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R K Zimmerman

Publications and source records attributed to R K Zimmerman.

At least 37 records · Page 2Linked to original sources
PubMed1999

Are vaccination rates higher if providers receive free vaccines and follow contraindication guidelines?

BACKGROUND AND OBJECTIVES: Economics has been suggested as a barrier to vaccination, but data that link clinician reports to actual immunization rates are limited. This study examined the relationship between clinicians' self-report regarding likelihood of vaccinating and actual age at vaccination from a registry of children seen by the clinicians. METHODS: Standardized telephone survey results of 29 providers were compared to the immunization records of children seeing these providers, using analysis of contingency tables (on time versus late) and conditional hierarchical linear models with log age at diphtheria-tetanus-pertussis (DTP)#3, DTP#4, and measles-mumps-rubella (MMR)#1 as the dependent variables. RESULTS: Children seeing providers likely to refer an uninsured child for immunization were vaccinated at a later log age at DTP#4 but not for DTP#3 or MMR#1 than children seeing providers unlikely to refer. Vaccination rates were higher for MMR#1 (77% versus 48%), DTP#3 (84% versus 71%), and DTP#4 (82% versus 66%) among providers who received free vaccine, compared with children seen by providers who did not receive free vaccine. These results remained significant in the hierarchical analyses. Providers likely to vaccinate an 18-month-old with watery diarrhea had higher vaccination rates than those unlikely to vaccinate for MMR#1, DTP#3, and DTP#4; the results were also significant in the hierarchical analyses. CONCLUSION: Children are vaccinated later in the practices of providers who are likely to refer uninsured children to a public vaccine clinic for vaccination, who do not receive free vaccine supplies, or who overinterpret contraindications.

Age Factors↗
PubMed1999

Relationship between primary payer and use of proactive immunization practices: a national survey.

OBJECTIVE: To quantify the national use and determinants of proactive immunization practices by examining the relationship to the primary practice payer. STUDY DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. PATIENTS AND METHODS: A stratified random sample of family physicians, pediatricians, and general practitioners across the United States was selected from the American Medical Association master file of physicians list, which included nonmembers. The main outcome measures were use of reminder systems and assessment of immunization rates. RESULTS: Of the 1769 physicians who were contacted, 1236 participated. Use of reminder systems varied by the practice's primary payer: 31% of health maintenance organization (HMO), 41% of Medicaid, 27% of fee-for-service (FFS), and 28% of no predominant payment source physicians reported using a reminder system (P < 0.01). Use of computerized reminders also varied according to practice primary payer (HMO, 68%; Medicaid, 34%; FFS, 51%; and no predominant payment source, 42%; P < 0.01) as did assessment of immunization rates in the practice (HMO, 57%; Medicaid, 40%; FFS, 28%; and no predominant payment source, 30%; P < 0.01). A majority of Medicaid physicians (84%) required a physical examination before immunization, compared to 49% of HMO, 56% of FFS, and 63% of no predominant source physicians (P < 0.01). CONCLUSIONS: The primary payment source of a practice appears to influence use of proactive immunization practices.

Child↗
PubMed1998

Physician concerns about vaccine adverse effects and potential litigation.

OBJECTIVE: To understand physician concerns about litigation and beliefs regarding vaccine safety. DESIGN: A stratified random sample of family physicians, pediatricians, and general practitioners younger than 65 years who were in office-based practices across the United States was selected from the American Medical Association list that includes nonmembers. A standardized telephone survey was conducted by trained interviewers in 1995. PARTICIPANTS: Physicians seeing 5 or more patients per week younger than 6 years and having 50% or more primary care patients were eligible for the study. RESULTS: Of the 1236 physicians who were surveyed, 32% and 13% overestimated the risk for serious adverse effects related to pertussis and measles vaccines, respectively. Among physicians who thought that serious adverse effects from diphtheria and tetanus toxoids and pertussis vaccine (DTP) were unlikely, 15% were highly concerned about litigation; however, among those with higher ratings of the likelihood of serious adverse effects, 38% were highly concerned about vaccine litigation (P < .01). Of those aware of the Vaccine Injury Compensation Program, only 41% believed that it afforded a high level of liability protection; 22% believed that it gives little protection, and 37% gave an intermediate answer. Among physicians highly concerned about vaccine litigation, 22% were unlikely to recommend the third dose of DTP for a child with a fever of 39.4 degrees C and no other symptoms after the second dose of DTP, whereas among those expressing little concern about litigation, only 12% were unlikely to vaccinate (P < .05). Although some physicians were concerned about litigation, most (86%) encouraged vaccination even if a parent was argumentative about possible adverse effects. CONCLUSION: Physicians' perceptions about the risk for adverse effects and protection afforded by the Vaccine Injury Compensation Program influence their concern about litigation and, to a lesser extent, their reported likelihood to administer immunizations.

