Reactions of pediatricians to a new Centers for Disease Control recommendation for universal immunization of infants with hepatitis B vaccine.

Despite immunization programs targeting high-risk groups, the incidence of hepatitis B has risen 37% over the last decade with 300,000 new infections and 5000 related deaths now occurring annually in the United States. As a new strategy to control the spread of hepatitis B, the Advisory Committee on Immunization Practices of the Centers for Disease Control (CDC) recommended in November 1991 universal hepatitis B immunization of infants. Details were published in an addendum to Morbidity and Mortality Weekly Report. There was no other federal effort to disseminate this recommendation. On February 14, 1992, the American Academy of Pediatrics (AAP) issued a similar recommendation. The time between the CDC and AAP recommendations presented the opportunity to determine the singular effect on clinical practice of the CDC's dissemination effort. The purpose of this study was to assess (1) the effectiveness of the CDC in disseminating a new immunization recommendation, (2) the effect of the new recommendation on clinical practice, and (3) the degree to which noneconomic barriers may affect adoption of universal hepatitis B immunization. All 778 pediatricians in North Carolina were surveyed by mail 2 to 3 months after publication of the new CDC recommendation. Descriptive statistics, chi 2 analysis, and logistic regression were used to assess the relationship of variables hypothesized to predict physician awareness of and/or agreement with the new recommendation. The response rate was 78%. Although 82% of pediatricians who administer immunizations were aware of the new recommendation, only 32% believed it was warranted in their practices.(ABSTRACT TRUNCATED AT 250 WORDS)

Universal hepatitis B immunization of infants: reactions of pediatricians and family physicians over time.

OBJECTIVE: In November 1991 the Advisory Committee on Immunization Practice (ACIP) recommended universal hepatitis B immunization of infants. In February 1992 the American Academy of Pediatrics (AAP) and in August 1992 the American Academy of Family Physicians (AAFP) issued similar recommendations. The purpose of this study was to assess over time the effectiveness and impact of the dissemination efforts of the ACIP, AAP, and AAFP regarding this new recommendation and to determine the factors affecting its adoption. DESIGN: Cohort survey over time. SETTING: North Carolina. PARTICIPANTS: All 778 pediatricians and a random sample of 300 family physicians in North Carolina were surveyed by mail 3 months after publication of the ACIP recommendation (January/February 1992), but before the AAP and AAFP recommendations. Response rate was 78%. Of these, 83% responded to a follow-up survey 8 months later (October 1992). MAIN OUTCOME MEASURES: Rates of agreement and adoption of the recommendation for universal infant immunization with hepatitis B vaccine; factors affecting agreement and adoption of the recommendation. RESULTS: In the first survey (3 months after the ACIP recommendation) more pediatricians than family physicians were aware of the new recommendation (82% vs 48%), yet only 37% of pediatricians and 23% of family physicians agreed that immunization of all newborns in their practice was warranted. Eight months later, after the AAP and AAFP recommendation, 66% of pediatricians and 32% of family physicians agreed universal immunization was warranted, but still only 53% of pediatricians and 23% of family physicians had adopted it into practice. Factors associated with these low rates of adoption include physician and practice characteristics, cost, perceived need for the vaccine, and aversion to multiple injections. CONCLUSIONS: Federal, AAP, and AAFP efforts have not been effective thus far in fostering widespread agreement and adoption of this recommendation. If this and future vaccine programs are to succeed, research is needed to determine influences on implementation of new recommendations and to address the economic and noneconomic concerns of physicians and parents.

Is universal neonatal hemoglobinopathy screening cost-effective?

OBJECTIVE: To determine whether and where universal neonatal screening for hemoglobinopathies, chiefly sickle-cell disease, could be performed at socially acceptable costs. METHODS: We made projections of the cost-effectiveness of nonuniversal and universal sickle-cell disease screening throughout the United States. We then compared the cost-effectiveness of universal sickle-cell disease screening with that of universal phenylketonuria screening. Finally, we asked if "high-cost" states, that is, those in which the cost of finding a case of sickle-cell disease exceeded one half the cost of finding a case of phenylketonuria, could enhance their cost-effectiveness by joining demographically complementary states in screening cooperatives. RESULTS: If all states conducted independent screening and if the value of finding a case of sickle-cell disease were no more than one half that of finding a case of phenylketonuria, seven of the 19 states that do not currently conduct universal screening for hemoglobinopathies would begin to do so, but six of the 34 that currently do so would stop. Of the six that would stop, three have already formed a screening cooperative, reducing their projected average costs for finding either sickle-cell disease or phenylketonuria or both; the other three could similarly improve cost-effectiveness through cooperative arrangements. Nineteen states realize economies of scale in six cooperative groups; more could do so. CONCLUSION: Universal neonatal hemoglobinopathy screening can be made available at socially acceptable costs to the citizens of demographically various states.

