Looking Cool, Doing Tricks, Managing Stress, and Nicotine Addiction: Youth Perspectives on Nicotine Vaping and Implications for Prevention.

PURPOSE: To understand the contextual and psychosocial factors associated with youth vaping in Colorado, the state with the highest youth vaping rates in 2019, and to propose strategies for prevention interventions. DESIGN: Focus groups. SETTING: In-person. PARTICIPANTS: 24 youth aged 11-17, including youth who had vaped (n = 11) and who had never vaped (n = 13). METHOD: Qualitative responses using a semi-structured focus group guide were analyzed using a matrix approach with a mixed deductive/inductive content analysis. RESULTS: Analysis revealed the highly social nature of vaping initiation and use; the use of vaping to control negative emotions; and the acquisition of vaping products through retail outlets, friends, family, and other youth who sell a variety of substances and devices to youth. Youth provided insight into how vaping is concealed from parents and teachers, and their attitudes about the health risks and benefits of vaping. CONCLUSION: When considered with other studies, our findings suggest a universality in the youth vaping experience that is highly social. Interventions should include peer-to-peer messaging with an emphasis on changing social norms and highlighting undesirable outcomes of vaping such as negative reactions by friends and close adults, adverse effects on athletic success and future aspirations, expense, addiction, and punishment. Parent education is also recommended. Rigorous research is needed to test interventions to reverse the growing trend of youth vaping.

Design and Effectiveness of the Youth Engaged Strategies for Changing Adolescent Norms! (YES-CAN!) Program for Reducing Skin Cancer Risk.

Adolescence is a critical period for reducing skin cancer risks, yet the development of effective interventions for middle and high school youth has lagged behind those for younger children. We developed and implemented the "Youth Engaged Strategies for Changing Adolescent Norms!" (YESCAN!) program, a school-based peer leader program that uses a youth-researcher partnership approach and a project-based curriculum to support high school students in developing and delivering short narrative videos and related material about skin cancer prevention to middle school students. Participating middle and high school students completed pre- and post-program surveys assessing skin cancer attitudes, perceived norms, and behavioral intentions. Middle school students (N = 97) reported positive pre- to post-program changes in future intentions to engage in sun protection and reduce UV exposure behaviors and on numerous measures of normative beliefs and attitudes. High school students (N = 13) reported positive changes on a smaller set of behavioral intentions, normative beliefs, and attitudes. These findings add to a growing body of support for youth-participatory, peer-led approaches to adolescent risk reduction in general and to skin cancer risks specifically. The YESCAN! program fills a need for effective skin cancer prevention among adolescents, while at the same time addressing educational objectives to develop 21st Century Skills.

Survey of Physician Practices, Attitudes, and Knowledge Regarding Recombinant Zoster Vaccine.

BACKGROUND: Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years. OBJECTIVE: To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions. DESIGN: Mail and internet-based survey conducted from May through July 2020. PARTICIPANTS: General internists and family physicians throughout the USA. MAIN MEASURES: Survey responses. KEY RESULTS: The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients. CONCLUSION: Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.

Reducing Youth Vaping: A Pilot Test of the Peer-Led "Youth Engaged Strategies for Changing Adolescent Norms!" (YES-CAN!) Program.

Effective prevention interventions are needed to stem the rising tide of nicotine vaping among adolescents. We conducted a quasi-experimental, non-equivalent comparison group pilot study of the effectiveness of the "Youth Engaged Strategies for Changing Adolescent Norms" (YES-CAN!) program for reducing risks for youth nicotine vaping. YES-CAN! is an innovative peer-led program that supports older adolescents in developing and delivering short narrative prevention videos and related prevention education to younger adolescents. High-school and middle-school program participants and non-program comparison group students completed pre and post surveys assessing vaping susceptibility, behavioral intentions, resistance, knowledge, attitudes, perceived harm, and normative beliefs. Vaping knowledge and the perceived number of friends and classmates who vape showed significantly greater pre- to post-program increases among high-school participants compared to non-participants, and positive vaping attitudes demonstrated significantly greater decreases. Among middle-school students, vaping knowledge increased significantly more among program participants compared to non-participants. The findings from this study indicate that the YES-CAN! program holds promise for reducing risks of nicotine vaping among adolescents. This contributes to a growing body of evidence regarding the utility of peer-led approaches to adolescent health promotion. Further evaluation of the YES-CAN! program in a large-scale randomized control trial is warranted to determine its effectiveness in curbing the escalation of youth nicotine vaping that has characterized the past decade. Future studies should monitor program effect on perceptions of vaping prevalence to ensure participation and/or exposure does not inadvertently promote vaping by increasing perceptions that others vape.

