PEDIATRICS Vol. 124 Supplement December 2009, pp. S466-S471 (doi:10.1542/peds.2009-1542F)
SUPPLEMENT ARTICLE |
Primary Care Physician Perspectives on Reimbursement for Childhood Immunizations
a Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan
b Child Health Evaluation and Research Unit
c Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES: The purpose of this research was to explore physicians' attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown.
METHODS: We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children.
RESULTS: The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that "reimbursement for vaccine purchase is adequate," and 17% strongly disagreed that "reimbursement for vaccine administration is adequate." Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year.
CONCLUSIONS: Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.
Key Words: finance • reimbursements • immunization • vaccine • private providers
Abbreviations: PCV7—heptavalent pneumococcal conjugate vaccine • AAP—American Academy of Pediatrics • FP—family physician • AMA—American Medical Association • MD—allopathic physician • DO—osteopathic physician • HPV—human papillomavirus vaccine • MCV4—meningococcal conjugate vaccine
When heptavalent pneumococcal conjugate vaccine (PCV7) (Prevnar [Wyeth, Collegeville, PA]) was added to the recommended childhood immunization schedule in 2000,1 the number of vaccine doses universally recommended for children through 6 years of age increased from 19 to 23,2 whereas the overall cost of purchasing these vaccines nearly doubled.3 Most physicians were quick to adopt the PCV7 recommendation,4,5 but concerns were raised regarding the high price of the vaccine, as well as delayed or inconsistent insurance coverage for it.5–7 Davis et al8 postulated that physicians' response to the financial challenges posed by PCV7 had implications for future recommendations of costly vaccines.
Since the PCV7 recommendation, the recommended childhood/adolescent immunization schedule has continued to expand,9 with 5 newly recommended vaccines,10–14 3 vaccines with expanded recommendations,15–17 and 4 newly licensed combination vaccines.18–21 The private sector cost to purchase all doses of the vaccines universally recommended for children and adolescents has risen to more than $1500 per child in 2008 compared with approximately $600 in 2000.22
Although recent research has highlighted the impact of increased vaccine costs on public sector vaccine financing,23 little is known about the impact on physicians in the private sector. Information has come mainly from articles in the lay press24–27 or through physician groups.28,29 The American Academy of Pediatrics (AAP) has voiced concerns over vaccine financing, stating that it is, "alarmed that the soaring costs of vaccines combined with lower reimbursements from insurance companies will lead to under-immunization of the nation's children and unnecessary outbreaks of diseases."28 Anecdotal reports circulated within the AAP suggesting that physicians will no longer provide vaccines to their patients (David Tayloe Jr, MD, president-elect, AAP, personal communication, May 5, 2008).
The extent to which private physicians are facing serious financial pressures because of vaccines is unknown. Also unknown is the likelihood that physicians will discontinue providing immunizations altogether. This study was designed to explore private provider attitudes and practices related to vaccine financing on a national level.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Sample
We drew a national random sample of 750 pediatricians and 750 family physicians (FPs) from the American Medical Association (AMA) Physician Masterfile through a contracted vendor. The AMA Physician Masterfile is the most comprehensive database of physicians licensed to practice in the United States and includes both AMA members and nonmembers. Our sampling frame included all allopathic (MD) and osteopathic (DO) physicians self-described as a pediatrician or FP in office-based, direct patient care. Excluded were physicians with any subspecialty board certification, age
70 years, currently in residency training, or employed at federally owned medical facilities (ie, Veterans' Affairs). After review of the 1500 records in the AMA Masterfile sample, we excluded 6 FPs who were found to not meet the inclusion criteria. We also excluded 93 pediatricians and 101 FPs located in universal purchase states, which supply childhood vaccines to private immunization providers for administration to all children regardless of insurance status.30 Physicians in these states would not typically purchase childhood vaccines in the private market, thus making the topic of the survey not relevant to their practice.
