Using Health Information Technology to Improve Delivery of HPV Vaccine (New York)

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Summary:

Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. and a primary risk factor for cervical cancer in women. Black and Hispanic women have higher cervical cancer incidence and mortality due to lower screening and later diagnosis. The vaccine to prevent HPV infection is now recommended for all females aged 11to26 years, and is highly effective if all three doses are received prior to exposure to HPV. Given its high efficacy, the HPV vaccine has the potential to dramatically reduce rates of cervical cancer. Many inner-city adolescents begin the HPV vaccine series, but few complete the three-dose series within the recommended timeframe. If poor and minority women have lower rates of vaccination than those in higher income groups, it could widen the disparity in cervical cancer rates and mortality that currently exists.

The overall objectives of this study were to 1) assess parent preferences for communicating with their adolescent’s physician and 2) implement a health informatics-based intervention to reduce missed opportunities, reduce intervals between doses, and increase completion of the HPV vaccination series in inner-city practices.

The specific aims of the project were as follows:

  • Measure preferences for parents of adolescents and adolescents themselves to understand how they prefer to receive immunization reminders and other information from the adolescent’s physician (e.g., phone, mail, email, text messages, personal health records [PHRs]). 
  • Measure baseline rates of missed opportunities for HPV vaccination, the intervals between HPV vaccine doses, and the proportion of patients who received 1, 2, or 3 vaccinations. 
  • Develop and implement a health information technology-based intervention to reduce missed opportunities, reduce intervals between doses, and increase completion of the HPV vaccination series in inner-city practices. 
  • Measure the post-intervention rates and analyze data. 

Four-hundred parents of adolescents (aged 11-17) completed a survey to assess their perspectives about preferences for communication with the adolescent’s physician, half in an urban area and half in a suburban area. They found that just over half of parents were accepting of their teens receiving their own vaccine reminders. Urban parents preferred communicating with the provider via telephone, whereas suburban parents preferred email for most issues, and a PHR for receipt of test results. In addition, being a younger parent was associated with preferring text message vaccine reminders.

Two randomized controlled trials were performed comparing use of reminders in three urban primary care clinics. Parents of adolescents 11-17 years old receiving an HPV vaccine chose which method of reminder, either phone or text, they preferred and after consenting were randomized to receive, or not receive, a reminder. Forty-eight percent of phone intervention participants compared to 40 percent of controls had received 3 HPV vaccine doses, while 49 percent of text intervention participants compared to 30 percent of controls completed the course. There was no significant difference in time from enrollment to receipt of the third HPV vaccine dose for those receiving a phone reminder compared to controls, but there was a significant difference in those receiving a text reminder.

Overall the study showed that some, but not all, parents are ready for electronic communication for their adolescents’ health care, and that a parent age and socio-economic divide exists. Providing options in the means in which parents communicate with an adolescent’s provider is ideal.

Using Health Information Technology to Improve Delivery of HPV Vaccine - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 017951
  • Project Period: 
    September 2009 – September 2014
  • AHRQ Funding Amount: 
    $745,995
  • PDF Version: 
    (PDF, 292.88 KB)

Summary: The three-dose vaccine to prevent human papillomavirus (HPV) infection is now recommended for all females ages 11 to 26. The vaccine is highly effective if all three doses are received prior to HPV exposure. Barriers to completion of the three-dose HPV vaccine regimen include health care provider factors (e.g., competing health care priorities during medical visits), and parent or adolescent factors (e.g., parental perception that vaccination increases sexual activity) that prevent patients from returning for booster doses.

This project will determine whether the use of electronic patient reminders can shorten intervals between HPV vaccine doses and increase overall rates of completion of the regimen in inner-city areas compared to practices without reminders. Two health information technology (IT) interventions were developed in the first phase of the project. The first and primary intervention is a reminder, delivered by telephone or text message, to patients for followup doses of vaccine. The second uses electronic medical record prompts for providers to reduce missed opportunities for immunization. Prompting effectiveness will be measured using a before-and-after study design.

Qualitative interviews with parents of adolescent girls and the girls themselves guided the intervention design. The study will perform a retrospective cross-sectional analysis of the intervention in four inner-city primary care practices. Post-intervention rates of missed opportunities for HPV vaccination, intervals between vaccine doses, overall rates of completed HPV vaccination courses, and health maintenance visits will be measured in several intervals at each practice. Dr. Rand and her project team will analyze data to assess the overall effectiveness of the prompting and patient reminder intervention in reducing missed opportunities and improving vaccination completion rates. The project will also assess rates of health maintenance visits and other vaccinations for adolescents in intervention and comparison practices. Outcomes will be measured at baseline, the electronic patient reminder will be implemented, and summary statistics will be generated 6, 12, and 18 months after the intervention begins.

