2022 national survey of immunizing community chain pharmacists: The case for codifying the PREP Act emergency authorities into practice.

BACKGROUND: Pharmacy-based immunization services have expanded since the mid-1990s but still face multiple challenges. Amendments to the Public Readiness and Emergency Preparedness (PREP) Act broadened patient-care scope and the pool of eligible pharmacy personnel who could administer vaccinations. The expiration of these amendments in 2024 may threaten recent gains in vaccine and other health care access newly available through pharmacies. OBJECTIVES: This study aimed to elicit community chain pharmacists' perspectives on immunization time demands, corporate guidance, data flow and information technology, workflow and workforce issues, and other newly provided services. METHODS: A survey questionnaire was developed, pretested, and electronically administered in mid-2022 to a randomly sampled national database of pharmacists maintained by the American Pharmacists Association. Descriptive analyses of survey responses were performed and findings used to identify salient themes. RESULTS: The survey collected 742 responses from a sample of 7845 community chain pharmacists (9.5% response rate). During the 2021-2022 influenza season, pharmacies administered on average 114 vaccinations daily (range 3-1000), mostly by appointment (51%). Pharmacists expressed somewhat greater preference for administering vaccinations (39%) than dispensing prescriptions (36%), and most (92%) considered it at least as important as other practice responsibilities. However, only 27% of pharmacists had adequate staff support and 67% spent more time addressing patients' vaccination confidence issues than before the pandemic. Most respondents (67%) had access to their patient's vaccination status, but only 51% said their company's computer system gave easy access. Only 49% considered corporate immunization feedback effective at enhancing their practice. Provision of nonvaccine services has expanded. CONCLUSIONS: Frontline community chain pharmacists reportedly preferred administering vaccinations over dispensing prescriptions. The pandemic resulted in an increased responsibility among pharmacists as immunizers. Notwithstanding recent progress, pharmacists continue to face staffing, corporate guidance and feedback, information management, and other structural and process barriers to optimally provide comprehensive immunization services. Survey findings support making permanent and expanding the emergency authorities that pharmacists gained under the PREP Act.

Understanding Physicians' Perceptions of Patient-Identified Barriers to Osteoporosis Medication Initiation: A Cognitive Mapping Approach.

Objective: Interventions to initiate medication and increase adherence for postmenopausal women who have had a fragility fracture were not always successful. The purpose of this study was to derive an empirical framework for patient-identified barriers to osteoporosis medication initiation and adherence from physician experts. Methods: A cognitive mapping approach involving nominal group technique (NGT) meetings and a card sorting and rating task were used to obtain formative data. We first conducted four NGT meetings with 18 women patients who were not on osteoporosis treatment to identify barriers to osteoporosis medication, then invited 27 osteoporosis physicians to sort and rate 25 patients identified barriers. Descriptive analysis, multidimensional scaling analysis, and hierarchical cluster analysis were applied for data analysis. Results: A two-dimensional five-cluster cognitive map was derived to provide an organizational framework for understanding patients perceived barriers to medication initiation and adherence. The five clusters were concerns about side effects, experience of side effects, lifestyle changes, medication access and complexity, and patient uncertainty about treatment and trust in the provider. The two dimensions were interpreted as internal to patients (X-axis) and external to patients (Y-axis). Conclusions/Implications: Views of patients solicited in a structured format provided directions to help in designing interventions to improve osteoporosis medication initiation and adherence.

Identifying Patient Profiles for Developing Tailored Diabetes Self-Management Interventions: A Latent Class Cluster Analysis.

