.

Inventory management of surgical supplies and sterile instruments in hospitals: a literature review.

Operating rooms are considered a significant revenue source, as well as the main source of waste and cost, among the hospital's departments. Any cost savings in operating rooms will have a broad financial impact. Over the last decades, many researchers and practitioners have conducted studies to deal with the issue of managing surgical supplies and instruments, which are highly affected by surgeons' preferences. The purpose of this article is to present an up-to-date review of research in the field of inventory management of surgical supplies and instruments. We have analysed the literature in a systematic manner and organised the identified papers into two groups: the papers that were published by scientific researchers and developed optimisation techniques and the papers that were published by practitioners and reported their observations of the current issues in the operating room. We also identify the future research directions leading to operating room inventory cost reduction.

Conceptual Framework to Evaluate Health Care Professionals' Satisfaction in Utilizing Telemedicine.

CONTEXT: Several advantages of telemedicine have been reported, such as improved patient satisfaction, reduced costs, and broader access to specialists. However, most studies have focused on patient satisfaction with telemedicine services. A literature gap exists in evaluating health care professionals' (both referring and performing professionals) satisfaction in delivering telemedicine services. A clear picture of professionals' telemedicine satisfaction has the potential to improve care quality, care accessibility, and telemedicine adoption and to reduce overall health care costs. OBJECTIVES: To develop a framework to evaluate health care professionals' satisfaction in delivering telemedicine services and to articulate the factors that can contribute to their satisfaction. METHODS: We developed an initial conceptual framework based on existing literature and the research team's expertise. The initial framework was validated by a convenience group of 12 osteopathic and allopathic physicians, and the framework was further revised and refined according to their input. RESULTS: The refined framework includes 5 main components (professionals' demographics, care settings, motivations, experiences, and overall satisfaction) that can contribute to health care professionals' satisfaction or dissatisfaction in delivering telemedicine services. Detailed itemization is provided under each component, including hierarchical organizations of the items, definitions, and potential value sets. CONCLUSIONS: The refined conceptual framework may provide a comprehensive evaluation reference for measuring professionals' satisfaction in delivering telemedicine. Further customization according to the specific setting of telemedicine services is needed. This refined conceptual framework can also be used to identify areas that can be improved and to ultimately improve telemedicine services and care quality.

Development and application of a rubric to compare strategies for improving access to health care in rural communities in the United States.

Rural areas are underserved in terms of the availability of and access to health care services. According to Healthy People 2020, access to health care continues to be the most frequently identified rural health priority in the United States. PURPOSE: The purpose was to develop an efficient approach for standardizing and prioritizing strategies to improve access to health care in rural areas across the United States. The rubric provides a quantitative metric of the effectiveness of each strategy in terms of impact and feasibility and allows community health departments and other access to care groups to compare strategies and facilitate discussion of various strategies' ability to meet the needs of diverse communities. FRAMEWORK: The Plan, Do, Check, Act (PDCA) cycle was used to create the rubric. The research team constructed a plan for creating a rubric to measure each strategy's impact and feasibility. We checked the rubric by applying it to selected access to care improvement strategies evaluated by the Robert Wood Johnson Foundation (RWJF). Members of a rural community Access to Care Workgroup applied the rubric to several RWJF What Works for Health strategies. The final step was to compare the results of the application phase through facilitated conversations with the goal of determining which strategy or strategies would best meet the needs of the rural community. DISCUSSION: A rubric is a valuable tool to facilitate assessment and discussion and for assisting community members in determining access to care priorities. After applying the rubric in a community setting, we identified two important tactics: 1) the rubric is best applied to strategies when they are summarized consistently and cohesively; and 2) it is important to involve community stakeholders early in the process of identifying strategies for evaluation. The next step is to apply the rubric to similar strategies in other rural communities to further validate the rubric's effectiveness.

Urinary Iodine, Perchlorate, and Thiocyanate Concentrations in U.S. Lactating Women.

