Impact of an EHR Reminder on HPV Vaccination
Impact of an EHR Reminder on HPV Vaccination
Background The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort).
Methods Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records.
Results Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort.
Conclusion More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.
The Advisory Committee on Immunization Practices (ACIP) currently recommends routine vaccination of girls and boys aged 11 or 12 years with 3 doses of a human papillomavirus (HPV) vaccine. The HPV vaccine is administered intramuscularly as 3 separate 0.5-mL doses, with the second dose occurring 1 to 2 months after the first dose and the third dose occurring 6 months after the first dose. The vaccination series can be started beginning at age 9 years, with catch-up vaccination recommended between 13 to 26 years. The vaccine series was approved for boys in 2010 by the US Food and Drug Administration and in 2011 by the Centers for Disease Control and Prevention.
National estimates of HPV vaccine uptake provided by the Centers for Disease Control and Prevention's National Immunization Survey reported 25.1% of adolescent girls aged 13 to 17 years initiated the vaccine series (≥1 dose) in 2007. Between 2008 to 2012, HPV vaccine initiation increased from 37.2% to 53.8% and HPV vaccine series completion (≥3 doses) increased from 17.9% to 33.4% among adolescent girls. During the same time period of increased initiation and completion of the HPV vaccine series, 84% of unvaccinated girls were missing one or more opportunities to get the vaccine in 2012. Uptake has been substantially lower among adult women, with available data from the National Immunization Survey–Adult indicating that only 10% of women ages 18 to 26 initiated HPV vaccination in 2007. An emerging body of literature examining factors associated with HPV vaccine initiation and/or series completion has identified several significant predictors of uptake, including age, race/ethnicity, student status, medical specialty, clinic type, insurance type, urban status, neighborhood education level, historic health service utilization, receipt of meningococcal vaccine, use of contraception requiring intramuscular injections every 3 months, perceived personal importance of vaccination, and strength of physician's recommendation. Another critical barrier reported by parents is not receiving a recommendation for the HPV vaccine from a health care professional.
The few published observational studies of adherence to dosing intervals used different definitions for "on-time" dosing. Tan et al examined factors associated with on-time dosing in a retrospective cohort study of female patients ages 9 to 26 with at least 1 HPV vaccine dose documented in the North Carolina Immunization Registry. During the 2-year study period, only 25% completed the HPV vaccine series on time, as defined by the dosing window used in the quadrivalent HPV vaccine trials, with significant differences in on-time series completion by age, race, ethnicity, insurance type, and clinic type. Widdice et al examined adherence to the dosing schedule recommended by the ACIP and factors associated with series completion within 7 and 12 months in a retrospective review of health records of 9- to 16-year-old patients who had initiated HPV vaccination at an academic medical center. They found low adherence to ACIP-recommended intervals; over half of doses were received late and only 28% of patients completed the 3-dose series by 1 year.
Reminder calls to families are, in general, effective for vaccine uptake. Only 3 studies that have examined reminder calls or prompts for adolescent vaccination have been published. Only the recent study demonstrated a clinician-focused intervention that included electronic health record (EHR) alerts was most effective at initiating the HPV vaccination series. However, EHR alerts were part of a more resource-intense intervention, however, so the impact of turning on alerts cannot be determined.
The objectives of this study were to examine the effect of simply turning on an EHR alert for HPV vaccine initiation, series completion, and adherence to ACIP-recommended dosing intervals among eligible female patients. This less resource-intense approach will become more common in our practices. We hypothesized that the practice with EHR prompts for the HPV vaccine would have higher initiation, more timely completion of the series, and more patients completing the series.
Abstract and Introduction
Abstract
Background The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort).
Methods Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records.
Results Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort.
Conclusion More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.
Introduction
The Advisory Committee on Immunization Practices (ACIP) currently recommends routine vaccination of girls and boys aged 11 or 12 years with 3 doses of a human papillomavirus (HPV) vaccine. The HPV vaccine is administered intramuscularly as 3 separate 0.5-mL doses, with the second dose occurring 1 to 2 months after the first dose and the third dose occurring 6 months after the first dose. The vaccination series can be started beginning at age 9 years, with catch-up vaccination recommended between 13 to 26 years. The vaccine series was approved for boys in 2010 by the US Food and Drug Administration and in 2011 by the Centers for Disease Control and Prevention.
National estimates of HPV vaccine uptake provided by the Centers for Disease Control and Prevention's National Immunization Survey reported 25.1% of adolescent girls aged 13 to 17 years initiated the vaccine series (≥1 dose) in 2007. Between 2008 to 2012, HPV vaccine initiation increased from 37.2% to 53.8% and HPV vaccine series completion (≥3 doses) increased from 17.9% to 33.4% among adolescent girls. During the same time period of increased initiation and completion of the HPV vaccine series, 84% of unvaccinated girls were missing one or more opportunities to get the vaccine in 2012. Uptake has been substantially lower among adult women, with available data from the National Immunization Survey–Adult indicating that only 10% of women ages 18 to 26 initiated HPV vaccination in 2007. An emerging body of literature examining factors associated with HPV vaccine initiation and/or series completion has identified several significant predictors of uptake, including age, race/ethnicity, student status, medical specialty, clinic type, insurance type, urban status, neighborhood education level, historic health service utilization, receipt of meningococcal vaccine, use of contraception requiring intramuscular injections every 3 months, perceived personal importance of vaccination, and strength of physician's recommendation. Another critical barrier reported by parents is not receiving a recommendation for the HPV vaccine from a health care professional.
The few published observational studies of adherence to dosing intervals used different definitions for "on-time" dosing. Tan et al examined factors associated with on-time dosing in a retrospective cohort study of female patients ages 9 to 26 with at least 1 HPV vaccine dose documented in the North Carolina Immunization Registry. During the 2-year study period, only 25% completed the HPV vaccine series on time, as defined by the dosing window used in the quadrivalent HPV vaccine trials, with significant differences in on-time series completion by age, race, ethnicity, insurance type, and clinic type. Widdice et al examined adherence to the dosing schedule recommended by the ACIP and factors associated with series completion within 7 and 12 months in a retrospective review of health records of 9- to 16-year-old patients who had initiated HPV vaccination at an academic medical center. They found low adherence to ACIP-recommended intervals; over half of doses were received late and only 28% of patients completed the 3-dose series by 1 year.
Reminder calls to families are, in general, effective for vaccine uptake. Only 3 studies that have examined reminder calls or prompts for adolescent vaccination have been published. Only the recent study demonstrated a clinician-focused intervention that included electronic health record (EHR) alerts was most effective at initiating the HPV vaccination series. However, EHR alerts were part of a more resource-intense intervention, however, so the impact of turning on alerts cannot be determined.
The objectives of this study were to examine the effect of simply turning on an EHR alert for HPV vaccine initiation, series completion, and adherence to ACIP-recommended dosing intervals among eligible female patients. This less resource-intense approach will become more common in our practices. We hypothesized that the practice with EHR prompts for the HPV vaccine would have higher initiation, more timely completion of the series, and more patients completing the series.
