Contact allergy to aluminium induced by commonly used pediatric vaccines
2017

E Bergfors
Department of Primary Health Care
Institute of Medicine
Sahlgrenska Academy
University of Gothenburg
GothenburgSweden

B Trollfors
Department of Primary Health Care
Institute of Medicine
Sahlgrenska Academy
University of Gothenburg
GothenburgSweden

A Inerot
Department of Primary Health Care
Institute of Medicine
Sahlgrenska Academy
University of Gothenburg
GothenburgSweden

A Gente Lidholm
Department of Primary Health Care
Institute of Medicine
Sahlgrenska Academy
University of Gothenburg
GothenburgSweden

Contact allergy to aluminium induced by commonly used pediatric vaccines

Clin Trans Med
64201710.1186/s40169-016-0129-yCOMMENTARY
which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

We would like to complete the paragraph on Adjuvants (page 6) in the review Vaccination in children with allergies to non active vaccine components by Francheschini et al. [1] which was initiated by the Italian Pediatric Society of Allergy and Immunology in 2013 and published in Clinical and Translational Medicine in 2015.

As mentioned in the review, aluminium (Al) salts are widely used as adjuvants in diphtheria-tetanus-pertussis (DTP) and hepatitis A and B vaccines. The list can be completed with pneumococcal and meningococcal conjugate vaccines, which today are included in the national vaccination schedules in most countries in Europe and the Americas, and also in vaccines against human papilloma virus (HPV) and tick-bore encephalitis (TBE).

According to the authors, the most known and frequent reaction to Al salts is "a palpable nodule at the injection site". This sounds harmless enough-but in typical cases the nodules are most annoying to the child due to severe pruritus for a very long time [2,3]. Besides, most children with persistent itching vaccination granulomas become sensitized against Al [4].

Itching vaccination granulomas are described since 1960 [5] but considered very rare [6] until the 1990s when they were reported in 745 of 76,000 children participating in studies on a monocomponent acellular pertussis vaccine in Sweden [7]. Since then, another 102 children in Sweden who received commercial DTaPpolio-Hib-(HepB) combinations (Infanrix ® , Pentavac ® ) and/or pneumococcal vaccines (Prevenar, Synflorix) are described [4,8,9]. The vaccines were given intramuscularly in three doses at 3, 5 and 12 months. In a prospective cohort study on 4758 toddlers the frequency of granulomas was 0.63% in those who received a DTaP combination vaccine alone and 1.18% in those who received an Al adsorbed pneumococcal vaccine at the same time. The risk for granulomas increased with the number of Alcontaining vaccine doses [4].

The itching nodules appear remarkably late (months or even years) after the vaccination. Histopathological examination shows granuloma formations in which Al crystals can be demonstrated [10]. Clinically, pruritus is the dominating symptom with intense local itching in the vaccination area on the thigh, often causing skin alterations like eczema, hypertrichosis and hyperpigmentation. Intensified itching and swelling of the nodules is often reported when the child has a cold or another infection. After a duration of ½-12 years (median 3-4 years) the nodules eventually disappear and the pruritus ceases.

In some cases nodules were mistaken as tumours leading to unnecessary anxiety, investigations and surgery [11,12].

Contact allergy to aluminium was verified in 77-95% of children with itching vaccination granulomas by epicutaneous testing with Al Chloride hexahydrate 2% and metallic Al (4,7,9). Sensitized individuals have reported contact dermatitis after the use of Al containing deodorants, pharmaceutics (ear drops, antiseptics), sun protectors, tattooing pigments and metallic aluminium [13]. Fortunately, and contrary to earlier belief, the sensitization to aluminium seems to vane with time [14].

The consequences of future vaccination with Al adsorbed vaccines in children who once reacted with itching granulomas and/or contact allergy to Al is only partially studied. Our clinical experience so far is that the risk for new granulomas diminishes with time and is very low when the original one has vanished and the itching ceased. In case of on-going severe pruritus the next dose may be postponed 6-12 months. The Al allergy is a delayed type IV reaction not associated with increased risk for anaphylaxis.