Survey Design
The 4-page, 21-item survey instrument addressed whether the respondent's practice currently purchases quadrivalent human papillomavirus vaccine (HPV), meningococcal conjugate vaccine (MCV4), or Pediarix (ie, a pentavalent vaccine that combines antigens for diphtheria, tetanus, pertussis, hepatitis B, and polio) and, if not, reasons for not purchasing; whether the practice has delayed purchasing any new vaccines in the previous 3 years due only to financial concerns; whether the practice has experienced a decrease in profit margin from childhood/adolescent immunizations; respondent attitudes regarding reimbursement for vaccine cost and administration; the extent to which the practice has considered no longer providing vaccines to insured patients; and practice characteristics.
An additional question targeted respondent decision-making involvement in the practice with respect to vaccine purchase, asking, "To what extent are you involved in decisions about vaccine purchase for your practice?" Respondents who reported that they are "directly involved in vaccine purchase decisions" were defined as "decision-makers." Those who said they were "only indirectly involved" or "not involved at all" were classified as "non–decision-makers."
We pilot tested the survey instrument to ensure clarity and ease of administration with a randomly selected subset of 10 pediatricians and 10 FPs from the 1300 charts in our sample (leaving 1280 charts for the actual survey mailing). Pilot surveys were not included in the analyses. The institutional review board of the University of Michigan Medical School approved this study.
Survey Administration
The initial survey mailing was sent in July 2007 to 1280 physicians (647 pediatricians and 633 FPs) and included a personalized cover letter, the survey instrument, and a $5 cash incentive. Two additional mailings to nonrespondents occurred at 
4-week intervals.
Data Analysis
We generated univariate frequencies for each variable and then performed 
2 analyses to examine associations between variables, with a 2-tailed 
-level of .05 as the threshold for statistical significance. All of the analyses were conducted by using SAS 8.2 (SAS Institute, Inc, Cary, NC).
Bivariate analyses focused on variation in survey responses by physician specialty (pediatricians versus FPs) and by respondent decision-making involvement with respect to vaccine purchase (decision-makers versus non–decision-makers). Response options (eg, 5-point Likert scale) generally were not combined for data analyses, so that we could explore variation in respondents selecting the strongest positions (eg, "strongly disagree").
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Response Rate
Of the 1280 physicians in the mailing sample, 72 were excluded because mailing materials were returned as undeliverable (33 pediatricians and 39 FPs). Survey materials were returned by 784 (430 pediatricians and 354 FPs) of the remaining 1208 physicians, for an overall response rate of 65% (70% pediatricians and 60% FPs). Respondents were more likely than nonrespondents to be MDs (versus DOs; P < .01), board certified (P < .01), and in group practice (P < .0001).
In response to the initial screener question, 148 respondents (45 pediatricians and 103 FPs) indicated that they do not provide immunizations to patients aged 0 to 18 years, leaving 636 eligible respondents (385 pediatricians and 251 FPs) and an eligible response rate of 60%. Of these 148, 68% (n = 100) do not provide any primary care to this population. Of the 636 eligible respondents, 597 (94%) indicated that their practice purchases private stock of vaccine (ie, vaccines purchased for privately insured patients); this group of 597 respondents was the focus of the analyses reported here.
Respondent and Practice Characteristics
The majority of the 597 respondents were male, MDs, board certified, and directly involved in decision-making regarding vaccine purchase. Most respondent and practice characteristics varied by physician specialty (Table 1).
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Vaccine Purchase
Most respondents report that their practice purchases HPV (84% [n = 501]) and MCV4 (87% [n = 519]); fewer purchase Pediarix (57% [n = 339]). Practices of pediatricians were more likely than those of FPs to purchase HPV (89% vs 77%; P
.001) and MCV4 (97% vs 73%; P .0001).
Almost half (49% [n = 288]) of respondents reported their practice had "delayed the purchase of a new vaccine due only to financial concerns" in the previous 3 years. This did not differ by specialty. Decision-makers were more likely than non–decision-makers to report that such a delay had occurred (62% vs 35%; P .0001). The vaccines most commonly cited for delayed purchase were HPV (67% [n = 194]) and MCV4 (34% [n = 97]).
Profit Margin From Immunizations
More than half (53% [n = 310]) of the respondents reported that their practice had experienced a decrease in profit margin from providing pediatric immunizations in the previous 3 years (Table 2). A "significant decrease (>20%)" in profit margin was reported by 21% (n = 123) of respondents overall and by more decision-makers than non–decision-makers. There was no difference by specialty. The 2 most commonly cited contributors to this decreased profit margin were "practice costs for immunization have increased" (64% [n = 212]) and "limited to no mark-up for vaccine purchase" (63% [n = 210]).
