Simple and Elaborated Clinician Reminder Prompts for Human Papillomavirus Vaccination: A Randomized Clinical Trial

Assessment of COVID-19 Messaging Strategies to Increase Testing for Students With Intellectual and Developmental Disabilities

BACKGROUND

Students with intellectual and developmental disabilities (IDD) were disproportionately impacted by the COVID-19 pandemic. This study's goal was to assess the effectiveness of 2 messaging strategies on participation in SARS-CoV-2 weekly testing.

METHODS

Cluster randomized trials were conducted at 2 school systems, the special school district (SSD) and Kennedy Krieger Institute (Kennedy) to assess messaging strategies, general versus enhanced, to increase weekly screening for SARS-CoV-2. Testing was offered to staff and students from November 23, 2020 to May 26, 2022. The primary outcomes were percentage of students and staff consented weekly and percentage of study participants who had a test performed weekly. Generalized estimating equation models were utilized to evaluate the primary outcomes.

RESULTS

Increases in enrollment and testing occurred during study start up, the beginning of school years, and following surges in both systems. No statistical difference was observed in the primary outcomes between schools receiving standard versus enhanced messaging.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Frequent and consistent communication is vital for families and staff. Weekly screening testing within schools is possible and highlighted the importance of utilizing equitable protocols to provide important testing to students with IDD.

CONCLUSION

Enhanced messaging strategies did not increase the number of participants enrolled or the percentage of enrolled participants being tested on a weekly basis.

Clinician Prompts for Human Papillomavirus Vaccination: A Cluster Randomized Trial

OBJECTIVE

We assessed the impact of an online intervention using clinician prompts for human papillomavirus (HPV) vaccination with a cluster randomized controlled trial.

METHODS

The randomized trial occurred July 2021-January 2022 in 48 primary care pediatric practices (24 intervention, 24 control) across the US. We trained clinicians via two online learning modules, plus weekly ''quick tips'' delivered via text or email. The training taught practices to implement a staff prompt to the clinician (e.g., printed reminders placed on the keyboard) plus electronic health record (EHR) prompts (if not already done) at well and acute/chronic visits for initial and subsequent HPV vaccination. We assessed missed opportunities for HPV vaccination using logistic regression models accounting for clustering by practice on an intent to treat basis. Surveys assessed facilitators and barriers to using prompts.

RESULTS

During the 6-month intervention, missed opportunities for HPV vaccination increased (worsened) in both intervention and control groups. However, at well child care visits, missed opportunities for the initial HPV vaccine increased by 4.5 (95% CI: -9.0%, -0.1%) percentage points less in intervention versus control practices. Change in missed opportunities for subsequent doses at well child care and non-well child care visits did not differ between trial groups. An end-of trial survey found understaffing as a common challenge.

CONCLUSIONS

Clinician prompts reduced missed opportunities for HPV vaccination at well child care visits. Understaffing related to the COVID-19 pandemic may have led to worsening missed opportunities for both groups and likely impeded practices in fully implementing changes.

Urban and rural healthcare providers' perspectives on HPV vaccination in Minnesota

Human papillomavirus (HPV) vaccination can dramatically reduce the incidence of HPV-associated cancers. However, HPV vaccination coverage in rural areas is lower than in urban areas, and overall HPV vaccination coverage in the United States remains lower than other adolescent vaccines. We conducted 20 qualitative interviews with adolescent healthcare providers and clinic staff in urban and rural Minnesota and assessed their perspectives on HPV vaccination. Guiding interview topics included: strategies to persuade families to vaccinate their children, the impact of the patient-provider relationship and the clinical environment on vaccination uptake, and provider perceptions of parents' vaccine attitudes. In thematic analysis, all participants reported using common vaccination strategies, such as framing the HPV vaccine in terms of cancer prevention. The analysis also revealed three themes described as occurring uniquely or more intensely in rural communities than urban communities: the rural value of choice or independence, the spread of misinformation, and close-knit, multifaceted patient-provider relationships in clinical practice. Interventions aimed at increasing HPV vaccination should consider the distinctive circumstances of rural healthcare providers and patients.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Enhancing Hepatitis A and B Vaccinations Through Electronic Clinical Decision Support Systems and Staff Education in a Correctional Facility

