Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network.

2023

47-56

12/2023

1876-2867

OBJECTIVE: To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS: In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS: Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS: Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

10.1016/j.acap.2022.07.006

Acad Pediatr

35853600

HPV Vaccinations at Acute Visits and Subsequent Adolescent Preventive Visits.

2022

12/2022

1098-4275

10.1542/peds.2022-058188

Pediatrics

36205071

Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network.

2022

07/2022

1876-2867

OBJECTIVE: To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS: In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS: Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS: Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

10.1016/j.acap.2022.07.006

Acad Pediatr

35853600

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

2021

2021 May 24

2168-6211

<p><strong>Importance: </strong>Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common.</p>

<p><strong>Objectives: </strong>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.</p>

<p><strong>Design, Setting, and Participants: </strong>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.</p>

<p><strong>Interventions: </strong>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.</p>

<p><strong>Main Outcomes and Measures: </strong>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.</p>

<p><strong>Results: </strong>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.</p>

<p><strong>Conclusions and Relevance: </strong>This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention.</p>

<p><strong>Trial Registration: </strong>ClinicalTrials.gov Identifier: NCT03599557.</p>

10.1001/jamapediatrics.2021.0766

JAMA Pediatr

34028494

Home visitation program effectiveness and the influence of community behavioral norms: a propensity score matched analysis of prenatal smoking cessation.

2012

1016

2012 Nov 21

1471-2458

<p><b>BACKGROUND: </b>The influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.</p><p><b>METHODS: </b>Retrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.</p><p><b>RESULTS: </b>The association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, p &lt; 0.001) than in an earlier implementation period (28.4% vs. 25.8%, p = 0.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (OR = 0.84 per 5 percentage point change in county smoking rate, p = 0.002).</p><p><b>CONCLUSIONS: </b>Following a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.</p>

10.1186/1471-2458-12-1016

BMC Public Health

23170927

Missed opportunities for human papillomavirus vaccination at office visits during which influenza vaccine was administered: An AAP pediatric research in office settings (PROS) national primary care research network study.

2020

2020 Jun 12

1873-2518

<p><strong>INTRODUCTION: </strong>Little is known about missed opportunities (MOs) for HPV vaccination during primary care visits at which influenza vaccination is delivered.</p>

<p><strong>METHODS: </strong>We extracted electronic health records for HPV vaccine-eligible 11-to-17-year-olds. We assessed the proportion of visits during which an influenza vaccine was given and an HPV vaccine was due, but not given (i.e., MOs).</p>

<p><strong>RESULTS: </strong>Of 56,135 eligible visits, 57.5% represented MOs for HPV vaccination. MOs were more common at visits where an initial versus subsequent HPV vaccine dose was due (68.6% vs. 31.3%) and for acute/chronic and nurse-only visits compared to preventive visits (74.0% and 80.2% vs. 36.7%). In a multivariable model, MOs were more likely for the initial HPV dose and for non-preventive visits, but did not vary by patient sex/age.</p>

<p><strong>CONCLUSIONS: </strong>HPV vaccine MOs were common during visits where influenza vaccine was administered. Increasing simultaneous administration of HPV and influenza vaccines could increase HPV vaccine coverage.</p>

10.1016/j.vaccine.2020.05.090

Vaccine

32540274

Vaccine hesitancy and influenza beliefs among parents of children requiring a second dose of influenza vaccine in a season: An American Academy of Pediatrics (AAP) Pediatric Research in Office Settings (PROS) study.

2020

1-8

2020 Feb 04

2164-554X

<p>To receive adequate protection against influenza, some children 6 months through 8 y old need two doses of influenza vaccine in a given season. Currently, only half of those receiving the first dose receive a second. Our objective was to assess vaccine hesitancy and influenza disease and vaccine knowledge, attitudes, and beliefs among caregivers of children who received the first of their two needed doses. As part of a national-randomized control trial of second dose text-message influenza vaccine reminders (2017-2018 season), a telephone survey collected caregiver and index child demographic information. Each child had received the first of two needed influenza vaccine doses. Caregivers completed a measure of general vaccine hesitancy - the five-question Parent Attitudes About Childhood Vaccines Survey Tool (PACV-5) - and questions about influenza infection and vaccine. We assessed associations between participant demographic characteristics, vaccine hesitancy, and influenza beliefs and calculated the standardized proportion of caregivers endorsing each outcome using logistic regression. Analyses included responses from 256 participants from 36 primary care practices in 24 states. Some caregivers (11.7%) reported moderate/high vaccine hesitancy and many had misperceptions about influenza disease and vaccine. In multivariable models, no single variable was consistently associated with inaccurate knowledge, attitudes, and beliefs. These results demonstrate that caregivers whose children received the first dose of influenza vaccine may still be vaccine hesitant and have inaccurate influenza beliefs. Pediatricians should consider broadly addressing inaccurate beliefs and promoting vaccination even after caregivers agree to the first dose.</p>

10.1080/21645515.2019.1707006

Hum Vaccin Immunother

32017643

Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children.

