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

Abstract

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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Szilagyi reported receiving grants from National Cancer Institute (NCI) National Institutes of Health (NIH) during the conduct of the study. Dr Humiston reported receiving grants from Pfizer Foundation and Pediatric Infectious Diseases Society Foundation; personal fees from the American Academy of Pediatrics (AAP) and its chapters, Immunization Action Coalition, University of California Los Angeles (UCLA), University of Rochester, and Sanofi Pasteur; Dr Humiston reported that her employer receives grant money for work sponsored by the Pediatric Infectious Diseases Society Foundation, which is funded for the project through unrestricted joint educational grants from Sanofi Pasteur US, Merck & Co Inc, Pfizer Inc, GlaxoSmithKline, and Seqirus USA Inc outside the submitted work. Dr Stephens-Shields reported receiving grants from the NCI during the conduct of the study. Dr Localio reported receiving grants from the NIH during the conduct of the study; and grants from the American College of Physicians, the NIH, and the US Department of Education outside the submitted work. Ms Kelly reported receiving grants from the NCI during the conduct of the study. Dr Grundmeier reported receiving grants from the NIH during the conduct of the study; and grants from the NIH, grants from Centers for Disease Control and Prevention (CDC), and grants from the Agency for Healthcare Research and Quality outside the submitted work. Ms Albertin reported receiving grants from the NIH during the conduct of the study. Dr Shone reported receiving grants from UCLA via subcontract to the AAP via Prime Awardee for work of Pediatric Research in Office Settings (PROS) network on the project during the conduct of the study; grants from Boston Children’s Hospital via Prime Award from the National Institute on Alcohol Abuse and Alcoholism, Children’s Hospital of Philadelphia via Prime Awards from the CDC and the Patient-Centered Outcomes Research Institute (PCORI), Columbia University via Prime Award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), University of Michigan via Prime Award from the National Heart, Lung, and Blood Institute, Seattle Children’s Hospital via Prime Award from the NICHD, Maternal Child Health Bureau salary support via grant to AAP from the Health Resources and Services Administration/Maternal and Child Health Bureau for PROS core network activities, and Boston Medical Center via Prime Award from NICHD outside the submitted work. Ms Steffes reported receiving grants from UCLA via subcontract to AAP from Prime Awardee during the conduct of the study; grants from Children’s Hospital of Philadelphia via Prime Award from CDC and PCORI, University of Michigan via Prime Award from NHLBI, Seattle Children’s Hospital via Prime Award from the NICHD, and Maternal and Child Health Bureau via Prime Award from the Health Resources and Services Administration/Maternal and Child Health Bureau outside the submitted work. Dr Rand reported receiving grants from the NCI during the conduct of the study. Ms Hannan reported that a family memberis employed by Merck. Dr Fiks reported receiving grants from NIH/NCI during the conduct of the study; receiving salary support from the AAP for serving as PROS Director and serving on multiple committees; receiving compensation from the American Medical Association to attend board meetings; serving on the editorial board of Annals of Family Medicine and receiving compensation to attend meetings; receiving an honorarium from Boston Medical Center for serving on an advisory board of a PCORI-funded study about anxiety; reimbursement from Children and Screens Foundation for travel to group meetings; honoraria from PCORI for reviewing research project summaries; honoraria from Prime for participating in an educational program; honoraria from University of Wisconsin for participating in a research study advisory board regarding patient-centered outcomes; receiving funding from the NIH for multiple research studies; receiving a the Health Resources and Services Administration/Maternal and Child Health Bureau grant that funds the PROS network; and honoraria from Washington University for participating in an educational program; developing software known as the Care Assistant, but holding no patent or licensing agreement, and earning no income from the invention. No other disclosures were reported.

Figures

Figure.. CONSORT Diagram Plus Practice and Adolescent Eligibility Criteria

Eligibility criteria for clinicians: worked in a participating practice and had at least 10 visits at the practice with an adolescent aged 11.0 to 17.9 years during the study period. Eligibility criteria for adolescents: aged 11.0 to 17.9 years on the day of the office visit. Adolescents were not recruited for the study. All adolescents meeting eligibility criteria at practices were included in analyses. The number of adolescents may be greater than the number of visits because some adolescents may not have had a human papillomavirus vaccine–eligible visit.