BACKGROUND: Iodine is an essential micronutrient for thyroid hormone production. Adequate iodine intake and normal thyroid function are important during early development, and breastfed infants rely on maternal iodine excreted in breast milk for their iodine nutrition. The proportion of women in the United States of childbearing age with urinary iodine concentration (UIC) <50 µg/L has been increasing, and a subset of lactating women may have inadequate iodine intake. UIC may also be influenced by environmental exposure to perchlorate and thiocyanate, competitive inhibitors of iodine transport into thyroid, and lactating mammary glands. Data regarding UIC in U.S. lactating women are limited. To adequately assess the iodine sufficiency of lactating women and potential associations with environmental perchlorate and thiocyanate exposure, we conducted a multicenter, cross-sectional study of urinary iodine, perchlorate, and thiocyanate concentrations in healthy U.S. lactating women. METHODS: Lactating women ≥18 years of age were recruited from three U.S. geographic regions: California, Massachusetts, and Ohio/Illinois from November 2008 to June 2016. Demographic information and multivitamin supplements use were obtained. Iodine, perchlorate, and thiocyanate levels were measured from spot urine samples. Correlations between urinary iodine, perchlorate, and thiocyanate levels were determined using Spearman's rank correlation. Multivariable regression models were used to assess predictors of urinary iodine, perchlorate, and thiocyanate levels, and UIC <100 µg/L. RESULTS: A total of 376 subjects (≥125 from each geographic region) were included in the final analyses [mean (SD) age 31.1 (5.6) years, 37% white, 31% black, and 11% Hispanic]. Seventy-seven percent used multivitamin supplements, 5% reported active cigarette smoking, and 45% were exclusively breastfeeding. Median urinary iodine, perchlorate, and thiocyanate concentrations were 143 µg/L, 3.1 µg/L, and 514 µg/L, respectively. One-third of women had UIC <100 µg/L. Spot urinary iodine, perchlorate, and thiocyanate levels all significantly positively correlated to each other. No significant predictors of UIC, UIC <100 µg/L, or urinary perchlorate levels were identified. Smoking, race/ethnicity, and marital status were significant predictors of urinary thiocyanate levels. CONCLUSION: Lactating women in three U.S. geographic regions are iodine sufficient with an overall median UIC of 143 µg/L. Given ubiquitous exposure to perchlorate and thiocyanate, adequate iodine nutrition should be emphasized, along with consideration to decrease these exposures in lactating women to protect developing infants.

Models of Care Delivery for Patients With Parkinson Disease Living in Rural Areas.

The elderly who suffer from chronic conditions have an increasingly difficult time accessing health care in rural areas compared with their healthy counterparts who seek and utilize less specialty care. Parkinson disease affects approximately 0.3% to 5% of the elderly population. However, a large portion of that population has difficulty accessing health care. The purpose of this study was to obtain an understanding of the access to care issues for patients with Parkinson disease and review solutions to aid their provision of care. A review of the literature found several models of care available to improve access to care issues for patients with Parkinson disease.

The Rate of Sepsis in a National Pediatric Population, 2006 to 2012.

INTRODUCTION: The rate of pediatric severe sepsis is reported to be on the rise in the United States, increasing by approximately 6000 cases annually. The goal of this study was to determine the rate of pediatric sepsis per 100 000 inpatient discharges over time. METHODS: The 2006, 2009, and 2012 Agency for Healthcare Research and Quality Healthcare Cost Utilization Project Kid's Inpatient Databases were used to analyze the rate of sepsis in children over time. RESULTS: The rate of pediatric sepsis has increased over time from 92.8 per 100 000 in 2006 to 158.7 per 100 000 in 2012. Children less than a year old with Medicaid coverage and 3 or more procedures during hospitalization have significantly higher rates than their counterparts. CONCLUSIONS: This study helps clarify the population demographics that are at greater risk for sepsis infections. Understanding the at-risk population aids policymakers and care providers in targeting these populations and make drastic changes to sepsis policies.

An interprofessional programme to culturally sensitise students to the needs of patients and realities of practice in rural areas.