Purpose: Interventions that are tailored to the specific psychosocial needs of people with diabetes may be more effective than a "one size fits all" approach. The purpose of this study is to identify patient profiles with distinct characteristics to inform the development of tailored interventions. Methods: A latent class cluster analysis was conducted with data from the ENCOURAGE trial based on participant responses to 6 baseline psychosocial measures, including trust in physicians, perceived discrimination, perceived efficacy in patient-physician interactions, social support, patient activation, and diabetes distress. The trial's primary outcomes were hemoglobin A1c, body mass index, systolic blood pressure, low-density lipoprotein cholesterol, and quality of life; secondary outcomes were diabetes distress and patient engagement. Results: Three classes of participants were identified: Class 1 (n = 72) had high trust, activation, perceived efficacy and social support; low diabetes distress; and good glycemic control (7.1 ± 1.3%). Class 2 (n = 178) had moderate values in all measures with higher baseline A1c (8.1 ± 2.1%). Class 3 (n = 155) had high diabetes distress; low trust, patient engagement, and perceived efficacy; with similar baseline A1c (8.2 ± 2.1%) as Class 2. Intervention effects differed for these 3 classes. Conclusion: Three distinct subpopulations, which exhibited different responses to the ENCOURAGE intervention, were identified based on baseline characteristics. These groups could be used as intervention targets. Future studies can determine whether these approaches can be used to target scarce resources efficiently and effectively in real-world settings to maximize the impact of interventions on population health, especially in impoverished communities.

Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies.

PURPOSE: Implementing efficacious physical activity interventions in real-world rural settings is needed because rural cancer survivors are more physically inactive and experience poorer health. To address this gap, this study evaluated effectiveness of an evidenced-based physical activity program (Better Exercise Adherence after Treatment for Cancer [BEAT Cancer]) for rural women cancer survivors when implemented by community-based, non-research staff. METHODS: 16 rural women cancer survivors received BEAT Cancer implemented by a rural, community organization and non-research staff; physical activity, patient-reported outcomes, and social cognitive constructs were measured at baseline and post-program. Cancer survivors and interventionists completed program evaluations post-program. RESULTS: Cancer survivor mean age was 58±12 years; 62% were White. Mean months since diagnosis was 54±72; 69% had breast cancer. Significant improvements from pre- to post-program occurred for self-report weekly minutes of moderate-to-vigorous physical activity (mean change [M] = 146±186, p = 0.009), anxiety (M = -1.3±1.8, p = 0.016), depression (M = -2.1±2.0, p = 0.001), self-efficacy (M = 20.9±30.5, p = 0.019), barriers interference (M = -15.0±14.1, p = 0.001), and social support (M = 5.0±7.4, p = 0.02). Cancer survivors ranked the program highly, identified strategies that were helpful (e.g., group activities, personalized exercise plan, etc.), and suggested additional implementation strategies (e.g., guide for home-based phase, etc.). Interventionists identified strategies (e.g., logistics, staff training and certification, cost, etc.) for enhancing organizational readiness for program delivery. CONCLUSION: Evidence-based physical activity programs can be effective when implemented by non-research staff in rural settings. Further research testing strategies that improve implementation is needed. PRACTICAL IMPLICATIONS: Effectiveness and identified strategies supporting delivery when implemented by a rural organization can improve physical activity promotion for rural, at-risk populations.

Cognitive mapping as an approach to facilitate organ donation among African Americans.

Making up 13.4% of the United States population, African Americans (AAs) account for 28.7% of candidates who are currently waiting for an organ donation. AAs are disproportionately affected by end-organ disease, particularly kidney disease, therefore, the need for transplantation among this population is high, and the high need is also observed for other solid organ transplantation. To this end, we worked with the AA community to derive an empirical framework of organ donation strategies that may facilitate AA decision-making. We used a cognitive mapping approach involving two distinct phases of primary data collection and a sequence of data analytic procedures to elicit and systematically organize strategies for facilitating organ donation. AA adults (n = 89) sorted 27 strategies identified from nominal group technique meetings in phase 1 based on their perceived similarities. Sorting data were aggregated and analyzed using Multidimensional scaling and hierarchical cluster analyses. Among 89 AA participants, 68.2% were female, 65.5% obtained > high school education, 69.5% reported annual household income ≤ $50,000. The average age was 47.4 years (SD = 14.5). Derived empirical framework consisted of five distinct clusters: fundamental knowledge, psychosocial support, community awareness, community engagement, and system accountability; and two dimensions: Approach, Donor-related Information. The derived empirical framework reflects an organization scheme that may facilitate AA decision-making about organ donation and suggests that targeted dissemination of donor-related information at both the individual-donor and community levels may be critical for increasing donation rates among AAs.

Community chain pharmacists' perceptions of increased technicians' involvement in the immunization process.

