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Gary L Freed

Publications and source records attributed to Gary L Freed.

52 records · Page 3Linked to original sources
PubMed2002

The need for surveillance of delay in age-appropriate immunization.

BACKGROUND: Vaccination status is assessed nationally in terms of up-to-date status without regard to the age at which recommended doses were actually received. Our study was conducted in 2000-2001 using the most current National Health Interview Survey (NHIS) public use files available. METHODS: Retrospective analysis to determine up-to-date and age-appropriate vaccination status for children aged 25 to 72 months. Five years of pooled data (1992-1996) were obtained from the NHIS Immunization Supplement for children aged 25 to 72 months with immunization data based on written records. The outcome measures used were months of vaccination delay relative to age-appropriate vaccination standard as well as up-to-date vaccination status for the fourth diphtheria-tetanus-pertussis (DTP 4), Polio3, the first measles-mumps-rubella (MMR1) doses, and the 4:3:1 series. RESULTS: Of the 9223 eligible children, 80% were up-to-date for the 4:3:1 vaccination series, but 48% had experienced delays relative to age-appropriate standards. For the DTP4 dose, 85% were up-to-date, although only 46% had received this dose at the appropriate age. Similarly, 90% of children were up-to-date with their Polio3 dose, with 64% receiving this dose at the appropriate age; 96% were up-to-date for the MMR1, and 58% received this dose at the appropriate age. Age-appropriate DTP4 vaccination increased by 17 percentage points from 1992 to 1996, whereas up-to-date DTP4 status increased by only 6% during the same period. CONCLUSIONS: Children with up-to-date vaccination status often experienced considerable delay relative to age-appropriate vaccination standards. Consequently, vaccination status measures based solely on up-to-date status tend to understate the degree of underimmunization in a population. National surveillance of age-appropriate vaccination is necessary to identify subpopulations with the greatest prevalence of vaccination delay and to reveal underlying trends that may not be evident through assessments of up-to-date status.

Child↗
PubMed2002

Using a productivity-based physician compensation program at an academic health center: a case study.

PURPOSE: With increased budget constraints, academic health centers (AHCs) have turned their focus on physician compensation. While many AHCs are concerned that compensation programs driven primarily by revenue generation will have a negative impact on their academic mission, little information is available to support this. The authors examined the effects on teaching and clinical productivity of an innovative compensation program for pediatrics primary care faculty at an AHC and related those effects to national standards for productivity. METHOD: A baseline productivity and compensation assessment was conducted for a group of 35 academic general pediatricians. The data were compared with Medical Group Management Association (MGMA) figures for general pediatricians. A productivity-based faculty compensation program using the work component of the relative-value unit (RVU) as the measure of productivity was designed and implemented. Productivity and compensation were measured after the first year of the program and compared with the baseline assessment. The numbers of hours precepting students and residents and the students' evaluations of their clinical experiences before and after implementation of the program were compared. RESULTS: The baseline assessment showed that over half of the faculty had productivity that fell below the MGMA 25th percentile, while the majority had compensation that exceeded this percentile. After implementation of the compensation program, 89% of the faculty increased their clinical productivity. The times faculty spent precepting and students' evaluations before and after program implementation were unchanged. CONCLUSIONS: Successful productivity-based physician compensation programs can be developed for AHCs.

Academic Medical Centers↗
PubMed2002

Childhood vaccine purchase costs in the public sector: past trends, future expectations.

OBJECTIVES: We examined recent public-sector trends in childhood vaccine costs and estimated future costs. METHODS: We used public-sector price data to calculate vaccine purchase cost per child for children aged 0 to 6 years from 1975 to 2001. We fit a linear regression model to historical data and then used it to project costs per child from 2002 to 2020, adjusted to 2001 US dollars. RESULTS: Controlling for inflation, the cost of vaccine purchase per child climbed from $10 in 1975 to $385 in 2001. The cost of vaccine purchase in the year 2020 following recommendation of 7 additional vaccines is estimated to be $1225 per child (95% confidence interval = $891, $1559). CONCLUSIONS: The cost per child for recommended vaccines at public-sector prices may triple over the next 2 decades. These projections have implications for vaccine financing at federal and state levels.

Child↗
PubMedDate not supplied

Risk factors for delay in age-appropriate vaccination.