Vaccine-associated liability risk and provider immunization practices.

OBJECTIVE: To explore the effect of concern about vaccine-associated malpractice litigation on provider immunization practices and attitudes. DESIGN: A cross-sectional mail survey. PARTICIPANTS: One thousand one hundred sixty-five pediatricians and 1849 family physicians. MAIN OUTCOME MEASURES: Physicians' perceptions of the legal and financial risks of providing immunizations and of the liability protection afforded by state programs and their current immunization practices. RESULTS: The response rate was 72% for pediatricians and 63% for family physicians. Overall, less than 30% of the respondents believed that federal and state programs protect them against vaccine-related lawsuits, with pediatricians more likely to believe so (32% vs 21%, P < .0001). Pediatricians were also more likely than family physicians to believe that the diphtheria, tetanus, and pertussis vaccine could be administered safely to children with a family history of seizures, a minor respiratory tract illness, or a previous local reaction to the vaccine. Liability issues were not significantly associated with any of the outcome variables, except that those physicians who believed that the whole-cell diphtheria, tetanus, and pertussis vaccine increased their risk for lawsuits were less likely to indicate that the diphtheria, tetanus, and pertussis vaccine was safe for children with a family history of seizures (P < .001). CONCLUSIONS: Liability-related variables were not independently associated with most immunization behaviors examined. This raises the question as to whether physicians cite liability as a reason for not immunizing children with acute and chronic illnesses, when their concerns are actually otherwise. These data suggest that educational efforts focused on liability issues alone will have little effect on inappropriate delaying of immunization for these children. Rather, education is needed regarding inappropriate contraindications themselves.

Variation in patient charges for vaccines and well-child care.

BACKGROUND: Several state and federal programs have attempted to boost immunization rates by reducing or eliminating provider vaccine costs. The relation between patient vaccine and well-child visit charges and vaccine financing systems is unknown. OBJECTIVES: To determine patient charges for vaccines and well-child visits in three states with varying vaccine financing systems and to examine the effects of a short-term reduction in provider vaccine costs. DESIGN: Cross-sectional survey study of a random sample of physicians in three states. PARTICIPANTS: A total of 2797 pediatricians and family physicians in North Carolina, Texas, and Massachusetts were surveyed. MAIN OUTCOME MEASURES: Current charges to patients for diphtheria-tetanus-pertussis vaccine (DTP), measles-mumps-rubella vaccine, Haemophilus influenzae type b vaccine (Hib), and combined DPT-Hib vaccine for well-child visits; changes in charges over the previous 8 months. RESULTS: Response rate was 62%. Vaccine and well-child visit charges were comparable in North Carolina and Texas. Massachusetts' average charges for well-child visits were higher than in the other states, although vaccine charges were lower; with the use of combined DPT-Hib vaccine, total simulated charges for vaccines and well-child care during the first 6 months of life averaged only 10% less in Massachusetts vs Texas and North Carolina. Neither regional variation in cost of living nor Medicaid reimbursement rates explained this difference. CONCLUSIONS: The average cost and composition of charges for well-child care in Massachusetts, a state with universal purchase of vaccines, compared with the other states, warrant further study to explore whether physicians shift costs to other preventive services to compensate for lower allowable immunization charges. If such cost shifting occurs, current federal immunization initiatives that lower or eliminate provider cost may not provide increased access to preventive services.

Impact of a new universal purchase vaccine program in North Carolina.

OBJECTIVE: To explore the effects of state universal purchase (UP) of vaccines for all children, regardless of income or insurance status, on North Carolina physicians and families. DESIGN: Cross-sectional survey. PARTICIPANTS: Pediatricians and family physicians (N = 2163) were surveyed in 1995 to compare immunization charges in North Carolina (new UP) with those of Massachusetts (UP) and Texas (free market). MAIN OUTCOME MEASURES: Patient charges for immunizations and well-child visits and physician perceptions of the effects of state immunization programs. Models were devised to simulate the net effect of the North Carolina UP program on immunization revenue for physicians and on families' out-of-pocket costs for well-child care. RESULTS: Physician participation rates in the 2 UP programs were very high. North Carolina physicians reported substantial decreases in immunization charges and reduced referrals to public clinics, but thought that UP increased their administrative burden. Sixty percent of North Carolina physicians increased charges for well-child visits, nearly twice that in the 2 control states. Families who previously had received immunizations from public clinics but chose to remain in the private-sector "medical home" for immunizations after implementation of UP had increased out-of-pocket expenses that varied by their insurance status. CONCLUSIONS: The North Carolina UP program is effective in decreasing patient immunization charges and reducing referrals to public clinics. However, UP does not eliminate cost as a barrier to immunization, nor does it enable all children to remain in their medical homes. Underinsured children still may face considerable financial barriers to immunization in a UP system.