Rural parents' attitudes and beliefs on the COVID-19 pediatric vaccine: An explanatory study.

The coronavirus disease 2019 (COVID-19) first came to the Unites States in January 2020. Though adult and pediatric vaccines became available to the public, vaccine uptake among youth and particularly younger children has been gradual. This explanatory study aimed to better understand parents' attitudes and beliefs of the pediatric COVID-19 vaccine and the barriers and facilitators to vaccine uptake in a rural community through a brief, online demographic survey, and in-depth qualitative interviews. Forty-one in depth interviews were conducted with parents (31-English and 10-Spanish-speaking) residing in rural and frontier counties in Colorado between September 2021 and February 2022. Six emergent themes related to COVID-19 pediatric vaccine uptake were identified among the population. These themes spanned the three levels of influence in the Social Ecological Model (individual, interpersonal, and community levels). The six themes were identified as such; 1) Vaccine accessibility was associated with pediatric COVID vaccine uptake in rural communities, 2) Previous pediatric vaccine behaviors were not associated with COVID-19 pediatric vaccine uptake, 3) Perceived health status of a child or family member influenced pediatric COVID-19 vaccine uptake, 4) COVID-19 health seeking behaviors, like COVID pediatric vaccine uptake, are influenced by an individual's prosocial or individualistic perspectives, 5) Child autonomy and "age of consent" frames vaccine decision making behaviors in parents, and lastly 6) Social networks impacted COVID-19 pediatric vaccine decision making. These findings inform next steps for COVID-19 pediatric vaccine uptake including targeted and tailored messaging for communities (cues to actions), engaging youth stakeholders, and identifying trusted sources to build rapport and trust between health professionals and community members. The growing vaccine hesitancy among parents has serious implications for disease eradication and future viral outbreaks. Understanding the perceived barriers and facilitators to pediatric vaccine uptake is important to maintain the health of our youth and communities.

Measles Experience, Practice, and Knowledge by Pediatricians in the Context of Resurgent US Outbreaks.

OBJECTIVE: To assess measles experience, practice, and knowledge by pediatricians in the context of resurgent US outbreaks in 2018-2019. STUDY DESIGN: A nationally representative network of pediatricians were surveyed by email and mail from January to April 2020. RESULTS: The response rate was 67% (297 of 444). In the 3 years preceding the survey, 52% of the respondents reported awareness of measles cases in/near their community. Most thought that media reports about recent measles outbreaks had decreased delay/refusal of measles, mumps, and rubella (MMR) vaccine (6% "greatly decreased"; 66% "moderately decreased"). More than 60% of the pediatricians responded correctly for 6 of 9 true/false measles knowledge items. Less than 50% responded correctly for 3 true/false items, including statements about pretravel MMR recommendations for a preschooler and measles isolation precautions. The most common resources that the pediatricians would "sometimes" or "often/always" consult for measles information were those from the American Academy of Pediatrics (72%), a state or local public health department (70%), and the Centers for Disease Control and Prevention (63%). More than 90% of the pediatricians reported correct clinical practice for MMR vaccination of a 9-month-old before international travel. More than one-third of the respondents did not have a plan for measles exposures in their clinic. Pediatricians aware of measles cases in/near their community in the previous 3 years and those working in a hospital/clinic or Health Maintenance Organization setting were more likely to have a plan for measles exposures. CONCLUSIONS: During this time of heightened risk for measles outbreaks, there are opportunities to strengthen the knowledge and implementation of measles pretravel vaccination and infection prevention and control recommendations among pediatricians.

Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

BACKGROUND: Rotavirus vaccine (RV) coverage levels for US infants are <80%. METHODS: We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age. RESULTS: Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age. CONCLUSIONS: US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.

US Primary Care Providers' Experiences and Practices Related to Routine Pediatric Vaccination During the COVID-19 Pandemic.