The University of North Dakota programme, Students/residents Experiences And Rotations in Community Health (SEARCH), was implemented to address recruitment and retention problems and stereotypes associated with practicing in rural areas by providing an opportunity for health profession students to gain experience living and practicing in rural areas and observing interprofessional practice. Each health profession student in the programme (n = 181) from 2001 to 2011 (excluding 2009) kept a four-week journal detailing daily or weekly interactions, general thoughts, and experiences. Students who participated were from medical, psychology, dental, social work, nurse practitioner, and physician assistant professions. Results were grouped into three major themes around whether the experience increased their knowledge of healthcare issues in rural areas in North Dakota, increased their knowledge about interprofessional teams, and expanded their rural awareness. Overall, students valued this interprofessional experience, learned how to work in collaborative teams, and reported having a better understanding of the needs and problems in rural healthcare. Recruitment and retention of healthcare professionals in rural healthcare exhibit many challenges. The SEARCH programme has helped to alleviate some of these challenges; however, continued support for these programmes is necessary to sustain the delivery of interprofessional healthcare in rural areas.

Enhanced Transitions of Care: Centralizing Discharge Phone Calls Improves Ability to Reach Patients and Reduces Hospital Readmissions.

BACKGROUND: The discharge phone call (DPC) is an important initiative aimed at improving transitions of care and reducing readmissions. It is of added importance as financial penalties will be imposed on hospitals with "excessive" Medicare readmissions. This study examines the impact of DPCs on percentages of patients reached through the DPCs and hospital readmission rates based on the centralized or noncentralized mode of DPCs. METHODS: The health system centralized the Studer Group Discharge Phone Call program into one central call center with the goals of reaching more discharged patients and to ultimately reduce hospital readmissions. The study analyzed hospital visits from 74,754 patient admissions that could result in an unplanned hospital readmission. Hospital discharge data were analyzed from August 2010 to January 2014. Primary outcomes included DPCs reaching discharged patients and effects on hospital readmission rates as a result of centralizing the DPC program. RESULTS: Centralized DPCs are significantly associated with increases in the percentage of patients reached by the DPC, which in turn reduces readmissions rates. Patients not reached were 1.32 times more likely to be readmitted than patients reached by centralized DPCs. CONCLUSIONS: Centralizing the DPC program within a call center helps reach more patients and reduce readmission rates further compared with noncentralized DPCs.

Studer Group® ' s evidence-based leadership initiatives.

PURPOSE: The purpose of this paper is to analyze the implementation of an organizational change initiative--Studer Group®'s Evidence-Based Leadership (EBL)--in two large, US health systems by comparing and contrasting the factors associated with successful implementation and sustainability of the EBL initiative. DESIGN/METHODOLOGY/APPROACH: This comparative case study assesses the responses to two pairs of open-ended questions during in-depth qualitative interviews of leaders and managers at both health systems. Qualitative content analysis was employed to identify major themes. FINDINGS: Three themes associated with success and sustainability of EBL emerged at both health systems: leadership; culture; and organizational processes. The theme most frequently identified for both success and sustainability of EBL was culture. In contrast, there was a significant decline in salience of the leadership theme as attention shifts from success in implementation of EBL to sustaining EBL long term. Within the culture theme, accountability, and buy-in were most often cited by interviewees as success factors, while sense of accountability, buy-in, and communication were the most reported factors for sustainability. ORIGINALITY/VALUE: Cultural factors, such as accountability, staff support, and communication are driving forces of success and sustainability of EBL across both health systems. Leadership, a critical factor in several stages of implementation, appears to be less salient as among factors identified as important to longer term sustainability of EBL.

Discharge phone calls: a technique to improve patient care during the transition from hospital to home.

The discharge process is a transitional period when the patient's care is shifted from the hospital to the home and can be stressful for patients. One technique used to improve the quality and continuity of care is the discharge phone call (DPC). A large, metropolitan hospital implemented the DPC program to improve quality of care and decrease readmission rates. Qualitative interviews were performed with 24 hospital leaders, managers, and staff to determine the impact of the DPC program on the quality of care during the discharge process. Interviewees responded that the main benefits to the DPCs related to patient's medication management, follow-up appointment reminders, and answering questions. From a hospital perspective, the DPC can provide feedback to help improve the care delivery process related to discharge planning through improved discharge instructions and reinforcement of prescribed steps upon the patient's return home.

Implementing a medical screening and referral program for rural emergency departments.