BACKGROUND: Over the past 2 decades, pharmacists have positioned immunization services as an important aspect of their expanding role in patient care. OBJECTIVES: To examine how community chain pharmacists view time spent on immunization, available in-store resources and barriers, and pharmacy technician involvement in the context of their views about the achievement of key National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice in their workplace. METHODS: A representative, nationwide survey was administered electronically to chain community pharmacists over a 4-week period. Community pharmacists offering year-round immunization in retail chain, supermarket, and mass-merchant settings, randomly sampled from a database maintained by the American Pharmacists Association. We examined several sets of interrelated relationships regarding pharmacists' perceived achievement of 3 key NVAC standards (assessment, recommendation and administration), time spent on the overall immunization process, the effectiveness of available in-store resources, immunization impediments, and the endorsement of increased technician involvement in community pharmacy-based immunization service (PBIS) delivery. RESULTS: A sample of 590 survey responses was obtained from 9717 e-mails delivered, with 489 deemed eligible (5% response rate). Sizeable numbers of pharmacists acknowledged that several activities integral to achieving optimal immunization levels were not being addressed. Although pharmacists accepted that appropriately trained pharmacy technicians should be able to ask (77%) and assess (66%) patients, only 24% agreed that technicians should be able to administer vaccine doses. Pharmacists satisfied with in-store immunization resources and technicians' involvement were more likely to report achieving the 3 key NVAC standards. Paradoxically, how pharmacists viewed their immunization time expenditures was unrelated to whether they agreed that pharmacy technicians should have an expanded role in asking, assessing, or administering vaccines to their patients. CONCLUSION: Overall, community pharmacies would likely better meet national immunization goals by achieving all 3 key NVAC standards and incorporating expanded roles for appropriately trained and supervised technicians in PBIS.

Determining patient needs to enhance exercise program implementation and uptake in rural settings for women after a cancer diagnosis.

PURPOSE: To qualitatively explore exercise barriers and facilitators experienced by rural female cancer survivors from the program interventionist and recipient perspective for the purpose of enhancing exercise program implementation and uptake in rural settings. METHODS: A descriptive qualitative study design was utilized. Focus groups were conducted prior to implementation of an evidence-based exercise program by a rural non-research cancer clinical site. Nineteen rural female cancer survivors (mean age = 61.7 ± 10.9 years) and 11 potential interventionists (mean age = 42.3 ± 15.3 years) completed focus groups (stratified by participant role). Focus groups were audio recorded, transcribed, coded, and analyzed using inductive thematic analysis with NVivo 11. RESULTS: Cancer survivors identified 12 barrier themes (cancer specific adverse effects, lack of support, lack of knowledge, perceived negative aspects of exercise, cost, lack of resources, motivation, inconvenience, lack of program flexibility, time, weather, safety) and eight facilitator themes (knowledge, ease of access, resources, awareness, cost, options, organized, fun) related to exercise. Interventionists identified seven barrier themes (cost, transportation, lack of cancer survivor and interventionist knowledge, fear, motivation, lack of support, lack of resources) and four facilitator themes (resources, support, knowledge, motivation). Narratives revealed differing role-specific perspectives on shared themes between survivors and interventionists as well as potential implementation strategies for enhancing exercise participation and exercise program uptake among rural female cancer survivors. CONCLUSION: Exploring multi-level stakeholder perspectives on cancer survivors' exercise needs and related strategies yields important information for organizations to consider when implementing exercise programs in rural contexts.

Factors associated with the provision of inpatient care in hospices.

BACKGROUND: Hospices provide end-of-life care to patients who have complex health care needs and whose symptoms are difficult to control. Understanding why some hospices offer inpatient hospice care to patients could bring more evidence for policy makers and researchers to focus on the role of inpatient care in hospice. PURPOSE: The purpose of this study was to examine market and organizational factors that are associated with the provision of hospice inpatient care. METHODOLOGY: This study used a retrospective, longitudinal design (2009-2013). The study sample was drawn from three data resources: the Area Health Resources Files, the Provider of Services files, and Hospice Cost Reports from Centers for Medicare & Medicaid Services. The sample size was 2,391 hospices or 10,999 hospice observations over 5 years. A generalized linear mixed-effects model was used to examine the association between market and organizational factors and hospice inpatient services offering. RESULTS: On average, 94.59% of hospices offer inpatient services to patients. Proportion of adults who were over 65 years old (OR = 1.12) and Medicare-managed care penetration (OR = 1.02) were positively associated with the provision of hospice inpatient services. The number of hospitals with hospice program was negatively related to hospice inpatient services offering (OR = .95). Other factors such as nursing skill mix, volunteer dependence, and census region were also associated with inpatient services offering. PRACTICE IMPLICATIONS: The age demand of hospice care and Medicare-managed care penetration are related to hospice inpatient services offering. Hospices located in the market with more competition from hospitals that offer hospice program are less likely to offer inpatient care.