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Perceptions on Reimbursement
With regard to the adequacy of reimbursement for vaccine purchase and in payments for administration fees (Table 3), 21% (31% decision-makers versus 9% non–decision-makers; P
.0001) strongly disagreed that reimbursement rates for vaccine purchase were adequate, whereas 17% (25% decision-makers versus 6% non–decision-makers; P .0001) strongly disagreed that reimbursement rates for vaccine administration were adequate. Overall, 65% said that they would not give a vaccine if the reimbursement price was less than the purchase price, with 40% (53% decision-makers versus 26% non–decision-makers; P .0001) strongly agreeing with this statement. There were no differences in these 4 items by physician specialty.
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Respondents were asked, "In the past year, to what extent has your practice seriously considered whether to stop providing all vaccines to privately insured patients due to vaccine cost/administration fee/reimbursement issues" (Table 4). Overall, 65 respondents (11%) said that they had seriously considered or discussed it, with higher proportions among FPs and decision-makers. Among decision-makers only, 34% of FPs versus 7% of pediatricians reported that their practice had seriously considered no longer providing vaccines to privately insured children.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A key finding from our study is that, in the previous year, 5% of pediatricians and 21% of FPs (11% of all respondents) have seriously considered whether to stop providing all vaccines to privately insured patients. Because pediatricians provide the vast majority of vaccines in this country,31 the immediate potential for a significant contraction in the nation's capacity to provide vaccines seems small. That is the good news. However, any decrease in the number of physicians providing vaccines to children should be of concern and could have a significant impact on the US infrastructure for administering vaccines.
A unique aspect of our study was the identification of respondents' involvement in decision-making regarding vaccine purchase within their practices. We hypothesize that the reported intentions and/or concerns of decision-makers are more likely to reflect potential action on the part of practices. In our study, the proportion of those experiencing and perceiving financial difficulty was higher among respondents who reported that they are directly involved in making decisions for their practice regarding vaccine purchase. The fact that 34% of decision-makers in family medicine practices (vs 7% in pediatric practices) have seriously considered whether to stop providing all vaccines to privately insured patients may be a harbinger of future actions among a significant group of FPs. Given the decline in the proportion of children's primary care visits made to FPs,32 the relevance of immunizations to their practice and their tolerance for marginal financial return may result in fewer FPs providing vaccines in the future. Although this may not result in a significant contraction in the nation's private-sector capacity for immunization delivery, discontinuation of immunization delivery by FPs, who are the predominant source of children's primary care in rural areas,33 may have a significant impact on rural children's access to immunization.
Importantly, although a significant decline in access to vaccines does not seem to be on the immediate horizon, the results of this study are consistent with the sentiment reported in the lay press that some physicians are having financial difficulties related to providing immunizations to privately insured children. Almost half of respondents have delayed introducing 1 new vaccines for financial reasons in the previous 3 years, and more than half reported that their practice experienced a decrease in profit margin from immunizations within the same time frame. In addition, many perceive reimbursement for both vaccine purchase and administration as inadequate.
However, it is important to keep such concerns in perspective. Concerns regarding reimbursement for medical services provided by physicians in general, and pediatricians specifically, have been reported across a variety of medical services, including tobacco cessation counseling,34 developmental assessments,35 adolescent gynecology,36 and mental health diagnosis and treatment.37 With specific regard to immunizations, financial concerns of providers are not new. A 1998 study found that more than half of physicians in both urban and rural areas of Colorado believed that reimbursement was inadequate.38 These studies do not diminish the importance of the views of the physicians in our study but rather ground them in controversies regarding reimbursements for a variety of services.
Discontinuation of physicians from providing immunizations should not be the only end point of concern. Almost half of the physicians in this study had delayed purchase of a recommended vaccine due only to financial concerns. Although the length of the delay was not specified, this implies that at least some children either did not receive recommended vaccines, and therefore remained at risk for vaccine preventable diseases, or that they may have been referred to the public health system for vaccination.