OBJECTIVE: To estimate the risk factors of children experiencing delay in age-appropriate vaccination using a nationally representative population of children, and to compare risk factors for vaccination delay with those based on up-to-date vaccination status models. METHODS: The authors compared predictors of delay in age-appropriate vaccination with those for children who were not up-to-date, using a nationally representative sample of children from five years of pooled data (1992-1996) from the National Health Interview Survey (NHIS) Immunization Supplement. Duration of delay was calculated for the DTP4, Polio3, MMR1 doses and 4:3:1 series using age-appropriate vaccination standards; up-to-date status (i.e., whether or not a dose was received) was also determined. Adjusted odds ratios were estimated using multivariate logistic regression for models of vaccination delay and up-to-date vaccination status. RESULTS: Absence of a two-parent household, large family size, parental education, Medicaid enrollment, absence of a usual provider, no insurance coverage, and households without a telephone were significantly related to increased odds of a child experiencing vaccination delay (p < or = 0.05). CONCLUSIONS: Many of the risk factors observed in models of vaccination delay were not found to be significant in risk models based upon up-to-date status. Consequently, risk models of delays in age-appropriate vaccination may foster identification of children at increased risk for inadequate vaccination. Populations at increased risk of inadequate vaccination can be more clearly identified through risk models of delays in age-appropriate vaccination.

Age Factors↗
PubMedDate not supplied

Pediatricians' views on financial barriers and values for pneumococcal vaccine for children.

OBJECTIVES: To 1) describe barriers to pneumococcal conjugate vaccine adoption and 2) estimate the value of the vaccine based on pediatricians' responses to willingness-to-pay questions. METHODS: In June 2000, we mailed a random sample of pediatricians in Massachusetts a questionnaire about barriers to adoption of the vaccine and willingness to pay for the vaccine and associated outcomes. Respondents were assigned at random to 1 of 2 survey versions: the Personal Perspective version, for which they imagined spending their own money for their own child, or the Public Perspective version, for which they imagined spending the government's money for the average child. RESULTS: Of the 546 pediatricians who responded (estimated completion rate, 80%), only 9% were using the vaccine routinely at the time of the survey. Most said that if the state did not provide the vaccine, financial barriers including inadequate insurance reimbursement would limit their use of the vaccine either a great deal (61%) or a moderate amount (25%). Pediatricians who were asked how much they would pay for the vaccine for their own child (personal perspective) gave a mean of $56 per dose, whereas those who were asked how much the government should pay on behalf of an average child (public perspective) gave a mean of $36 per dose. Alternatively, when we used a decision analysis model and incorporated pediatricians' values for preventing pneumococcal infections to estimate the vaccine's value, the value per dose was $38 from the personal perspective and $34 from the public perspective. CONCLUSIONS: Pediatricians in Massachusetts identified significant financial barriers to the adoption of pneumococcal conjugate vaccine related to insurance arrangements. Based on willingness-to-pay questions, the value of the vaccine is lower than the current list price. The methods used to estimate the value of a vaccine, including the perspective used to frame questions, may substantially influence the results.

Attitude of Health Personnel↗
PubMedDate not supplied

Effect of state vaccine-financing strategy on hepatitis B immunization in hospital nurseries.

OBJECTIVE: Changes in recommendations for newborn hepatitis B vaccination offer an opportunity to examine the association between newborn hepatitis B vaccination in hospital nurseries and state vaccine-financing strategies, which include the Vaccines for Children (VFC) program alone, an enhanced VFC program, and universal purchase. METHODS: We conducted a cross-sectional telephone survey of nursery directors from a national random sample of 290 hospital nurseries. RESULTS: Directors at 207 (71%) of 290 eligible nurseries responded. After the end of the temporary suspension of the hepatitis B vaccine birth dose, 59 (29%) of the 207 nurseries did not return to their previous policy and adopted a less strict policy for offering this vaccination to low-risk infants. In logistic regression analysis, compared with nurseries in states with VFC-only financing, nurseries in states with universal purchase financing were more likely to return a strict policy of routinely offering hepatitis B vaccination (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.11-0.78), and nurseries in states with enhanced VFC financing were less likely to return to a strict policy of routinely offering hepatitis B vaccination (OR, 3.00; 95% CI, 1.14-7.88). The presence of residents or students in the nursery was associated with a lower likelihood of not returning to a strict policy of routinely offering hepatitis B vaccination (OR, 0.32; 95% CI, 0.10-0.97). CONCLUSIONS: State vaccine-financing strategy for the birth dose of hepatitis B vaccine is associated with nursery policy to routinely offer this vaccine in the nursery. The temporary change in national hepatitis B vaccination recommendations in 1999 served as a window of opportunity for the adoption of new hospital nursery policies and showed the effects of state vaccine financing on the adoption of newborn immunization recommendations.

Financing, Government↗
PubMedDate not supplied

Receipt of specialty eye care by children.

