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 Introduction |
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| The Immunization Research Group has a number of ongoing studies focusing on immunizations, health disparities, and preventive services. As part of the EXCEED Project (Edmund M. Ricci, Principal Investigator), the group has worked with four inner city health centers to improve adult immunization rates. Building on previous research that found large racial disparities in immunization rates, the team worked with health centers to implement strategies tailored to the individual practice to facilitate and encourage annual influenza vaccination and receipt of pneumococcal polysaccharide vaccine. Four annual patient surveys have provided a wealth of information regarding patient views on immunizations, cancer screening, and trust and religiosity in relation to health care. |
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| Randomized Trial of Alternative HPV Vaccination Schedules |
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START DATE: August, 2007
END DATE: Fall, 2009
FUNDING SOURCE: Merck, Inc.
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): ): Richard Zimmerman, MD, MPH, Principal Investigator; Dwight Fox, DMD, Project Coordinator
COLLABORATORS: Jennifer Hayes, APRN-BC; Gaye Cost, RN, Co-investigators
DESCRIPTION OF PROJECT: This is a randomized, open label trial of HPV vaccine, comparing an on-time administration of the third dose with delayed administration of the third dose. All participants will receive the first and second doses according to schedule. They will be randomized to receive the third dose of vaccine either at 6 months or at 12 months after the first dose. Blood will be drawn for titers just before receiving the first dose of vaccine and one month after receiving the final dose. Our primary aim is to determine if the delay in giving the third dose is immunologically inferior to the standard administration schedule.
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Immunization Research Group
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| Office Barriers and Facilitators to Overcoming Disparities in Elderly Vaccinations |
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START DATE: : December 2005
END DATE: August, 2008
FUNDING SOURCE: CDC/ATPM
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): ): Richard Zimmerman, MD, MPH, Principal Investigator; Mary Patricia Nowalk, PhD, RD, Project Coordinator
COLLABORATORS: Melissa Tabbarah, PhD, Co-Investigator; Martha Terry, PhD, Co-Investigator; Stephen Wilson, MD, Co-Investigator
DESCRIPTION OF PROJECT: Racial disparities exist in rates of pneumococcal polysaccharide vaccine (PPV) and influenza vaccine resulting in unprotected persons who suffer from preventable diseases and deaths. Recent research indicates that blacks and whites are largely treated by different providers and that these providers differ in training and in resources. In order to investigate the extent to which practice-level differences contribute to racial disparities, we plan to: (1) identify strategies used by the medical practices to facilitate immunizations; (2) characterize the practices in order to understand current organization and patterns of patient care as well as critical pathways for potential change; and (3) calculate PPV and influenza vaccination rates for the various practices and, using hierarchical regression analyses, calculate the determinants of these rates.
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| Influenza Vaccination of Health Care Workers in a Diverse Hospital Network |
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START DATE: September, 2005
END DATE: May, 2008
FUNDING SOURCE: CDC
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): Richard Zimmerman, MD, MPH, Principal Investigator; Dwight Fox, DMD- Project Coordinator
COLLABORATORS: Chyongchiou Lin, PhD, Co-Investigator; Mary Patricia Nowalk, PhD, RD, Co-Investigator; Jay Harper, MD, MPH; Mark Tanis, RN
DESCRIPTION OF PROJECT: We plan to increase the influenza vaccination rates of health care workers (HCWs) at hospitals in the University of Pittsburgh Medical Center (UPMC) health system, which is one of the largest health systems in the nation. This study is designed to accomplish the following aims:
1. Increase vaccination rates among majority and minority HCWs at eight diverse UPMC hospitals by the following means:
A. Develop systems, administrative changes, and interventions to raise rates. B. Identify key business unit leaders, educated them about the interventions, and divide responsibilities.
C. Implement the interventions (mass vaccination clinics with food incentives and peer vaccination on nursing units) in a culturally sensitive manner.
D. Analyze the results using a before and after intervention design with concurrent and historical controls. E. Identify the most successful strategies to raise influenza vaccination rates.
2. Determine barriers to the intervention, determinants of vaccination, and attitudes by a web-based survey of HCWs, with oversampling of HCWs of color.
3. Determine the cost of these vaccination strategies, distinguishing between fixed and variable costs.
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| Alternative Strategies for Adult Polysaccharide Vaccination: A Cost-Effective Analysis |
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START DATE: September 2004
END DATE: May 2007
FUNDING SOURCE: Merck, Inc.
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): Richard Zimmerman, MD, MPH, Principal Investigator; Kenneth Smith, MD, MS, Co-Investigator; Chyongchiou Lin, PhD, Co-Investigator; Mary Patricia Nowalk, PhD, RD, Co-Investigator; Feng-Shou Ko, Phd, Co-Investigator; Catherine McEllistrem, MD, MS, Co-Investigator; Mark Roberts, MD, MPP, Co-Investigator
DESCRIPTION OF PROJECT: Pneumococcal polysaccharide vaccine (PPV) to prevent invasive pneumococcal disease (IPD) has been recommended for all persons aged ≥65 and for younger persons with comorbidities. Routine vaccination of younger adults and scheduled revaccinations at 10-15 year intervals are being considered. Recent changes in the epidemiology due to the childhood conjugate vaccine complicate vaccine policy making.