Hospice inpatient services provision, utilization, and financial performance.

BACKGROUND: Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. PURPOSE: The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. METHODOLOGY/APPROACH: A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. RESULTS: When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). CONCLUSION: Hospice inpatient services provision was associated with average LOS and financial performance. PRACTICE IMPLICATIONS: Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.

Input from multiple stakeholder levels prioritizes targets for improving implementation of an exercise intervention for rural women cancer survivors.

BACKGROUND: Although evidence-based interventions for increasing exercise among cancer survivors (CSs) exist, little is known about factors (e.g., implementation facilitators) that increase effectiveness and reach of such interventions, especially in rural settings. Such factors can be used to design implementation strategies. Hence, our study purpose was to (1) obtain multilevel perspectives on improving participation in and implementation of a multicomponent exercise behavior change intervention for rural women CSs and (2) identify factors important for understanding the context using the Consolidated Framework for Implementation Research (CFIR) for comparison across three levels (CSs, potential interventionists, community/organizational stakeholders). METHODS: We conducted three nominal group technique meetings with rural women CSs, three with community/organizational stakeholders, and one with potential interventionists. During each meeting, participants were asked to respond silently to one question asking what would make a multicomponent exercise intervention doable from intervention participation (CSs) or implementation (potential interventionists, stakeholders) perspectives. Responses were shared, discussed to clarify meaning, and prioritized by group vote. Data was deductively coded using CFIR. RESULTS: Mean age of CSs (n = 19) was 61.8 ± 11.1 years, community stakeholders (n = 16) was 45.9 ± 8.1 years, and potential interventionists (n = 7) was 41.7 ± 15.2 years. There was considerable consensus among CSs, potential interventionists, and stakeholders in terms of CFIR domains and constructs, e.g., "Design quality and packaging" (Innovation Characteristics), "Patients needs and resources" (Outer Setting), "Available resources" (Inner Setting), and "Engaging" (Process). However, participant-specific CFIR domains and constructs were also observed, e.g., CSs endorsed "Knowledge and beliefs about the intervention," "Individual stage of change," and "Self-efficacy" (Characteristics of Individuals); potential interventionists valued "Tension for change" (Inner Setting) and "Innovation participants" and "Key stakeholder" (Process); stakeholders emphasized "Goals and feedback" and "Network and communication" (Inner Setting), and "Planning" (Process). How the three participant levels conceptualized the CFIR constructs demonstrated both similarities and differences. CONCLUSIONS: Multilevel input yielded diversity in type, relative priority, and conceptualization of implementation facilitators suggesting foci for future implementation strategy development and testing. Findings also reinforced the importance of multilevel implementation strategies for increasing exercise in an underserved, at-risk population.

Optimizing the immunization activities of community chain pharmacists: Insights from a national survey.

OBJECTIVES: To assess (1) the practices, attitudes, and perceptions of immunizing chain community pharmacists regarding implementation of immunization services per the National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice and (2) how community pharmacists view the effectiveness of corporate initiatives toward improving immunization volumes. DESIGN: Following extensive formative research and pilot-testing, a cross-sectional survey was administered electronically to chain community pharmacists over a 4-week period. SETTING AND PARTICIPANTS: Respondents were chain community pharmacists engaged in year-round immunization in the United States, randomly sampled from a list of 9717 maintained by the American Pharmacists Association. OUTCOME MEASURES: Pharmacists' reports of immunization volumes, patterns of time use, perceptions of time spent on the immunization process, immunization attitudes, and confidence in completing NVAC standard components. Pharmacists also evaluated the utility of corporate goals, feedback, and incentives received. RESULTS: The survey yielded 590 responses, with 489 meeting the eligibility criteria (5% response rate) and distributed from across the country. In total, 84% of respondents reported giving 26 or more vaccinations/week during the influenza season, whereas only 6% reported as many outside of the influenza season. Pharmacists spent, on average, 29% of their day addressing the immunization process during the influenza season and 12% outside of the influenza season. Only 29% of respondents were confident that their patients' complete immunization needs were assessed at each patient encounter and only 46% were confident that their patients received strong recommendations regarding their specific immunization needs. Most pharmacists viewed corporate goals and the messages and strategies to achieve them as limited in scope and largely inadequate. CONCLUSION: In the context of their current role expectations, most community pharmacists who responded were not confident that key NVAC Standards were being implemented to improve patient immunization rates and did not view corporate initiatives as effective toward that effort.

