Jeff Evans

WASHINGTON — A new preoperative grading system for adult hemispheric low-grade gliomas produced accurate prognoses for disease stage, Dr. Edward F. Chang said at the annual meeting of the American Association of Neurological Surgeons.

“There are few standards for guiding both the medical and surgical management of low-grade gliomas,” said Dr. Chang, a third-year resident in the department of neurologic surgery at the University of California, San Francisco. To construct a system, Dr. Chang reviewed 280 patients who had undergone operations for histologically confirmed grade 2 gliomas (from biopsy to maximal surgical resection) during 1989–2005 at UCSF.

Median patient age was 38 years at presentation. Most (88%) had seizures. A majority had a Karnofsky Performance Scale score of 100 or 90. Most tumors were in the frontal (72%) or temporal lobe (34%); median diameter was 4.5 cm.

In the follow-up period, patients survived for a median of 12 years; 65 died. A total of 134 events of progression or recurrence occurred. The median time of progression-free survival was 6 years.

The investigators used four variables highly predictive of lower survival in their grading. (See box.) The strongest was the presence of tumor in “eloquent” brain regions, particularly the sensorimotor cortex (specifically the pre- and postsensory gyri), perisylvian dominant language areas, insular areas, basal ganglia-internal capsule, thalamus, and hypothalamus. Tumor presence in an area of eloquence was the only significant, independent predictor of progression or recurrence.

The interobserver reliability of the grading system had a kappa value of 0.86 between a neurosurgery resident and an attending neurosurgeon blinded to the outcome of a subset of 200 random cases from the study.

When the study sample was graded, the median survival fell from 16 years for patients with low risk to nearly 11 years for those with intermediate risk and 8 years high risk. The median period of progression-free survival dropped as risk grew.

The researchers also analyzed predictors of the extent of resection. Tumors in an area of eloquence had a diameter greater than 4 cm with diffuse borders on MRI; tumors in the temporal lobe were significantly more likely to be treated with subtotal resection; parietal tumors were significantly more likely to undergo gross total resection.

The grading system currently is undergoing external validation.

Low-Grade Glioma Grading System

▸ Age 50 years or older

▸ Karnofsky Performance Scale score less than 90

▸ Maximum tumor diameter more than 4 cm

▸ Tumor located in “eloquent” area

A “yes” answer is given a score of 1 and a “no,” a score of 0. The categories for risk of death or progression were defined as:

Low = 0–1

Intermediate = 2

High = 3–4

Source: Dr. Chang

WASHINGTON — A new preoperative grading system for adult hemispheric low-grade gliomas produced accurate prognoses for disease stage, Dr. Edward F. Chang said at the annual meeting of the American Association of Neurological Surgeons.

“There are few standards for guiding both the medical and surgical management of low-grade gliomas,” said Dr. Chang, a third-year resident in the department of neurologic surgery at the University of California, San Francisco. To construct a system, Dr. Chang reviewed 280 patients who had undergone operations for histologically confirmed grade 2 gliomas (from biopsy to maximal surgical resection) during 1989–2005 at UCSF.

Median patient age was 38 years at presentation. Most (88%) had seizures. A majority had a Karnofsky Performance Scale score of 100 or 90. Most tumors were in the frontal (72%) or temporal lobe (34%); median diameter was 4.5 cm.

In the follow-up period, patients survived for a median of 12 years; 65 died. A total of 134 events of progression or recurrence occurred. The median time of progression-free survival was 6 years.

The investigators used four variables highly predictive of lower survival in their grading. (See box.) The strongest was the presence of tumor in “eloquent” brain regions, particularly the sensorimotor cortex (specifically the pre- and postsensory gyri), perisylvian dominant language areas, insular areas, basal ganglia-internal capsule, thalamus, and hypothalamus. Tumor presence in an area of eloquence was the only significant, independent predictor of progression or recurrence.

The interobserver reliability of the grading system had a kappa value of 0.86 between a neurosurgery resident and an attending neurosurgeon blinded to the outcome of a subset of 200 random cases from the study.

When the study sample was graded, the median survival fell from 16 years for patients with low risk to nearly 11 years for those with intermediate risk and 8 years high risk. The median period of progression-free survival dropped as risk grew.

The researchers also analyzed predictors of the extent of resection. Tumors in an area of eloquence had a diameter greater than 4 cm with diffuse borders on MRI; tumors in the temporal lobe were significantly more likely to be treated with subtotal resection; parietal tumors were significantly more likely to undergo gross total resection.

The grading system currently is undergoing external validation.

Low-Grade Glioma Grading System

▸ Age 50 years or older

▸ Karnofsky Performance Scale score less than 90

▸ Maximum tumor diameter more than 4 cm

▸ Tumor located in “eloquent” area

A “yes” answer is given a score of 1 and a “no,” a score of 0. The categories for risk of death or progression were defined as:

Low = 0–1

Intermediate = 2

High = 3–4

Source: Dr. Chang

WASHINGTON — A new preoperative grading system for adult hemispheric low-grade gliomas produced accurate prognoses for disease stage, Dr. Edward F. Chang said at the annual meeting of the American Association of Neurological Surgeons.

“There are few standards for guiding both the medical and surgical management of low-grade gliomas,” said Dr. Chang, a third-year resident in the department of neurologic surgery at the University of California, San Francisco. To construct a system, Dr. Chang reviewed 280 patients who had undergone operations for histologically confirmed grade 2 gliomas (from biopsy to maximal surgical resection) during 1989–2005 at UCSF.

Median patient age was 38 years at presentation. Most (88%) had seizures. A majority had a Karnofsky Performance Scale score of 100 or 90. Most tumors were in the frontal (72%) or temporal lobe (34%); median diameter was 4.5 cm.

In the follow-up period, patients survived for a median of 12 years; 65 died. A total of 134 events of progression or recurrence occurred. The median time of progression-free survival was 6 years.

The investigators used four variables highly predictive of lower survival in their grading. (See box.) The strongest was the presence of tumor in “eloquent” brain regions, particularly the sensorimotor cortex (specifically the pre- and postsensory gyri), perisylvian dominant language areas, insular areas, basal ganglia-internal capsule, thalamus, and hypothalamus. Tumor presence in an area of eloquence was the only significant, independent predictor of progression or recurrence.

The interobserver reliability of the grading system had a kappa value of 0.86 between a neurosurgery resident and an attending neurosurgeon blinded to the outcome of a subset of 200 random cases from the study.

When the study sample was graded, the median survival fell from 16 years for patients with low risk to nearly 11 years for those with intermediate risk and 8 years high risk. The median period of progression-free survival dropped as risk grew.

The researchers also analyzed predictors of the extent of resection. Tumors in an area of eloquence had a diameter greater than 4 cm with diffuse borders on MRI; tumors in the temporal lobe were significantly more likely to be treated with subtotal resection; parietal tumors were significantly more likely to undergo gross total resection.

The grading system currently is undergoing external validation.

