Andrea L Benin

Publications (15)63.72 Total impact

• Article: Postpartum Mothers’ Attitudes, Knowledge, and Trust Regarding Vaccination

  Ann Chen Wu, Daryl J. Wisler-Sher, Katherine Griswold, Eve Colson, Eugene D. Shapiro, Eric S. Holmboe, Andrea L. Benin
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  ABSTRACT: Objective To examine attitudes and knowledge about vaccinations in postpartum mothers. Methods This cross-sectional study collected data via written survey to postpartum mothers in a large teaching hospital in Connecticut. We used multivariable analysis to identify mothers who were less trusting with regard to vaccines. Results Of 228 mothers who participated in the study, 29% of mothers worried about vaccinating their infants: 23% were worried the vaccines would not work, 11% were worried the doctor would give the wrong vaccine, and 8% worried that “they” are experimenting when they give vaccines. Mothers reported that the most important reasons to vaccinate were to prevent disease in the baby (74%) and in society (11%). Knowledge about vaccination was poor; e.g., 33% correctly matched chicken pox with varicella vaccine. Mothers who were planning to breastfeed (P=.01), were primiparous (P=.01), or had an income <$40,000 but did not receive support from the women, infants, and children (WIC) program were less trusting with regard to vaccines (P=.03). Although 70% wanted information about vaccines during pregnancy, only 18% reported receiving such information during prenatal care. Conclusion Although the majority of infants receive vaccines, their mothers have concerns and would like to receive immunization information earlier. Mothers who are primiparous, have low family incomes but do not qualify for the WIC program, or are breastfeeding may need special attention to develop a trusting relationship around vaccination. Mothers would benefit from additional knowledge regarding the risks and benefits of vaccines particularly during prenatal care.
  Maternal and Child Health Journal 04/2012; 12(6):766-773. · 2.24 Impact Factor
• Article: How good are the data? Feasible approach to validation of metrics of quality derived from an outpatient electronic health record.

  Andrea L Benin, Ada Fenick, Jeph Herrin, Grace Vitkauskas, John Chen, Cynthia Brandt
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  ABSTRACT: Although electronic health records (EHRs) promise to be efficient resources for measuring metrics of quality, they are not designed for such population-based analyses. Thus, extracting meaningful clinical data from them is not straightforward. To avoid poorly executed measurements, standardized methods to measure and to validate metrics of quality are needed. This study provides and evaluates a use case for a generally applicable approach to validating quality metrics measured electronically from EHR-based data. The authors iteratively refined and validated 4 outpatient quality metrics and classified errors in measurement. Multiple iterations of validation and measurement resulted in high levels of sensitivity and agreement versus the "gold standard" of manual review. In contrast, substantial differences remained for measurement based on coded billing data. Measuring quality metrics using an EHR-based electronic process requires validation to ensure accuracy; approaches to validation such as those described in this study should be used by organizations measuring quality from EHR-based information.
  American Journal of Medical Quality 09/2011; 26(6):441-51. · 1.64 Impact Factor
• Article: Secure web messaging in a pediatric chronic care clinic: a slow takeoff of "kids' airmail".

  Allen L Hsiao, Alia Bazzy-Asaad, Concettina Tolomeo, Diana Edmonds, Beverly Belton, Andrea L Benin
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  ABSTRACT: Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care. Impact and usability of these secure systems have not been broadly assessed. To evaluate the impact of a secure electronic messaging system implemented for a pediatric subspecialty clinic. This study was performed in an outpatient, academic pediatric respiratory clinic in spring 2009 in New Haven, Connecticut. Patients were surveyed prior to implementation regarding internet usage. The Kryptiq messaging system was implemented and messages were monitored continuously and tracked. Open-ended qualitative interviews with 28 users and nonusers were conducted, and we described the process of implementation. All of the 127 patients/families surveyed expressed interest in using the Internet to contact their clinic providers, and they all reported having the ability to access the Internet. In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2363 phone calls. Themes emerged from the open-ended interviews that indicated promoters, barriers, and potential uses. Prominent barriers included the lack of convenience and personal touch and being technically difficult to use. Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.
  PEDIATRICS 02/2011; 127(2):e406-13. · 4.47 Impact Factor
• Article: How can we communicate about vaccines with adolescents and their parents?