Specific Aims:

  • Measure parent and adolescent preferences for methods of communication with the adolescent’s provider. (Achieved)
  • Measure baseline rates of missed opportunities for HPV vaccination, the intervals between HPV vaccine doses, and the proportion of patients who received one, two, or three vaccinations.
    (Ongoing)
  • Develop and implement a health IT-based intervention to reduce missed opportunities, reduce intervals between doses, and increase completion of the HPV vaccination series in inner-city
    practices. (Achieved)
  • Measure post-intervention rates and analyze data. (Upcoming)
  • Complete educational objectives. (Ongoing)

In addition to the specific research project aims, as part of this Mentored Clinical Scientist Research Career Development Award, Dr. Rand will complete the following education objectives: 1) learn health informatics theory and be able to apply it to both clinical decision support for providers and self-management support for patients; 2) become expert in implementing and sustaining quality improvement (QI) projects based in health IT and teach these skills to other health care providers; 3) implement qualitative research methods and develop advanced skills in the application of quantitative statistical methods; 4) improve career skills by writing manuscripts and competitive grants; and 5) network with leaders in health IT, immunization delivery, QI, and adolescent preventive health.

2012 Activities: A new electronic health record that facilitated access to necessary data was implemented. Survey results that explored communication preferences of adolescents and parents were analyzed and two manuscripts were drafted. The project began recruitment of subjects and implementation of additional strategies to increase participation. Participation required both parent and teen consent, and the project team worked with a text messaging company to establish consent forms and processes. Almost 400 patients were recruited to get a phone or text message reminder. Two control groups, one for each the phone and the text, were established. Text messaging was turned on but provider reminders were not.

Dr. Rand is enrolling in her last credit for the IT certificate and is working on a review of the use of personal health records in pediatric practices.

Preliminary Impact and Findings: Project results indicate that 95 percent of urban and 99 percent of suburban parents own a cell phone. Ninety percent reported at least weekly use of the Internet and 81 percent reported weekly use of e-mail. Eighty-seven percent of urban and 95 percent of suburban parents use text messaging and most do not pay for that service. Overall, 52 percent of parents would accept text messaging reminders, with no difference in acceptability based on parent gender, insurance, or residence. Parents were more likely to accept text messaging reminders if they were younger and not charged for text messaging, with no difference based upon residence.

Target Population: Adults, Inner City*, Teenagers, Women*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

Using Health Information Technology to Improve Delivery of HPV Vaccine - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 017951
  • Project Period: 
    September 2009 - September 2014
  • AHRQ Funding Amount: 
    $745,995
  • PDF Version: 
    (PDF, 194.09 KB)

Summary: The vaccine to prevent human papillomavirus (HPV) infection is now recommended for all females aged 11-to-26 years. The vaccine is highly effective if all three doses are received prior to exposure to HPV. Barriers to completion of the three-dose HPV vaccine regimen include health care provider factors (e.g., competing health care priorities during medical visits), and parent or adolescent factors that prevent patients from returning for booster doses.

This project will determine whether the use of electronic patient reminders can shorten intervals between HPV vaccine doses and increase overall rates of completion of HPV vaccination regimen in inner-city areas compared to practices without reminders. Dr. Rand has planned two health information technology (IT) interventions. The first and primary intervention will be a reminder, delivered by telephone or text message, to patients for followup doses of vaccine. The second will use electronic medical record prompts for providers to reduce missed opportunities for immunization. Prompting effectiveness will be measured using a before-and-after study design.

Quantitative interviews with parents of adolescent girls and the girls themselves guided the intervention design. The study will perform a retrospective cross-sectional analysis of the intervention in four innercity primary care practices. Post-intervention rates of missed opportunities for HPV vaccination, intervals between vaccine doses, overall rates of completed HPV vaccination courses, and health maintenance visits will be measured in several intervals at each practice. The study will analyze data to assess the overall effectiveness of the prompting and patient reminder intervention in reducing missed opportunities and improving vaccination completion rates. The project will also assess rates of health maintenance visits and other vaccinations for adolescents in intervention and comparison practices. Outcomes will be measured at baseline, the electronic patient reminder will be implemented, and summary statistics will be generated 6-, 12-, and 18-months after the intervention begins.

Specific Aims:

  • Measure parent and adolescent preferences for methods of communication with the adolescent's provider. (Achieved)
  • Measure baseline rates of missed opportunities for HPV vaccination, the intervals between HPV vaccine doses, and the proportion of patients who received one, two, or three vaccinations. (Ongoing)
  • Develop and implement a health IT-based intervention to reduce missed opportunities, reduce intervals between doses, and increase completion of the HPV vaccination series in innercity practices. (Ongoing)
  • Measure post-intervention rates and analyze data.(Upcoming)
  • Complete educational objectives.(Ongoing)

In addition to the specific research project aims, as part of this Mentored Clinical Scientist Research Career Development Award, Dr. Rand will complete the following education objectives: 1) learn health informatics theory and be able to apply it to both clinical decision support for providers and self-management support for patients; 2) become expert in implementing and sustaining quality improvement (QI) projects based in health IT and teach these skills to other health care providers; 3) implement qualitative research methods and develop advanced skills in the application of quantitative statistical methods; 4) improve career skills by writing manuscripts and competitive grants; and 5) network with leaders in health IT, immunization delivery, QI, and adolescent preventive health.