We want to point out that itching granulomas are benign and self-limiting and no cause to refrain from vaccination in consideration of the risk for a serious infectious disease. They are poorly known but easy to Open Access *Correspondence: email@example.com Department of Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden recognize once you are aware of them. They should be familiar to all health care staff working with children to avoid mistrust and anxiety in the parents and unnecessary investigations of the child.
 Authors' contributions EB participated in the pertussis vaccine study, organized the follow-up and testing of children with itching vaccination granulomas, performed the prospective cohort study and drafted the manuscript. BT organized and performed the clinical study on the monocomponent acellular pertussis vaccine in Göteborg and participated in the follow-up of the itching children. AI performed the testing of the children in the pertussis vaccine study. AGL performed the re-testing study where aluminium sensitization was showed to vane with time. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.
Vaccination in children with allergy to non active vaccine components. F Franceschini, P Bottau, S Caimmi, 10.1186/s4016901400430doi:10.1186/ s4016901400430Clin Transl Med. Franceschini F, Bottau P, Caimmi S et al (2015) Vaccination in children with allergy to non active vaccine components. Clin Transl Med. doi:10.1186/ s4016901400430

Post-vaccination granuloma due to aluminium hydroxide. A L Bordet, P Michenet, C Cohen, Ann Pathol. 21Bordet AL, Michenet P, Cohen C et al (2001) Post-vaccination granuloma due to aluminium hydroxide. Ann Pathol 21:149-152

Persistent vaccination granuloma due to aluminium hypersensitivity. H A Fawcett, Br J Dermatol. 113Fawcett HA (1985) Persistent vaccination granuloma due to aluminium hypersensitivity. Br J Dermatol 113:101-102

How common are longlasting, intensely itching vaccination granulomas and contact allergy to aluminium induced by currently used pediatric vaccines?. E Bergfors, G Hermansson, B Trollfors, Eur J Pediatr. 173Bergfors E, Hermansson G, Trollfors B et al (2014) How common are long- lasting, intensely itching vaccination granulomas and contact allergy to aluminium induced by currently used pediatric vaccines? Eur J Pediatr 173:1297-1307

Uber ein cirka ein Jahr altes Impfstoffgranulom beim Menschen. H Voss, Zbl Bakt Microbiol Hyg. 170Voss H (1960) Uber ein cirka ein Jahr altes Impfstoffgranulom beim Men- schen. Zbl Bakt Microbiol Hyg 170:291-299

Granulomas associated with tetanus toxoid immunization. D Cominos, G Strutton, I Busmanis, Am J Dermatopathol. 15Cominos D, Strutton G, Busmanis I (1993) Granulomas associated with tetanus toxoid immunization. Am J Dermatopathol 15:114-117

Unexpectedly high incidence of persistent itching nodules and delayed hypersensitivity to aluminium in children after the use of adsorbed vaccines from a single manufacturer. E Bergfors, B Trollfors, A Inerot, Vaccine. 22Bergfors E, Trollfors B, Inerot A (2003) Unexpectedly high incidence of persistent itching nodules and delayed hypersensitivity to aluminium in children after the use of adsorbed vaccines from a single manufacturer. Vaccine 22:64-69

Nineteen cases of persistent pruritic nodules and contact allergy to aluminium after injection of commonly used aluminium-adsorbed vaccines. E Bergfors, C Björkelund, B Trollfors, Eur J Pediatr. 164Bergfors E, Björkelund C, Trollfors B (2005) Nineteen cases of persistent pruritic nodules and contact allergy to aluminium after injection of com- monly used aluminium-adsorbed vaccines. Eur J Pediatr 164:691-697

Sixty-four children with persistent itching nodules and contact allergy to aluminium after vaccination with aluminium-adsorbed vaccines-prognosis and outcome after booster vaccination. E Bergfors, B Trollfors, Eur J Pediatr. 172Bergfors E, Trollfors B (2013) Sixty-four children with persistent itch- ing nodules and contact allergy to aluminium after vaccination with aluminium-adsorbed vaccines-prognosis and outcome after booster vaccination. Eur J Pediatr 172:171-177