BACKGROUND

Despite the prevalence and risks for hepatitis A virus (HAV) and hepatitis B virus (HBV) infection and the availability of safe and effective vaccines, HAV/HBV vaccinations are disproportionately low in jails. This quality improvement project evaluated the effectiveness of clinical decision support systems: electronic standing orders to nurses, clinical alerts to nurses and healthcare providers, and secondarily staff education in enhancing HAV and HBV vaccination and knowledge of hepatitis infection.

METHODS

We distributed a validated self-report hepatitis knowledge questionnaire (α = 0.7-0.8) before and after an educational presentation to nurses, nurse practitioners, and physicians ( N = 26) at a Northeastern state jail and then embedded electronic clinical alerts and standing orders in the electronic medical record. The questionnaire assessed pre- and posteducation knowledge scores. The number of vaccine status screenings and vaccinations was retrieved from the electronic medical record 3 months pre- and post-implementation. Descriptive statistics and the Wilcoxon signed-ranks test were used for data analysis.

RESULTS

Twenty-one participants completed the pretest, 18 attended the educational intervention, and 15 completed the posttest. Vaccine status screening increased by 97.5%, and HAV and HBV vaccinations increased by 8.7%. Knowledge scores improved significantly post-intervention ( p = 0.04), with an effect size of r = 0.67).

DISCUSSION/CONCLUSION

Using the Donabedian quality of care model, we showed that quality initiatives are feasible in a jail setting. Implementing a clinical decision support system and education improved the vaccination rate, which may decrease HAV/HBV incidence in the jail and prevent community spread.

Systematic review and meta-analysis comparing educational and reminder digital interventions for promoting HPV vaccination uptake

Global Human papillomavirus (HPV) vaccination rates remain low despite available WHO-approved vaccines. Digital interventions for promoting vaccination uptake offer a scalable and accessible solution to this issue. Here we report a systematic review and meta-analysis examining the efficacy of digital interventions, comparing educational and reminder approaches, for promoting HPV vaccination uptake (HVU). This study also identifies factors influencing the effectiveness of these interventions. We searched PubMed, PsycInfo, Web of Science, and the Cochrane Library from each database's inception to January 2023. Three raters independently evaluate the studies using a systematic and blinded method for resolving disagreements. From 1929 references, 34 unique studies (281,280 unique participants) have sufficient data. Client reminder (OR, 1.41; 95% CI, 1.23-1.63; P < 0.001), provider reminder (OR, 1.39; 95% CI, 1.11-1.75; P = 0.005), provider education (OR, 1.18; 95% CI, 1.05-1.34; P = 0.007), and client education plus reminder interventions (OR, 1.29; 95% CI, 1.04-1.59; P = 0.007) increase HVU, whereas client education interventions do not (OR, 1.08; 95% CI, 0.92-1.28; P = 0.35). Digital intervention effectiveness varies based on participants' gender and the digital platform used. Interventions targeting male or mixed-gender participants demonstrate greater benefit, and reminder platforms (SMS, preference reminders, or electronic health record alerts) are more effective in increasing HVU. Digital interventions, particularly client and provider reminders, along with provider education, prove significantly more effective than client education alone. Incorporating digital interventions into healthcare systems can effectively promote HPV vaccination uptake. Reminder interventions should be prioritized for promoting HVU.