Low-Grade Glioma Grading System

▸ Age 50 years or older

▸ Karnofsky Performance Scale score less than 90

▸ Maximum tumor diameter more than 4 cm

▸ Tumor located in “eloquent” area

A “yes” answer is given a score of 1 and a “no,” a score of 0. The categories for risk of death or progression were defined as:

Low = 0–1

Intermediate = 2

High = 3–4

Source: Dr. Chang

Etanercept appears safe through 8 years of continuous use in children with polyarticular-course juvenile rheumatoid arthritis without any incidence of cancers or serious opportunistic infections.

That is the conclusion of a multicenter, randomized, controlled trial, later extended into an open-label study, looking at the long-term safety of the anti-tumor necrosis factor-α drug. “Etanercept [Enbrel] was the first of the anti-TNF agents tested in children with JRA, and thus we have the longest and most clinical experience with it,” said Dr. Daniel Lovell of the Cincinnati Children's Hospital Medical Center, in an interview.

Of 69 patients originally randomized into the trial, Dr. Lovell and Dr. Andreas Reiff and colleagues followed 58 into the open-label extension; all had taken at least one etanercept dose.

In the original trial, all patients initially received etanercept for 3 months. Those who responded were randomized to etanercept or placebo. Corticosteroids and anti-inflammatory drugs were allowed in both the randomized trial and the extension, but few patients were allowed to take methotrexate again, said Dr. Reiff, head of the division of rheumatology and rehabilitation at Children's Hospital Los Angeles. In the ongoing safety study, 42 of the original patients (61%) received at least 4 years of etanercept, and 16 (23%) received at least 8 continuous years of the drug. All used the recommended dosage for the subcutaneous injection formulation (0.4 mg/kg twice per week). Overall, 16 patients (23%) reported adverse events. Long-term use did not significantly increase the rate of adverse events. Between years 4 and 8 of follow-up, only one severe adverse event (pyelonephritis) occurred. No lupus, demyelinating disorders, tuberculosis, opportunistic infections, malignancy, or deaths were reported.

Three cases of varicella infection occurred in follow-up, according to Dr. Reiff. Although Dr. Lovell said etanercept had a good safety profile, he expressed caution about an increased risk of varicella in children on etanercept who lack protective antibodies to this virus.

Dr. Lovell recommended all children be tested for varicella antibodies (IgG) before etanercept treatment. Precautions should be taken to avoid exposing nonimmune children on etanercept to active varicella.

Even patients on immunosuppressive drugs who were vaccinated may not have a protective antibody level, said Dr. Reiff, who noted he serves as an adviser and speaker for Amgen Inc. and Wyeth, which comarket etanercept.

“There is definitely a possibility that varicella can be more severe on these drugs,” Dr. Reiff said in an interview. But since etanercept has a half-life of nearly 5 days, it takes 3–4 weeks before it is cleared from the body after stopping. “We watch these patients very carefully. We treat them for their chicken pox, and if we see that their course is aggressive or prolonged, we admit them for IV treatment.”

Dr. Lovell noted when parents vaccinate or revaccinate nonimmune children against varicella, initiation of etanercept is delayed by 3 months. Prophylactic acyclovir is needed in children on etanercept with known exposure to varicella.

Nonimmune children on etanercept should not be exposed to varicella because of increased susceptibility. DR. LOVELL

Etanercept appears safe through 8 years of continuous use in children with polyarticular-course juvenile rheumatoid arthritis without any incidence of cancers or serious opportunistic infections.

That is the conclusion of a multicenter, randomized, controlled trial, later extended into an open-label study, looking at the long-term safety of the anti-tumor necrosis factor-α drug. “Etanercept [Enbrel] was the first of the anti-TNF agents tested in children with JRA, and thus we have the longest and most clinical experience with it,” said Dr. Daniel Lovell of the Cincinnati Children's Hospital Medical Center, in an interview.

Of 69 patients originally randomized into the trial, Dr. Lovell and Dr. Andreas Reiff and colleagues followed 58 into the open-label extension; all had taken at least one etanercept dose.

In the original trial, all patients initially received etanercept for 3 months. Those who responded were randomized to etanercept or placebo. Corticosteroids and anti-inflammatory drugs were allowed in both the randomized trial and the extension, but few patients were allowed to take methotrexate again, said Dr. Reiff, head of the division of rheumatology and rehabilitation at Children's Hospital Los Angeles. In the ongoing safety study, 42 of the original patients (61%) received at least 4 years of etanercept, and 16 (23%) received at least 8 continuous years of the drug. All used the recommended dosage for the subcutaneous injection formulation (0.4 mg/kg twice per week). Overall, 16 patients (23%) reported adverse events. Long-term use did not significantly increase the rate of adverse events. Between years 4 and 8 of follow-up, only one severe adverse event (pyelonephritis) occurred. No lupus, demyelinating disorders, tuberculosis, opportunistic infections, malignancy, or deaths were reported.

Three cases of varicella infection occurred in follow-up, according to Dr. Reiff. Although Dr. Lovell said etanercept had a good safety profile, he expressed caution about an increased risk of varicella in children on etanercept who lack protective antibodies to this virus.

Dr. Lovell recommended all children be tested for varicella antibodies (IgG) before etanercept treatment. Precautions should be taken to avoid exposing nonimmune children on etanercept to active varicella.

Even patients on immunosuppressive drugs who were vaccinated may not have a protective antibody level, said Dr. Reiff, who noted he serves as an adviser and speaker for Amgen Inc. and Wyeth, which comarket etanercept.

“There is definitely a possibility that varicella can be more severe on these drugs,” Dr. Reiff said in an interview. But since etanercept has a half-life of nearly 5 days, it takes 3–4 weeks before it is cleared from the body after stopping. “We watch these patients very carefully. We treat them for their chicken pox, and if we see that their course is aggressive or prolonged, we admit them for IV treatment.”

Dr. Lovell noted when parents vaccinate or revaccinate nonimmune children against varicella, initiation of etanercept is delayed by 3 months. Prophylactic acyclovir is needed in children on etanercept with known exposure to varicella.

Nonimmune children on etanercept should not be exposed to varicella because of increased susceptibility. DR. LOVELL

Etanercept appears safe through 8 years of continuous use in children with polyarticular-course juvenile rheumatoid arthritis without any incidence of cancers or serious opportunistic infections.

That is the conclusion of a multicenter, randomized, controlled trial, later extended into an open-label study, looking at the long-term safety of the anti-tumor necrosis factor-α drug. “Etanercept [Enbrel] was the first of the anti-TNF agents tested in children with JRA, and thus we have the longest and most clinical experience with it,” said Dr. Daniel Lovell of the Cincinnati Children's Hospital Medical Center, in an interview.

Of 69 patients originally randomized into the trial, Dr. Lovell and Dr. Andreas Reiff and colleagues followed 58 into the open-label extension; all had taken at least one etanercept dose.