Persistent nodules at injection sites (aluminium granuloma)-clinicopathological study of 14 cases with a diverse range of histological reaction patterns. H Chong, K Brady, D Metze, E Calonje, Histopathology. 482Chong H, Brady K, Metze D, Calonje E (2006) Persistent nodules at injec- tion sites (aluminium granuloma)-clinicopathological study of 14 cases with a diverse range of histological reaction patterns. Histopathology 48(2):182-188

A tumour in the breast: vaccination granuloma as a differential diagnosis. N N Al-Suliman, D A Grabau, H Kiaer, Eur J Surg Oncol. 25Al-Suliman NN, Grabau DA, Kiaer H et al (1999) A tumour in the breast: vaccination granuloma as a differential diagnosis. Eur J Surg Oncol 25:34-37

A child with a longstanding, intensely itching subcutaneous nodule on a thigh: an uncommon (?) reaction to commonly used vaccines. E Bergfors, K Lundmark, Nyström Kronander, 10.1136/bcr2012007779doi:10.1136/ bcr2012007779BMJ Case Rep. Bergfors E, Lundmark K, Nyström Kronander U (2013) A child with a long- standing, intensely itching subcutaneous nodule on a thigh: an uncom- mon (?) reaction to commonly used vaccines. BMJ Case Rep. doi:10.1136/ bcr2012007779

Aspects of pertussis, pertussis vaccination and adverse events associated with aluminium adsorbed vaccines. Dissertation, Department of Primary Health Care. E Bergfors, 9162867148Göteborg UniversityBergfors E (2006) Aspects of pertussis, pertussis vaccination and adverse events associated with aluminium adsorbed vaccines. Disserta- tion, Department of Primary Health Care, Göteborg University. ISBN: 9162867148

Unexpected loss of contact allergy to aluminium induced by vaccine. Gente Lidholm, A Bergfors, E Inerot, A Trollfors, B , Contact Dermat. 68Gente Lidholm A, Bergfors E, Inerot A, Trollfors B et al (2013) Unexpected loss of contact allergy to aluminium induced by vaccine. Contact Dermat 68:286-292


BMC Family Practice Length of patient-physician relationship and patients' satisfaction and preventive service use in the rural south: a cross-sectional telephone study

Katrina E Donahue firstname.lastname@example.com
Department of Family Medicine
University of North Carolina at Chapel Hill
Chapel Hill

North Carolina
27599USA

Evan Ashkin email@example.com
Department of Family Medicine
University of North Carolina at Chapel Hill
Chapel Hill

North Carolina
27599USA

Donald E Pathman
Department of Family Medicine
University of North Carolina at Chapel Hill
Chapel Hill

North Carolina
27599USA

Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Chapel Hill

North Carolina
27599USA

BMC Family Practice Length of patient-physician relationship and patients' satisfaction and preventive service use in the rural south: a cross-sectional telephone study
10.1186/1471-2296-6-40BioMed Central Page 1 of 8 (page number not for citation purposes) Research article * Corresponding author
Background: Physicians and patients highly value continuity in health care. Continuity can be measured in several ways but few studies have examined the specific association between the duration of the patient-doctor relationship and patient outcomes. This study (1) examines characteristics of rural adults who have had longer relationships with their physicians and (2) assesses if the length of relationship is associated with patients' satisfaction and likelihood of receiving recommended preventive services.Methods: Cross-sectional telephone survey of health care access indicators of adults in selected non-metropolitan counties of eight U.S. predominantly southern states. Analyses were restricted to adults who see a particular physician for their care and weighted for demographics and county sampling probabilities.Results:Of 3176 eligible respondents, 10.8% saw the same physician for the past 12 months, 11.8% for the previous 13-24 months, 20.7% for the past 25-60 months and 56.7% for more than 60 months. Compared to persons with one year or less continuity with the same physician, respondents with over five years continuity more often were Caucasian, insured, a high school graduate, and more often reported good to excellent health and an income above $25,000. Compared to those with more than five years of continuity, participants with either less than one year or one to two years of continuity with the same physician were more often not satisfied with their overall health care (OR 2.34; OR 1.78), participants with less than one year continuity were more often not satisfied with the concern shown them by their physician (O.R. 1.90) and having their health questions answered, and those with one to two years continuity were more often not satisfied with the quality of their care (OR 2.37). No significant associations were found between physician continuity and use rates of any of the queried preventive services.Conclusion: Over half of this rural population has seen the same physician for more than five years. Longer continuity of care was associated with greater patient satisfaction and confidence in one's physician, but not with a greater likelihood of receiving recommended preventive services.