Adult↗
PubMed1998

How important is early childhood hepatitis B vaccination? A survey of primary care physicians.

BACKGROUND: Although early childhood hepatitis B vaccination rates have risen dramatically in the United States, there are still areas with low rates. Understanding the barriers to vaccination as perceived by primary care physicians is key to raising rates in such areas. METHODS: A stratified random sample of family physicians, pediatricians, and general practitioners--younger than age 65 and having office-based practices across the United States--was selected from the American Medical Association physician list, including nonmembers. A standardized telephone survey was conducted by trained interviewers in 1995. Physicians seeing 5 or more patients younger than age 6 per week and having a practice comprising > or = 50% primary care patients were eligible. RESULTS: Most physicians (78%) rated the importance of hepatitis B vaccine as high. Based on regression analyses, the primary determinants of the importance of hepatitis B vaccine were: no stated concerns about its routine use (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.7-4.7), low disease incidence/importance in the practice (OR = .33; 95% CI, .18-.60), preference for administering hepatitis B vaccine during adolescence (OR = .36; 95% CI, .18-.72), specialty as family physician (OR = .36; 95% CI, .23-.57), and specialty as general practitioner (OR = .37; 95% CI, .21-.63). CONCLUSIONS: Most primary care physicians recommend hepatitis B vaccination, although a number of concerns exist. Given that only 4 years had elapsed from the time of the new recommendations for routine early childhood hepatitis B vaccination in 1991 until this survey, remarkable progress has been made.

Attitude of Health Personnel↗
PubMed1997

Impact of free vaccine and insurance status on physician referral of children to public vaccine clinics.

CONTEXT: Concerns about financial barriers to vaccination led to the development of the Vaccines for Children (VFC) program, which provides free vaccines to states for children who are uninsured, Medicaid eligible, or Native American or Native Alaskan. OBJECTIVE: To understand the effect of economic factors on physician likelihood of referring children to public vaccine clinics for immunizations and to evaluate the VFC program. DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. SETTING AND PARTICIPANTS: A stratified random sample of family physicians, pediatricians, and general practitioners younger than 65 years who were in office-based practices across the United States. MAIN OUTCOME MEASURES: Likelihood of referral of a child to a health department for vaccination by child's insurance status and by the physician's receipt of free vaccines. RESULTS: Of the 1769 physicians with whom an interviewer spoke, 1236 participated. Most respondents (66%) were likely to refer an uninsured child to the health department for vaccination, whereas only 8% were likely to refer a child who had insurance that covers vaccination. The majority (58%) of physicians reported differential referral based on insurance status. Among physicians who received free vaccine supplies from the VFC program or elsewhere, 44% were likely to refer an uninsured child whereas 90% of those not receiving free vaccine were likely to refer the same child (P<.001). In regression analysis, the receipt of free vaccine supplies accounted for 24% of the variance in the likelihood to refer an uninsured child for vaccination. CONCLUSIONS: Physicians receiving free vaccine supplies report being less likely to refer children to public clinics for vaccinations.

Child↗
PubMed1997

Developing curricula to promote preventive medicine skills. The Teaching Immunization for Medical Education (TIME) Project. TIME Development Committee.

