Rates of vaccination against the human papillomavirus (HPV) remain low among adolescents in the United States, despite wide availability of the vaccine since 2006 for girls and 2009 for boys. Now, a new randomized controlled clinical trial suggests that patients may complete the HPV vaccine series when clinicians use an intervention specifically designed to facilitate communication with patients and their parents about the vaccine.
Implementation of this intervention resulted in an increase of 9.5 percentage points “in HPV vaccine series initiation compared with control practices, which was both clinically and statistically significant,” Amanda F. Dempsey, MD, PhD, MPH, and colleagues write in an article published online March 5 in JAMA Pediatrics.
The study included more than 40,000 adolescents 11 to 17 years of age attending 16 medical practices in the Denver, Colorado, metropolitan area.
Overall, the effect of the intervention was “modest, and all practices’ vaccination levels remained well below the national goal of 80% coverage,” the authors write. Nevertheless, sharing this information among primary care clinicians nationwide “could substantially increase national adolescent HPV vaccination levels, particularly among boys.”
The intervention, which was developed by Dempsey, an associate professor of pediatrics at the University of Colorado in Denver, and colleagues, consisted of five components. Clinicians particularly liked two components: fact sheets with practice-specific information about HPV infection and vaccination, and a 2-hour training for clinicians on using motivational interviewing techniques to improve their communication about the vaccine with patients and parents. The other components included a parent education website, visual images depicting diseases associated with HPV, and a decision aid for HPV vaccination.
Between February 1, 2015, and January 31, 2016, the authors conducted a 2-group, controlled cluster randomized clinical trial of 4 family medicine and 12 pediatric practices consisting of 188 physicians, nurse practitioners, medical assistants, and physician assistants. In the eight practices assigned to the intervention group, clinicians received maintenance of certification credits for their participation in the communication training, but no other incentive. Practices in the control group continued with their usual communication methods about the HPV vaccine, and the clinicians received no incentive for participation.
During the study period, vaccine data were gathered on 21,240 patients in the intervention group (median age at baseline, 12.5 years; interquartile range [IQR], 10.7-14.6; 50.8% girls) and 21,892 patients in the control group (median age at baseline, 12.6 years; IQR, 10.8-14.8; 49.7% girls). The proportion of eligible adolescents initiating the vaccine series increased significantly in both groups over time.
However, an intention-to-treat analysis including adjustment for medical specialty, practice type, age, sex, and insurance showed that the increases were significantly larger in the intervention group, at 11.3% vs 1.8% in the control group (P <. 001).
The adjusted odds ratio (aOR) for initiation was 1.46, and 1.56 for completion.
Moreover, “series completion significantly decreased in the control practices, while remaining stable in the intervention practices, resulting in intervention practices having significantly higher odds of completing the series than control practices,” the authors write.
The effect of the intervention was greater in pediatric and private practices compared with family medicine and public practices.
Private insurance was significantly associated with a higher rate of vaccine series initiation, but not completion, compared with public insurance. When analyzed over time, series initiation increased among patients with private insurance (aOR, 1.76; 95% confidence interval [CI], 1.55 – 1.99), but remained largely flat among patients with public insurance (aOR, 0.93; 95% CI, 0.76 – 1.14).
Of the five intervention components, clinicians used the communication techniques and the fact sheets most frequently, “with 72.2% to 90.0% and 51.5% to 84.4% of medical professionals reporting using them over the study period, respectively,” the authors add. In a survey conducted at the end of the study, more than 90% of the participants said they were likely to continue using those tools in their practices.
Intervention practices also experienced a significant reduction in missed opportunities for vaccination during well-child checkups compared with control practices (aOR, 0.61; 95% CI, 0.54 – 0.69). However, no significant difference was seen during sick-child visits (aOR, 0.87; 95% CI, 0.68 – 1.12). Because adolescents visit the physician more often for sick rather than preventive visits, the authors conclude, “finding mechanisms to improve vaccination at sick visits is a clear research priority.”
Dempsey reported serving on advisory boards for Merck, Pfizer, and Sanofi Pasteur and reported being a consultant to Pfizer. She also reported that she does not receive any research funding from these agencies and that they had no role in the research described in the study. The other study authors have disclosed no relevant financial relationships.
JAMA Pediatr. Published online March 5, 2018. Full text
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