Background

Both physicians and patients highly value continuity in healthcare [1,2]. The Institute of Medicine (IOM) holds that continuity, defined as an ongoing partnership between patients and physicians, is a central and important component of primary care [3]. Continuity fosters personal relationships and is believed to improve health outcomes, although the latter has been difficult to demonstrate formally.

Continuity has been measured in various ways with different associated outcomes. Concepts of continuity include having a usual place for healthcare, having a usual physician and actually having a greater proportion of one's visits with a particular physician [4][5][6]. Continuity reportedly increases use rates of some services, including some preventive services, and is associated with lower health care costs for certain populations [7][8][9][10][11][12]. However, continuity has shown no effect on the use of some particular preventive services, including Pap smears and mammograms [4,13]. Evidence for the relationship between continuity with hospitalization rates is conflicting [4,10,14,15]. Lack of continuity care is associated with fewer follow-up care visits and fewer medical prescriptions given for chronic illness [16]. Few studies, however, have examined outcomes for continuity as defined as having a longer standing relationship with one's physician [9,11]. The outcomes of this notion of continuity are less clearly known.

Elements of trust and satisfaction, important to the ongoing patient-physician relationship, are also important to examine in the context of continuity. Continuity over time allows physicians to get to know and better understand their patients [17] and is associated with greater trust [18]. In older patients, longer relationships are associated with the perception that their provider is more knowledgeable and thorough [11]. Considering these aspects of satisfaction may further the understanding of the benefits of a continuous health care relationship [19,20].

The purpose of this study is to examine the characteristics of rural adults who have longer versus shorter relationships with their current physicians. We also examine if the length of this relationship is associated with aspects of patient satisfaction and with the likelihood that patients have received recommended preventive services.

Methods

Study population

Cross-sectional data were obtained from a telephone survey of adults in the rural U.S. Southeast. The survey was conducted as part of an evaluation of the Southern Rural Access Program (SRAP), an initiative to improve access to health care in targeted rural areas of eight U.S. states: Ala-bama, Arkansas, Georgia, Louisiana, Mississippi, South Carolina, Texas and West Virginia [21]. Professional Research Consultants, Inc. of Omaha, Nebraska (PRC), a survey research firm, fielded the telephone survey with 4,879 adult respondents living in 150 non-metropolitan counties of these eight states from October 2002 to July 2003. PRC administered the survey using a computerassisted telephone interview (CATI) system with randomly generated numbers within telephone exchanges and active number blocks within each county. Eligible adults included those age 18 and older who had lived in the immediate area for at least 12 months and spoke English or Spanish; a minimum of 10 attempts were made to contact someone at each number. After a number was contacted and confirmed to be a household, a specific adult to be interviewed was randomly selected from among the eligible adults in that household using the next birthday method of identification [22]. The overall participation rate was 51.0% (4879 participants and 4682 refusals). The study protocol was reviewed and exempted by the University of North Carolina School of Medicine's Committee on the Protection of Human Subjects Research.

Eligibility

Participants were asked, "Is there a place that you usually go to when you are sick or need advice about your health?", if they saw a particular person there for their care and how long that person had been their doctor. Of the 4879 respondents, 4367 (89.5%) reported a usual place of care, 3402 (69.7%) saw a particular person for their care and 3197 (65.5%) stated that person was a doctor.

