Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine.

BACKGROUND: Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine. METHODS: An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals. RESULTS: Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females. CONCLUSIONS: We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

Improvements in appropriate ambulatory antibiotic prescribing using a bundled antibiotic stewardship intervention in general pediatrics practices.

OBJECTIVE: To improve appropriate antibiotic prescribing for children in Tennessee. DESIGN: We performed a before-and-after intervention study with 3 comparison periods: period 1 (P1, baseline) May 2018-September 2019; period 2 (P2, intervention before the COVID-19 pandemic) November 11, 2019-March 20, 2020; and period 3 (P3, intervention during the coronavirus disease 2019 [COVID-19] pandemic) March 21, 2020-November 10, 2020. We additionally surveyed participating providers to assess acceptance of the intervention. SETTING: Community general pediatrics practices. PARTICIPANTS: In total, 81 general pediatricians, family medicine physicians, and nurse practitioners in 5 general pediatrics practices participated in this study. INTERVENTIONS: Each practice identified a practice and operations champion for the project. Practices chose 2-4 implementation strategies previously shown to be effective at reducing outpatient antibiotic use to implement in their practice throughout the study intervention period. Study personnel also held quarterly meetings with all providers to review deidentified peer comparison feedback both across practices enrolled in the study and at the provider level within each practice. RESULTS: We detected improvements in guideline-concordant antibiotic use in the pre-COVID-19 intervention period, and they were sustained in the study period during the pandemic (P3): otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%). CONCLUSIONS: Bundled implementation strategies led to significant increases in guideline-concordant antibiotic prescribing for all diagnoses. Survey results demonstrate that the bundled implementation strategies were well-accepted by providers.

Patient and Provider Perspectives on Pediatric Telemedicine During the COVID-19 Pandemic.

The COVID-19 pandemic led to rapid expansion of telemedicine services. We surveyed parent/guardians from March 10 to June 29, 2020, in an academic and community pediatric practice, and community pediatric providers from June 5 to July 13, 2020, to better understand their perceptions of telemedicine and compare parent/guardian satisfaction between in-person and telemedicine encounters. Overall patient satisfaction scores were high in both settings and did not differ between in-person and telemedicine visits (community setting: 93.36 ± 12.87 in-person vs. 88.04 ± 22.04 telemedicine; academic setting: 92.25 ± 11.2 vs. 95.37 ± 8.21). Most providers (82.5%) would be willing to use telemedicine in a nonpandemic situation. Telemedicine should remain available for primary care pediatrics during and after resolution of the pandemic.

Providers' Perceptions of Parental Human Papillomavirus Vaccine Hesitancy: Cross-Sectional Study.

BACKGROUND: Human papillomavirus (HPV) vaccine hesitancy among parents contributes to low vaccination coverage in adolescents. To improve health care provider communication and vaccine recommendation practices with hesitant parents, it is important to understand how providers perceive parental HPV vaccine hesitancy. OBJECTIVE: This study aimed to characterize perceived reasons for parental HPV vaccine hesitancy and identify factors associated with perceived parental hesitancy among providers at community-based pediatric clinics. METHODS: In 2018, providers in 23 community-based pediatric clinics in Tennessee were invited to complete a Web-based baseline survey as part of a larger quality improvement study focused on HPV vaccine uptake. These survey data were used for a cross-sectional, secondary data analysis. Scale scores ranging from 0 to 100 were calculated for provider self-efficacy (confidence in ability to recommend HPV vaccine), provider outcome expectations (expectations that recommendation will influence parents' decisions), and perceived parental HPV vaccine hesitancy. Provider confidence in HPV vaccine safety and effectiveness were categorized as high versus low. Clinic-level exposures examined were clinic size and rural-urban location. Descriptive analyses were used to characterize perceived parental barriers by provider type. Mixed-effects linear regression models were fit taking one exposure variable at a time, whereas controlling for provider type, age, gender, and race to identify provider- and clinic-level factors associated with perceived parental barriers to HPV vaccination. RESULTS: Of the 187 providers located in the 23 clinics, 137 completed the survey. The majority of physician providers were white and female, with a higher percentage of females among nurse practitioners (NPs) and physician assistants (PAs). The most common parental barriers to HPV vaccination perceived by providers were concerns about HPV vaccine safety (88%), child being too young (78%), low risk of HPV infection for child through sexual activity (70%), and mistrust in vaccines (59%). In adjusted mixed models, perceived parental HPV vaccine hesitancy was significantly associated with several provider-level factors: self-efficacy (P=.001), outcome expectations (P<.001), and confidence in HPV vaccine safety (P=.009). No significant associations were observed between perceived parental HPV vaccine hesitancy and clinic-level factors clinic size nor location. CONCLUSIONS: Researchers developing provider-focused interventions to reduce parental HPV vaccine hesitancy should consider addressing providers' self-efficacy, outcome expectations, and confidence in HPV vaccine safety to help providers communicate more effectively with HPV vaccine hesitant parents.