BACKGROUND: No nationally representative data are available regarding use of eye care services by children. OBJECTIVES: To determine the proportion of children who receive specialty eye care and to evaluate the association of such care with age and other factors associated with health care utilization. METHODS: We used the 2000 National Health Interview Survey to estimate the proportion of nonblind children who received eye care in the preceding 12 months. The association between eye care and the factors of interest among children aged 6-17 years was measured through adjusted bivariate comparisons and logistic regression modeling. RESULTS: Eye care was received in the preceding 12 months by an estimated 7.3% (95% confidence interval [CI] 6.0-8.6) of the 22.8 million children aged 0-5 years and 24.8% (95% CI 23.5-26.2) of the 48.5 million children aged 6-17 years. Among children aged 6-17 years, girls had 29% greater odds than boys to have received eye care (P=.001). Among children <200% of the federal poverty level, those with public health insurance had greater odds of receiving eye care than did uninsured children or those with private health insurance (P<.001). Among children >200% of the federal poverty level, uninsured children had lower odds than did children with public or private health insurance (P<.004) to receive eye care. Well-child care was associated with increased eye care utilization among children aged 12-14 years (P<.001). CONCLUSIONS: Receipt of specialty eye care is common and increases with age. However, there are marked variations among school-aged children. Future studies should address the causes and effects of these findings.

Adolescent↗
PubMedDate not supplied

When insurance status is not static: insurance transitions of low-income children and implications for health and health care.

OBJECTIVES: Among low-income children, to characterize the frequency of transitions in health insurance coverage and examine associations of transitions with health status and health care access. METHODS: Data from the 1999 National Survey of America's Families were used in weighted analyses to identify sociodemographic characteristics associated with health insurance transitions for children living in households with income <200% of the federal poverty level over the preceding 12 months. In logistic regression models, we examined associations of insurance transitions with children's health status (fair/poor health), postponement of children's medical care or prescription medications, and lack of physician visits. RESULTS: Among 27.93 million low-income children in 1999, 5.7 million (20.4%) had experienced an insurance transition in the preceding year. Non-Hispanic black children (24.5%) and children whose parents did not have a partner or spouse (23.5%) were significantly more likely than other children to have experienced transitions. Hispanic children (16%) were least likely to have experienced transitions. Compared with children with continuous private coverage, children who had transitioned from public to private coverage were more likely to report fair or poor health, children who experienced transitions that included a period of no coverage were more likely to report postponed medical care and prescription drugs, and children who experienced a no-coverage-to-private-coverage transition were more likely to have foregone physician visits. CONCLUSION: Transitions in insurance coverage affect many low-income children and may represent barriers to their health care. Considering insurance transitions may provide a more complete picture of children's health and health care utilization.

Child↗
PubMedDate not supplied

The impact of the 'aging of America' on children.

The continued demographic trend of the "aging of America" has many implications for U.S. society. Although their population has remained relatively constant, children are becoming a smaller proportion of the overall population. The rapidly changing age-related U.S. demographics raises issues we have not yet chosen to address. These changes have important implications for children and will become manifest in the financing of both public programs and private markets for health, education, and social services, whether or not specific political actions are taken. Investment in children's health can affect the health and productivity of the next generation of Americans.

Aging↗
PubMedDate not supplied

Vaccine policies across the pond: looking at the U.K. and U.S. systems.

Major differences exist in the immunization programs of the United Kingdom and the United States. If one believes that most health policy decisions in Western industrialized democracies are political, then many of the differences may seem to reflect the variance in the nature of political systems. However, each program has unique components that appear paradoxical, and what works in one society will not necessarily work in another. Those who seek to substitute portions of one vaccine system with those of another must appreciate the context within which each functions.

Culture↗
PubMedDate not supplied

One-year uptake of pneumococcal conjugate vaccine: a national survey of family physicians and pediatricians.

BACKGROUND: Pneumococcal conjugate vaccine (PCV7) was recommended by June 2000 for administration to all US children </=23 months old and to children at high risk for pneumococcal disease 24 to 59 months old. We sought to identify physician characteristics associated with adoption of the recommendation within 1 year. METHODS: We conducted a cross-sectional mail survey from April to July, 2001, of 788 family physicians (FP) and 833 pediatricians (PD) in 24 states. We measured whether physicians had adopted PCV7 recommendations, their expectations of the effectiveness of PCV7, the number of vaccine injections they would consider administering at 1 visit, and barriers to administering multiple injections. RESULTS: Response rate was 60%. Overall, 87% of physicians had adopted PCV7 recommendations (68% FP; 99% PD; P <.001). FP adopters are significantly more likely than nonadopters to believe PCV7 will be effective in preventing pneumococcal sepsis and meningitis, as well as >25% of cases of otitis media. In multivariable logistic regression analyses of adoption of PCV7, FP who have higher proportions of African American patients and patients on Medicaid, see greater numbers of newborns, work in practices of >/=4 physicians, and are willing to consider administering at least 4 vaccine injections at 1 visit are significantly more likely to have adopted PCV7. Concerns about vaccine cost and reimbursement were the most commonly cited factors in physicians' decisions not to adopt PCV7 recommendations. CONCLUSIONS: One year after PCV7 was recommended, nearly all pediatricians and a majority of family physicians had incorporated this vaccine into their practices. Barriers to higher rates of uptake-especially among family physicians-must be addressed to achieve immunization goals with this new vaccine.