In the original trial, all patients initially received etanercept for 3 months. Those who responded were randomized to etanercept or placebo. Corticosteroids and anti-inflammatory drugs were allowed in both the randomized trial and the extension, but few patients were allowed to take methotrexate again, said Dr. Reiff, head of the division of rheumatology and rehabilitation at Children's Hospital Los Angeles. In the ongoing safety study, 42 of the original patients (61%) received at least 4 years of etanercept, and 16 (23%) received at least 8 continuous years of the drug. All used the recommended dosage for the subcutaneous injection formulation (0.4 mg/kg twice per week). Overall, 16 patients (23%) reported adverse events. Long-term use did not significantly increase the rate of adverse events. Between years 4 and 8 of follow-up, only one severe adverse event (pyelonephritis) occurred. No lupus, demyelinating disorders, tuberculosis, opportunistic infections, malignancy, or deaths were reported.

Three cases of varicella infection occurred in follow-up, according to Dr. Reiff. Although Dr. Lovell said etanercept had a good safety profile, he expressed caution about an increased risk of varicella in children on etanercept who lack protective antibodies to this virus.

Dr. Lovell recommended all children be tested for varicella antibodies (IgG) before etanercept treatment. Precautions should be taken to avoid exposing nonimmune children on etanercept to active varicella.

Even patients on immunosuppressive drugs who were vaccinated may not have a protective antibody level, said Dr. Reiff, who noted he serves as an adviser and speaker for Amgen Inc. and Wyeth, which comarket etanercept.

“There is definitely a possibility that varicella can be more severe on these drugs,” Dr. Reiff said in an interview. But since etanercept has a half-life of nearly 5 days, it takes 3–4 weeks before it is cleared from the body after stopping. “We watch these patients very carefully. We treat them for their chicken pox, and if we see that their course is aggressive or prolonged, we admit them for IV treatment.”

Dr. Lovell noted when parents vaccinate or revaccinate nonimmune children against varicella, initiation of etanercept is delayed by 3 months. Prophylactic acyclovir is needed in children on etanercept with known exposure to varicella.

Nonimmune children on etanercept should not be exposed to varicella because of increased susceptibility. DR. LOVELL

BARCELONA — Treatment of rheumatoid arthritis with a combination of certolizumab pegol and methotrexate improved symptoms in a significantly greater proportion of patients than methotrexate alone, according to the results of a phase III trial.

In the 52-week, multicenter, randomized, double-blind trial, about 60% of patients who received dosing regimens with either 200 mg or 400 mg of certolizumab pegol (Cimzia) and methotrexate achieved an American College of Rheumatology (ACR) 20 level of response at 24 weeks on an intent-to-treat basis, compared with only 14% of those who received placebo plus methotrexate.

An ACR 20 level of response is achieved when there is 20% improvement in the number of tender and swollen joints as well as a 20% improvement in at least three of five other parameters.

The rheumatoid arthritis patients in the current trial, which was called RAPID 1, had to have had an inadequate response to methotrexate therapy alone for at least 6 months prior to the start of the study, Dr. Edward C. Keystone reported at the annual European Congress of Rheumatology.

Certolizumab pegol is a humanized monoclonal Fab' fragment conjugated to polyethylene glycol, which prolongs the amount of time that the drug remains in the bloodstream.

It is the first anti-tumor necrosis factor-α drug to be constructed without the Fc fusion protein, which may cause adverse effects in other anti-TNF-α agents.

The drug also is produced in bacteria rather than in Chinese hamster ovary cells said Dr. Keystone, director of the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease at the University of Toronto.

He has received research funds from and has been a consultant for the biopharmaceutical company Union Chimique Belge (UCB), which funded the study.

The RAPID 1 trial tested the lyophilized formulation of the drug, whereas the RAPID 2 trial evaluated the liquid form of the drug.

The 397 patients who were assigned to the 200-mg arm initially received a 400-mg loading dose of certolizumab pegol at 0, 2, and 4 weeks, followed by 200 mg every 2 weeks. The 394 individuals in the 400-mg arm received 400 mg every 2 weeks.

The 201 placebo-treated patients followed the same schedule as the 400-mg group. If the patients did not reach an ACR 20 response by 16 weeks, they entered an open-label extension in which they received 400 mg certolizumab pegol every 2 weeks, Dr. Keystone said.

At baseline, patients averaged 52 years of age, 6 years of RA, 13 mg/week methotrexate, 1.5 treatment failures on disease-modifying antirheumatic drugs other than methotrexate, a Disease Activity Score of 7, and about 30 tender and 20 swollen joints.

On an intent-to-treat basis, similar percentages of patients who took the 200-mg and 400-mg certolizumab pegol dosages achieved an ACR 50 level of response (37% and 40%, respectively) or ACR 70 level of response (21% in each of the groups).

ACR 50 and 70 responses occurred in 8% and 3%, respectively, of patients in the placebo group.

Most patients who achieved either an ACR 50 or ACR 70 level of response did so by 16 weeks, which is earlier than has been seen with other anti-TNF agents, Dr. Keystone said.

About 80% of placebo-treated patients withdrew from the study, compared with about 25% of 400-mg patients and 30% of 200-mg patients.

Treatment-emergent adverse events, including serious events, occurred at similar rates between the groups.

There was a trend toward more nonserious and serious infections in the certolizumab pegol-treated groups.

The trial also had a primary end point of Total Modified Sharp Score at the end of 52 weeks, but Dr. Keystone did not report on it at the meeting.

Most patients who achieved an ACR 50 or ACR 70 response on the combined regimen did so by 16 weeks. DR. KEYSTONE

BARCELONA — Treatment of rheumatoid arthritis with a combination of certolizumab pegol and methotrexate improved symptoms in a significantly greater proportion of patients than methotrexate alone, according to the results of a phase III trial.

In the 52-week, multicenter, randomized, double-blind trial, about 60% of patients who received dosing regimens with either 200 mg or 400 mg of certolizumab pegol (Cimzia) and methotrexate achieved an American College of Rheumatology (ACR) 20 level of response at 24 weeks on an intent-to-treat basis, compared with only 14% of those who received placebo plus methotrexate.

An ACR 20 level of response is achieved when there is 20% improvement in the number of tender and swollen joints as well as a 20% improvement in at least three of five other parameters.

The rheumatoid arthritis patients in the current trial, which was called RAPID 1, had to have had an inadequate response to methotrexate therapy alone for at least 6 months prior to the start of the study, Dr. Edward C. Keystone reported at the annual European Congress of Rheumatology.

Certolizumab pegol is a humanized monoclonal Fab' fragment conjugated to polyethylene glycol, which prolongs the amount of time that the drug remains in the bloodstream.

It is the first anti-tumor necrosis factor-α drug to be constructed without the Fc fusion protein, which may cause adverse effects in other anti-TNF-α agents.

The drug also is produced in bacteria rather than in Chinese hamster ovary cells said Dr. Keystone, director of the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease at the University of Toronto.

He has received research funds from and has been a consultant for the biopharmaceutical company Union Chimique Belge (UCB), which funded the study.

The RAPID 1 trial tested the lyophilized formulation of the drug, whereas the RAPID 2 trial evaluated the liquid form of the drug.

The 397 patients who were assigned to the 200-mg arm initially received a 400-mg loading dose of certolizumab pegol at 0, 2, and 4 weeks, followed by 200 mg every 2 weeks. The 394 individuals in the 400-mg arm received 400 mg every 2 weeks.