Systematic review of the hospice performance literature.

BACKGROUND: Hospice is the key provider of end-of-life care to patients. As the number of U.S. hospice agencies has rapidly increased, the performance has been scrutinized more deeply. PURPOSE: To foster understanding of how hospice performance is measured and what factors are associated with performance, we conducted a systematic review of empirical research on hospice performance in the United States. METHODS: Both structure-process-outcome and structure-conduct-performance frameworks were applied to categorize and summarize the hospice performance literature. A total of 36 studies were included in the systematic review. RESULTS: Hospice agencies adopted different strategies (e.g., service provision strategy and staffing strategy) to improve performance. Two strategic approaches (innovation and volunteer usage) were associated with better outcomes. Hospice organizational factors, market environment, and patient characteristics were related to hospice strategic conduct and performance. Majority of hospice performance studies have examined the relationship between hospice structure and strategic conduct/process, with fewer studies focusing on structure performance and even fewer concentrating on strategy performance. PRACTICE IMPLICATIONS: Patient, organizational, and market factors are associated with hospice strategic conduct and performance. The majority of the literature considered the impact of hospice organizational characteristics, whereas only a few studies included patient and market factors. The summarization of factors that may influence hospice performance provides insight to different stakeholders.

Beyond efficacy: a qualitative organizational perspective on key implementation science constructs important to physical activity intervention translation to rural community cancer care sites.

PURPOSE: To identify constructs relevant to implementation of evidence-based physical activity (PA) behavior change interventions for rural women cancer survivors from an organizational perspective. METHODS: During the development of a PA intervention implementation toolkit, 11 potential interventionists and 19 community and organizational stakeholders completed focus groups stratified by role. Narratives were audio recorded, transcribed, and coded for Consolidated Framework for Implementation Research (CFIR) constructs. RESULTS: Multiple CFIR constructs were identified: Implementation Process (i.e., Engaging, Reflecting and Evaluating), Intervention Characteristics (i.e., Design Quality and Packaging, Cost, Evidence Strength and Quality, Adaptability, Complexity), Inner Setting (i.e., Implementation Readiness, Implementation Climate, Structural Characteristics), Outer Setting (i.e., Patient Needs and Resources, Cosmopolitanism), and Characteristics of Individuals (i.e., Knowledge and Beliefs, Stage of Change). Narratives identified rural implementation barriers (e.g., transportation) and facilitators (e.g., community-oriented). Unique needs of the cancer survivor (e.g., coping during cancer treatment and long-term effects on physical abilities) were emphasized as important barriers potentially addressed through Adaptability and Readiness implementation strategies. Narratives identified multi-level (i.e., individual-, organizational-, and community-level) strategies for targeting the identified constructs. CONCLUSIONS: Fourteen CFIR constructs emerged as potentially important for organizations to consider when implementing PA interventions. Constructs were integrated into our implementation toolkit and research testing their potential mechanisms of action when implementing PA interventions in rural settings is warranted. IMPLICATIONS: Strategies that target the identified constructs may enhance the implementation of PA programs for rural cancer survivors. Cancer survivors can facilitate these efforts by partnering with their health care providers and community organizations. IMPLICATIONS FOR CANCER SURVIVORS: Organizations promoting physical activity programs for cancer survivors must overcome implementation barriers including but not limited to cost, necessary expertise, and lack of awareness. Cancer survivors can facilitate these efforts by partnering with their health care providers, cancer center, and local community organizations to raise awareness and champion these efforts. It will "take a village", with cancer survivors being their own best advocate, to bring physical activity promotion to a broad range of cancer survivors.