A comparison of dermatologists and generalists. Management of childhood atopic dermatitis.

BACKGROUND AND DESIGN: To compare the approaches of generalist physicians and dermatologists in the management of childhood atopic dermatitis (AD), a 6-page questionnaire was developed to assess specific practice characteristics and therapeutic preferences. Surveys were mailed to all board-certified dermatologists in North Carolina (n = 173) and to a sample of pediatricians (n = 200) and family medicine physicians (n = 300) randomly selected from the North Carolina Health Professions Database. There were 307 eligible respondents, defined as those who see children with AD, and 112 ineligible respondents. The response rate of eligible respondents was 62%. The specialty-specific response rates were as follows: 76% for dermatologists, 70% for pediatricians, and 49% for family medicine physicians. RESULTS: Dermatologists reported seeing the largest number of patients with AD, followed by pediatricians and family medicine physicians. Dermatologists also reported seeing the highest percentage of pediatric patients with moderate or severe AD (59%), followed by pediatricians (27%) and family medicine physicians (19%). Regardless of the severity of the AD, dermatologists consistently indicated a greater preference for more intensive therapy compared with generalists, as demonstrated by their preference for prescribing more potent topical steroids. Also, dermatologists were more likely than pediatricians (22%) and family medicine physicians (8%) to report "frequent use" of oral antibiotics for AD (63%). CONCLUSIONS: These striking interspecialty differences are likely to affect the outcome and cost of care of childhood AD. The data support the argument for conducting further studies of generalists' and dermatologists' approach to childhood AD, correlating therapeutic approaches with clinical outcomes and costs.

Reported response rates to mailed physician questionnaires.

OBJECTIVE: To examine response rate information from mailed physician questionnaires reported in published articles. DATA SOURCES/STUDY SETTING: Citations for articles published between 1985 and 1995 were obtained using a key word search of the Medline, PsychLit, and Sociofile databases. STUDY DESIGN: A 5 percent random sample of relevant citations was selected from each year. DATA COLLECTION/EXTRACTION METHODS: Citations found to be other than physician surveys were discarded and replaced with the next randomly assigned article. Selected articles were abstracted using a standardized variable list. PRINCIPAL FINDINGS: The average response rate for mailed physician questionnaires was 61 percent. The average response rate for large sample surveys (> 1,000 observations) was 52 percent. In addition, only 44 percent of the abstracted articles reported a discussion of response bias, and only 54 percent reported any type of follow-up. CONCLUSIONS: (1) Response rates have remained somewhat constant over time, and (2) researchers need to document the efforts used to increase response rates to mailed physician questionnaires.

Medical education and the retention of rural physicians.

OBJECTIVE: This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN: Design is a prospective cohort study. PARTICIPANTS: Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION: In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS: Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS: These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.

Responsive medical professionalism: integrating education, practice, and community in a market-driven era.

Revolutionary changes in the nature and form of medical practice institutions are likely to reverberate backward into medical education as leaders of the new practice organizations demand that the educational mission be responsive to their needs, and as these demands are increasingly backed by market power. In the face of this pressure, medical education's traditional response--that it should have autonomy in defining its mission--is no longer viable. Instead, more explicit, formal, and systemic linkages between practice and educational institutions are inevitable. The crucial question is whether these linkages will reflect the values of the market, oriented by economic self-interest, or the values of medical professionalism, oriented by the obligation to sacrifice economic self-interest in the service of patients. The authors maintain that the realization of the normative ideal of professionalism in medical education within the emerging market environment requires that a vision be articulated that is distinct from that of either autonomy or the market, and that combined lay-professional institutions be established to integrate--and perhaps merge--education and practice, and to foster responsiveness to lay values and community needs. The authors conclude by briefly describing examples of current efforts in this direction.

Transforming practice organizations to foster lifelong learning and commitment to medical professionalism.