CONTEXT: Emergency Department (ED) overcrowding due to nonemergent use is an ongoing concern. In 2011, a regional health system that primarily serves rural communities in Texas instituted a new program to medically screen and refer nonemergent patients to nearby affiliated rural health clinics (RHCs). PURPOSE: This formative evaluation describes the program goals, process, and early implementation experiences at 2 sites that adopted the program before wider implementation within the rural health system. METHODS: Primary data collection including document review, internal stakeholder interviews, and direct observation of program processes were used for this formative evaluation of program implementation in light of program goals and objectives. Fourteen key informants were asked questions related to the program concept, structure, and implementation. RESULTS: The program, as implemented, aligned with initial program goals, but it was dependent on ED screening staff and RHC availability. Some adjustments to the program were needed, including RHC hours, consistency among staff in making referrals, patient education, and improving patient uptake on the referral. Stakeholders reported lessons learned related to training, staff buy-in, Emergency Medical Treatment and Labor Act (EMTALA), and intraorganizational cooperation. DISCUSSION: The system was able to leverage excess capacity of affiliated RHCs to accommodate low-acuity patients referred from the ED and may lead to improvements in Triple Aim goals of increased patient satisfaction, better population health and outcomes, and lower per capita costs. Lessons learned from this program may inform similar processes aimed to reduce nonemergency ED utilization by other rural health systems.

Initial impact of Medicare's nonpayment policy on catheter-associated urinary tract infections by hospital characteristics.

AIMS AND OBJECTIVES: The goal of this study was to evaluate the trend in urinary tract infections (UTIs) from 2005 to 2009 and determine the initial impact of Medicare's nonpayment policy on the rate of UTIs in acute care hospitals. BACKGROUND: October 2008 commenced Medicare's nonpayment policy for the additional care required as a result of hospital-acquired conditions, including catheter-associated urinary tract infections (CAUTIs). CAUTIs are the most common form of hospital-acquired infections. METHODS: Rates of CAUTIs were analyzed by patient and hospital characteristics at the hospital level on a quarterly basis, yielding 20 observation points. October 2008 was used as the intervention point. A time series analysis was conducted using the 2005-2009 Nationwide Inpatient Sample datasets. A repeated measures Poisson regression growth curve model was used to analyze the rate of CAUTIs by hospital characteristics. RESULTS: The annual rate of CAUTIs continues to rise; however the annual rate of change is starting to decline. The change in rate of CAUTIs was not significantly different before and after the policy's payment change. The results of the adjusted time series analysis show that various hospital characteristics were associated with a significant decline in rate of CAUTIs in quarters 16-20 (after the policy implementation) compared to the rate in time 1-15 (before the policy implementation), while other characteristics were associated with a significant increase in CAUTIs. CONCLUSIONS: Medicare's nonpayment policy was not associated with a reduction in hospitals' CAUTI rates. The use of administrative data, improper coding of CAUTIs at the hospital level, and the short time period post-policy implementation were all limitations in this study.

Factors associated with influenza vaccination among US children in 2008.

BACKGROUND: Relative to adults, children have a higher risk of influenza-related illnesses, and they play a major role in the spread of infections through a household. Because the primary caregiver is responsible for the overall health of the child, it is important to analyze the relationship between caregiver characteristics and childhood immunizations. This study examined the characteristics of the caregiver, household, and child to identify factors associated with childhood influenza immunizations. METHODS: Data for children aged 19-35 months (n=25,256) were collected from the 2008 National Immunization Survey (NIS). The studied caregiver characteristics included age, education level, and marital status. Demographic variables included the child's age, sex, race/ethnicity, firstborn status, and insurance status in addition to household size, region, and poverty status. All analyses were weighted to reflect the complex sampling frame of the NIS. RESULTS: Overall, 56.39% of children aged 19-35 months had received a flu vaccination. Factors associated with an increased likelihood of vaccination included the primary caregiver being older, married, and more educated and living in the Northeast. A child with private insurance was more likely to be immunized than a child with any other type of insurance (public: OR 0.6483, 0.5589, 0.7521; no insurance: OR 0.6759, 0.4694, 0.9732). Hispanic children (OR 1.1554, 1.0312, 1.2945) were more likely to be vaccinated than their counterparts. CONCLUSIONS: Understanding the characteristics related to the rates of childhood influenza immunization can help policy makers develop and tailor programs to improve immunization education and delivery, especially to the groups that are least likely to participate.