Attitude of Health Personnel↗
PubMedDate not supplied

Services provided for preschool-aged children with suspected amblyopia.

BACKGROUND: Little is known about the pattern and variation of care offered to preschool-aged children who have had an abnormal vision screening test. PURPOSE: To evaluate the variations in pediatric eye care services and availability of optometrists and ophthalmologists for preschool-aged patients, referral patterns, and barriers to providing care as perceived by eye care specialists. METHODS: A survey was mailed to 542 ophthalmologists and a random sample of 501 optometrists actively practicing in Michigan. RESULTS: The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%; P < .001). Of these, most managed amblyopia (80% vs 77%; P = .372) and strabismus (89% vs 80%; P = .002) themselves. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; P < .001). The leading barrier to care for preschool-aged children reported by both optometrists and ophthalmologists was difficulty of the examination (25% vs 23%; P = .501). Optometrists reported that most of their patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred from primary care providers. CONCLUSIONS: There are different sources of referrals for optometrists and ophthalmologists. Although most eye care specialists treat amblyopia, the types of care offered by optometrists and ophthalmologists differ. Future studies should address the impact that these patterns have on outcomes and cost. The results of these studies should be shared with those responsible for screening.

Amblyopia↗
PubMedDate not supplied

Expected adverse events in a mass smallpox vaccination campaign.

CONTEXT: Recent anthrax attacks in the United States have raised concern about the nation's vulnerability to a smallpox attack. Many strategies have been suggested to minimize the impact of such an attack, ranging from quarantine and vaccination of case contacts to resumption of routine vaccination. Before the latter strategy is adopted, an understanding of the likely consequences of mass vaccination is essential. COUNT: Number of adverse events resulting from two vaccination campaigns: vaccinating persons 1 to 29 years of age and vaccinating those 1 to 65 years of age. CALCULATION: Number of adverse events = incidence rate of adverse events x number vaccinated. We assumed 75% vaccine uptake in the target group (i.e., we estimated that about 25% of potential vaccine recipients would be excluded because they are, or have close contact with, individuals who have eczema or are immunocompromised). DATA SOURCE: Historical data on the incidence of adverse events from smallpox vaccination were identified by a literature search. Number vaccinated was drawn from the January 2000 U.S. Census estimate. RESULTS: Fever (<1 case per 5 vaccine recipients) and rash (<1 case per 100 vaccine recipients) would be the most common adverse events. Serious adverse events, including encephalitis (<3 cases per million) and death (<2 cases per million), although rare, would be more common than with other currently recommended vaccines. After excluding high-risk individuals and their contacts, we estimate that a vaccination strategy directed at people aged 1 to 29 years would result in approximately 1600 serious adverse events and 190 deaths. Vaccinating people aged 1 to 65 years would result in approximately 4600 serious adverse events and 285 deaths. LIMITATIONS: While advances in health care over the past three decades could mitigate vaccine complications, the increased number of unimmunized high-risk individuals (e.g., those with eczema or immune suppression) could increase complication rates. CONCLUSIONS: The decision to resume smallpox vaccination depends on weighing the likelihood of a smallpox attack and its anticipated mortality against expected harm from a mass immunization program. Smallpox vaccine has a higher complication rate than any other vaccine currently being used. Careful prevaccination exclusion of high-risk individuals and their close contacts would be essential to minimize complications of a mass vaccination campaign, although such exclusions necessarily mean that some proportion of the population will remain susceptible to smallpox.

Adolescent↗
PubMedDate not supplied

Medicaid reimbursement for alternative therapies.

CONTEXT: A growing number of complementary and alternative therapies are eligible for reimbursement by third party payers in the United States. No studies have examined current trends in the use of public funds for the payment of complementary and alternative medicine (CAM). OBJECTIVE: To determine the reimbursement polices of state Medicaid programs for CAM. DESIGN: Cross-sectional study. PARTICIPANTS: 46 state Medicaid reimbursement specialists. INTERVENTION: Telephone survey. RESULTS: Of the 46 states participating in the study, 36 Medicaid programs (78.3%) provide coverage for at least 1 alternative therapy. The most commonly reimbursed therapies are chiropractic by 33 programs (71.7%), biofeedback by 10 programs (21.7%), acupuncture by 7 programs (15.2%), and hypnotherapy and naturopathy by 5 programs each (10.8%). CONCLUSIONS: Many Medicaid programs are paying for the use of CAM. Further research is needed to determine if Medicaid recipients are aware of these reimbursement policies and the extent to which recipients are using CAM for their healthcare.

Complementary Therapies↗