Parent-reported Barriers and Parental Beliefs Associated with Intentions to Obtain HPV Vaccination for Children in a Primary care Patient Population in Minnesota, USA

Human papillomavirus (HPV) vaccine uptake among adolescents remains suboptimal in the US. The COVID-19 pandemic posed new challenges to increase HPV vaccination rates. To characterize parent-reported barriers to obtain HPV vaccination for their children and to identify psychosocial factors associated with parents' intention to vaccinate their children for HPV, we administered parent surveys between April 2020 and January 2022 during a randomized pragmatic trial assessing the impact of evidence-based implementation strategies on HPV vaccination rates for adolescent patients at six Mayo Clinic primary care practices in Southeast Minnesota. A total of 342 surveys were completed (response rate 34.1%). Analyses were focused on parents of unvaccinated children (n = 133). The survey assessed the main reason the child did not receive the HPV vaccine, parental beliefs about the vaccine, and the parent's intention to vaccinate the child for HPV in the next 12 months. Frequently reported awareness and access barriers to HPV vaccination included not knowing the child was due (17.8%) and COVID-19 related delay (11.6%). Frequently reported attitudinal barriers include the belief that the child was too young for the vaccine (17.8%) and that the vaccine is not proven to be safe (16.3%). Injunctive social norm (Adjusted-OR = 3.15, 95%CI: 1.94, 5.41) and perceived harm beliefs (Adjusted-OR = 0.58, 95%CI: 0.35, 0.94) about the HPV vaccine were positively and negatively associated with HPV vaccination intention, respectively. Our findings suggest that continued efforts to overcome parental awareness, access, and attitudinal barriers to HPV vaccination are needed and underscore the importance of utilizing evidence-based health system-level interventions.

The Effect of Clinical Decision Prompts in Improving Human Papillomavirus Vaccination Rates in a Multispecialty Practice in a Predominantly Hispanic Population: Quasi-Experimental Study

BACKGROUND

The human papillomavirus (HPV) is implicated in the causal pathway of cancers of the vulva, vagina, penis, cervix, anus, and oropharyngeal region. It is the most common sexually transmitted infection in the United States. Despite the documented safety and effectiveness of the HPV vaccine, rates lag behind those of other vaccines given at the same age.

OBJECTIVE

Provider recommendation is identified as a robust predictor of HPV vaccine uptake, and physician-prompting is shown to increase the provision of preventive care services in general. Theoretically, providing reminders to providers should increase opportunities for providing HPV vaccine recommendations and therefore affect vaccination rates. The objective of our study was to assess the effectiveness of an electronic medical record (EMR) prompt in improving HPV vaccination rates in an academic clinic setting caring for a predominantly Hispanic border population.

METHODS

We used a quasi-experimental design with a retrospective chart audit to evaluate the effect of a clinical decision prompt (CDP) on improving HPV immunization rates in different specialty settings. We introduced an EMR prompt to remind providers to recommend the HPV vaccine when seeing appropriate patients in an obstetrics and gynecology (OBGYN), pediatrics (PD), and family medicine (FM) clinic in a large multispecialty academic group located along the Texas-Mexico border. We assessed HPV vaccination rates in all the departments involved before and after introducing the prompts. Participants included male and female patients between the ages of 9 and 26 years, presenting at the clinics between January 2014 and December 2015.

RESULTS

We reviewed over 2800 charts in all 3 clinics. After adjusting for age, ethnicity, race, type of insurance, preferred language, and clinic, the odds of immunization were 92% (P<.001) higher in patients after the prompt implementation of the EMR. In addition, there was an overall statistically significant increase in the overall HPV vaccination completion rates after implementing the CDP (31.96% vs 21.22%; P<.001). Again, OBGYN saw the most significant improvement in vaccination completion rates, with rates at follow-up 66.02% higher than baseline rates (P=.04). PD and FM had somewhat similar but no less impressive improvements (57.7% and 58.36%; P<.001).

CONCLUSIONS

Implementing an EMR CDP improved our overall odds of HPV vaccination completion by 92%. We theorize that the decision prompts remind health care providers to discuss or recommend the HPV vaccination during clinical service delivery. CDPs in the EMR help increase HPV vaccination rates in multiple specialties and are a low-cost intervention for improving vaccination rates.

Human Papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: a clinic cluster-randomized control trial

INTRODUCTION

Human papillomavirus (HPV) vaccination rates are low in young adults. Clinical decision support (CDS) in primary care may increase HPV vaccination. We tested the treatment effect of algorithm-driven, web-based, and electronic health record-linked CDS with or without shared decision-making tools (SDMT) on HPV vaccination rates compared to usual care (UC).