The 201 placebo-treated patients followed the same schedule as the 400-mg group. If the patients did not reach an ACR 20 response by 16 weeks, they entered an open-label extension in which they received 400 mg certolizumab pegol every 2 weeks, Dr. Keystone said.

At baseline, patients averaged 52 years of age, 6 years of RA, 13 mg/week methotrexate, 1.5 treatment failures on disease-modifying antirheumatic drugs other than methotrexate, a Disease Activity Score of 7, and about 30 tender and 20 swollen joints.

On an intent-to-treat basis, similar percentages of patients who took the 200-mg and 400-mg certolizumab pegol dosages achieved an ACR 50 level of response (37% and 40%, respectively) or ACR 70 level of response (21% in each of the groups).

ACR 50 and 70 responses occurred in 8% and 3%, respectively, of patients in the placebo group.

Most patients who achieved either an ACR 50 or ACR 70 level of response did so by 16 weeks, which is earlier than has been seen with other anti-TNF agents, Dr. Keystone said.

About 80% of placebo-treated patients withdrew from the study, compared with about 25% of 400-mg patients and 30% of 200-mg patients.

Treatment-emergent adverse events, including serious events, occurred at similar rates between the groups.

There was a trend toward more nonserious and serious infections in the certolizumab pegol-treated groups.

The trial also had a primary end point of Total Modified Sharp Score at the end of 52 weeks, but Dr. Keystone did not report on it at the meeting.

Most patients who achieved an ACR 50 or ACR 70 response on the combined regimen did so by 16 weeks. DR. KEYSTONE

BARCELONA — Treatment of rheumatoid arthritis with a combination of certolizumab pegol and methotrexate improved symptoms in a significantly greater proportion of patients than methotrexate alone, according to the results of a phase III trial.

In the 52-week, multicenter, randomized, double-blind trial, about 60% of patients who received dosing regimens with either 200 mg or 400 mg of certolizumab pegol (Cimzia) and methotrexate achieved an American College of Rheumatology (ACR) 20 level of response at 24 weeks on an intent-to-treat basis, compared with only 14% of those who received placebo plus methotrexate.

An ACR 20 level of response is achieved when there is 20% improvement in the number of tender and swollen joints as well as a 20% improvement in at least three of five other parameters.

The rheumatoid arthritis patients in the current trial, which was called RAPID 1, had to have had an inadequate response to methotrexate therapy alone for at least 6 months prior to the start of the study, Dr. Edward C. Keystone reported at the annual European Congress of Rheumatology.

Certolizumab pegol is a humanized monoclonal Fab' fragment conjugated to polyethylene glycol, which prolongs the amount of time that the drug remains in the bloodstream.

It is the first anti-tumor necrosis factor-α drug to be constructed without the Fc fusion protein, which may cause adverse effects in other anti-TNF-α agents.

The drug also is produced in bacteria rather than in Chinese hamster ovary cells said Dr. Keystone, director of the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease at the University of Toronto.

He has received research funds from and has been a consultant for the biopharmaceutical company Union Chimique Belge (UCB), which funded the study.

The RAPID 1 trial tested the lyophilized formulation of the drug, whereas the RAPID 2 trial evaluated the liquid form of the drug.

The 397 patients who were assigned to the 200-mg arm initially received a 400-mg loading dose of certolizumab pegol at 0, 2, and 4 weeks, followed by 200 mg every 2 weeks. The 394 individuals in the 400-mg arm received 400 mg every 2 weeks.

The 201 placebo-treated patients followed the same schedule as the 400-mg group. If the patients did not reach an ACR 20 response by 16 weeks, they entered an open-label extension in which they received 400 mg certolizumab pegol every 2 weeks, Dr. Keystone said.

At baseline, patients averaged 52 years of age, 6 years of RA, 13 mg/week methotrexate, 1.5 treatment failures on disease-modifying antirheumatic drugs other than methotrexate, a Disease Activity Score of 7, and about 30 tender and 20 swollen joints.

On an intent-to-treat basis, similar percentages of patients who took the 200-mg and 400-mg certolizumab pegol dosages achieved an ACR 50 level of response (37% and 40%, respectively) or ACR 70 level of response (21% in each of the groups).

ACR 50 and 70 responses occurred in 8% and 3%, respectively, of patients in the placebo group.

Most patients who achieved either an ACR 50 or ACR 70 level of response did so by 16 weeks, which is earlier than has been seen with other anti-TNF agents, Dr. Keystone said.

About 80% of placebo-treated patients withdrew from the study, compared with about 25% of 400-mg patients and 30% of 200-mg patients.

Treatment-emergent adverse events, including serious events, occurred at similar rates between the groups.

There was a trend toward more nonserious and serious infections in the certolizumab pegol-treated groups.

The trial also had a primary end point of Total Modified Sharp Score at the end of 52 weeks, but Dr. Keystone did not report on it at the meeting.

Most patients who achieved an ACR 50 or ACR 70 response on the combined regimen did so by 16 weeks. DR. KEYSTONE

BARCELONA, SPAIN — Rheumatoid arthritis patients in remission while taking the standard dose of etanercept may be able to switch to a lower dosing regimen and still maintain remission, Dr. Leonardo Punzi reported at the annual European Congress of Rheumatology.

He presented the results of a single-center trial. He looked at 105 adult rheumatoid arthritis (RA) patients who had maintained a Disease Activity Score of less than 1.6 for at least 6 months (defined as remission) on the standard dose of etanercept (Enbrel) in combination with a methotrexate regimen (7.5–10 mg/week). The patients were randomized to receive either a continuation of the standard dose of etanercept (25 mg twice per week) or a lower dose of the drug (25 mg once per week) for 24 weeks. The investigators excluded patients who had received other tumor necrosis factor-α antagonists prior to the trial. Methotrexate and other drugs were kept at the same dosages as before the trial.

At the end of the trial, the percentage of patients who maintained remission on the Disease Activity Score was similar in the lower-dose (73%, 38 of 52) and standard-dose groups (89%, 47 of 53), said Dr. Punzi of the rheumatology unit in the department of clinical and experimental medicine at the University of Padua (Italy).

All of the 14 patients in the lower-dose group who did not maintain remission and withdrew from the trial because of a lack of efficacy returned to the standard dose; 9 (64%) of them again achieved remission, whereas the other 5 switched to another anti-TNF-α drug.

Scores on the Health Assessment Questionnaire also did not differ significantly between the groups at 8, 16, and 24 weeks. Adverse events, including serious infections, occurred at similar rates in each group.

BARCELONA, SPAIN — Rheumatoid arthritis patients in remission while taking the standard dose of etanercept may be able to switch to a lower dosing regimen and still maintain remission, Dr. Leonardo Punzi reported at the annual European Congress of Rheumatology.

