Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine.
Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine.
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DOI：
10.1186/s12911-022-02083-2
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发表时间：
2022-12-22
影响因子：
3.5
通讯作者：
Hull, Pamela C. C.
中科院分区：
文献类型：
--
作者：
Chang, Rachel S. S.;Shing, Jaimie Z. Z.;Erves, Jennifer C. C.;Du, Liping;Koyama, Tatsuki;Deppen, Stephen;Rentuza, Alyssa B. B.;McAfee, Caree;Stroebel, Christine;Cates, Janet;Harnack, Lora;Andrews, David;Bramblett, Robert;Hull, Pamela C. C.
评估和反馈是提高医疗保健提供者对临床指南的忠诚度的常见实施策略。对于免疫指南，保真度通常是通过符合条件的就诊期间施用的剂量来衡量的。添加患者拒绝措施可以更完整地捕获提供者的忠诚度（即提供者推荐疫苗，导致接种或拒绝的所有实例），并使提供者能够跟踪患者疫苗犹豫模式。然而，许多电子健康记录 (EHR) 系统没有结构化字段来记录拒绝特定疫苗的多个实例，并且现有的拒绝计费代码并非特定于疫苗。本研究评估了针对人乳头瘤病毒 (HPV) 疫苗的研究中使用的拒绝记录新方法的可行性。采用观察性、描述性比较、混合方法研究设计来对实施效果试验进行二次数据分析。家长试验比较了基于教练和基于网络的实践促进（包括评估和反馈），以增加 21 个社区私人儿科诊所的 HPV 疫苗接种。提供者被要求在 EHR 免疫表格中记录最初拒绝接种 HPV 疫苗的情况，并使用虚拟程序代码记录随后拒绝接种的情况，以用于评估和反馈报告。该分析检查了在符合条件的井访问期间拒绝记录方法的采用和维护，确定了记录的障碍和促进因素，并描述了患者拒绝的人口统计模式。七个实践采用了拒绝记录方法。在采用者实践中，有记录的拒绝在基线时占合格探井的 2.4%，在实施开始时增加到 14.2%，达到峰值 24.0%，然后下降到 18.8%。拒绝记录的障碍包括优先级低、工作流程集成和计费流程复杂化。促进者包括高度的积极性、文档说明和教练支持。在采用者实践中，15-17 岁患者拒绝接种 HPV 疫苗的几率比 11-12 岁患者高 25%，男性比女性低 18%。我们证明了患者拒绝记录对于衡量 HPV 疫苗接种指南保真度的价值以及在未来研究中改进的方法。创建特定于疫苗的拒绝计费代码或 EHR 改编以记录特定疫苗拒绝的多个实例将有助于一致的拒绝记录。试验注册 NCT03399396 于 2018 年 1 月 16 日在 ClinicalTrials.gov 注册。
Assessment 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. An 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. Seven 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. We 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.
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