METHODS

In a clinic cluster-randomized control trial conducted in a healthcare system serving a largely rural population, we randomized 34 primary care clinic clusters (with three clinics sharing clinicians randomized together) to: CDS; CDS+SDMT; UC. The sample included young adults aged 18-26 due for HPV vaccination with a study index visit from 08/01/2018-03/15/2019 in a study clinic. Generalized linear mixed models tested differences in HPV vaccination status 12 months after index visits by study arm.

RESULTS

Among 10,253 patients, 6,876 (65.2%) were due for HPV vaccination, and 5,054 met study eligibility criteria. In adjusted analyses, the HPV vaccination series was completed by 12 months in 2.3% (95% CI: 1.6%-3.2%) of CDS, 1.6% (95% CI: 1.1%-2.3%) of CDS+SDMT, and 2.2% (95% CI: 1.6%-3.0%) of UC patients, and at least one HPV vaccine was received by 12 months in 13.1% (95% CI: 10.6%-16.1%) of CDS, 9.2% (95% CI: 7.3%-11.6%) of CDS+SDMT, and 11.2% (95% CI: 9.1%-13.7%) of UC patients. Differences were not significant between arms. Females, those with prior HPV vaccinations, and those seen at urban clinics had significantly higher odds of HPV vaccination in adjusted models.

DISCUSSION

CDS may require optimization for young adults to significantly impact HPV vaccination.

TRIAL REGISTRATION

clinicaltrials.gov NCT02986230, 12/6/2016.

Impact of a Virtual Reality Curriculum on Human Papillomavirus Vaccination: A Pilot Trial

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p<0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted.

Overcoming Vaccine Hesitancy for Future COVID-19 and HIV Vaccines: Lessons from Measles and HPV Vaccines

BACKGROUND

The discovery of vaccines significantly reduced morbidity and mortality of infectious diseases and led to the elimination and eradication of some. Development of safe and effective vaccines is a critical step to the control of infectious diseases; however, there is the need to address vaccine hesitancy because of its potential impact on vaccine uptake.

METHODS

We conducted a narrative review of studies on interventions to address measles and human papillomavirus vaccine hesitancy. We discussed how lessons learned from these studies could be applied towards COVID-19 and future human immunodeficiency virus vaccines.

RESULTS

We found that there are several successful approaches to improving vaccine acceptance. Interventions should be context specific and build on the challenges highlighted in various settings.

CONCLUSION

Strategies could be used alone or in combination with others. The most successful interventions directly targeted the population for vaccination. Use of financial incentives could be a potential tool to improve vaccine uptake.

School Health Service Provider Perceptions on Facilitated Interactive Role-Play Around HPV Vaccine Recommendation

The purpose of this study was to evaluate a facilitated interactive role-playing activity on increasing human papillomavirus (HPV) vaccine recommendation skills for school nurses and school-based health center staff. A 1-day workshop was implemented for school-based clinicians focused on improving HPV vaccination rates in schools. The workshop included a facilitated interactive role-playing activity involving five scenarios related to recommending the HPV vaccine to parents. Participants completed a usability survey with open-ended questions assessing their experience. A general inductive approach was used to examine responses. Sixteen participants completed the usability survey. The major strength identified specific to the activity included opportunity to practice evidence-based recommendation skills (n = 10). Weaknesses of the activity identified included lack of diversity (n = 4) and complexity within the scenarios (n = 2). Results could shift current educational and clinical paradigms through the implementation of hands-on education strategies to effectively train school-based clinicians to strongly recommend the HPV vaccine.

Implementation of a provider-focused intervention for maximizing human papillomavirus (HPV) vaccine uptake in young cancer survivors receiving follow-up care in pediatric oncology practices: protocol for a cluster-randomized trial of the HPV PROTECT intervention

BACKGROUND

Childhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age.