Subjects' were asked 'How long has this person been your doctor?' and asked to respond in one of four duration categories: previous year (0-12 months), the past one to two years (13-24 months), the past three to five years (25-60 months) and more than 5 years (61 months or more). Of the 3197 eligible subjects, 3176 (99.3%) responded to this question and served as the population for this study.

Satisfaction questions

Several satisfaction questions were included in the questionnaire based on previous national and regional surveys and a published study [23][24][25]; responses were provided on five-point Likert scales with a neutral middle option offered. Participants were asked how satisfied they were with their overall health care and with the quality of care they usually received. Participants were also asked how satisfied they were with having their health questions answered during care visits and how welcome and comfortable they were made to feel by the office staff. In addition, participants were asked how satisfied they were with the concern shown for them by their doctor and how confident they were in the abilities of their doctor to help them.

Preventive service questions

Respondents who reported they had a 'routine medical checkup' in the past year were asked several questions pertaining to the preventive services they had received. They were asked how long it had been since they last had a mammogram, Pap smear, flexible sigmoidoscopy/colonoscopy, influenza vaccine and cholesterol level check. They were also asked if they were counseled about tobacco use (if a smoker), physical activity/exercise and nutrition/ diet in the previous 12-months.

Analysis

Participants were sorted into four groups based on the number of years they had received care from the same physician: less than a year, one to two years, three to five years and more than five years. Chi-square tests were used to compare the demographic, satisfaction and preventive health care characteristics of each group of years of continuous care to the group with over five-years of care.

Logistic regression was performed to assess the relationship of continuity to the outcomes of satisfaction and preventive service use rates. Dummy variables were constructed for the years subjects had received care from their primary source of care, with more than five years of care as the omitted (comparison) category. Models for each outcome were adjusted for subject age, gender, race, income, health insurance status and self-reported general health status.

For all analyses STATA 8 (College Station, Texas) [27] was used. When respondent demographics were compared against the 2000 U.S. Census data, survey participation rates were found to be lower for males, persons 18-39 years of age, African-Americans, and those with household incomes below $15,000. Analyses were accordingly weighted to adjust for both the over-sampling in small counties and to correct differential response likelihood by demographic groups.

Results

Among the 3176 persons identifying a particular physician from whom they received their health care, 10.8% (N = 319) had seen the same individual for the past year, 11.8% (N = 369) for the past one to two years, 20.7% (N = 669) for the past three to five years and 56.7% (1819) had seen the same physician for more than five years. Associations between sociodemographic characteristics and duration of care are shown in Table 1. Compared to persons with one year or less continuity with the same physician, respondents with more than five years continuity were more often Caucasian (66.9% versus 61.5%, p = 0.007), more often had insurance (77.3% versus 68.5%, p = 0.001), had more education (43.6% versus 37.5% had at least some college, p = 0.006), more often had an income $25,000 or more (62.4% versus 45.6%, p < 0.001) and more often reported good to excellent health (76.0% versus 66.2%, p < 0.001). Respondents with more than five years continuity also more often had an income higher then $25,000 (62.4%) than the groups reporting only one to two years of continuity (50.1%, p < 0.001) and three to five years continuity (57.6%, p = 0.035). Otherwise, the one to two-year, three to five-year and over five-year continuity groups did not differ in their characteristics.

In terms of putative outcomes of continuity, compared to those with more than five years continuity, more respondents with one year or less of continuity reported being neutral or dissatisfied with their overall health care (10.6% versus 4.5%, p < 0.001), with the quality of their health care (6.7% versus 3.3%, p = 0.022) with having their health questions answered (7.2% versus 3.8%, p = 0.021) and with the concerns shown to them by their physicians (7.0% versus 3.4%, p = 0.004) ( Table 2). A higher proportion of persons with one year or less continuity were also neutral or not confident in the abilities of their physician to help them than those with more than five years of continuity (20.1% versus 14.5%, p = 0.035). There were no significant differences in rates of any of the preventive services, except those who reported seeing a physician for one year or less were more likely to report being counseled in nutrition over the past year (57.8% versus 48.1%, p = 0.008).