CONTEXT: Vaccines are underused in the United States, resulting in needless morbidity. Many experts have concluded that clinician education is critical to increasing the nation's vaccination rates. OBJECTIVE: To develop and evaluate case-based curricular materials on immunizations that promote preventive medicine skills. DESIGN: Before-and-after trial of an educational intervention. SETTING AND PARTICIPANTS: Medical schools and primary care residency programs from 20 institutions across the United States participated in the Teaching Immunization for Medical Education (TIME) project. INTERVENTION: A multidisciplinary team developed learning objectives, abstracted clinical cases, and created case-based modules that use contextual learning and small-group interaction to solve clinical and public health problems. The case-based methods are multistation clinical teaching scenarios (MCTS) and problem-based learning (PBL). MAIN OUTCOME MEASURES: Knowledge gained by learners from pretest to posttest and the overall ratings of the sessions by learners and facilitators based on evaluation questionnaires. RESULTS: Pretest and posttest results were obtained on a total of 1122 learners for all modules combined. For the MCTS method, mean scores increased from the 10-item pretest to the posttest by 3.1 items for measles, 3.8 for influenza, 1.8 for hepatitis B, 3.9 for pertussis, 1.9 for adult vaccination, 1.9 for childhood vaccination, and 2.6 for Haemophilus influenzae type b (P<.01 for each). For the PBL method, mean scores increased by 3.4 items for measles, 3.3 for influenza, 2.6 for hepatitis B, and 2.5 for pertussis (P<.01 for each). Most learners (MCTS, 98%; PBL, 89%) and most facilitators (MCTS, 97%; PBL, 100%) rated the sessions overall as very good or good. CONCLUSIONS: Use of TIME modules increases knowledge about immunizations, an essential step to improving vaccination practices of future clinicians. Given the realities of decreased faculty time and budgets, educators face major challenges in developing case-based curricula that prepare learners for the 21st century. Nationally tested libraries of cases such as the TIME modules address this dilemma.

Adult↗
PubMed1997

A national survey to understand why physicians defer childhood immunizations.

OBJECTIVE: To determine the causes of low childhood immunization rates based on physicians' knowledge, attitudes, and self-reported practices concerning childhood immunization. DESIGN: A standardized telephone survey conducted by trained interviewers. SETTING: Primary care physicians across the United States. PARTICIPANTS: A stratified random sample of office-based family physicians, pediatricians, and general practitioners younger than 65 years was selected from the American Medical Association master file list that includes nonmembers. Physicians seeing 5 or more patients per week younger than 6 years and having 50% or more primary care patients were eligible for study. Of 1769 eligible physicians who spoke directly with the interviewers, 70% (N = 1241) completed the questionnaire. INTERVENTIONS: The interview was designed to determine physicians' likelihood of recommending vaccination in common clinical scenarios and to probe reasons behind these decisions. RESULTS: Only 4% of physicians who thought the risk for side effects was increased by upper respiratory tract infection (URI) were likely to vaccinate a child with URI vs 55% of physicians who thought there would be no increased risk (P < .001). Eighty-three percent of those who thought the efficacy of measles, mumps, and rubella vaccine would not be affected by a URI recommended vaccination vs only 8% of physicians who thought efficacy would decrease (P < .001). Some respondents (11%) would not administer 3 injectable vaccines simultaneously based on beliefs about side effects, parental objections, and vaccine efficacy. Physicians' likelihood of vaccination also varied by type of visit: 47% were less likely to vaccinate a child with a URI in an acute care as opposed to a well-child setting. CONCLUSION: Physicians' beliefs and practice policies materially influence their likelihood of recommending vaccinations.

Attitude of Health Personnel↗
PubMed1997

Influenza, influenza vaccine, and amantadine/rimantadine.

Influenza viruses are highly contagious viruses that are transmitted from person to person, usually by the airborne route. Persons in semi-closed or crowded environments, such as students and residents of nursing homes, are at high risk of exposure. The illness attack rate in children ranges from 14% to 40% yearly. Fatality rates are highest in persons who have chronic medical conditions, such as chronic obstructive lung disease, cardiovascular disease, and diabetes mellitus, particularly if they are elderly. The effectiveness of influenza vaccine in preventing or attenuating illness varies, depending primarily on (1) the degree of similarity between the virus strains included in the vaccine and those that circulate during the influenza season, and (2) the age and immunocompetence of the vaccine recipient. When there is a good match between vaccine and circulating viruses, influenza vaccine has been shown to prevent illness in approximately 70% to 90% of healthy persons less than 65 years of age. Adverse events following influenza vaccine include mild, local reactions at the injection site (up to 20%) and occasionally fever in approximately 1% of vaccinees. Despite the availability of an effective vaccine, only 55% of persons 65 years of age and older reported receiving influenza vaccine in 1994. Vaccination levels are even lower in persons less than 65 years of age with high-risk medical conditions. Important procedures to improve vaccination rates are (1) assessment of a practice's or medical facility's current vaccination rates, (2) identification of target populations for vaccination, (3) formation of a specific goal (ie, percentage of target population to be immunized), (4) development of a plan of action, and (5) provision of ongoing feedback to the individual physicians about vaccination rates of their own patients.