METHODS

This study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach.

DISCUSSION

This multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis

BACKGROUND AND OBJECTIVES

Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents.

METHODS

We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis.

RESULTS

Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found.

CONCLUSIONS

Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

Video-based messages to reduce COVID-19 vaccine hesitancy and nudge vaccination intentions

Vaccines are highly effective for curbing the spread of SARS-CoV-2 (COVID-19). Yet, millions of Americans remain hesitant about getting vaccinated, jeopardizing our ability to end the COVID-19 pandemic by fueling the spread and development of new variants. We show that brief video-based messages of encouragement addressing specific COVID-19 vaccine concerns increase vaccination intentions, and that vaccination intentions, in turn, are predictive of future vaccine uptake. Results from our online experiment reveal that willingness to get vaccinated is driven by messages that increase confidence in COVID-19 vaccines and perceived behavioral control to get vaccinated. Importantly, messages were particularly effective among more skeptical populations including people who identify as politically conservative or moderate and those who express low trust in government institutions. Our findings corroborate the real-world behavioral significance of vaccination intentions, and devise how even short, scalable online messages can provide governments and health authorities an inexpensive, yet effective tool for increasing intentions to vaccinate against COVID-19 among populations most reluctant to get them.

Human papillomavirus dose reminder preferences among parents from a diverse clinical sample: a qualitative study

Reminders are an important method for encouraging patients to return for follow-up visits, such as for successive doses of the human papillomavirus (HPV) vaccine. However, patients may have preferences for different types of reminders. This study examined which reminder methods parents of pediatric patients found most useful and their thoughts on how the reminders helped them to complete their children’s HPV vaccine series. This qualitative study was conducted on a purposively sampled group of parents who participated in a multi-level intervention intended to improve uptake and completion of the HPV vaccine series. Parents who agreed to participate were interviewed by phone using semi-structured interviews about their satisfaction with different program components, including reminders they received. Interviews were conducted between May 26, 2016 and October 18, 2017. Thematic analyses of data were conducted using NVivo software. Among 269 program participants invited to participate in the interviews, 157 agreed (58.4%) and 89 were successfully interviewed (33.1%). Participants thought that reminders were effective at helping them return for follow-up visits to ensure their children received all recommended HPV vaccine doses. Although most parents preferred texts, many also favored other reminder methods by themselves or in combination with texts. Parents suggested that the reminders indicate the purpose of the appointment and for which child. Reminders are an important part of a multi-component intervention that aims to increase completion of the HPV vaccine series. Program enrollees prefer different types of reminders, so offering several options may improve returns for follow-up doses.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Implementation of quality improvement coaching versus physician communication training for improving human papillomavirus vaccination in primary care: a randomized implementation trial

Many US health departments (HDs) conduct in-person quality improvement (QI) coaching to help primary care clinics improve their HPV vaccine delivery systems and communication. Some HDs additionally conduct remote communication training to help vaccine prescribers recommend HPV vaccination more effectively. Our aim was to compare QI coaching and communication training on key implementation outcomes. In a cluster randomized trial, we offered 855 primary care clinics: 1) QI coaching; 2) communication training; or 3) both interventions combined. In each trial arm, we assessed adoption (proportion of clinics receiving the intervention), contacts per clinic (mean number of contacts needed for one clinic to adopt intervention), reach (median number of participants per clinic), and delivery cost (mean cost per clinic) from the HD perspective. More clinics adopted QI coaching than communication training or the combined intervention (63% vs 16% and 12%, both p < .05). QI coaching required fewer contacts per clinic than communication training or the combined intervention (mean = 4.7 vs 29.0 and 40.4, both p < .05). Communication training and the combined intervention reached more total staff per clinic than QI coaching (median= 5 and 5 vs 2, both p < .05), including more prescribers (2 and 2 vs 0, both p < .05). QI coaching cost $439 per adopting clinic on average, including follow up ($129/clinic), preparation ($73/clinic), and travel ($69/clinic). Communication training cost $1,287 per adopting clinic, with most cost incurred from recruitment ($653/clinic). QI coaching was lower cost and had higher adoption, but communication training achieved higher reach, including to influential vaccine prescribers.