Controlling for age, gender, race, income, insurance and health status, participants with one year or less and one to two years of continuity with their physician remained more likely to be neutral or dissatisfied with their overall health care compared to those with more than 5 years of continuity (OR 2.34; 95% CI: 1.39-3.93 and OR 1.78; 95% CI: 1.04-3.06, respectively) ( Table 3). Those with one to two years of continuity were also more likely to be neutral or dissatisfied with the quality of health care they usually received (OR 2.37; 95% CI: 1. 35-4.15). Those with one year or less continuity were also more likely to be neutral or dissatisfied with the concern shown by their physician (OR 1.90; 95% CI: 1.12-3.23) and having their questions answered (OR 1.98; 95% CI: 1.10-3.57). There were no significant differences across groups with various lengths of relationships with their physicians and their confidence in their physician, feeling welcome by office staff, reported rates of counseling for smoking and physical activity and receipt of preventive services (Table 4). Persons with shorter periods of continuity were more likely, however, to report having received nutrition counseling in the past year (OR 1.47; 95% CI: 1.08-2.02).

Discussion

Continuity can be measured in a number of ways. When measured as the length of the patient-physician relationship, we find continuity varies with patient demographics and with elements of satisfaction. Over half of adults of this study's 150 rural communities report seeing the same physician for more than five years. Those who saw the same physician for less than five years tended to be nonwhite, without health insurance, less educated, more often report income of less than $25,000 and more often report fair to poor health status. This group was also less likely to be satisfied with their overall health care and its quality and with components of the doctor-patient relationship. Patients and their physicians value continuity [28][29][30][31]; in this study of rural participants, satisfaction appears associated with length of the continuity relationship, as similarly noted in other studies [11,18,32]. The elements of greater satisfaction found in persons with longer relationships with their physicians lend credence to the importance of the continuity relationship to patient outcomes. However, in this study, there appears to be a threshold effect at one or two years of continuity beyond which satisfaction does not rise significantly further.

Even a relationship length of two years is becoming difficult to maintain in the current U.S. healthcare system, especially in urban areas, with the pressures of competitive managed care plans which encourage patients and their employers to change health plans, and the growth of urgent care centers [33]. In the 1996-97 Community Tracking Study household survey, 17% of privately insured persons changed their health plan during the year prior to the survey [34]. Of those changing health plans, a little over half cited changes in their insurance as the reason for also changing their source of care. Increases in insurance premiums could contribute to further health provider switching.

Satisfaction, as an indicator of quality of care [28], has been found to affect other outcomes, including patient adherence to their physicians' recommendations [35].

Mothers are more likely to follow a physician's treatment recommendations for their child if she feels the physician is friendly and understands the complaint [36]. Patients with hypertension are more likely to adhere to treatment and have their blood pressure under control when the physician considers the patient an active participant in treatment [37].

Previous studies note the importance of having a usual source of care versus no source to the timely receipt of preventive services for younger adults [38,39]. However no differences in preventive care services were observed for older Americans in long-term relationships [9]. In our study preventive services outcomes did not differ significantly by length of continuity as well. For preventive services, it appears that having a usual source of care is important but no additional benefit comes with having a longer-term relationship with that source of care.

Respondents with one year or less continuity, interestingly, were more likely to report receiving nutrition coun- Table 4: Adjusted relationships between receipt of preventive service variables and years of care from the same physician: logistic regression results: Statistical comparisons to group with more than 5 years of continuity seling than those in the five-year or more continuity category. Possibly more patients are asking about nutrition issues in the first year or are specifically changing doctors to discuss nutrition. Another possibility is that the developing familiarity with the patient in a long term relationship may be associated with less vigilance by the physician or less counseling in areas in which the patient may have initially shown resistance [40].