  Andrea L Benin, Ann C Wu, Eric S Holmboe, Eugene D Shapiro, Walter Anyan
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  ABSTRACT: To describe parents' and adolescents' perceptions about vaccination. Qualitative interviews of 22 mothers/grandmothers and 25 10- to 14-year-olds. Themes emerged in 3 focus areas. (a) Understanding: Both adults and adolescents had difficulty understanding concepts of risks, benefits, prevention, and vaccination. (b) Decision making: Adults saw vaccination as an opportunity to help their adolescent develop skills for transition to adulthood. Adolescents worried about being lied to (reinforced by being told "it won't hurt"), physical pain, and cleanliness. ( c) Preventing sexually transmitted infections: Adults were divided between those who felt their child would not need such a vaccine and those who wanted to "be safe" to protect their child in the future. At the same time that even basic concepts about vaccination should be explained to both adults and adolescents, adolescence represents a time for learning about responsible decision making. Discussion regarding the risks and benefits of vaccines can be part of transitioning to adult decision making.
  Clinical Pediatrics 04/2010; 49(4):373-80. · 1.15 Impact Factor
• Article: Risk factors for invasive pneumococcal disease among Navajo adults.

  James P Watt, Katherine L O'Brien, Andrea L Benin, Sandra I McCoy, Connie M Donaldson, Raymond Reid, Anne Schuchat, Elizabeth R Zell, Michael Hochman, Mathuram Santosham, Cynthia G Whitney
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  ABSTRACT: Invasive pneumococcal disease (IPD) is 3-5 times more common among Navajo adults than in the general US population. The authors conducted a case-control study to identify risk factors for IPD among Navajo adults. Navajos aged > or =18 years with IPD were identified through prospective, population-based active laboratory surveillance (December 1999-February 2002). Controls matched to cases on age, gender, and neighborhood were selected. Risk factors were identified through structured interviews and medical record reviews. The authors conducted a matched analysis based on 118 cases and 353 controls. Risk factors included in the final multivariable analysis were chronic renal failure (odds ratio (OR) = 2.6, 95% confidence interval (CI): 0.9, 7.7), congestive heart failure (OR = 5.6, 95% CI: 2.2, 14.5), self-reported alcohol use or alcoholism (OR = 2.9, 95% CI: 1.5, 5.4), body mass index (weight (kg)/height (m)(2)) <5th (OR = 3.2, 95% CI: 1.0, 10.6) or >95th (OR = 2.8, 95% CI: 1.0, 8.0) percentile, and unemployment (OR = 2.6, 95% CI: 1.2, 5.5). The population attributable fractions were 10% for chronic renal failure, 18% for congestive heart failure, 30% for self-reported alcohol use or alcoholism, 6% for body mass index, and 20% for unemployment. Several modifiable risk factors for IPD in Navajos were identified. The high prevalence of renal failure, alcoholism, and unemployment among Navajo adults compared with the general US population may explain some of their increased risk of IPD.
  American Journal of Epidemiology 11/2007; 166(9):1080-7. · 5.22 Impact Factor
• Article: Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust.

  Andrea L Benin, Daryl J Wisler-Scher, Eve Colson, Eugene D Shapiro, Eric S Holmboe
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  ABSTRACT: The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants. The purpose of this research was to investigate decision-making about vaccinations for infants. We conducted qualitative, open-ended interviews. Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months. We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated ("vaccinators," n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate ("nonvaccinators," n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician's discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk. Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.
  PEDIATRICS 06/2006; 117(5):1532-41. · 4.47 Impact Factor
• Article: Validity of using an electronic medical record for assessing quality of care in an outpatient setting.

  Andrea L Benin, Grace Vitkauskas, Elizabeth Thornquist, Eugene D Shapiro, John Concato, Mihaela Aslan, Harlan M Krumholz
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  ABSTRACT: We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS). For children ages 3-18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines. Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001). The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data.
  Medical Care 08/2005; 43(7):691-8. · 3.41 Impact Factor
• Article: Validation of a system for quality improvement: preliminary data.

  Andrea L Benin, Harlan M Krumholz, Eugene D Shapiro, Cynthia Brandt
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  ABSTRACT: Electronic Health Records (EHRs) are designed for patient-centered care and not for cross-patient analyses. Thus to ensure that measurements of quality of care derived from data extracted from EHRs are meaningful, they must be validated.1 We present preliminary data regarding validation of measurements of quality of care in a pediatric clinic.
  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 02/2005;
• Article: Invasive pneumococcal disease among Navajo adults, 1989-1998.