OBJECTIVE: To describe, among pediatricians (Peds) and family physicians (FPs), 1) changes made to routine childhood vaccination delivery as a result of the pandemic, and 2) perceived barriers to delivering vaccinations from March 2020 through the time of the survey. METHODS: A nationally representative survey among Peds and FPs was administered by mail or Internet in October-December 2020. RESULTS: Response rate was 64% (579/909). For children aged 0 to 2 years, among those who vaccinated that age group prepandemic (Peds n = 265, FPs n = 222), 5% of Peds and 15% of FPs reported they had stopped vaccinating these children at any time. For children aged 4 to 6 years (Peds n=264, FPs n = 229), 19% of Peds and 17% of FPs reported they had stopped vaccinating at any time. For children aged 11-18 years (Peds n = 265, FPs n = 251), 24% of Peds and 19% of FPs reported they had stopped vaccinating at any time. Nearly all reported returning to prepandemic vaccination services at the time of the survey. Factors most frequently reported as major/moderate barriers to providing vaccinations included fewer in-person visits because patients/parents were concerned about risk of SARS-CoV-2 infection (Peds, 52%; FPs, 54%), fewer in-person visits for sports clearance (Peds, 39%; FPs, 44%), and fewer back-to-school in-person visits because some children were in virtual learning (Peds, 25%; FPs, 33%). CONCLUSIONS: Although some physicians reported interrupting vaccination services at some point during the pandemic, the majority reported continuing to provide vaccinations throughout, with essentially all returning to prepandemic vaccination services by end of 2020.

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention.

OBJECTIVES: To assess pediatricians' mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices. STUDY DESIGN: Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ2 test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting. RESULTS: The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or "don't know" for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities. CONCLUSIONS: Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.

Physician attitudes regarding the Advisory Committee on Immunization Practices Adult Immunization Schedule.

The Advisory Committee on Immunization Practices (ACIP) was created out of the need to formalize vaccine recommendations for the United States. Annually, ACIP delivers recommendations to the CDC director for guidance about United States vaccine use and publishes the Adult Immunization Schedule. Updated schedules feature changes to vaccine recommendations as well as changes to the schedule's usability for physicians. The objective of this study was to determine physicians' attitudes about the Adult Immunization Schedule. Surveys were administered to a sentinel physician network from October 2019 through January 2020. Physicians that responded were comfortable using the Adult Immunization Schedule, but reported confusion about some medical condition-based indications. Physicians reported a lack engagement with mobile applications, CDC Vaccine Schedules and Shots by STFM (the Society for Teachers of Family Medicine). Future work should focus on increasing clarity regarding the recommendations with medical condition-based indications and increasing knowledge of mobile applications for physicians.

Physician survey regarding updated PCV13 vaccine recommendations for adults ≥65 years.

BACKGROUND: In June 2019, the Advisory Committee on Immunization Practices recommended discontinuing the routine use of the pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years and instead recommended PCV13 be used based on shared clinical decision making (SCDM). OBJECTIVES: We wanted to assess among primary care physicians (1) knowledge and attitudes regarding the new SCDM PCV13 recommendation and (2) how the new recommendation will affect their likelihood of recommending PCV13 to adults aged ≥65 years. DESIGN: This was done by mail and internet-based survey, which was conducted October 2019 through January 2020. The study was carried out on a nationally representative sample of general internists (GIMs) and family physicians (FPs). RESULTS: The response rate was 64% (617/968, GIM 57%, FP 71%). Only 41% of respondents were aware of the SCDM PCV13 recommendation in adults aged ≥65 years; 76% agreed (37% "Strongly," 39% "Somewhat") that their patients aged ≥65 years will get confused by having a SCDM recommendation for PCV13 and a routine recommendation for the pneumococcal polysaccharide vaccine (PPSV23); 60% agreed (18% "Strongly," 42% "Somewhat") that they were unsure of what points to emphasize when having a SCDM conversation with an adult aged ≥65 years about receiving PCV13. Just over 50% reported they would be less likely to recommend PCV13 for adults aged ≥65 years as a result of the new recommendation, but 42% reported that their recommendation for PCV13 would not change. CONCLUSIONS: Word of the new ACIP recommendation for PCV13 for adults aged ≥65 years needs to be further disseminated. Investigation into why some physicians do not plan to change their recommendations is warranted.

Primary Care Physicians' Perspective on Pharmacists Delivering Vaccines to Adults.

INTRODUCTION: Since 2009, pharmacists in all 50 states have been authorized to provide vaccinations to adults. The objective of this study was to assess primary care physicians' (PCPs) experiences with and attitudes about pharmacists administering vaccinations. METHODS: Internet and mail survey of PCPs representative of American College of Physicians' and American Academy of Family Physicians' memberships. RESULTS: Response rate was 69% (642/926). Ninety-eight percent of respondents agreed (79% "Strongly," 19% "Somewhat") that it is their responsibility to assure their adult patients receive recommended vaccinations. Most respondents agreed that pharmacists either did not have access to patient medical information (33% "Strongly," 45% "Somewhat") or did not have adequate vaccination history (33% "Strongly," 41% "Somewhat"). The majority also agreed that pharmacists did not inform them when vaccinations were given (35% "Strongly," 39% "Somewhat") and did not enter vaccinations administered into immunization information systems (IISs) (20% "Strongly," 37% "Somewhat"). However, 83% agreed (31% "Strongly," 52% "Somewhat") that it is helpful to have pharmacists share the role of vaccinating adults. CONCLUSIONS: PCPs have mixed feelings about pharmacists delivering vaccines. Universal use of IISs by pharmacists could partially address physicians' concerns by providing a systematic way for pharmacists and physicians to share patient vaccination histories.