Limitations

The cross-sectional design of this study limits our ability to attribute causation to the statistical relationships demonstrated or know the directions of any causal connections. We do not know if continuity results in higher trust and satisfaction or if the opposite is true. Our data are limited in that the outcomes of having received counseling and other preventive services were self-reported and may not accurately reflect care patients received. Telephone surveys also limit the population to those persons with a working phone, although weighting upwards for households with low incomes and minorities partially adjusts for this. The survey response rate of 51% was moderate but similar to other U.S. national telephone surveys [41]. Response bias is a possibility. This study addressed a rural population statistically representative of the U.S. rural South, thus its findings may not apply to urban and other regions of the U.S. or to other countries. However, we know of no reason to expect that the association between longer-term doctor-patient relationships and satisfaction differs elsewhere.

Conclusion

Over half of this rural population has seen the same physician for more than five years. Longer continuity was significantly related to aspects of the patient-physician relationship, specifically people's satisfaction with and confidence in their physicians, but not with one's likelihood of receiving recommended preventive services. Fostering long-term relationships between patients and their physicians may help promote the outcome of greater patient satisfaction with care.

Standards of appropriate preventive services were adapted from the conservative recommendations of the US Preventive Services Task Force [26]: (1) mammogram in adult women 50-69 years old in the past year, (2) Pap smear in women 18-64 years old in the past three years, (3) flexible sigmoidoscopy or colonoscopy in people 50 and older ever (at least one), (4) influenza vaccine in people 65 and older in the past year and (5) cholesterol level check in persons 45 years and older in the past five years. Counseling variables included if a doctor or nurse: (1) advised a smoker to quit or stop using tobacco in the past year, (2) had given the participant advice about diet and nutrition in the past year, and (3) had given the participant advice about physical activity or exercise in the past year.

Table 1 :
1Characteristics of subjects who have received care from the same physician for ≤ 1 year, >1 to 2 years, >2 to 5 years, and more than 5 years: Statistical comparisons to group with more than 5 years of continuity *P < 0.05 difference for each group with >5 years continuity **P < 0.01 difference for each group with >5 years continuity ***P < or = 0.001 difference for each group with >5 years continuityPatient Characteristics
%≤ 1 yr
(0-12 mo)
N = 319

% 1-2 yrs
(13-24 mo)
N = 369

% 3-5 yrs
(25-60 mo)
N = 669

%>5 yrs
(61 mos or more)
N = 1819

Age
18-39
35.8
38.4
36.9
33.0
40-64
42.3
38.3
44.4
44.3
65+
21.9
23.2
18.7
22.7

Gender
Male
42.1
44.5
42.3
45.2
Female
57.9
55.5
57.6
54.8

Race/Ethnicity
**
White, Non Hispanic
61.5
67.5
61.6
66.9
White, Hispanic
3.3
0.5
1.1
1.0
Black
33.5
29.5
33.2
29.3
Other
1.7
2.5
4.1
2.7

Insurance
***
Yes
68.5
72.9
77.7
77.3
No
31.5
27.1
22.2
22.7

Education
**
Less than high school
26.2
17.8
19.4
18.0
High school diploma
29.3
32.7
30.1
30.4
Trade school
7.1
8.1
8.1
8.0
Some College or more
37.5
41.4
42.4
43.6

Income
***
***
*
< $25,000
54.4
50.0
42.4
37.6
≥ $25,000
45.6
50.1
57.6
62.4

General health
***
Good to Excellent
66.2
72.7
73.1
76.0
Fair to Poor
33.8
27.3
26.9
24.2

Table 2 :
2Association between preventive services and lack of satisfaction with number of years of care from the same physician: Statistical comparisons to group with more than 5 years of continuityOutcomes
Total Sample
N = 3176