As with other studies using mailed surveys, the potential for response bias is the main limitation. Respondents may be more interested in vaccine finance issues or have other unmeasured characteristics that differ from nonrespondents. Our response rate is on the higher end relative to other studies using physician surveys, suggesting that our sample was neither more nor less likely to answer questions about vaccine finance issues than about other topics.39–42 In addition, although we found that our respondents were more likely to be MDs, board certified, and in group practice, this is consistent with the demographic make-up of physicians who provide care to children and unlikely impacts the generalizability of our results. Recall bias for certain items may have occurred. For questions using a Likert scale, we varied the phrasing of questions to be either in the positive or negative frame to avoid bias.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Physicians report dissatisfaction with reimbursement levels for vaccine purchase and administration and indicate that they are under increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address the root causes of these financial pressures, particularly for FPs, should be undertaken.
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ACKNOWLEDGMENTS |
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This work was funded by the Centers for Disease Control and Prevention.
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FOOTNOTES |
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Accepted Aug 25, 2009.
Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Division of General Pediatrics, 300 N Ingalls, Room 6E08, Ann Arbor, MI 48109-5456. E-mail: gfreed{at}umich.edu
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
|---|
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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1. Centers for Disease Control and Prevention. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49 (RR-9):1 –55[Medline]
2. Centers for Disease Control and Prevention. Recommended childhood immunization schedule: United States, 2001. MMWR Morb Mortal Wkly Rep. 2001;50 (1):7 –10, 19[Medline]
3. Davis MM, Zimmerman JL, Wheeler JR, Freed GL. Childhood vaccine purchase costs in the public sector: past trends, future expectations.
Am J Public Health. 2002;92
(12):1982
–1987
4. Schaffer SJ, Szilagyi PG, Shone LP, et al. Physician perspectives regarding pneumococcal conjugate vaccine. Pediatrics. 2002;110 (6). Available at: www.pediatrics.org/cgi/content/full/110/6/e68
5. Davis MM, Ndiaye SM, Freed GL, Clark SJ. One-year uptake of pneumococcal conjugate vaccine: a national survey of family physicians and pediatricians. J Am Board Fam Pract. 2003;16 (5):363 –371[CrossRef][Medline]
6. Davis MM, Andreae M, Freed GL. Physicians' early responses to pneumococcal conjugate vaccine. Ambul Pediatr. 2001;1 (6):302 –305[CrossRef][Web of Science][Medline]
7. Lieu TA, Finkelstein JA, Adams MM, et al. Pediatricians' views on financial barriers and values for pneumococcal vaccine for children. Ambul Pediatr. 2002;2 (5):358 –366[CrossRef][Web of Science][Medline]
8. Davis MM, Ndiaye SM, Freed GL, Kim CS, Clark SJ. Influence of insurance status and vaccine cost on physicians' administration of pneumococcal conjugate vaccine.
Pediatrics. 2003;112
(3 pt 1):521
–526
9. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0–18 years: United States, 2008. Morb Mortal Wkly Rep. 2008;57 (1):Q1 –Q4
10. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56 (RR-2):1 –32[Medline]
11. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54 (RR-7):1 –28[Medline]
12. Centers for Disease Control and Prevention. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55 (RR-12):1 –16[Medline]
13. Advisory Committee on Immunization Practices. ACIP Provisional Recommendations for the Prevention of Rotavirus Gastroenteritis Among Infants and Children. Available at: www.cdc.gov/vaccines/recs/provisional/downloads/roto-7-1-08-508.pdf. Accessed July 31, 2008
14. Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55 (RR-3):1 –50[Medline]
15. Centers for Disease Control and Prevention. Prevention of Hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55 (RR-7):1 –30[Medline]
16. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56 (RR-6):1 –60[Medline]
17. Centers for Disease Control and Prevention. Prevention and control of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56 (RR-4):1 –48[Medline]
18. Centers for Disease Control and Prevention. FDA licensure of diphtheria and tetanus toxoids and acellular pertussis adsorbed, hepatitis B (recombinant), and poliovirus vaccine combined (PEDIARIX) for use in infants [published correction appears in MMWR Morb Mortal Wkly Rep. 2003;52(16):379]. MMWR Morb Mortal Wkly Rep. 2003;52 (10):203 –204.[Medline]
19. Centers for Disease Control and Prevention. Licensure of a combined live attenuated measles, mumps, rubella, and varicella vaccine [published correction appears in MMWR Morb Mortal Wkly Rep. 2005;54(48):1237]. MMWR Morb Mortal Wkly Rep. 2005;54 (47):1212 –1214.