  James P Watt, Katherine L O'Brien, Andrea L Benin, Cynthia G Whitney, Katherine Robinson, Alan J Parkinson, Raymond Reid, Mathuram Santosham
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  ABSTRACT: Compared with white and black persons in the United States, some Native American groups are at increased risk for invasive pneumococcal disease (IPD). To characterize the epidemiology of IPD among Navajo adults, we conducted active surveillance for IPD on the Navajo Nation and reviewed medical records of patients with IPD. For 1997-1998, the annual incidence (cases per 100,000 persons) was 56 for Navajos aged 18-64 years and 190 for Navajos aged > or =65 years. The corresponding rates were 10 and 57 for white and 44 and 82 for black persons in the United States. The case-fatality rate was 14%. Eighty percent of cases were caused by serotypes included in the 23-valent pneumococcal polysaccharide vaccine. Navajo adults have rates of IPD that are 3-5-fold higher than those of the general US population. Additional research is needed to understand the reasons for this elevated risk and to develop prevention strategies.
  Clinical Infectious Diseases 03/2004; 38(4):496-501. · 9.15 Impact Factor
• Article: Reasons physicians accepted or declined smallpox vaccine, February through April, 2003.

  Andrea L Benin, Louise Dembry, Eugene D Shapiro, Eric S Holmboe
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  ABSTRACT: From February to April 2003, we performed an e-mail-based survey to assess responses of physicians at Yale University to being offered smallpox vaccine. Of 58 respondents, 3 (5%) had been or intended to be vaccinated. Reasons cited for declining vaccination included: belief that benefits did not outweigh risks (55%), belief that the vaccination program was unnecessary (18%), desire to wait and see what side effects occurred in vaccinees (11%), and worries about compensation or liability (7%). Most (94%) considered risks to themselves, family, or patients in their decision. Only 3% thought a smallpox attack in the next 5 years was likely or very likely. Physicians did not accept the smallpox vaccine because they did not believe the potential benefits were sufficient.
  Journal of General Internal Medicine 02/2004; 19(1):85-9. · 2.83 Impact Factor
• Article: Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a useful role for the electronic medical record.

  Andrea L Benin, Grace Vitkauskas, Elizabeth Thornquist, Richard N Shiffman, John Concato, Harlan M Krumholz, Eugene D Shapiro
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  ABSTRACT: Because of rising resistance to antibiotics, appropriate use of antibiotics is an important measure of quality of care. The purpose of this study was to use an electronic medical record (EMR) to assess use of diagnostic testing and of antibiotics for pharyngitis in a pediatric outpatient setting and to target areas for improvement. Using data retrieved from the EMR, we analyzed visits from March 1, 2001 to February 28, 2002 for children 3 to 18 years old diagnosed with pharyngitis. We determined the proportion of episodes with a diagnostic test for group A streptococci, the proportion for which a prescription for an antibiotic was dispensed and factors that predicted prescribing and testing. Of 391 episodes of pharyngitis, a test was ordered for 303 (78%). Antibiotics were prescribed for 90 (23%); for 76 of 90 (84%) a test was ordered. Clinicians were less likely to order tests late in the week [relative risk (RR), 0.76; 95% confidence interval (CI), 0.66, 0.87)], more likely to order tests for patients with an exudate (RR 1.2; 95% CI 1.1, 1.3) and more likely to prescribe an antibiotic for patients with an exudate (RR 1.5; 95% CI 1.1, 2.1). When prescribing an antibiotic clinicians were less likely to order tests late in the week (RR 0.1; 95% CI 0.02, 0.5) and for patients diagnosed with scarlet fever (RR 0.07; 95% CI 0.01, 0.4). Using data from the EMR, we could assess adherence to the guidelines for antibiotic use and identify areas to target for improving diagnostic testing and reducing overuse of antibiotics in our clinic.
  The Pediatric Infectious Disease Journal 01/2004; 22(12):1043-7. · 3.58 Impact Factor
• Article: Effectiveness of the 23-valent polysaccharide vaccine against invasive pneumococcal disease in Navajo adults.

  Andrea L Benin, Katherine L O'Brien, James P Watt, Raymond Reid, Elizabeth R Zell, Scott Katz, Connie Donaldson, Alan Parkinson, Anne Schuchat, Mathuram Santosham, Cynthia G Whitney
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  ABSTRACT: Invasive pneumococcal disease occurs 2-3-fold more often among Navajo adults than among adults in the general United States population. The objective of this observational study was to determine the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) among Navajo adults. Active surveillance identified cases of invasive pneumococcal disease during 1996-1997. Three control patients per case patient were matched according to underlying medical conditions, sex, age, and location of medical care. Effectiveness was calculated by regression analysis of case-control sets and by indirect cohort methodology. Diabetes and alcoholism occurred in 41% and 43% of 108 case patients, respectively; 62% of case patients and 64% of control patients were immunized. Overall vaccine effectiveness was 26% (95% confidence interval [CI], -29% to 58%); 15% (95% CI, -116% to 67%) for patients with diabetes and -5% (95% CI, -141% to 54%) for patients with alcoholism. Overall vaccine effectiveness, as determined by use of the indirect cohort methodology, was 35% (95% CI, -33% to 69%). PPV23 was not significantly effective among Navajo adults and may be inadequate to prevent serious pneumococcal disease in this population.
  The Journal of Infectious Diseases 08/2003; 188(1):81-9. · 6.41 Impact Factor
• Article: Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis.

