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Research ArticleOriginal Research

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion

Mack T. Ruffin, Melissa A. Plegue, Pamela G. Rockwell, Alisa P. Young, Divya A. Patel and Mark W. Yeazel
The Journal of the American Board of Family Medicine May 2015, 28 (3) 324-333; DOI: https://doi.org/10.3122/jabfm.2015.03.140082
Mack T. Ruffin IV
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
MD, MPH
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Melissa A. Plegue
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
MA
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Pamela G. Rockwell
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
DO
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Alisa P. Young
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
MD
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Divya A. Patel
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
PhD
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Mark W. Yeazel
From the Departments of Family Medicine (MTR, PGR, APY) and Obstetrics and Gynecology (DAP) and the Center for Statistical Consultation and Research (MAP), University of Michigan, Ann Arbor; and the Department of Family and Community Medicine, University of Minnesota, Minneapolis (MWY).
MD, MPH
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Article Figures & Data

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    Figure 1.

    Odds ratios (95% confidence intervals) of series initiation at the prompted site versus the unprompted site, at the level of covariates. The odds ratios from clustered logistic regression predicting receipt of ≥1 human papillomavirus doses versus no vaccination during observation, including age, race, number of visits, and interaction of all variables with study site. Analysis also adjusted for practice clustering using generalized estimated equations with an exchangeable working correlation structure. The dotted line represents an odds ratio of 1, which would indicate no significant site effect.

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    Figure 2.

    Odds ratios (95% confidence intervals) of series completion at the prompted site versus the unprompted site, at levels of covariates, among patients who initiated the human papillomavirus vaccine series and had the opportunity to complete the series during the observation period. The odds ratios from clustered logistic regression predicting receipt of all 3 vaccination doses versus any (i.e., 1 or 2) doses during observation, including age, race, number of visits, and interaction of all variables with study site. Analysis also adjusted for practice clustering using generalized estimated equations with an exchangeable working correlation structure. A total of 1936 patients at the prompted site and 1706 at the unprompted site had an opportunity to complete the series. The dotted line represents an odds ratio of 1, which would indicate no significant site effect.

  • Figure 3.
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    Figure 3.

    Time to each vaccine dose. The shaded boxes represent the interquartile range (25th to 75th percentile); the solid vertical lines within the shaded boxes represent the median. Dots are outliers beyond 1.5 times the interquartile range from the 75th percentile. The red dashed lines in each panel represent the “on time” time range for each interval.

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    Figure 4.

    Time between dose 1 to 2, 2 to 3, and 1 to 3 by age and race for each cohort. Hazard ratios were estimated using Cox proportional hazard models, with clustered standard errors, including age, race, study site, age*site interaction, and race*site interaction. Analysis for doses 1 to 2 and doses 1 to 3 included the 4,019 patients who initiated the series. Analysis for doses 2 to 3 included the 2,731 patients who received a second dose during the study period. The dotted line represents a hazard ratio of 1, which would indicate no significant site effect.

Tables

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    Table 1. Characteristics of Clinics, By Cohort
    Prompted CohortUnprompted Cohort
    Clinic 1Clinic 2Clinic 3Clinic 4Clinic 5Clinic 6Clinic 7Clinic 8Clinic 9
    FTE faculty physicians98.74.78.14.71011610
    Middle-level cliniciansYesYesYesYesYesNoYesNoNo
    Medical studentsYesYesYesYesYesYesYesYesYes
    ResidentsNoYesNoNoYesYesYesYesYes
    Patient visits in 200731,61130,32116,21318,38922,02226,21530,36721,54029,595
    Patient visits per FTE faculty physician3,512.33,485.23,449.62,270.24,685.52,621.52,760.63,590.02,959.5
    • FTE, full-time equivalent.