Practice organizations will increasingly engage in activities that are the functional equivalents of continuing medical education. The authors maintain that if these activities are properly structured within practice organizations, they can become powerful engines of socialization to enhance physicians' lifelong learning and commitment to medical professionalism. They propose that this promise can be realized if new or reformed practice organizations combine education and service delivery and institutionalize processes of individual and collective reflection. The resulting "institutions of reflective practice" would be ones of collegial, experiential, reflective lifelong learning concerning the technical and normative aspects of medical work. They would extend recent methods of medical education such as problem-based learning into the practice setting and draw on extant methods used in complex organizations to maximize the advantages and minimize the disadvantages that practice organizations typically present for adult learning. As such, these institutions would balance the potentially conflicting organizational needs for, on the one hand, (1) self-direction, risk taking, and creativity; (2) specialization; and (3) collegiality; and, on the other hand, (4) organizational structure, (5) coordination of division of labor, and (6) hierarchy. Overall, this institutionalization of reflective practice would enrich practice with education and education with practice, and accomplish the ideals of what the authors call "responsive medical professionalism." The medical profession would both contribute and be responsive to social values, and medical work would be valued intrinsically and as central to practitioners' self-identity and as a contribution to the public good.

Preparing and retaining rural physicians through medical education.

PURPOSE: To identify educational approaches that best prepare physicians for rural work and small-town living, and that promote longer rural practice retention. METHOD: In two mail surveys (1991 and 1996-97), the authors collected data from primary care physicians who had moved to rural practices nationwide from 1987 through 1990. A total of 456 eligible physicians responded to both surveys (response rate of 69.0%). The authors identified those features of the physicians' training that correlated with their self-reported preparedness for rural practice and small-town living, and with how long they stayed in their rural practices. Analyses controlled for six features of the physicians and their communities. RESULTS: The physicians' sense of preparedness for small-town living predicted their retention duration (hazard ratio, 0.74, p < .0001), whereas their preparedness for rural medical practice did not predict their retention duration after controlling for preparedness for small-town living (hazard ratio, 0.92; p = .27). For the physicians who had just finished their training, only a few features of their training predicted either rural preparedness or retention. Residency rural rotations predicted greater preparedness for rural practice (p = .004) and small-town living (p = .03) and longer retention (hazard ratio, 0.43, p = .003). Extended medical school rural rotations predicted only greater preparedness for rural practice (p = .03). For the physicians who had prior practice experience, nothing about their medical training was positively associated with preparedness or retention. CONCLUSION: Physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices. Residency rotations in rural areas are the best educational experiences both to prepare physicians for rural practice and to lengthen the time they stay there.

Comparison of physical activity in adolescents with cystic fibrosis versus age-matched controls.

The aims of this study were to compare self-reported vigorous physical activity and participation in sports among adolescents with cystic fibrosis (CF) to those of age matched peers from the general population, and to determine which CF patient characteristics are associated with regular physical activity. One hundred and sixteen of 141 (82%) adolescents aged 12-19 years identified through North Carolina CF Care Center registries confidentially completed a self-administered questionnaire (the CDC's Youth Risk Behavior Survey) addressing health-compromising and health-enhancing behaviors, including physical activity. They were age- and gender-matched to adolescents from North Carolina schools who completed the same survey. Adolescents with CF did not differ significantly from their matched peers with regard to participating three or more times a week in activities that "make you sweat or breathe hard" (63% vs. 67%, P = 0.37), physical education class (59% vs. 61%, P = 0.81), or team sports (52% vs. 61%, P = 0.10). For all categories of activity, participation declined among adolescents aged 17 years or older. After adjusting for gender and health status, early (14 years or younger) and middle (15-16 years) adolescents were more likely to participate in all three types of activity than older adolescents with CF. Like their peers in the general population, adolescents aged 17 and older are much less likely to report regular physical activity, or participation in physical education class or in team sports. Healthcare providers should be aware of this decline in activity in late adolescence and should consider efforts to maintain physical activity among older teenagers and young adults.

The wineglass model: tracking the locational histories of health professionals.

This paper introduces a space-time continuum model to evaluate the effectiveness of programs that encourage recruitment and retention of health professionals. Based on the shape of a wineglass, the model provides a framework to study the locational histories of a cohort of health professionals, both conceptually and quantitatively. A key component of the model is that it measures geographic dispersion over time from a medical school, residency program, or other shared location. Geographic dispersion can be studied in the model through standard deviational ellipses, standard distance, or average distance circles. The model enables analysis through structuration theory, which is used as a guide for analyzing the interplay between human agency (e.g., individual decisions on practice location) and structure (e.g., medical education). Space-time modeling is linked with structuration theory. Variations in the shape of the wineglass reveal how people may be bound by a general structure, yet through lifetime locational decisions may change that structure over space and time. Using data on University of Nebraska alumni, the authors constructed a pilot demonstration to test and confirm the model's potential usefulness. In the pilot demonstration, standard deviational ellipses represented the range of physician locations during each year, overlaid on maps of the US. The pilot demonstration indicated the model's strength in identifying changing mobility over time, while also pointing to concerns about unevenness in data availability from one year to the next. Further application of the wineglass model could be used toward studying the life histories of health professionals. The impact of community-based training on long- or short-term retention, changes in the mobility of male vs female providers, and the career trajectories of people in different health professions or medical schools are only a few examples of potential future applications of the model.

