Clinician Prompts for Human Papillomavirus Vaccination: A Cluster Randomized Trial.

OBJECTIVE: We assessed the impact of an online intervention using clinician prompts for human papillomavirus (HPV) vaccination with a cluster randomized controlled trial. METHODS: The randomized trial occurred July 2021-January 2022 in 48 primary care pediatric practices (24 intervention, 24 control) across the US. We trained clinicians via two online learning modules, plus weekly ''quick tips'' delivered via text or email. The training taught practices to implement a staff prompt to the clinician (e.g., printed reminders placed on the keyboard) plus electronic health record (EHR) prompts (if not already done) at well and acute/chronic visits for initial and subsequent HPV vaccination. We assessed missed opportunities for HPV vaccination using logistic regression models accounting for clustering by practice on an intent to treat basis. Surveys assessed facilitators and barriers to using prompts. RESULTS: During the 6-month intervention, missed opportunities for HPV vaccination increased (worsened) in both intervention and control groups. However, at well child care visits, missed opportunities for the initial HPV vaccine increased by 4.5 (95% CI: -9.0%, -0.1%) percentage points less in intervention versus control practices. Change in missed opportunities for subsequent doses at well child care and non-well child care visits did not differ between trial groups. An end-of trial survey found understaffing as a common challenge. CONCLUSIONS: Clinician prompts reduced missed opportunities for HPV vaccination at well child care visits. Understaffing related to the COVID-19 pandemic may have led to worsening missed opportunities for both groups and likely impeded practices in fully implementing changes.

Missed Opportunities for Adolescent Immunizations at Well-Care Visits During the COVID-19 Pandemic.

PURPOSE: The Coronavirus Disease 2019 pandemic disrupted healthcare, but the impact on vaccination missed opportunities (MOs, vaccine-eligible visits without vaccination) is unknown. We evaluated pandemic-related trends in MOs at adolescent well-care visits for three vaccines: human papillomavirus; quadrivalent meningococcal conjugate; and tetanus, diphtheria, and acellular pertussis (Tdap). METHODS: We analyzed electronic health record data from 24 pediatric primary care practices in 13 states from 1/1/2018 to 12/31/2021. Segmented logistic regression estimated risk differences for MOs during the pandemic relative to prepandemic trends. RESULTS: Among 106,605 well-care visits, we observed decreases in MOs prepandemic followed by an increase in MOs during the pandemic for all three vaccines. Relative to prepandemic, MOs increased for human papillomavirus (+15.9%, 95% confidence interval [CI]: 11.7%, 20.1%), meningococcal conjugate (+9.4%, 95% CI: 5.2%, 13.7%), and tetanus, diphtheria, and acellular pertussis (Tdap) (+ 8.2%, 95% CI: 4.3%, 12.1%). DISCUSSION: Increases in vaccine MOs during the pandemic equaled or exceeded pre-pandemic decreases. Reducing MOs in adolescent well-care could raise vaccine coverage.

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

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.

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

Importance: Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. Objectives: 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. Design, Setting, and Participants: 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. Interventions: 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. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT03599557.

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.

INTRODUCTION: Little is known about missed opportunities (MOs) for HPV vaccination during primary care visits at which influenza vaccination is delivered. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

Influenza A(H3N2) Variant Virus Outbreak at Three Fairs - Maryland, 2017.

On September 17, 2017, the Maryland Department of Agriculture (MDA) was notified by fair and 4-H officials of ill swine at agricultural fair A, held September 14-17. That day, investigation of the 107 swine at fair A revealed five swine with fever and signs of upper respiratory tract illness. All five respiratory specimens collected from these swine tested positive for influenza A virus at the MDA Animal Health Laboratory, and influenza A(H3N2) virus was confirmed in all specimens by the U.S. Department of Agriculture National Veterinary Services Laboratory (NVSL). On September 18, MDA was notified by fair and 4-H officials that swine exhibitors were also ill. MDA alerted the Maryland Department of Health (MDH). A joint investigation with MDH and the local health department was started and later broadened to Maryland agricultural fairs B (September 13-17) and C (September 15-23). In total, 76 persons underwent testing for variant influenza, and influenza A(H3N2) variant (A(H3N2)v) virus infection was identified in 40 patients with exposure to swine at these fairs (Figure), including 30 (75%) who had more than one characteristic putting them at high risk for serious influenza complications; 24 (60%) of these were children aged <5 years. Twenty-six (65%) patients reported direct contact with swine (i.e., touching swine or swine enclosure), but 14 (35%) reported only indirect contact (e.g., walking through a swine barn). Two children required hospitalization; all patients recovered. This outbreak highlights the risk, particularly among children, for contracting variant influenza virus at agricultural fairs after direct or indirect swine contact. Publicizing CDC's recommendation that persons at high risk for serious influenza complications avoid pigs and swine barns might help prevent future variant influenza outbreaks among vulnerable groups (1).