Amantadine↗
PubMed1997

Hepatitis B virus infection, hepatitis B vaccine, and hepatitis B immune globulin.

Hepatitis B virus (HBV) infection is a major health problem in the United States; in 1995, approximately 128,000 cases occurred. Transmission of HBV occurs primarily by blood exchange (eg, by shared needles during injection drug use) and by sexual contact. Persons infected early in life are much more likely to become chronically infected than those infected during adulthood: as many as 90% of infants infected perinatally develop chronic infection and up to 25% will die of HBV-related chronic liver disease as adults. Clinical signs of acute hepatitis occur in about 50% of infected adults but in only 5% of infected preschool-aged children. In the United States, hepatitis B vaccine is currently made by recombinant DNA technology using baker's yeast. Preexposure vaccination results in protective antibody levels in almost all infants and children (> 95%) and healthy adults younger than 40 years of age (> 90%). The most common adverse event following administration of hepatitis B vaccine is pain at the injection site, which occurs in 13% to 29% of adult and 3% to 9% of children. A comprehensive hepatitis B vaccination policy is now recommended that includes (1) routine infant vaccination; (2) catch-up vaccination of 11- to 12-year-olds who were not previously vaccinated; (3) catch-up vaccination of young children at high risk for infection; (4) vaccination of adolescents and adults based on lifestyle or environmental, medical, and occupational situations that place them at risk; and (5) prevention of perinatal HBV infection.

Adolescent↗
PubMed1996

Varicella vaccine: rationale and indications for use.

The recently released varicella vaccine is effective and cost-effective. Routine immunization with one dose of varicella vaccine is now indicated for all children 12 months to 18 months of age. Catch-up immunization for children 18 months to 12 years of age is indicated if the child does not have a history of chickenpox. For susceptible persons over 12 years of age, two doses given four to eight weeks apart are recommended. Because the varicella vaccine contains live virus, proper evaluation for contraindications is necessary. The varicella vaccine should be administered subcutaneously and is sensitive to heat.

Chickenpox Vaccine↗
PubMed1996

Influence of family functioning and income on vaccination in inner-city health centers.

OBJECTIVES: To assess family functioning and consumer decision-making about vaccinations and to compare the results with age at vaccination. DESIGN: Self-administered survey that was mailed to parents with comparison to vaccination records from chart audits. SETTINGS: Two inner-city health centers in Pittsburgh, Pa, that receive free vaccine supplies. PARTICIPANTS: Systematic sample from the billing computer records of parents whose children were aged 2 to 4 years as of July 2, 1993. INTERVENTIONS: The survey used simplified versions of the Family Profile and the Triandis model of consumer decision-making that includes perceived consequences of vaccinations, attitude about vaccinations, social influences, and facilitating conditions (eg, ease of obtaining an appointment). MAIN OUTCOME MEASURES: Variables associated with age at vaccination for third diphtheria and tetanus toxoids and pertussis vaccine immunization and first measles-mumps-rubella immunization. RESULTS: Of 395 families, 167 responded. Higher family dysfunction scores and lower family concordance scores each were associated with receiving first measles-mumps-rubella vaccination (P < or = .02) and third diphtheria and tetanus toxoids and pertussis vaccination (P < = .02) at later ages. Many (30%-54%) of the respondents reported that they knew little about the risks and benefits of vaccination. However, knowledge about vaccines was not associated with vaccination status. Those respondents with an annual income of less than $10000 received the first measles-mumps-rubella vaccination later than those with an annual income $10000 or greater (P < .02) when the data were analyzed by age at vaccination but not when the data were analyzed as on-time vs late vaccinations. CONCLUSIONS: To increase vaccination rates in innercity clinics, strategies need to consider family dysfunction and income and not merely focus on education. The use of age at vaccination as a continuous variable offers advantages over the dichotomy of immunized vs not immunized.

Age Factors↗