Effect of decision support on missed opportunities for human papillomavirus vaccination

Abstract

Background: Missed opportunities for human papilloma virus (HPV) vaccination are common, presenting a barrier to achieving widespread vaccine coverage and preventing infection.

Purpose: To compare the impact of clinician- versus family-focused decision support, none, or both on captured opportunities for HPV vaccination.

Design: Twelve-month cluster randomized controlled trial conducted in 2010-2011.

Setting/participants: Adolescent girls aged 11-17 years due for HPV Dose 1, 2, or 3 receiving care at primary care practices.

Intervention: Twenty-two primary care practices were cluster randomized to receive a three-part clinician-focused intervention (educational sessions, electronic health record-based alerts, and performance feedback) or none. Within each practice, girls were randomized at the patient level to receive family-focused, automated, educational phone calls or none. Randomization resulted in four groups: clinician-focused, family-focused, combined, or no intervention.

Main outcome measures: Standardized proportions of captured opportunities (due vaccine received at clinician visit) were calculated among girls in each study arm. Analyses were conducted in 2013.

Results: Among 17,016 adolescent girls and their 32,472 visits (14,247 preventive, 18,225 acute), more HPV opportunities were captured at preventive than acute visits (36% vs 4%, p<0.001). At preventive visits, the clinician intervention increased captured opportunities by 9 percentage points for HPV-1 and 6 percentage points for HPV-3 (p≤0.01), but not HPV-2. At acute visits, the clinician and combined interventions significantly improved captured opportunities for all three doses (p≤0.01). The family intervention was similar to none. Results differed by practice setting; at preventive visits, the clinician intervention was more effective for HPV-1 in suburban than urban settings, whereas at acute visits, the clinician intervention was more effective for all doses at urban practices.

Conclusions: Clinician-focused decision support is a more effective strategy than family-focused to prevent missed HPV vaccination opportunities. Given the persistence of missed opportunities even in intervention groups, complementary strategies are needed. This study is registered at clinicaltrials.gov NCT01159093.

Figure 1. Randomization of study subjects

Girls were randomized as they became eligible during the study period. Adolescents vaccinated at family planning visits were excluded to protect confidentiality. Only girls who had at least one acute or preventive visit during the study period were included in the analysis. Nurse or medical assistant only visits were excluded.

Figure 1. Randomization of study subjects

Girls were randomized as they became eligible during the study period. Adolescents vaccinated at family planning visits were excluded to protect confidentiality. Only girls who had at least one acute or preventive visit during the study period were included in the analysis. Nurse or medical assistant only visits were excluded.