20. Food and Drug Administration. Product approval information: Kinrix. Available at: www.fda.gov/cber/products/kinrix.htm. Accessed July 31, 2008
21. Food and Drug Administration. Product approval information: Pentacel. Available at: www.fda.gov/cber/products/pentacel.htm. Accessed July 31, 2008
22. Centers for Disease Control and Prevention. CDC vaccine price list. Available at: www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm. Accessed April 10, 2008.
23. Lee GM, Santoli JM, Hannan C, et al. Gaps in vaccine financing for underinsured children in the United States.
JAMA. 2007;298
(6):638
–643
24. Pollack A. In need of a booster shot; rising costs make doctors balk at giving vaccines. New York Times. March 24, 2007: Available at: query.nytimes.com/gst
25. Berry E. Pediatricians warn they are losing money on vaccinations. Chattanooga Times Free Press. April 29, 2007: Available at: iis.timesfreepress.com/archive
26. Boodman SG. Who gets stuck? Doctors, patients want insurers to pay more for vaccine. Washington Post. May 1, 2007:F-1
27. Colliver V. Doctor-insurer disputes force parents to pay up front for shots. San Francisco Chronicle. September 21, 2007:A-1
28. Pediatricians say rising vaccine costs are putting children at risk [press release]. Available at: www.aap.org/advocacy/releases/apr07vaccinecosts.htm. Accessed April 13, 2007
29. Wyckoff AS. AAP-AMA Immunization Congress draws up solutions to vaccine financing, access issues.
AAP News. 2007;28
(4):1
30. Centers for Disease Control and Prevention. Vaccine supply policy CY 2006. Available at: www.cdc.gov/vaccines/programs/vfc/projects/data/vacc-supply-public-2006.htm. Accessed June 1, 2007
31. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for children program, United States, 1997. Pediatrics. 1999;104 (2). Available at: www.pediatrics.org/cgi/content/full/104/2/e15
32. Freed GL, Nahra TA, Wheeler JRC. Which physicians are providing health care to America's children? Trends and changes during the past 20 years.
Arch Pediatr Adolesc Med. 2004;158
(1):22
–26
33. Rosenblatt RA. A view from the periphery: health care in rural America.
N Engl J Med. 2004;351
(11):1049
–1051
34. American Academy of Pediatrics, Division of Health Services Research. Pediatricians cite barriers to tobacco cessation counseling.
AAP News. 2006;27
(12):17
35. Halfon N, Hochstein M, Harvinder S, O'Conner KG, Inkelas M, Olson LM. Barriers to the provision of developmental assessments during pediatric health supervision. Presented at the Pediatric Academic Societies Meeting; April 28–May 1, 2001; Baltimore, MD
36. Shah P, Norlin C, Lodsdon V, Samson-Fang L. Gynecological care for adolescents with disability: physician comfort, perceived barriers, and potential solutions. J Pediatr Adolesc Gynecol. 2005;18 (2):101 –104[CrossRef][Medline]
37. Horwitz SM, Kelleher KJ, Stein REK, et al. Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics. 2007;119 (1). Available at: www.pediatrics.org/cgi/content/full/119/1/e208
38. Brayden R, Lowery E, Siegel C, Steiner J, Berman S. Physician perceptions about immunization reimbursement in urban and rural Colorado. Presented at the Pediatric Academic Societies Meeting; May 1–5, 1998; New Orleans, LA
39. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50 (10):1129 –1136[CrossRef][Web of Science][Medline]
40. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res. 2001;35 (6):1347 –1355[Web of Science][Medline]
41. Cull WL, O'Connor KG, Sharp S, Tang SF. Response rates and response bias for 50 surveys of pediatricians. Health Serv Res. 2005;40 (1):213 –226[CrossRef][Web of Science][Medline]
42. Kellerman SE, Herold J. Physician response to surveys: a review of the literature. Am J Prev Med. 2001;20 (1):61 –67[Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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