Recommend, but also Discuss: Different Patterns of Physician-Perceived Barriers to Discussing HPV Vaccination and Their Association with Vaccine Administration in 11-12 Year-Old Girls.

Objectives We examined variation in primary care physicians' (PCPs') perceptions of barriers to physician-initiated discussion of HPV vaccination, and how this is associated with the rates at which they discuss, initiate and continue to administer vaccination with 11-12 year-old girls. Methods We surveyed 301 PCPs using systematic random sampling. PCP variation in perceived barriers to discussing HPV vaccination was modeled using latent class analysis (LCA). The distinct PCP groups identified were compared with each other using three iterative logistic regression models to predict the likelihood of initiating vaccine discussion and the reported percentages of 11-12 year-old patients who initiated HPV vaccination and received follow-up shots. Results LCA revealed three groups of PCPs who perceived major, moderately significant and relatively minor barriers (17.9, 41.9 and 40.2 % of respondents, respectively). Pediatricians, PCPs who were female, had minority racial/ethnic status and who perceived only minor barriers had significantly higher odds of initiating discussion. PCPs were more likely to initiate HPV vaccination if they had initiated discussion and perceived minor or moderate communication barriers. Increased likelihood to administer follow-up HPV vaccine was associated with having initiated discussion, perceiving only minor barriers and working outside Deep South states, but not with having initiated vaccination. Conclusions for Practice PCPs who discuss HPV vaccination with girls aged 11-12 and their mothers are more likely to start and sustain vaccine administration. However, different PCPs perceive barriers to discussion in different ways. Interventions tailored to different groups of PCPs should assist them in overcoming barriers to discussing their recommendations when necessary.

Mapping Perceptions of Lupus Medication Decision-Making Facilitators: The Importance of Patient Context.

OBJECTIVE: Numerous factors can impede or facilitate patients' medication decision-making and adherence to physicians' recommendations. Little is known about how patients and physicians jointly view issues that affect the decision-making process. Our objective was to derive an empirical framework of patient-identified facilitators to lupus medication decision-making from key stakeholders (including 15 physicians, 5 patients/patient advocates, and 8 medical professionals) using a patient-centered cognitive mapping approach. METHODS: We used nominal group patient panels to identify facilitators to lupus treatment decision-making. Stakeholders independently sorted the identified facilitators (n = 98) based on their similarities and rated the importance of each facilitator in patient decision-making. Data were analyzed using multidimensional scaling and hierarchical cluster analysis. RESULTS: A cognitive map was derived that represents an empirical framework of facilitators for lupus treatment decisions from multiple stakeholders' perspectives. The facilitator clusters were 1) hope for a normal/healthy life, 2) understand benefits and effectiveness of taking medications, 3) desire to minimize side effects, 4) medication-related data, 5) medication effectiveness for "me," 6) family focus, 7) confidence in physician, 8) medication research, 9) reassurance about medication, and 10) medication economics. CONCLUSION: Consideration of how different stakeholders perceive the relative importance of lupus medication decision-making clusters is an important step toward improving patient-physician communication and effective shared decision-making. The empirically derived framework of medication decision-making facilitators can be used as a guide to develop a lupus decision aid that focuses on improving physician-patient communication.

Primary Care Physicians' Adherence to Guidelines and Their Likelihood to Prescribe the Human Papillomavirus Vaccine for 11- and 12-Year-Old Girls.

