What Affects Influenza Vaccination Rates among Older Patients? An Analysis from Inner-city, Suburban, Rural, and Veterans Affairs Practices

BACKGROUND: Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients. METHODS: A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age ≥66 years and an office visit after September 30, 1998. RESULTS: Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P \u3c 0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P \u3c 0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P \u3c 0.001). CONCLUSION: Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions

Renal transplantation in children managed with lymphocyte depleting agents and low-dose maintenance tacrolimus monotherapy

OBJECTIVE. Describe the safety and efficacy of antithymocyte globulin or alemtuzumab preconditioning, steroid avoidance and reduced calcineurin inhibitor (CNI) immunosuppression in 34 children undergoing renal transplantation. METHODS. ATG (n=8) or alemtuzumab (n=26) were infused at the time of transplantation. This was followed by low-dose twice a day tacrolimus monotherapy with consolidation to once daily dosing by 6 months and once every other day dosing by 12 months. Follow-up ranged from 0.5-2.9 years (mean 1.33 years), with a minimum of 6 months. RESULTS. Both ATG and alemtuzumab were well tolerated. Lymphopenia occurred routinely and resolved after 3-6 months. Acute cellular rejection occurred in 9%; it was related to medical nonadherence in two patients and resulted in one graft loss at 1.5 years. Important adverse events included transient neutropenia in 10 children (none with serious infection), and autoimmune hemolytic anemia in two (resolved with a steroid course in both and conversion to sirolimus in one). Estimated glomerular filtration rate (e-GFR) was stable and averaged 88 mL/min/1.73 m at latest follow-up. Fifteen preadolescents had a greater increase in height Z-score at 1 year (1.3 vs. 0.5, P=0.001), and a higher e-GFR (94.8±21 vs. 76.6±20 ml/min/1.73 m, P<0.05), when compared to case-matched historical controls who were weaned off steroids by 6 months after transplantation and received twice daily tacrolimus monotherapy. CONCLUSION. This simple regimen appears safe, has a low risk for acute cellular rejection or other adverse effects, and is associated with excellent growth and renal function. Such a regimen may also improve compliance and limit CNI nephrotoxicity. © 2007 Lippincott Williams & Wilkins, Inc

Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison

BACKGROUND: The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector. METHODS: Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization. RESULTS: The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001). CONCLUSION: Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices

Statistical testing alone and estimation plus testing: Reporting study outcomes in biomedical journals

Background: The outcomes of a research investigation are presented as statistically significant or not statistically significant, or testing alone, including the reporting of p-values. This information conveys the statistical outcomes, or statistical findings, in response to the hypotheses of interest. A companion issue is the results of the estimation plus testing, clinical or practical significance, or the findings for the hypotheses of interest. Estimation plus testing, clinical or practical significance, findings provide information as to the strength of the finding, the differences that were detected between treatment groups, or other such conclusions. Objectives: Effect sizes are recommended as a measure of estimation plus testing, clinical significance, since they are generalizable and invariant. A case is made for the reporting of estimation plus testing for outcomes in biomedical journals. Design: A review of recent publications reporting effect sizes as well as a review of publication polices for biomedical journals are discussed. Results: Of the 113 articles in 38 medical journals that mentioned effect size, 35% were meta-analyses or systematic reviews. Of the original research reported, 12% reporting effect size were randomized control trials, 54% were descriptive or observational studies. Six of the 16 Public Health/Epidemiology journals contained effect size statistics in 24 articles. Studies reporting meta-analyses accounted for 17% of the total number of Public Health/Epidemiology articles reviewed. Of the 38 medical journals and 16 Public Health/Epidemiology journals reviewed, the "Instructions for Authors" were typically stylistic in nature. Conclusions: When a criterion for testing alone, namely statistical significance, is met and a criterion for estimation plus testing, namely clinical significance is met, then a conclusion of effectiveness may be reached. For a complete interpretation of research results, the authors strongly encourage the reporting of estimation plus testing.

An empirical study of the effects of small datasets and varying prior variances on item parameter estimation in BILOG

Long-standing difficulties in estimating item parameters in item response theory (IRT) have been addressed recently with the application of Bayesian estimation models. The potential of these methods is enhanced by their availability in the BILOG computer program. This study investigated the ability of BILOG to recover known item parameters under varying conditions. Data were simulated for a two-parameter logistic IRT model under conditions of small numbers of examinees and items, and different variances for the prior distributions of discrimination parameters. The results suggest that for samples of at least 250 examinees and 15 items, BILOG accurately recovers known parameters using the default variance. The quality of the estimation suffers for smaller numbers of examinees under the default variance, and for larger prior variances in general. This raises questions about how practitioners select a prior variance for small numbers of examinees and items. Index terms: BILOG, item parameter estimation, item response theory, parameter recovery, prior distributions, simulation