From activated patient to pacified activist: a study of the self-care movement in the United States.

Self-care education programs in operation in the United States during the mid-1980s are surveyed by mailed questionnaire to determine the nature and content of the curricula of these programs, their organizational sponsorship, the level and types of staff working in them, and their principal prevention emphases. Results indicate that over 75% of these programs offer instruction or sponsored activities intended to help individuals or their families to: (1) increase wellness or health status through lifestyle change; (2) reduce an established risk factor; and/or (3) prevent the onset of illness or injury. Fifty-five percent of the organizations offering these services classified themselves as health services delivery organizations. A surprising finding, given the American popular media treatment of self-care as a 'movement', is that relatively few laypersons function as instructors in these programs. The paper describes the way in which self-care has been absorbed into the mainstream of American health care, even though the concept of self-care has tended to drop from scholarly attention in the socio-medical sciences in the United States.

Older adults as a community resource: results from the National Survey of Self-Care and Aging.

Using data collected from the first wave of a longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined the extent and type of assistance older people provided to others. Age, gender, and perceived health status were the most consistent predictors of the four types of assistance: personal care, child care, volunteer work, and listening/offering advice and support. Help with instrumental activities of daily living either alone or in combination with other activities of daily living was the most common type of personal care provided.

On the subject of sampling . . .

Abstract There is probably no subject related to evaluation causing as much confusion and unnecessary anxiety as the matter of sampling. In this article we provide some general guidelines or principles to keep in mind with respect to the number of program participants (or number of program components) to be included in a formal evaluation. We do not provide a description of the methods for the actual selection of a sample, for there are many good descriptions already available in other sources. Our goal here is to provide a very practical way of thinking about sampling as an essential part of program evaluation. Our most important point is that sampling is an essential part of the "science" of program evaluation, but the reasoning underlying the use of sampling is straightforward and should be part of sound program planning and development. Careful thought about these issues at the outset of a project can greatly enhance the generalizability and replicability of project results.

A rural-urban comparative study of nonphysician providers in community and migrant health centers.

This is a study of the employment of nonphysician providers--nurse practitioners, physician assistants, and certified nurse midwives--in both rural and urban Community and Migrant Health Centers and of factors associated with their employment, based on a 1991 national survey of 383 Centers. Results of the survey suggest that nonphysician providers, in particular nurse practitioners and certified nurse midwives, primarily serve as physician substitutes, and are more likely to be employed by Centers that are larger and have affiliations with nonphysician provider training programs. Rural or urban location is not significantly related to the employment of nonphysician providers after controlling for center size. The fact that rural centers employ fewer nonphysician providers than urban centers can primarily be accounted for by their relatively small size, rather than a lack of interest. These findings demonstrate that the use of nonphysician providers is an important way both to achieve cost containment and improve access to primary care for those residing in medically underserved areas.

Determination of supply and requirements in physical therapy: some considerations and examples.

This article is an exploration of the specific application of need-based and demand-based models for assessing health personnel supply requirements to the field of physical therapy. Definitions and examples of these models are offered. Problems presented in the field of physical therapy in accurately defining need and demand are presented. Specific examples of current data collection at a variety of levels (professional association, private sector, state, and federal) are given.

Predicting mortality from community surveys of older adults: the importance of self-rated functional ability.

Using data from the 1990 baseline of the National Survey of Self-Care and Aging (NSSCA), and nearly three years of follow-up mortality data, we examined the association between self-rated functional ability, a global measure of perceived ability of function independently, and mortality among a national sample of older adults. The study included 3,485 subjects selected from the Medicare Beneficiary Files according to a stratified random sampling design, with approximately equal numbers of adults by gender in each of three age categories, 65-74, 75-84, and 85 and over. Self-rated functional ability was found to have an independent contribution to the subsequent risk of death among older adults. Using multivariate models that accounted for self-rated health, age, gender, medical conditions, functional status, and assistance from others, poor self-ratings on this single item nearly doubled the risk of death during the follow-up period. These findings suggest the importance, for both researchers and clinicians, of measuring the potential prognostic importance of self-ratings of health and self-ratings of functional ability among older adults.