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018.

OBJECTIVES: To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time. STUDY DESIGN: We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010. RESULTS: Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001). CONCLUSIONS: Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

BACKGROUND: In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines. OBJECTIVE: To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM. DESIGN: Survey conducted in October 2019-January 2020 by mail or internet based on preference. PARTICIPANTS: Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships. MAIN MEASURES: Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted. KEY RESULTS: Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians.

BACKGROUND: Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years. OBJECTIVE: We sought to examine family physicians' (FPs) and general internal medicine physicians' (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016-2017 and 2018-2019 influenza seasons. DESIGN: E-mail and mail surveys conducted February-March 2017, January-February 2019. PARTICIPANTS: Nationally representative samples of FPs and GIMs. MAIN MEASURES: Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019). KEY RESULTS: Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% "almost always/always" recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016-2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018-2019 influenza season, and 8% recommended LAIV. CONCLUSIONS: Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.

US Primary Care Physicians' Viewpoints on HPV Vaccination for Adults 27 to 45 Years.

INTRODUCTION: In June 2019, the Advisory Committee on Immunization Practices (ACIP) recommended shared clinical decision making (SCDM) regarding human papillomavirus (HPV) vaccination for adults 27 to 45 years. Our objectives were to assess among primary care physicians 1) recent practice regarding HPV vaccination for adults 27 to 45 years, 2) knowledge of HPV and the new SCDM recommendation, and 3) attitudes toward and anticipated effect of the new SCDM recommendation. METHODS: From October to December 2019, we administered an Internet and mail survey to national networks of 494 general internist (GIM) and 474 family physician (FP) members of the American College of Physicians and American Academy of Family Physicians, respectively. RESULTS: Response rate was 64% (617/968; GIM, 57%; FP, 71%). Fifty-eight percent were aware of the new ACIP recommendation; 42% had recommended HPV vaccination to adults 27 to 45 years, but most had administered HPV vaccine to very few of these patients (73% to 0% and 22% to 1 to 3). Fifty-five percent and 63% were unaware that HPV vaccination does not prevent progression of existing HPV-related cancers or infections, respectively and 57% were not sure what to emphasize when having a SCDM conversation about HPV vaccination. A majority reported they will be more likely recommend HPV vaccination to adults in the 27-to-45-year age range as a result of the new recommendation. CONCLUSIONS: Physicians are interested in recommending HPV vaccination for adults age 27 to 45 years despite ACIP not routinely recommending it in this age range. The majority need more education about the optimal use of HPV vaccine in this age group.

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates.

OBJECTIVE: To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race. DATA SOURCES: Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files. STUDY DESIGN: Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument. DATA COLLECTION/EXTRACTION METHODS: Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011. PRINCIPAL FINDINGS: Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses. CONCLUSIONS: Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.

Use of Standing Orders for Vaccination Among Pediatricians.

OBJECTIVES: Standing orders are an effective way to increase vaccination rates, yet little is known about how pediatricians use this strategy for childhood immunizations. We assessed current use of, barriers to using, and factors associated with use of standing orders for vaccination among pediatricians. METHODS: Internet and mail survey from June 2017 to September 2017 among a nationally representative sample of pediatricians. In the principal component analysis of barrier items, we identified 2 factors: physician responsibility and concerns about office processes. A multivariable analysis that included barrier scales and physician and/or practice characteristics was used to identify factors associated with use of standing orders. RESULTS: The response rate was 79% (372 of 471); 59% of respondents reported using standing orders. The most commonly identified barriers among nonusers were concern that patients may mistakenly receive the wrong vaccine (68%), concern that patients prefer to speak with the physician about a vaccine before receiving it (62%), and belief that it is important for the physician to be the person who recommends a vaccine to patients (57%). These 3 items also made up the physician responsibility barrier factor. Respondents with higher physician responsibility scores were less likely to use standing orders (risk ratio: 0.59 [95% confidence interval: 0.53-0.66] per point increase). System-level decision-making about vaccines, suburban or rural location, and lower concerns about office processes scores were each associated with use of standing orders in the bivariate, but not the multivariable, analysis. CONCLUSIONS: Among pediatricians, use of standing orders for vaccination is far from universal. Interventions to increase use of standing orders should address physicians' attitudinal barriers as well as organizational factors.