He presented the results of a single-center trial. He looked at 105 adult rheumatoid arthritis (RA) patients who had maintained a Disease Activity Score of less than 1.6 for at least 6 months (defined as remission) on the standard dose of etanercept (Enbrel) in combination with a methotrexate regimen (7.5–10 mg/week). The patients were randomized to receive either a continuation of the standard dose of etanercept (25 mg twice per week) or a lower dose of the drug (25 mg once per week) for 24 weeks. The investigators excluded patients who had received other tumor necrosis factor-α antagonists prior to the trial. Methotrexate and other drugs were kept at the same dosages as before the trial.

At the end of the trial, the percentage of patients who maintained remission on the Disease Activity Score was similar in the lower-dose (73%, 38 of 52) and standard-dose groups (89%, 47 of 53), said Dr. Punzi of the rheumatology unit in the department of clinical and experimental medicine at the University of Padua (Italy).

All of the 14 patients in the lower-dose group who did not maintain remission and withdrew from the trial because of a lack of efficacy returned to the standard dose; 9 (64%) of them again achieved remission, whereas the other 5 switched to another anti-TNF-α drug.

Scores on the Health Assessment Questionnaire also did not differ significantly between the groups at 8, 16, and 24 weeks. Adverse events, including serious infections, occurred at similar rates in each group.

BARCELONA, SPAIN — Rheumatoid arthritis patients in remission while taking the standard dose of etanercept may be able to switch to a lower dosing regimen and still maintain remission, Dr. Leonardo Punzi reported at the annual European Congress of Rheumatology.

He presented the results of a single-center trial. He looked at 105 adult rheumatoid arthritis (RA) patients who had maintained a Disease Activity Score of less than 1.6 for at least 6 months (defined as remission) on the standard dose of etanercept (Enbrel) in combination with a methotrexate regimen (7.5–10 mg/week). The patients were randomized to receive either a continuation of the standard dose of etanercept (25 mg twice per week) or a lower dose of the drug (25 mg once per week) for 24 weeks. The investigators excluded patients who had received other tumor necrosis factor-α antagonists prior to the trial. Methotrexate and other drugs were kept at the same dosages as before the trial.

At the end of the trial, the percentage of patients who maintained remission on the Disease Activity Score was similar in the lower-dose (73%, 38 of 52) and standard-dose groups (89%, 47 of 53), said Dr. Punzi of the rheumatology unit in the department of clinical and experimental medicine at the University of Padua (Italy).

All of the 14 patients in the lower-dose group who did not maintain remission and withdrew from the trial because of a lack of efficacy returned to the standard dose; 9 (64%) of them again achieved remission, whereas the other 5 switched to another anti-TNF-α drug.

Scores on the Health Assessment Questionnaire also did not differ significantly between the groups at 8, 16, and 24 weeks. Adverse events, including serious infections, occurred at similar rates in each group.

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, Dr. Daniel B. Mark said at the annual meeting of the Heart Failure Society of America.

There are more than 100 reward or incentive programs that have started in the private U.S. health care sector under the control of employer groups or managed care organizations, according to Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention, he said.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.” Furthermore, very little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark said, although he noted that that may be an oversimplification of the outcomes of such programs.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups. “If these had been clinical trials, they would have all been considered extremely underpowered and preliminary,” Dr. Mark said.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation in immunization studies without any actual change in the number of immunizations given or effect on care. The studies did not include any information on the optimal duration of these programs or whether or not their effect persisted after the program was terminated. Only one study had a preliminary examination of the cost-effectiveness of a program.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMs' Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate in the program to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” according to Dr. Mark. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases as well as measures related to the organization of care and the patient's experience. The National Health Service substantially increased its deficit that year because the approximately $3.2 billion that was allocated for the project was eaten by greater than predicted success in achieving the quality indicators (83% achieved vs. an expected 75%). This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90). And it is not clear what effect the program had on other conditions that were not a part of the incentive program. In any case, the U.K. government has significantly tightened up its requirements for earning extra money in the program in 2008, according to Dr. Mark.

Another study showed that public reporting of quality measures alone could improve a set of quality indicators on heart failure and acute myocardial infarction by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, Dr. Daniel B. Mark said at the annual meeting of the Heart Failure Society of America.

There are more than 100 reward or incentive programs that have started in the private U.S. health care sector under the control of employer groups or managed care organizations, according to Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention, he said.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.” Furthermore, very little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark said, although he noted that that may be an oversimplification of the outcomes of such programs.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups. “If these had been clinical trials, they would have all been considered extremely underpowered and preliminary,” Dr. Mark said.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation in immunization studies without any actual change in the number of immunizations given or effect on care. The studies did not include any information on the optimal duration of these programs or whether or not their effect persisted after the program was terminated. Only one study had a preliminary examination of the cost-effectiveness of a program.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMs' Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate in the program to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” according to Dr. Mark. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases as well as measures related to the organization of care and the patient's experience. The National Health Service substantially increased its deficit that year because the approximately $3.2 billion that was allocated for the project was eaten by greater than predicted success in achieving the quality indicators (83% achieved vs. an expected 75%). This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90). And it is not clear what effect the program had on other conditions that were not a part of the incentive program. In any case, the U.K. government has significantly tightened up its requirements for earning extra money in the program in 2008, according to Dr. Mark.

Another study showed that public reporting of quality measures alone could improve a set of quality indicators on heart failure and acute myocardial infarction by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

WASHINGTON — The few studies that have examined the effectiveness of incentivized pay-for-performance programs have found a mix of moderate to no improvement in quality measures, which, in some instances, have led to unintended consequences, Dr. Daniel B. Mark said at the annual meeting of the Heart Failure Society of America.

There are more than 100 reward or incentive programs that have started in the private U.S. health care sector under the control of employer groups or managed care organizations, according to Dr. Mark, but congressionally authorized programs by the Centers for Medicare and Medicaid Services have received the most attention, he said.

It is important to examine the evidence base that pay-for-performance programs actually improve quality because “people are making this association,” said Dr. Mark, director of the Outcomes Research and Assessment Group at the Duke (University) Clinical Research Institute, Durham, N.C.

During the last 20 years, incentivized performance programs have shown that “what you measure generally improves and what gets measured is generally what's easiest to measure. But the ease of measurement does not necessarily define the importance of the measurement.” Furthermore, very little, if anything, is known about whether these initiatives are cost effective for the health care system at large, Dr. Mark said, although he noted that that may be an oversimplification of the outcomes of such programs.

A systematic overview of 17 studies published during 1980–2005 on pay-for-performance programs found that 1 of 2 studies on system-level incentives had a positive result in which all performance measures improved. In nine studies of incentive programs aimed at the provider group level, seven had partially positive or fully positive results but had “quite small” effect sizes. Positive or partially positive results were seen in five of six programs at the physician level (Ann. Int. Med. 2006;145:265–72).

Nine of the studies were randomized and controlled, but eight of these had a sample size of fewer than 100 physicians or groups; the other study had fewer than 200 groups. “If these had been clinical trials, they would have all been considered extremely underpowered and preliminary,” Dr. Mark said.

