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

BMC Medical Informatics and Decision Making

Research

Lora Harnack¹  Janet Cates¹  Liping Du²  Tatsuki Koyama²  Jennifer C. Erves³  Alyssa B. Rentuza⁴  Stephen Deppen⁴  Jaimie Z. Shing⁴  Caree McAfee⁵  Christine Stroebel⁶  Pamela C. Hull⁷  Rachel S. Chang⁸  David Andrews⁹  Robert Bramblett⁹ 

[1] Cumberland Pediatric Foundation, Nashville, TN, USA;Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA;Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA;Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA;Markey Cancer Center, University of Kentucky, 2365 Harrodsburg Rd, Suite A230, 40504-3381, Lexington, KY, USA;Markey Cancer Center, University of Kentucky, 2365 Harrodsburg Rd, Suite A230, 40504-3381, Lexington, KY, USA;Cumberland Pediatric Foundation, Nashville, TN, USA;Markey Cancer Center, University of Kentucky, 2365 Harrodsburg Rd, Suite A230, 40504-3381, Lexington, KY, USA;Department of Behavioral Science, University of Kentucky, Lexington, KY, USA;School of Medicine, Vanderbilt University, Nashville, TN, USA;Sharecare, Atlanta, GA, USA;

关键词: Measurement;    Fidelity;    Clinical guidelines;    Assessment and feedback;    Vaccine refusal;   

DOI  :  10.1186/s12911-022-02083-2

 received in 2022-11-17, accepted in 2022-12-13,  发布年份 2022

来源: Springer

【 摘 要 】

BackgroundAssessment 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.MethodsAn 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.ResultsSeven 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.ConclusionsWe 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.

【 授权许可】

CC BY   
© The Author(s) 2022

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