Timing of Puberty in Overweight Versus Obese Boys.

BACKGROUND AND OBJECTIVE: Studies of the relationship of weight status with timing of puberty in boys have been mixed. This study examined whether overweight and obesity are associated with differences in the timing of puberty in US boys. METHODS: We reanalyzed recent community-based pubertal data from the American Academy of Pediatrics' Pediatric Research in Office Settings study in which trained clinicians assessed boys 6 to 16 years for height, weight, Tanner stages, testicular volume (TV), and other pubertal variables. We classified children based on BMI as normal weight, overweight, or obese and compared median age at a given Tanner stage or greater by weight class using probit and ordinal probit models and a Bayesian approach. RESULTS: Half of boys (49.9%, n = 1931) were white, 25.8% (n = 1000) were African American, and 24.3% (n = 941) were Hispanic. For genital development in white and African American boys across a variety of Tanner stages, we found earlier puberty in overweight compared with normal weight boys, and later puberty in obese compared with overweight, but no significant differences for Hispanics. For TV (≥3 mL or ≥4 mL), our findings support earlier puberty for overweight compared with normal weight white boys. CONCLUSIONS: In a large, racially diverse, community-based sample of US boys, we found evidence of earlier puberty for overweight compared with normal or obese, and later puberty for obese boys compared with normal and overweight boys. Additional studies are needed to understand the possible relationships among race/ethnicity, gender, BMI, and the timing of pubertal development.

To report or not to report: examination of the initial primary care management of suspicious childhood injuries.

OBJECTIVE: This study examined the validity of primary health care providers' (PHCPs) assessment of suspicion that an injury was caused by child abuse and their decision to report suspected child abuse to child protective services (CPS). METHODS: By using a subsample of injuries drawn from the 15,003 childhood injuries evaluated in the Child Abuse Recognition and Evaluation Study, PHCPs completed telephone interviews concerning a stratified sample (no suspicion of abuse; suspicious but not reported; and suspicious of abuse and reported) of 111 injury visits. Two techniques were used to validate the PHCPs' initial decision: expert review and provider retrospective self-assessment. Five child abuse experts reviewed clinical vignettes created by using data prospectively collected by PHCPs about the patient encounter. The PHCPs' opinions 6 weeks and 6 months after the injury-related visits were elicited and analyzed. RESULTS: PHCPs and experts agreed about the suspicion of abuse in 81% of the cases of physical injury. PHCPs did not report 21% of injuries that experts would have reported. Compared with expert reviewers, PHCPs had a 68% sensitivity and 96% specificity in reporting child abuse. A PHCP's decision to report suspected child abuse to CPS did not reduce the frequency of primary care follow-up in the 6 months after the index visit. PCHPs received information from their state CPS in 70% of the reported cases. CONCLUSIONS: Child abuse experts and PHCPs are in general agreement concerning the assessment of suspected child physical abuse, although experts would have reported suspected abuse to CPS more frequently than the PHCPs. Future training should focus on clear guidance for better recognition of injuries that are suspicious for child abuse and state laws that mandate reporting.

From suspicion of physical child abuse to reporting: primary care clinician decision-making.

OBJECTIVES: The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS: In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS: Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS: Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.

Clinicians' description of factors influencing their reporting of suspected child abuse: report of the Child Abuse Reporting Experience Study Research Group.

OBJECTIVES: Primary care clinicians participating in the Child Abuse Reporting Experience Study did not report all suspected physical child abuse to child protective services. This evaluation of study data seeks (1) to identify factors clinicians weighed when deciding whether to report injuries they suspected might have been caused by child abuse; (2) to describe clinicians' management strategies for children with injuries from suspected child abuse that were not reported; and (3) to describe how clinicians explained not reporting high-suspicion injuries. METHODS: From the 434 pediatric primary care clinicians who participated in the Child Abuse Reporting Experience Study and who indicated they had provided care for a child with an injury they perceived as suspicious, a subsample of 75 of 81 clinicians completed a telephone interview. Interviewees included 36 clinicians who suspected child abuse but did not report the injury to child protective services (12 with high suspicion and 24 with some suspicion) and 39 who reported the suspicious injury. Interviews were analyzed for major themes and subthemes, including decision-making regarding reporting of suspected physical child abuse to child protective services and alternative management strategies. RESULTS: Four major themes emerged regarding the clinicians' reporting decisions, that is, familiarity with the family, reference to elements of the case history, use of available resources, and perception of expected outcomes of reporting to child protective services. When they did not report, clinicians planned alternative management strategies, including active or informal case follow-up management. When interviewed, some clinicians modified their original opinion that an injury was likely or very likely caused by abuse, to explain why they did not report to child protective services. CONCLUSIONS: Decisions about reporting to child protective services are guided by injury circumstances and history, knowledge of and experiences with the family, consultation with others, and previous experiences with child protective services.