We used a Markov model to examine nine strategies: no vaccination, one vaccination (age 50 or 65), two vaccinations (50/65 or 65/80), three vaccinations (50/65/80, 50/60/65, 50/60/70) or four vaccinations (50/60/70/80) in US population cohorts. We used NHIS data to segment cohorts into comorbid illness groups to model differential vaccine effectiveness and IPD rates based on age and comorbidity. CDC data (Active Bacterial Core surveillance) were used to model IPD rates and diminishing IPD likelihood from PPV contained serotypes. A Delphi panel supplied estimates of PPV efficacy based on age of and time since vaccination, number of previous PPVs, and comorbidities present. Vaccination side effect data were from the literature. We have reported preliminary results, with effectiveness measured as the relative proportion of IPD cases prevented.
Routine PPV starting at age 50 with a second dose at age 65 is indicated by this analysis due to the reduction in IPD deaths.
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| Standing Orders for Vaccination of Hospitalized Elderly |
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START DATE: January, 2004
END DATE: December, 2006
FUNDING SOURCE: CDC/ATPM
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): Donald Middleton, MD- Principal Investigator; Dwight Fox, DMD- Project Coordinator
COLLABORATORS: Mary Patricia Nowalk, PhD, RD; Susan Skledar, RPh; Denise Sokos, PharmD; Richard Zimmerman, MD, MPH; Kelly Ervin, CPhT; Chyongchiou Lin, PhD; Kenneth Smith, MD, MS; Mark Roberts, MD, MPP.
DESCRIPTION OF PROJECT: Standing order programs (SOPs), which allow vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested sites for SOP utilization are hospital inpatient units to reach those most likely to benefit from vaccination. However, there are many institutional, provider-related, and patient-related barriers to effectively establishing an effective inpatient SOP. We worked with key administrators and clinicians in a community hospital and a tertiary care hospital to implement SOPs at these institutions. We then evaluated the effectiveness of these efforts, identifying and classifying barriers to establishing a standing orders program (SOP) for adult vaccination in acute care inpatient facilities, and we provided recommendations for overcoming these roadblocks. The cost-effectiveness (C/E) of this approach in elderly hospitalized persons was unknown, so we undertook to estimate the C/E of pneumococcal polysaccharide vaccine (PPV) vaccination SOPs for those age ≥65 years in the two hospital settings.
We found that a strong commitment by key individuals in the facility’s administration; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate are essential for successful implementation of SOPs for vaccination of eligible inpatients. We found that after SOPs were implemented, PPV vaccination rates increased by 30.5% in the tertiary care hospital and by 15.3% in the community-based hospital. In our cost-effectiveness analysis, we found that SOPs to improve PPV rates in hospitalized elderly patients result in higher vaccination rates and are economically favorable compared to no SOPs.
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| Influenza Vaccination of Children in the Inner City |
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START DATE: September, 2002
END DATE: November, 2006
FUNDING SOURCE: ATPM-CDC Cooperative Agreement
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): Richard Zimmerman, MD, MPH, Principal Investigator
COLLABORATORS: Melissa Tabbarah, PhD, Co-Investigator; Mary Patricia Nowalk, PhD, RD, Co-Investigator
DESCRIPTION OF PROJECT: The purpose of this project is to design interventions to maximize influenza vaccination among children 6-23 months and high risk children age 2-17 years, evaluate their success by determining vaccination rates and the impact (if any) on other vaccines, quantitate the costs associated with establishing such programs, evaluate parent response to the vaccine recommendation and estimate the impact of the recommendation on the VFC. Inner-city health centers serving large proportions of low-income and minority children participated in a study to introduce influenza vaccination among healthy infants in 2002-2003 and 2003-2004.
Social support for influenza vaccination of healthy infants increased over the two years of the encouragement period, suggesting that information regarding this vaccine was reaching the general public. The most important facilitators of influenza immunization were physician recommendation, parental support and reminders. This suggests that reminders from physicians should specifically state that the doctor recommends influenza vaccine and address common misperceptions about influenza vaccine. These findings may have broader applications as the age groups for whom influenza vaccination is recommended continue to expand. |
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| Determinants of Cancer Screening in Diverse Practices |
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START DATE: September 2004
END DATE: May 2007
FUNDING SOURCE: National Cancer Institute
PROJECT PERSONNEL (NAME AND ROLE IN PROJECT): Richard Zimmerman, MD, MPH, Principal Investigator; Melissa Tabbarah, PhD, Co-Investigator; Mary Patricia Nowalk, PhD, RD, Co-Investigator
DESCRIPTION OF PROJECT: To explain why rates of colorectal cancer (CRC) screening including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy (CS), and barium enema (BE), are low, this study assessed determinants of CRC screening from medical records.
Specific Aims:
1. Quantify and analyze the colorectal cancer (CRC), prostate cancer and breast cancer
screening rates from medical record reviews.
2. Correlate CRC, prostate cancer and breast cancer screening with influenza and
pneumococcal vaccination rates by practice.
3. From the patient and physician interviews, identify determinants of CRC, prostate cancer
and breast cancer screening including social influences, communication with primary care
physician, transportation, health habits, demographics.
4. Determine main predictors of CRC, prostate cancer and breast cancer screening rates in
bivariate and multivariate analyses.
Data were abstracted from patients aged > or =64 years selected from each clinician from 30 diverse primary care practices (n = 981). Measurements included the rates of annual FOBT, ever receiving FOBT, ever receiving FS/CS/BE under a combination variable, endoscopy/barium enema (EBE). We found that overall CRC screening rates were low, but were related to the number of primary care office visits. FOBT was related to immunization status, suggesting the possible benefit of linking these preventive services. |
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