2018

2018 Aug 16

1876-2867

<p><strong>OBJECTIVES: </strong>To describe the percentage and characteristics of children &lt;24 months old with non-motor vehicle crash (non-MVC)-related injuries who 1) undergo a skeletal survey and 2) have occult fractures.</p>

<p><strong>METHODS: </strong>We performed a retrospective chart review of a stratified, systematic random sample of 1769 children &lt;24 months old with non-MVC-related bruises, burns, fractures, abdominal injuries, and head injuries at 4 children's hospitals from 2008-2012. Sampling weights were assigned to each child to allow for representative hospital-level population estimates. Logistic regression models tested for associations between patient characteristics with outcomes of skeletal survey completion and occult fracture identification.</p>

<p><strong>RESULTS: </strong>Skeletal surveys were performed in 46.3% of 0-5 month olds, 21.1% of 6-11 month olds, 8.0% of 12-17 month olds and 6.2% of 18-24 month olds. Skeletal surveys were most performed in children with traumatic brain injuries (64.7%) and rib fractures (100%) and least in burns (2.1%) and minor head injuries (4.4%). In adjusted analyses, increased age, private insurance and reported history of accidental trauma were associated with decreased skeletal survey use (all p≤0.001). The prevalence of occult fractures on skeletal survey ranged from 24.6% in infants 0-5 month olds to 3.6% in 18-24 month olds, and varied within age categories based on the presenting injury (p&lt;0.001).</p>

<p><strong>CONCLUSIONS: </strong>The high rate of occult fractures in infants 0-5 months old underscores the importance of increasing the use of skeletal surveys in this population. Further research is needed to identify the injury characteristics of older infants and toddlers most at risk for occult fractures.</p>

10.1016/j.acap.2018.08.007

Acad Pediatr

30121318

Electronic health record (EHR) based postmarketing surveillance of adverse events associated with pediatric off-label medication use: A case study of short-acting beta-2 agonists and arrhythmias.

2018

2018 May 27

1099-1557

<p><strong>PURPOSE: </strong>Use electronic health record (EHR) data to (1) estimate the risk of arrhythmia associated with inhaled short-acting beta-2 agonists (SABA) in pediatric patients and (2) determine whether risk varied by on-label versus off-label prescribing.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of 335&nbsp;041 children ≤18&nbsp;years using EHR primary care data from 2 pediatric health systems (2011-2013). A series of monthly pseudotrials were created, using propensity score methodology to balance baseline characteristics between SABA-exposed (identified by prescription) and SABA-unexposed children. Association between SABA and subsequent arrhythmia for each health system was estimated through pooled logistic regression with separate estimates for children initiating under and over 4&nbsp;years old (off-label and on-label, respectively).</p>

<p><strong>RESULTS: </strong>Eleven percent of the cohort received a SABA prescription, 57% occurred under the age of 4&nbsp;years (off-label). During the follow-up period, there were 283 first arrhythmia events, most commonly atrial tachyarrhythmias and premature ventricular/atrial contractions. In 1 health system, adjusted risk for arrhythmia was increased among exposed children (OR 1.89, 95% CI 1.31-2.73) without evidence of interaction between label status and risk. The absolute adjusted rate difference was 3.6/10&nbsp;000 person-years of SABA exposure. The association between SABA exposure and arrhythmias was less strong in the second system (OR 1.26, 95% CI 0.30-5.33).</p>

<p><strong>CONCLUSION: </strong>Using EHR data, we could estimate the risk of a rare event associated with medication use and determine difference in risk related to on-label versus off-label status. These findings support the value of EHR-based data for postmarketing drug studies in the pediatric population.</p>

10.1002/pds.4562

Pharmacoepidemiol Drug Saf

29806185

Incidence of Healthcare-Associated Influenza-Like Illness After a Primary Care Encounter Among Young Children.

2018

2018 Mar 22

2048-7207

<p><strong>Background: </strong>Despite potential respiratory virus transmission in pediatric clinics, little is known about the risk of healthcare-associated viral infections attributable to outpatient encounters. We evaluated whether exposure to a pediatric clinic visit was associated with subsequent influenza-like illness (ILI).</p>

<p><strong>Methods: </strong>Using electronic health record data, we conducted a retrospective cohort study of all children aged &lt;6 years who presented to a provider in a 29-clinic pediatric primary care network for a non-ILI-related encounter over 2 respiratory virus seasons (September 1, 2012, to April 30, 2014). We defined a risk period for potential healthcare-associated (HA) ILI of 1 to 8 days after a non-ILI clinic visit and identified all cases of ILI to compare the incidences of ILI visits 1 to 8 days after a non-ILI encounter and those of visits &gt;8 days after a non-ILI encounter.</p>

<p><strong>Results: </strong>Among 149987 children &lt;6 years of age (mean age, 2.5 years) with ≥1 non-ILI visit during the study period, 531928 total encounters and 13951 (2.9%) ILI encounters were identified; 1941 (13.9%) occurred within the HA-ILI risk window. The incidence rate ratios (IRRs) for ILI 1 to 8 days after compared with ILI &gt;8 days after a non-ILI visit during season 1 were 1.36 (95% confidence interval, 1.22-1.52) among children ≥2 years of age and 1.01 (95% confidence interval, 0.93-1.09) among children &lt;2 years of age. Estimates remained consistent during season 2 and with a risk window of 3, 4, or 9 days.</p>

<p><strong>Conclusions: </strong>Pediatric clinic visits during a respiratory virus season were significantly associated with an increased incidence of subsequent ILI among children aged 2 to 6 years but not among those aged &lt;2 years. These findings support the hypothesis that respiratory virus transmission in a pediatric clinic can result in HA ILI in young children.</p>

10.1093/jpids/piy023

J Pediatric Infect Dis Soc

29579251