Long-Term Multilevel Intervention Impact on Human Papillomavirus Vaccination Rates Spanning the COVID-19 Pandemic

OBJECTIVE

The aim of the study was to evaluate the long-term sustainability of a multilevel intervention and the COVID-19 pandemic impact on adolescent human papillomavirus (HPV) vaccination coverage.

MATERIALS AND METHODS

In 2016, a pediatric and family medicine practice within a federally qualified health center completed a multilevel intervention, Development of Systems and Education for Human Papillomavirus Vaccination. We examined the intervention impact on HPV vaccine initiation and completion rates among adolescents 10-18 years between March 2016 and October 2020. We determined the total number of HPV vaccine doses administered monthly. Data were plotted on statistical process control charts.

RESULTS

Vaccine initiation increased from an average of 14% to an average of 42% for 10-year-old patients and from an average of 72% to an average of 92% for 11- to 12-year-old patients between March 2016 and January 2017 and remained stable through March 2020. Complete vaccination by age 13 years increased from 62% to 88% through October 2020.

CONCLUSIONS

This intervention led to continued improvement for on-time HPV vaccination coverage 4 years after intervention completion.Clinical Trial Registration: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT02812732).

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates: A Cluster Randomized Clinical Trial

IMPORTANCE

Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common.

OBJECTIVES

To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates.

DESIGN, SETTING, AND PARTICIPANTS

From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice.

INTERVENTIONS

Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment.

MAIN OUTCOMES AND MEASURES

Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline.

RESULTS

Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices.

CONCLUSIONS AND RELEVANCE

This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03599557.

Impact of a Multilevel Quality Improvement Intervention Using National Partnerships on Human Papillomavirus Vaccination Rates

OBJECTIVE

To evaluate the effectiveness of a multilevel intervention using national partnerships on human papillomavirus (HPV) vaccination rates.

METHODS

The American Cancer Society's Vaccinate Adolescents against Cancer program is a multilevel intervention focusing on systems and providers. The 2017 cohort introduced national partnerships to deliver intervention elements and Maintenance of Certification and continuing medical education credits for physicians. Eleven federally qualified health center (FQHC) systems completed interventions in 2017. Interventions included provider training and ≥1 other evidence-based systems improvement. We compared adolescent vaccination rates in the preintervention period (2016) and intervention period (2017) among adolescents who turned 13 during the calendar year. Intervention effectiveness was assessed using repeated measures paired t tests and Cohen's d effect size for vaccination rate change.

RESULTS

All FQHC systems implemented provider training plus an average of 2.3 additional systems improvements. Series initiation increased by an average of 23.6 percentage points (47.2%-70.8%). HPV completion rates increased by an average of 22.7 percentage points (24.6%-46.3%). Meningococcal and Tdap vaccination rates increased by 23.3 and 25.9 percentage points respectively (47.9%-71.2% and 48.8%-74.7%). All changes were statistically significant (all P < .05) and indicated large effect sizes (Cohen's d³ 1.15). Among clinicians completing postintervention surveys, 90% reported making changes to their health care system or direct patient care based on what they had learned.

CONCLUSIONS

Multilevel interventions focusing on provider training and systems changes can substantially improve on-time adolescent vaccination coverage and can be successfully performed using national partnerships and a train-the-trainer model.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

A Systematic Review of Interventions to Improve HPV Vaccination Coverage

Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide. Although most HPV infections are transient and asymptomatic, persistent infection with high-risk HPV types may results in diseases. Although there are currently three effective and safe prophylactic HPV vaccines that are used across the world, HPV vaccination coverage remains low. This review evaluates the effects of the interventions to improve HPV vaccination coverage. We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Scopus, and the World Health Organization International Clinical Trials Registry Platform and checked the reference lists of relevant articles for eligible studies. Thirty-five studies met inclusion criteria. Our review found that various evaluated interventions have improved HPV vaccination coverage, including narrative education, outreach plus reminders, reminders, financial incentives plus reminders, brief motivational behavioral interventions, provider prompts, training, training plus assessment and feedback, consultation, funding, and multicomponent interventions. However, the evaluation of these intervention was conducted in high-income countries, mainly the United States of America. There is, therefore, a need for studies to evaluate the effect of these interventions in low-and middle-income countries, where there is a high burden of HPV and limited HPV vaccination programs.

Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles.

Improving Patient-Centered Communication about Sudden Unexpected Death in Epilepsy through Computerized Clinical Decision Support

BACKGROUND

Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, parents, and professional societies clearly recommend discussing with patients and families. However, this conversation does not routinely happen.

OBJECTIVES

This pilot study aimed to demonstrate whether computerized decision support could increase patient communication about SUDEP.

METHODS

A prospective before-and-after study of the effect of computerized decision support on delivery of SUDEP counseling. The intervention was a screening, alerting, education, and follow-up SUDEP module for an existing computerized decision support system (the Child Health Improvement through Computer Automation [CHICA]) in five urban pediatric primary care clinics. Families of children with epilepsy were contacted by telephone before and after implementation to assess if the clinician discussed SUDEP at their respective encounters.

RESULTS

The CHICA-SUDEP module screened 7,154 children age 0 to 21 years for seizures over 7 months; 108 (1.5%) reported epilepsy. We interviewed 101 families after primary care encounters (75 before and 26 after implementation) over 9 months. After starting CHICA-SUDEP, the number of caregivers who reported discussing SUDEP with their child's clinician more than doubled from 21% (16/75) to 46% (12/26; p = 0.03), and when the parent recalled who brought up the topic, 80% of the time it was the clinician. The differences between timing and sampling methodologies of before and after intervention cohorts could have led to potential sampling and recall bias.

CONCLUSION

Clinician-family discussions about SUDEP significantly increased in pediatric primary care clinics after introducing a systematic, computerized screening and decision support module. These tools demonstrate potential for increasing patient-centered education about SUDEP, as well as incorporating other guideline-recommended algorithms into primary and subspecialty cares.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT03502759.

A quality improvement collaborative to increase human papillomavirus vaccination rates in local health department clinics

Human papillomavirus (HPV) vaccination rates are well below the Healthy People 2020 goal of 80%. Vaccinating in settings other than primary care, such as local health departments (LHDs), may help achieve higher HPV immunization rates. We tested the effect of a quality improvement (QI) collaborative to reduce missed opportunities (MOs) for HPV vaccine in LHDs. Between 2016 and 2019, we conducted four consecutive cohorts of a virtual QI collaborative at 24 LHDs across multiple states. Participants were trained on topics including how to provide an effective recommendation for HPV vaccine, strategies to reduce MOs, and motivational interviewing. Throughout the 6-month project implementation, LHDs tested strategies to reduce MOs through Plan-Do-Study-Act cycles, performed chart reviews to identify and characterize MOs, and received feedback reports to assess progress on MOs. HPV vaccination rates were assessed pre- and post-intervention. LHDs reduced MOs for HPV vaccine in all four cohorts with aggregated data showing a 25.3 percentage point reduction in MOs. Modified Poisson regression analysis found a 44% reduction in the relative risk of missing the opportunity for an HPV vaccine at a visit (RR = 0.56, 0.46-0.68, p < .001). This project shows that strategies effective in reducing MO for HPV vaccine in primary care settings are also effective in LHD settings. Training LHD staff on these strategies may help the U.S. approach national goals for HPV vaccine coverage.

Identifying Strategies to Reduce Missed Opportunities for HPV Vaccination in Primary Care: A Qualitative Study of Positive Deviants

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system-level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US

BACKGROUND

While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.

METHODS

In April 2019, we surveyed families with adolescents 11-17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.

RESULTS

2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent's health-care provider's recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.

CONCLUSIONS

HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial

OBJECTIVES

To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention.

METHODS

DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months.