Programs in four studies appeared to have created unintended consequences, including “gaming the baseline level of illness,” avoiding sicker patients, and an improvement in documentation in immunization studies without any actual change in the number of immunizations given or effect on care. The studies did not include any information on the optimal duration of these programs or whether or not their effect persisted after the program was terminated. Only one study had a preliminary examination of the cost-effectiveness of a program.

Another study compared patients with acute non-ST-elevation myocardial infarction in 57 hospitals that participated in CMs' Hospital Quality Incentive Demonstration and 113 control hospitals that did not participate in the program to determine if a pay-for-performance strategy produced better quality of care. There was “very little evidence that there was any intervention effect,” according to Dr. Mark. Measures that were not incentivized by CMS also did not appear to change (JAMA 2007;297:2373–80).

In the United Kingdom, family practice physicians participated in a pay-for-performance program in 2004 that focused on 146 quality indicators for 10 chronic diseases as well as measures related to the organization of care and the patient's experience. The National Health Service substantially increased its deficit that year because the approximately $3.2 billion that was allocated for the project was eaten by greater than predicted success in achieving the quality indicators (83% achieved vs. an expected 75%). This led to an average increase in the physicians' pay of about $40,000 that year (N. Engl. J. Med. 2006;355:375–84).

Other investigators noted that in the 1998–2003 period prior to the NHS project all of the quality indicators had already been improving, “so it's not clear how much the program's achievements can actually be attributed to the program itself,” he said (N. Engl. J. Med. 2007;357:181–90). And it is not clear what effect the program had on other conditions that were not a part of the incentive program. In any case, the U.K. government has significantly tightened up its requirements for earning extra money in the program in 2008, according to Dr. Mark.

Another study showed that public reporting of quality measures alone could improve a set of quality indicators on heart failure and acute myocardial infarction by the same magnitude as a pay-for performance program that included public reporting (N. Engl. J. Med. 2007;356:486–96).

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers. The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers. The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers. The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Nursing homes remain segregated in most parts of the United States, providing unequal care that appears to be perpetuated by their growth in segregated residential areas and the practices of not-for-profit facilities, according to a report on survey data from the year 2000.

“The more segregated a metropolitan area, the more likely, and the larger, the black-white disparity in access to good-quality nursing home care,” Vincent Mor, Ph.D., said during a teleconference briefing on the study.

“Disparities in treatment will persist even in the absence of any disparities of treatment within nursing homes because of the differences in the homes providing care to blacks and whites,” said David Barton Smith, Ph.D., emeritus professor at Temple University, Philadelphia, and his colleagues (Health Aff. 2007;26:1448–58).

The disparities found in the report, which the researchers suggest differ little from other parts of the health system, could be reduced several ways. These include paying adjustments to nursing homes that have a higher proportion of Medicaid residents, equalizing Medicaid and private-pay payments, responding to racial-disparity concerns in regional planning, and performing ongoing monitoring and rigorous enforcement of Title VI of the 1964 Civil Rights Act, which prohibits segregation and other forms of discrimination in any organization receiving federal funds.

Although it would take a long time to eliminate such disparities, Dr. Smith said immediate steps can be taken, such as having patients review the quality measures of nursing homes in their area, providing patients with all available choices, discharging hospital patients to higher-quality nursing homes, and considering segregation and disparities during state inspections.

The investigators sought to analyze segregation and disparities across nursing home facilities in the United States because little data have been available to document the extent of these disparities since Title VI was enacted. Unlike hospitals, nursing homes never were required to certify their compliance with Title VI to qualify for Medicare when it began in 1967. They had only to post signs and certify that they did not discriminate. No requests were made for information on admission practices or racial or ethnic composition, and no federal civil rights inspections were made.

Based on data from the Centers for Medicare and Medicaid Services' Online Survey Certification and Reporting System and Nursing Home Minimum Data Set, they analyzed 147 metropolitan statistical areas (MSAs) with at least a 5% black residential population, four or more freestanding nursing homes, and 100 or more black nursing home residents. This included 7,196 non-hospital-based nursing homes and 837,810 residents, or about 50% of all freestanding nursing homes and residents in the United States.

Black residents were concentrated in a small percentage of nursing homes. More than 50% of blacks in for-profit facilities lived in fewer than 10% of for-profit homes, and more than 70% of blacks in nonprofit facilities lived in fewer than 10% of nonprofit homes.

Nationwide, nursing homes had a dissimilarity index of 0.65. The index, the most commonly used measure of segregation, calculates the combined percentage of black and white residents who would have to be relocated for there to be the same proportion of black and white residents in every nursing home within an MSA. Homes seemed to be most segregated in MSAs in the Midwest and least segregated in the South, ranging from 0.77 in Cleveland to 0.16 in Columbus, Ga.

Within most MSAs, blacks were significantly more likely to be in facilities that fell into the bottom quartile of many structural and performance measures of quality. They were 31%–70% more likely to be in a facility that was in the highest quartile of total severe inspection deficiencies for a particular MSA, was cited with a deficiency causing actual harm or immediate jeopardy to residents, and was later terminated from participation in Medicare and Medicaid than were white residents.

Compared with white residents, black residents were 19% less likely to be in a home in an MSA with the highest staffing level of direct-care providers and 23% less likely to be in facilities with the highest ratio of registered nurses to all nursing staff. The study was funded by the Commonwealth Fund.

Nursing homes remain segregated in most parts of the United States, providing unequal care that appears to be perpetuated by their growth in segregated residential areas and the practices of not-for-profit facilities, according to a report on survey data from the year 2000.

“The more segregated a metropolitan area, the more likely, and the larger, the black-white disparity in access to good-quality nursing home care,” Vincent Mor, Ph.D., said during a teleconference briefing on the study.

“Disparities in treatment will persist even in the absence of any disparities of treatment within nursing homes because of the differences in the homes providing care to blacks and whites,” said David Barton Smith, Ph.D., emeritus professor at Temple University, Philadelphia, and his colleagues (Health Aff. 2007;26:1448–58).

The disparities found in the report, which the researchers suggest differ little from other parts of the health system, could be reduced several ways. These include paying adjustments to nursing homes that have a higher proportion of Medicaid residents, equalizing Medicaid and private-pay payments, responding to racial-disparity concerns in regional planning, and performing ongoing monitoring and rigorous enforcement of Title VI of the 1964 Civil Rights Act, which prohibits segregation and other forms of discrimination in any organization receiving federal funds.

Although it would take a long time to eliminate such disparities, Dr. Smith said immediate steps can be taken, such as having patients review the quality measures of nursing homes in their area, providing patients with all available choices, discharging hospital patients to higher-quality nursing homes, and considering segregation and disparities during state inspections.

The investigators sought to analyze segregation and disparities across nursing home facilities in the United States because little data have been available to document the extent of these disparities since Title VI was enacted. Unlike hospitals, nursing homes never were required to certify their compliance with Title VI to qualify for Medicare when it began in 1967. They had only to post signs and certify that they did not discriminate. No requests were made for information on admission practices or racial or ethnic composition, and no federal civil rights inspections were made.