2011 Activities: Surveying of adolescents and their parents has been completed and a preliminary analysis done. Further analysis and development of a manuscript is ongoing. Dr. Rand reduced the number of practices from four to three because the electronic medical record implementation was significantly delayed in one practice. As a result, the study was revised to randomize the patients instead of the practices. There are no anticipated changes to the timeline nor anticipated impact on the project based on these changes. Institutional Review Board approval was obtained for all practices and baseline data was collected for one.

Dr. Rand completed courses in qualitative research and consumer health informatics. She has one more credit to be complete, which she expects to fulfill through a mentorship in Maine.

Preliminary Impact and Findings: Project results indicate that 95 percent of urban and 99 percent of suburban parents own a cell phone. Ninety percent reported at least weekly use of the Internet and 81 percent weekly use of e-mail. Eighty-seven percent of urban and 95 percent of suburban parents use text messaging (TM) and most do not pay for that service. Overall, 52 percent of parents would accept TM reminders, with no difference in acceptability based on parent gender, insurance, or residence. Parents were more likely to accept TM reminders if they were younger and not charged for TM, with no difference based upon residence.

Target Population: Adults, Inner City*, Teenagers, Women*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Using Health Information Technology to Improve Delivery of HPV Vaccine - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-085: Mentored Clinical Scientist Research Career Development Award (K08)
  • Grant Number: 
    K08 HS 017951
  • Project Period: 
    September 2009 – September 2014
  • AHRQ Funding Amount: 
    $745,995
  • PDF Version: 
    (PDF, 363.14 KB)


Target Population: Adults, Inner City*, Teenagers, Women*

Summary: A vaccine to prevent human papillomavirus (HPV) infection is now recommended for all females aged 11-to-26 years. The vaccine is highly effective if all three doses are received prior to exposure to HPV strains. However, approval and recommendation of a vaccine does not ensure its receipt. Barriers to completion of the three-dose HPV vaccine regimen include health care provider factors (e.g., competing health care priorities during medical visits), and parent or adolescent factors that prevent patients from returning for booster doses.

This project will determine whether the use of electronic patient reminders can shorten intervals between HPV vaccine doses and increase overall rates of completion of HPV vaccination regimen in inner-city settings as compared to practices without reminders. Two health information technology (IT) interventions are planned. The first and primary intervention will be an electronic reminder, delivered by e-mail, text message, or a social networking site, to patients for followup doses of vaccine. The second will use electronic medical record prompts for providers to reduce missed opportunities for immunization. Prompting effectiveness will be measured using a before-and-after study design.

Quantitative interviews with parents of adolescent girls, and adolescents themselves will guide the intervention design. A retrospective cross-sectional analysis of the intervention will be performed in four inner-city primary care practices. Post-intervention rates of missed opportunities for HPV vaccination, intervals between vaccine doses, overall rates of completed HPV vaccination courses, and health maintenance visits will be measured in several intervals at each practice. Data will be analyzed to assess the overall effectiveness of the prompting and patient reminder intervention in reducing missed opportunities and improving vaccination completion rates. The project will also assess rates of health maintenance visits and other vaccinations for adolescents in intervention and comparison practices. Outcomes will be measured at baseline, the electronic patient reminder will then be implemented, and summary statistics will be generated 6, 12, and 18 months after the intervention begins.

Specific Aims:
  • Measure parent and adolescent preferences for methods of communication with the adolescent’s provider. (Ongoing)
  • Measure baseline rates of missed opportunities for HPV vaccination, the intervals between HPV vaccine doses, and the proportion of patients who received one, two, or three vaccinations. (Ongoing)
  • Develop and implement a health IT-based intervention to reduce missed opportunities, reduce intervals between doses, and increase completion of the HPV vaccination series in inner-city practices. (Upcoming)
  • Measure post-intervention rates and analyze data. (Upcoming)
  • Complete educational objectives. (Ongoing)

In addition to the specific research project aims, as part of this Mentored Clinical Scientist Research Career Development Award, Dr. Rand will complete the following education objectives: learn health informatics theory and be able to apply it to both clinical decision support for providers and self-management support for patients; become expert in implementing and sustaining quality improvement (QI) projects based in health IT and teach these skills to other health care providers; skillfully implement qualitative research methods and develop advanced skills in the application of quantitative statistical methods; improve career skills by writing sound manuscripts and competitive grants; and networking with leaders in health IT, immunization delivery, QI, and adolescent preventive health.

2010 Activities: Dr. Rand completed a retrospective chart review in one practice to build a dashboard and measure HPV vaccination rates. A survey to evaluate patient access to technology and preferences for reaching them was designed and piloted. Institutional review board approval for working with additional practices and the survey was submitted. Significant progress toward the completion of the Dr. Rand’s educational objectives continued.

Preliminary Impact and Findings: The project does not have any findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

Using Health Information Technology to Improve Delivery of HPV Vaccine - Final Report

Citation:
Rand C. Using Health Information Technology to Improve Delivery of HPV Vaccine - Final Report. (Prepared by the University of Rochester under Grant No. K08 HS017951). Rockville, MD: Agency for Healthcare Research and Quality, 2015. (PDF, 142.79 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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