RESULTS

In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention).

CONCLUSIONS

Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Evidence-based strategies to increase vaccination uptake: a review

PURPOSE OF REVIEW

To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

SUMMARY

Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.

Implementing Evidence-Based Strategies to Improve HPV Vaccine Delivery

BACKGROUND

High-quality evidence indicates that intervening with health care providers improves human papillomavirus (HPV) vaccine delivery. However, scaling up evidence-based strategies in real-world clinical practice remains challenging. We sought to improve the reach and impact of strategies for HPV vaccination quality improvement (QI) through local adaptation and implementation in a large, not-for-profit health care system.

METHODS

We conducted an HPV vaccination QI program using existing materials to support physician training coupled with assessment and feedback. Local physicians with high HPV vaccination rates facilitated training, which included didactic instruction and video vignettes modeling effective communication. We randomly assigned 25 clinics with 77 physicians to the QI arm or the wait-list control arm. We used hierarchical linear models to assess HPV vaccination coverage (≥1 dose) over 6 months among patients aged 12 to 14.

RESULTS

Of 45 physicians in the QI arm, the program reached 43 (95%) with training plus assessment and feedback. In the overall sample, HPV vaccination coverage increased in both the QI and control arms (8.6 vs 6.4 percentage points, respectively), although the 2.2-percentage point difference did not reach statistical significance. Sensitivity analyses that excluded physicians with poor data quality indicated a statistically significant advantage of 3.3 percentage points for QI versus control (b = 0.034; SE = 0.015; P < .05).

CONCLUSIONS

Our locally adapted QI program achieved excellent reach, with small improvements in HPV vaccination coverage. Future implementation research is needed to bolster program impact and support health systems in leveraging local resources to conduct these programs efficiently.

Understanding the use of digital technology to promote human papillomavirus vaccination - A RE-AIM framework approach

The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

Physician clinical decision support system prompts and administration of subsequent doses of HPV vaccine: A randomized clinical trial

BACKGROUND

HPV vaccine is effective in preventing several cancers and anogenital warts, yet rates of HPV vaccination series completion in the United States are low. A primary reason identified by parents for vaccinating children against HPV is a health care provider's recommendation. Although most clinicians embrace vaccine recommendations, they are not always carried out evenly and subsequent HPV vaccines are missed.

METHODS

Using an electronic health records-based decision support system (CHICA) clinicians were randomized to either usual practice or to receive an automated reminder to recommend the 2nd or 3rd dose of HPV vaccine. The reminder was delivered to clinicians of all intervention group eligible adolescents who had already initiated the vaccine series. Logistic regression models with generalized estimating equations were used for data analysis.

RESULTS

A total of 1285 clinical encounters were observed across 29 randomized pediatric providers over a 13-month time frame (50.7% control group, 49.3% intervention group). Overall, patients were 44.9% female, 59.4% Black, 22.1% Hispanic, and 48.8% were ages 11-12 yrs. Within the control group, 421 (64.7%) received a subsequent HPV vaccine, compared to 481 (75.9%) (OR: 1.72, (95% CI 1.35-2.19)). Adjusted analysis showed no difference between the groups (aOR 1.52 (95% CI 0.88-2.62)) or when examined by age (11-12yrs aOR 1.66, (95% CI 0.79-3.48)) and 13-17yrs (aOR 1.19, (95% CI 0.76-1.85)) or gender female (aOR 1.39 (95% CI 0.71-2.72)) and males (aOR 1.67 (95% CI 0.95-2.92)). When results were stratified by both age and gender, there was similarly no statistically significant effect between the two groups.

CONCLUSIONS

Automated physician reminders for subsequent 2nd and 3rd doses of HPV vaccination were used. Despite increased rates of vaccination in the intervention group, the differences did not reach the level of statistical significance. Future studies with multifaceted approaches may be needed to examine the efficacy of computer-based reminders.

CLINICAL TRIAL REGISTRATION

NCT02558803, "HPV Vaccination: Evaluation of Reminder Prompts for Doses 2 & 3".