Based on data from the Centers for Medicare and Medicaid Services' Online Survey Certification and Reporting System and Nursing Home Minimum Data Set, they analyzed 147 metropolitan statistical areas (MSAs) with at least a 5% black residential population, four or more freestanding nursing homes, and 100 or more black nursing home residents. This included 7,196 non-hospital-based nursing homes and 837,810 residents, or about 50% of all freestanding nursing homes and residents in the United States.

Black residents were concentrated in a small percentage of nursing homes. More than 50% of blacks in for-profit facilities lived in fewer than 10% of for-profit homes, and more than 70% of blacks in nonprofit facilities lived in fewer than 10% of nonprofit homes.

Nationwide, nursing homes had a dissimilarity index of 0.65. The index, the most commonly used measure of segregation, calculates the combined percentage of black and white residents who would have to be relocated for there to be the same proportion of black and white residents in every nursing home within an MSA. Homes seemed to be most segregated in MSAs in the Midwest and least segregated in the South, ranging from 0.77 in Cleveland to 0.16 in Columbus, Ga.

Within most MSAs, blacks were significantly more likely to be in facilities that fell into the bottom quartile of many structural and performance measures of quality. They were 31%–70% more likely to be in a facility that was in the highest quartile of total severe inspection deficiencies for a particular MSA, was cited with a deficiency causing actual harm or immediate jeopardy to residents, and was later terminated from participation in Medicare and Medicaid than were white residents.

Compared with white residents, black residents were 19% less likely to be in a home in an MSA with the highest staffing level of direct-care providers and 23% less likely to be in facilities with the highest ratio of registered nurses to all nursing staff. The study was funded by the Commonwealth Fund.

Nursing homes remain segregated in most parts of the United States, providing unequal care that appears to be perpetuated by their growth in segregated residential areas and the practices of not-for-profit facilities, according to a report on survey data from the year 2000.

“The more segregated a metropolitan area, the more likely, and the larger, the black-white disparity in access to good-quality nursing home care,” Vincent Mor, Ph.D., said during a teleconference briefing on the study.

“Disparities in treatment will persist even in the absence of any disparities of treatment within nursing homes because of the differences in the homes providing care to blacks and whites,” said David Barton Smith, Ph.D., emeritus professor at Temple University, Philadelphia, and his colleagues (Health Aff. 2007;26:1448–58).

The disparities found in the report, which the researchers suggest differ little from other parts of the health system, could be reduced several ways. These include paying adjustments to nursing homes that have a higher proportion of Medicaid residents, equalizing Medicaid and private-pay payments, responding to racial-disparity concerns in regional planning, and performing ongoing monitoring and rigorous enforcement of Title VI of the 1964 Civil Rights Act, which prohibits segregation and other forms of discrimination in any organization receiving federal funds.

Although it would take a long time to eliminate such disparities, Dr. Smith said immediate steps can be taken, such as having patients review the quality measures of nursing homes in their area, providing patients with all available choices, discharging hospital patients to higher-quality nursing homes, and considering segregation and disparities during state inspections.

The investigators sought to analyze segregation and disparities across nursing home facilities in the United States because little data have been available to document the extent of these disparities since Title VI was enacted. Unlike hospitals, nursing homes never were required to certify their compliance with Title VI to qualify for Medicare when it began in 1967. They had only to post signs and certify that they did not discriminate. No requests were made for information on admission practices or racial or ethnic composition, and no federal civil rights inspections were made.

Based on data from the Centers for Medicare and Medicaid Services' Online Survey Certification and Reporting System and Nursing Home Minimum Data Set, they analyzed 147 metropolitan statistical areas (MSAs) with at least a 5% black residential population, four or more freestanding nursing homes, and 100 or more black nursing home residents. This included 7,196 non-hospital-based nursing homes and 837,810 residents, or about 50% of all freestanding nursing homes and residents in the United States.

Black residents were concentrated in a small percentage of nursing homes. More than 50% of blacks in for-profit facilities lived in fewer than 10% of for-profit homes, and more than 70% of blacks in nonprofit facilities lived in fewer than 10% of nonprofit homes.

Nationwide, nursing homes had a dissimilarity index of 0.65. The index, the most commonly used measure of segregation, calculates the combined percentage of black and white residents who would have to be relocated for there to be the same proportion of black and white residents in every nursing home within an MSA. Homes seemed to be most segregated in MSAs in the Midwest and least segregated in the South, ranging from 0.77 in Cleveland to 0.16 in Columbus, Ga.

Within most MSAs, blacks were significantly more likely to be in facilities that fell into the bottom quartile of many structural and performance measures of quality. They were 31%–70% more likely to be in a facility that was in the highest quartile of total severe inspection deficiencies for a particular MSA, was cited with a deficiency causing actual harm or immediate jeopardy to residents, and was later terminated from participation in Medicare and Medicaid than were white residents.

Compared with white residents, black residents were 19% less likely to be in a home in an MSA with the highest staffing level of direct-care providers and 23% less likely to be in facilities with the highest ratio of registered nurses to all nursing staff. The study was funded by the Commonwealth Fund.

BARCELONA — Rheumatoid arthritis patients who use corticosteroids frequently over the long term can maintain a low disease activity state but suffer deterioration of their functional capability, Dr. Eiichi Tanaka reported at a poster session at the annual European Congress of Rheumatology.

“A low disease activity state caused by corticosteroid use may not represent a 'true' low disease activity state,” noted Dr. Tanaka of Tokyo Women's Medical University, and his associates.

The investigators followed 224 RA patients with a low disease activity state during 2000–2005.

The patients had a mean age of 56 years and a mean disease duration of about 8 years, and were enrolled in the study for at least 3 years.

Every 6 months, the investigators collected measurements on the Disease Activity Score-28 (DAS-28) and Japanese version of the Health Assessment Questionnaire (J-HAQ).

DAS-28 scores did not change substantially over the course of the study in 135 patients who never used corticosteroids, 33 who used steroids an average of less than 9 months per year, and 56 who took steroids an average of more than 9 months per year.

No patient had a DAS-28 greater than 3.2 at each assessment.

But long-term functional capacity, as measured by the J-HAQ, declined in the heavy corticosteroid users, improved slightly among moderate corticosteroid users, and improved the most in patients who did not use corticosteroids.

The use of corticosteroids was the most significant factor contributing to the final J-HAQ score, after the adjustment of a multiple linear regression analysis for age, gender, disease duration, initial J-HAQ score, and seasonal effects.

A little more than 90% of the patients in each group used disease-modifying anti-rheumatic drugs during the study.

“Along with the achievement of a low disease activity state, long-term efficacy, long-term functional prognosis, and the quality of remission also need to be considered in the strict control of RA activity,” Dr. Tanaka and his colleagues concluded.

BARCELONA — Rheumatoid arthritis patients who use corticosteroids frequently over the long term can maintain a low disease activity state but suffer deterioration of their functional capability, Dr. Eiichi Tanaka reported at a poster session at the annual European Congress of Rheumatology.

“A low disease activity state caused by corticosteroid use may not represent a 'true' low disease activity state,” noted Dr. Tanaka of Tokyo Women's Medical University, and his associates.