  Andrea L Benin, Robert F Benson, Richard E Besser
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  ABSTRACT: New diagnostic tests and empirical therapy for pneumonia may have important ramifications for the identification, treatment, and control of legionnaires disease (LD). To determine trends in the epidemiology of LD, we analyzed data for 1980-1998 from the passive surveillance system of the Centers for Disease Control and Prevention. During this time period, there were 6757 confirmed cases of LD (median annual number, 360 cases/year). Diagnosis by culture and by direct fluorescent antibody and serologic testing decreased significantly; diagnosis by urine antigen testing increased from 0% to 69%. The frequency of isolates other than Legionella pneumophila serogroup 1 (LP1) decreased from 38% to 4% (P=.003). The case-fatality rate decreased significantly, from 34% to 12% (P<.001) for all cases, from 46% to 14% (P<.0001) for nosocomial cases, and from 26% to 10% (P=.05) for community-acquired cases. LD-related mortality has decreased dramatically. The decrease in culture-based diagnosis limits the recognition of non-LP1 disease and impairs outbreak investigation, because fewer Legionella isolates are provided for further examination.
  Clinical Infectious Diseases 11/2002; 35(9):1039-46. · 9.15 Impact Factor
• Article: An outbreak of travel-associated Legionnaires disease and Pontiac fever: the need for enhanced surveillance of travel-associated legionellosis in the United States.

  Andrea L Benin, Robert F Benson, Kathryn E Arnold, Anthony E Fiore, Patricia G Cook, L Keoki Williams, Barry Fields, Richard E Besser
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  ABSTRACT: Travel-associated outbreaks of legionnaires disease (LD) and combined outbreaks of LD and Pontiac fever (PF) are rarely identified. During one travel-associated combined outbreak at a hotel, a cohort study of potentially exposed persons and an environmental investigation were performed. Two LD and 22 PF cases were identified. Legionella pneumophila serogroup 6 (Lp6) isolates from the index patient and the hotel whirlpool spa were found to be identical by amplified fragment-length polymorphism typing. Disease occurred in 10 of 26 guests who were exposed to the spa versus 2 of 29 guests who were exposed only to the pool area (38% vs. 7%; P=.005). Immunoglobulin M (IgM) antibody to the outbreak Lp6 strain was more common among persons with PF (4 of 9) than among non-ill persons (2 of 32) (44% vs. 6%; P=.02). Spa exposure correlated with disease (P=.001) and IgM seropositivity (P=.007). New laboratory techniques facilitate outbreak investigation; to expedite outbreak interruption and measure the impact of travel-associated legionellosis, surveillance must be improved.
  The Journal of Infectious Diseases 02/2002; 185(2):237-43. · 6.41 Impact Factor
• Article: Delivering pneumococcal vaccine to a high risk population: the Navajo experience.

  Andrea L Benin, James P Watt, Katherine L O'Brien, Raymond Reid, Elizabeth R Zell, Scott Katz, Connie Donaldson, Anne Schuchat, Mathuram Santosham, Cynthia G Whitney
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  ABSTRACT: High rates of preventable diseases such as pneumococcal disease occur among the Navajo despite their universal health insurance through the Indian Health Service. The objective of this study was to determine the proportion of Navajo adults vaccinated with pneumococcal polysaccharide vaccine and to examine key features of vaccination programs of the Navajo Indian Health Service. For this cross-sectional study, medical charts of Navajo patients with vaccine indications were randomly selected and reviewed to determine who had been vaccinated as of January 1, 1999. Among 480 Navajo>or=65 years old, 73% were vaccinated (95% confidence interval [CI]: 69%-77%). Among 111 Navajo 18-64 years old with vaccine indications, 54% were vaccinated (95% CI: 45% -63%). Vaccination programs utilized extensive public health nursing, home visits, standing orders, and "express lane" clinics. In spite of excellent delivery systems and universal healthcare, the proportion of Navajo persons vaccinated was still below the goals for Healthy People 2010 of having 90% of persons>or=65 years old vaccinated and 60% of high-risk persons 18-64 years old vaccinated.
  Human vaccines 1(2):66-9. · 3.58 Impact Factor