%≤ 1 yr
(0-12 mo)
N = 319

% 1-2 yrs
(12-24 mo)
N = 369

% 3-5 yrs
(25-60 mo)
N = 669

%>5 yrs
(61 mos or more)
N = 1819

Lack of Satisfaction

% Neutral or dissatisfied with overall health care
N = 3150
10.6***
7.7*
3.8
4.5
% Neutral or dissatisfied with quality of health care
N = 3156
6.7*
7.3**
3.5
3.3
% Neutral or not confident in physician
N = 3156
20.1*
15.4
16.6
14.5
% Neutral or dissatisfied with concern shown by physician
N = 3159
7.0**
4.8
5.3*
3.4
% Neutral or dissatisfied with having questions answered
N = 3161
7.2*
5.3
4.4
3.8
% Felt neutral or not welcome and comfortable by staff
N = 3165
5.6
4.8
3.5
4.3

Preventive Services (only asked to those reporting a routine checkup in past year)

Mammogram within past year in women 50 and older
N = 1234
56.2
61.6
59.7
60.4
Pap smear in women 18-64 years old in past 3 years
N = 1579
89.0
89.3
90.7
88.0
Flu shot in persons 65 and older in past year
N = 720
62.0
64.9
72.0
69.5
Flexible sigmoidoscopy or colonoscopy in persons 50 and older N = 1756
46.6
52.3
50.5
50.5
Cholesterol in persons 45 and older
N = 2108
87.6
89.9
88.4
88.3
Smoking counseling in past year
N = 634
68.6
73.0
72.9
69.8
Physical activity counseling in past year
N = 2641
56.4
51.2
55.6
51.2
Nutrition counseling in past year
N = 2632
57.8*
47.5
54.6*
48.1

*P < 0.05 difference for each group with >5 years continuity
**P < 0.01 difference for each group with >5 years continuity
***P <0.001 difference for each group with >5 years continuity

Table 3 :
3Adjusted relationships between lack of satisfaction and years of care from the same physician: logistic regression results*:Statistical comparisons to group with more than 5 years of continuity

Lack of Satisfaction
%≤1 yr care
OR (95% CI)

% 1-2 yrs care
OR (95% CI)

% 3-5 yrs care
OR (95% CI)

% Neutral or dissatisfied with overall health care
2.34
1.78
0.81
(1.39-3.93)
(1.04-3.06)
(0.50-1.32)
p = 0.001
p = 0.04
p = 0.40
% Neutral or dissatisfied with quality of health care
1.87
2.37
1.05
(0.98-3.60)
(1.35-4.15)
(0.56-1.97)
p = 0.058
p = 0.003
p = 0.87
% Neutral or not confident in physician
1.36
1.07
1.11
(0.94-1.98)
(0.77-1.50)
(0.83-1.49)
p = 0.10
p = 0.65
p = 0.47
% Neutral or dissatisfied with concern shown by physician
1.90
1.42
1.37
(1.12-3.23)
(0.74-2.76)
(0.83-2.27)
p = 0.02
p = 0.29
p = 0.21
% Neutral or dissatisfied with having questions answered
1.98
1.55
1.18
(1.10-3.57)
(0.81-2.94)
(0.70-2.00)
p = 0.02
p = 0.18
p = 0.52
% Felt neutral or not welcome and comfortable by staff
1.28
1.14
0.77
(0.66-2.52)
(0.60-2.15)
(0.48-1.23)
p = 0.46
p = 0.69
p = 0.27

*Adjusted for age, gender, race, income ≥ 25,000, health insurance status, and health status. Statistical comparisons to group with more than 5 years

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AcknowledgementsThis work was supported by the Robert Wood Johnson Foundation Grant #036829. We acknowledge the thoughtful reviews and input given to us by the fellows and faculty of the UNC-Chapel Hill Southern Rural Access Program writers group. This work was presented at the Academy Health Annual Research Meeting, June 2004, San Diego, California.Competing interestsThe author(s) declare that they have no competing interests.Authors' contributionsKD conceived and designed the study, performed the analyses, and drafted the manuscript. EA participated in the design, interpretation and helped draft the manuscript. DP participated in the design, analyses and critical review of the manuscript. All authors read and approved the final manuscript.Publish with Bio Med Central and every scientist can read your work free of chargePre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/6/40/prepub
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