The investigators followed 224 RA patients with a low disease activity state during 2000–2005.

The patients had a mean age of 56 years and a mean disease duration of about 8 years, and were enrolled in the study for at least 3 years.

Every 6 months, the investigators collected measurements on the Disease Activity Score-28 (DAS-28) and Japanese version of the Health Assessment Questionnaire (J-HAQ).

DAS-28 scores did not change substantially over the course of the study in 135 patients who never used corticosteroids, 33 who used steroids an average of less than 9 months per year, and 56 who took steroids an average of more than 9 months per year.

No patient had a DAS-28 greater than 3.2 at each assessment.

But long-term functional capacity, as measured by the J-HAQ, declined in the heavy corticosteroid users, improved slightly among moderate corticosteroid users, and improved the most in patients who did not use corticosteroids.

The use of corticosteroids was the most significant factor contributing to the final J-HAQ score, after the adjustment of a multiple linear regression analysis for age, gender, disease duration, initial J-HAQ score, and seasonal effects.

A little more than 90% of the patients in each group used disease-modifying anti-rheumatic drugs during the study.

“Along with the achievement of a low disease activity state, long-term efficacy, long-term functional prognosis, and the quality of remission also need to be considered in the strict control of RA activity,” Dr. Tanaka and his colleagues concluded.

BARCELONA — Rheumatoid arthritis patients who use corticosteroids frequently over the long term can maintain a low disease activity state but suffer deterioration of their functional capability, Dr. Eiichi Tanaka reported at a poster session at the annual European Congress of Rheumatology.

“A low disease activity state caused by corticosteroid use may not represent a 'true' low disease activity state,” noted Dr. Tanaka of Tokyo Women's Medical University, and his associates.

The investigators followed 224 RA patients with a low disease activity state during 2000–2005.

The patients had a mean age of 56 years and a mean disease duration of about 8 years, and were enrolled in the study for at least 3 years.

Every 6 months, the investigators collected measurements on the Disease Activity Score-28 (DAS-28) and Japanese version of the Health Assessment Questionnaire (J-HAQ).

DAS-28 scores did not change substantially over the course of the study in 135 patients who never used corticosteroids, 33 who used steroids an average of less than 9 months per year, and 56 who took steroids an average of more than 9 months per year.

No patient had a DAS-28 greater than 3.2 at each assessment.

But long-term functional capacity, as measured by the J-HAQ, declined in the heavy corticosteroid users, improved slightly among moderate corticosteroid users, and improved the most in patients who did not use corticosteroids.

The use of corticosteroids was the most significant factor contributing to the final J-HAQ score, after the adjustment of a multiple linear regression analysis for age, gender, disease duration, initial J-HAQ score, and seasonal effects.

A little more than 90% of the patients in each group used disease-modifying anti-rheumatic drugs during the study.

“Along with the achievement of a low disease activity state, long-term efficacy, long-term functional prognosis, and the quality of remission also need to be considered in the strict control of RA activity,” Dr. Tanaka and his colleagues concluded.

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880–5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885–8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively. The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880–5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885–8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively. The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Immunization coverage in 2006 for children aged 19–35 months held steady for most recommended vaccines and grew for several types, but more recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success, according to results from the most recent National Immunization Survey.

The Centers for Disease Control and Prevention estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007;56:880–5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Adolescents aged 13–17 years—who were included in the survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%). But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885–8).

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively. The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success as achieved in children aged 19–35 months, according to results from the most recent National Immunization Survey.

Adolescents aged 13–17 years—who were included in the Centers for Disease Control and Prevention survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%).

But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

In contrast, the CDC estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007; 56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual adolescents and children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success as achieved in children aged 19–35 months, according to results from the most recent National Immunization Survey.

Adolescents aged 13–17 years—who were included in the Centers for Disease Control and Prevention survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%).

But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

In contrast, the CDC estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007; 56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual adolescents and children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.

Recent recommendations in coverage for adolescents aged 13–17 years have not yet reached the same levels of success as achieved in children aged 19–35 months, according to results from the most recent National Immunization Survey.

Adolescents aged 13–17 years—who were included in the Centers for Disease Control and Prevention survey for the first time—fulfilled the recommended immunizations at high percentages for measles, mumps, and rubella vaccine (87% for 13–15 years of age) and hepatitis B vaccine (82%).

But recommendations made in 2005 for vaccination with tetanus-diphtheria or tetanus, reduced diphtheria, and acellular pertussis vaccines (Tdap) and meningococcal conjugate vaccine (MCV4) reached levels of only 60% (after age 10 years) and 12%, respectively (MMWR 2007;56:885-8).

In contrast, the CDC estimated that the percentage of children aged 19–35 months who have received the recommended series of childhood vaccines grew from 76% in 2005 to 77% in 2006 (MMWR 2007; 56:880-5).

“While we're very pleased with how high the complete series coverage is, we know we still have a way to go to reach the 80% goal for [the Healthy People 2010 target] and the 90% coverage for individual vaccines,” Dr. Melinda Wharton, deputy director for the National Center for Immunization and Respiratory Diseases at the CDC, said during a teleconference on the survey results.

Any new vaccine recommended by the Advisory Committee on Immunization Practices has a target coverage of 90% or higher within 5 years of the recommendation, according to the CDC.

The survey did not report on human papillomavirus (HPV) vaccination because it was conducted before HPV vaccination recommendations were published.

The survey estimated immunization coverage through a quarterly, random-digit-dialed sample of telephone numbers in each of the 50 states, plus 30 local areas (counties and cities). The household responses are then corroborated with vaccination records from their health care providers.

The household response rates for the child and adolescent surveys were 65% and 56%, respectively.

The 21,044 children with provider-reported vaccination records represented 70% of all children with completed household interviews, whereas the 2,882 adolescents with provider-reported vaccination records represented 53% of adolescents with completed household interviews.

For children aged 19–35 months, the levels of coverage rose significantly from 2005 levels for pneumococcal conjugate vaccine (from 83% to 87%, for three or more doses), varicella vaccine (from 88% to 89%), and poliovirus vaccine (from 92% to 93%).

Across the states, the percentage of children who received the recommended series of childhood vaccines ranged from 84% in Massachusetts to 60% in Nevada. These rates also varied across local areas, ranging from 81% in Boston to 65% in Detroit.

Coverage for the recommended series of childhood vaccines was significantly lower for black children than white children (74% vs. 78%), but after adjustment for income the difference in coverage was no longer significant.

“Vaccination funding through the federal Vaccines for Children program has contributed to record coverage levels among children who are uninsured or underinsured, but additional measures are needed to deliver vaccines to children who live below the poverty level,” according to the CDC.

“Clearly we need to do more to get information to parents and health care providers, and to make sure that everyone has a good understanding of the recommendations and the health benefits that the vaccines provide,” Dr. Wharton said.

Dr. Wharton suggested that physicians can use immunization registries or electronic medical records to track the immunization status of individual adolescents and children. Such systems “can really be part of the solution because many children may move from provider to provider or community to community,” and may have already received vaccines even though it has not been recorded.