    • View popup
    Table 2. Characteristics of Study Patients
    CharacteristicsPrompted Cohort (n = 5994)Unprompted Cohort (n = 9027)P Value
    Age (years)<.001
        9–183304 (55.1)4585 (50.8)
        19–262690 (44.9)4442 (49.2)
        Mean (SD)17.8 (4.3)18.5 (4.8)<.001
    Race<.001
        White4026 (67.2)1437 (15.9)
        African American1101 (18.4)2957 (32.8)
        Other769 (12.9)1643 (18.2)
        Missing98 (1.6)2990 (33.1)
    HPV vaccine<.001
        03899 (65.0)7103 (78.7)
        1456 (7.6)832 (9.2)
        2431 (7.2)588 (6.5)
        31199 (20.0)492 (5.5)
        >39 (0.2)12 (0.1)
    • HPV, human papillomavirus; SD, standard deviation.

    • View popup
    Table 3. HPV Vaccine Given By Clinic Site Within Each Cohort by Age and Race*
    Prompted SitesUnprompted Sites
    Clinic 1Clinic 2Clinic 3Clinic 4Clinic 5Clinic 6Clinic 7Clinic 8Clinic 9
    Age (years)†
        9–18911 (52.2)738 (62.9)475 (53.8)591 (66.1)589 (45.4)1134 (52.2)879 (50.7)1066 (40.1)1506 (61.2)
        19–26835 (47.8)436 (37.1)408 (46.2)303 (33.9)708 (54.6)1039 (47.8)855 (49.3)1593 (59.9)955 (38.8)
        Mean (SD)18.0 (4.4)17.3 (4.2)17.8 (4.6)16.8 (4.3)18.8 (4.1)18.4 (4.9)18.5 (4.8)19.7 (4.4)17.3 (4.6)
    Race†
        White1175 (67.3)1116 (95.1)512 (58.0)778 (87.0)445 (34.3)210 (9.7)354 (20.4)611 (23.0)262 (10.6)
        African American331 (19.0)9 (0.8)90 (10.2)10 (1.1)661 (51.0)450 (20.7)208 (12.0)1184 (44.5)1115 (45.3)
        Other233 (13.3)37 (3.2)250 (28.3)69 (7.7)180 (13.9)548 (25.2)619 (35.7)301 (11.3)175 (7.1)
        Missing7 (0.4)12 (1.0)31 (3.5)37 (4.1)11 (0.8)965 (44.4)553 (31.9)563 (21.2)909 (36.9)
    HPV vaccine given during study period
        01169 (67.0)729 (62.1)652 (73.8)594 (66.4)755 (58.2)1602 (73.7)1160 (66.9)2114 (79.5)2227 (90.5)
        1102 (5.8)87 (7.4)40 (4.5)58 (6.5)169 (13.0)255 (11.7)238 (13.7)218 (8.2)121 (4.9)
        2114 (6.5)66 (5.6)52 (5.9)42 (4.7)157 (12.1)182 (8.4)187 (10.8)154 (5.8)65 (2.6)
        3360 (20.6)292 (24.9)136 (15.4)199 (22.3)212 (16.3)129 (5.9)147 (8.5)168 (6.3)48 (2.0)
        >31 (0.1)0 (0.0)3 (0.3)1 (0.1)4 (0.3)5 (0.2)2 (0.1)5 (0.2)0 (0.0)
    • ↵* Significant differences between clinics, within the same cohort, on all 3 variables (analysis of variance and χ2 P values <.001).

    • ↵† Includes patients eligible for HPV vaccine during the study period.

    • HPV, human papillomavirus; SD, standard deviation.

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The Journal of the American Board of Family     Medicine: 28 (3)
The Journal of the American Board of Family Medicine
Vol. 28, Issue 3
May-June 2015
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Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion
Mack T. Ruffin, Melissa A. Plegue, Pamela G. Rockwell, Alisa P. Young, Divya A. Patel, Mark W. Yeazel
The Journal of the American Board of Family Medicine May 2015, 28 (3) 324-333; DOI: 10.3122/jabfm.2015.03.140082

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Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion
Mack T. Ruffin, Melissa A. Plegue, Pamela G. Rockwell, Alisa P. Young, Divya A. Patel, Mark W. Yeazel
The Journal of the American Board of Family Medicine May 2015, 28 (3) 324-333; DOI: 10.3122/jabfm.2015.03.140082
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