BACKGROUND: Inadequate physician adherence to guidelines has received scant attention as a possible cause of suboptimal human papillomavirus (HPV) vaccination rates. We assessed the extent to which primary care physicians (PCPs) adhere to clinical guidelines and their reported intentions to prescribe HPV vaccine to females in the targeted age group, and how this is influenced by perceptions of guideline clarity and other factors. METHODS: We surveyed 301 PCPs to explore their sociodemographic and practice-related characteristics, beliefs, professional norms, and perceived barriers to administer HPV vaccine. Logistic regression predicted the likelihood to prescribe HPV vaccine to 11- and 12-year-old girls on an array of variables hypothesized to influence physicians' recommendations. RESULTS: Only 67% of PCPs reported being likely to prescribe HPV vaccine to 11- and 12-year-old patients. PCPs were more likely to prescribe vaccine to 11- and 12-year-old girls if they believed HPV vaccine guidelines were clear (odds ratio [OR], 1.85; 95% CI, 1.03-3.35), agreed with a mandate requirement (OR, 2.39; 95% CI, 1.01-5.61), felt comfortable discussing HPV vaccination with early adolescent girls (OR, 5.10; 95% CI, 2.75-9.45), and had at least 25% of their patients using public assistance to pay for their clinic visits (OR, 3.82; 95% CI, 1.91-7.34). Practice specialty (family physicians or pediatricians) and region were not significant predictors. CONCLUSIONS: PCPs exhibit moderate levels of adherence to professional guidelines regarding HPV vaccination. Potential public health benefits will not be realized without stronger efforts to improve the rates at which PCPs administer the vaccine, particularly to 11- and 12-year-olds for whom it is preferentially recommended.

Minorities with lupus nephritis and medications: a study of facilitators to medication decision-making.

BACKGROUND: Medication decision-making poses a challenge for a significant proportion of patients. This is an even more challenging for patients who have complex, rare, immune conditions that affect them at a young age and are associated with the use of life-long treatment, perceived by some as having significant risk of side effects and toxicity. INTRODUCTION: The aim of our study was to examine the perspectives of women with lupus nephritis on facilitators to medication decision-making. METHODS: We used the nominal group technique (NGT), a structured formative process to elicit patient perspectives. An NGT expert moderated eight patient group meetings. Participants (n = 52) responded to the question "What sorts of things make it easier for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized facilitators to medication decisional processes. RESULTS: Fifty-two women with lupus nephritis participated in eight NGT meetings (27 African-American, 13 Hispanic, and 12 Caucasian). Average age was 40.6 years (standard deviation (SD) = 13.3), and disease duration was 11.8 years (SD = 8.3); 36.5 % obtained at least a college education, and 55.8 % had difficulty in reading health materials. Patients generated 280 decision-making facilitators (range of 26 to 42 per panel). Of these, 102 (36 %) facilitators were perceived by patients as having relatively more influence in decision-making processes than others. Prioritized facilitators included effective patient-physician communication regarding benefits/harms, patient desire to live a normal life and improve quality of life, concern for their dependents, experiencing benefits and few/infrequent/no harms with lupus medications, and their affordability. Relative to African-Americans, Caucasian and Hispanic patients endorsed a smaller percentage of facilitators as influential. Level of agreement with which patients within panels independently agreed in their selections of the three most influential facilitators ranged from 33 % to 60 %. CONCLUSIONS: We identified facilitators to lupus medication decision-making. This information will be used to populate a decision aid for lupus nephritis.

Barriers to Medication Decision Making in Women with Lupus Nephritis: A Formative Study using Nominal Group Technique.

OBJECTIVE: To assess the perspectives of women with lupus nephritis on barriers to medication decision making. METHODS: We used the nominal group technique (NGT), a structured process to elicit ideas from participants, for a formative assessment. Eight NGT meetings were conducted in English and moderated by an expert NGT researcher at 2 medical centers. Participants responded to the question: "What sorts of things make it hard for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized barriers to decisional processes involving medications for treating lupus nephritis. RESULTS: Fifty-one women with lupus nephritis with a mean age of 40.6 ± 13.3 years and disease duration of 11.8 ± 8.3 years participated in 8 NGT meetings: 26 African Americans (4 panels), 13 Hispanics (2 panels), and 12 whites (2 panels). Of the participants, 36.5% had obtained at least a college degree and 55.8% needed some help in reading health materials. Of the 248 responses generated (range 19-37 responses/panel), 100 responses (40%) were perceived by patients as having relatively greater importance than other barriers in their own decision-making processes. The most salient perceived barriers, as indicated by percent-weighted votes assigned, were known/anticipated side effects (15.6%), medication expense/ability to afford medications (8.2%), and the fear that the medication could cause other diseases (7.8%). CONCLUSION: Women with lupus nephritis identified specific barriers to decisions related to medications. Information relevant to known/anticipated medication side effects and medication cost will form the basis of a patient guide for women with systemic lupus erythematosus, currently under development.