HPV vaccine standing orders and communication in primary care: A qualitative study.

BACKGROUND: Standing orders may improve HPV vaccination rates, but clinical staff's readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups. METHODS: Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis. RESULTS: Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses' and medical assistants' confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible. CONCLUSION: Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.

A Pragmatic Cluster-Randomized Trial of a Standing Order Entry Intervention for Colony-Stimulating Factor Use Among Patients at Intermediate Risk for Febrile Neutropenia.

PURPOSE: Primary prophylactic colony-stimulating factors (PP-CSFs) are prescribed to reduce febrile neutropenia (FN) but their benefit for intermediate FN risk regimens is uncertain. Within a pragmatic, randomized trial of a standing order entry (SOE) PP-CSF intervention, we conducted a substudy to evaluate the effectiveness of SOE for patients receiving intermediate-risk regimens. METHODS: TrACER was a cluster randomized trial where practices were randomized to usual care or a guideline-based SOE intervention. In the primary study, sites were randomized 3:1 to SOE of automated PP-CSF orders for high FN risk regimens and alerts against PP-CSF use for low-risk regimens versus usual care. A secondary 1:1 randomization assigned 24 intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF for intermediate-risk regimens. Clinicians were allowed to over-ride the SOE. Patients with breast, colorectal, or non-small-cell lung cancer were enrolled. Mixed-effect logistic regression models were used to test differences between randomized sites. RESULTS: Between January 2016 and April 2020, 846 eligible patients receiving intermediate-risk regimens were registered to either SOE to prescribe (12 sites: n = 542) or an alert to not prescribe PP-CSF (12 sites: n = 304). Rates of PP-CSF use were higher among sites randomized to SOE (37.1% v 9.9%, odds ratio, 5.91; 95% CI, 1.77 to 19.70; P = .0038). Rates of FN were low and identical between arms (3.7% v 3.7%). CONCLUSION: Although implementation of a SOE intervention for PP-CSF significantly increased PP-CSF use among patients receiving first-line intermediate-risk regimens, FN rates were low and did not differ between arms. Although this guideline-informed SOE influenced prescribing, the results suggest that neither SOE nor PP-CSF provides sufficient benefit to justify their use for all patients receiving first-line intermediate-risk regimens.

Maximizing the impact of, and sustaining standing orders protocols for adult immunization in outpatient clinics.

BACKGROUND: Low adult immunization rates leave adults at risk from infectious disease, and the resulting complications of vaccine-preventable diseases. Standing orders protocols (SOPs) for adult immunization have not been implemented widely in clinics serving adult patients. Our purpose was to evaluate the impact of SOPs on adult immunization rates and identify challenges to sustaining adult immunization coverage rates after implementation of SOPs. METHODS: Baseline adult vaccination rates were calculated for the year prior to SOPs implementation in 5 diverse clinics. Vaccines included in the implemented standing orders included Tdap, influenza, pneumococcal, human papillomavirus, herpes zoster, and hepatitis B. Adult vaccination rates were tracked for 1 year after SOPs implementation. RESULTS: Sites generally sustained modest gains in coverage rates (4%-8% increase) after SOP implementation, but greater success was found in practices that used SOPs as a foundation on which additional interventions were built. Challenges to increasing coverage rates included prioritization of acute and chronic conditions over adult vaccination, Medicare Part D reimbursement policies, electronic medical record issues related to data reporting and programming for patient alerts, and the lack of interoperability between the state immunization information system (missing patient vaccination history) and electronic medical record. CONCLUSIONS: SOPs may provide a good starting point for increasing adult immunization coverage rates. Using additional interventions, quality-based metrics, or incentives could lead to sustained adult immunization prioritization.

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings.

BACKGROUND: Many young and middle-aged women receive their primary health care from their obstetrician-gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician-gynecology practices. Evidence-based best practices for vaccination delivery include the establishment of vaccination standing orders. OBJECTIVES: As part of an intervention to increase adoption of evidence-based vaccination strategies for women in safety-net and private obstetrician-gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician-gynecology sites when establishing vaccination standing orders. STUDY DESIGN: At 6 safety-net and private obstetrician-gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team-based data analysis to identify major themes and subthemes within the interview data. RESULTS: All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice- and staff-level competing demands, pregnant women's preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility. CONCLUSIONS: With guidance and commitment to integration of new processes, obstetrician-gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician-gynecology practice setting, and provide access to preventive health care for many women.