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The American Journal of Managed Care November 2017
Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
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Brock O’Neil, MD; Mark Tyson, MD; Amy J. Graves, SM, MPH; Daniel A. Barocas, MD, MPH; Sam S. Chang, MD, MBA; David F. Penson, MD, MPH; and Matthew J. Resnick, MD, MPH
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Ann S. O’Malley, MD, MPH; Deborah Peikes, PhD, MPA; Claire Wilson, PhD; Rachel Gaddes, MPH; Victoria Peebles, MSW; Timothy J. Day, MSPH; and Janel Jin, MSPH
Impact of Health Reform on Young Adult Prescription Medication Utilization
Amy Pakyz, PharmD, PhD, MS; Hui Wang, PhD; and Peter Cunningham, PhD
Reframing the Unaffordability Debate: Patient Responsibility for Physician Care
Katherine Hempstead, PhD; Josh Gray, MBA; and Anna Zink, BA
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Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use
Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
Changes in Cardiovascular Care Provision After the Affordable Care Act
Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
Diabetes Care Improvement in Pharmacist- Versus Nurse-Supported Patient-Centered Medical Homes
Lillian Min, MD, MSHS; Christine T. Cigolle, MD, MS; Steven J. Bernstein, MD, MPH; Kathleen Ward, MPA; Tisha L. Moore, MPH; Jinkyung Ha, PhD; and Caroline S. Blaum, MD, MS
Validation of a Claims-Based Algorithm to Characterize Episodes of Care
Chad Ellimoottil, MD, MS; John D. Syrjamaki, MPH; Benedict Voit, MBA; Vinay Guduguntla, BS; David C. Miller, MD, MPH; and James M. Dupree, MD, MPH

Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use

Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
The use of the electronic health record’s clinical reminder functionality is systematically related to higher human papillomavirus vaccine administration rates.
ABSTRACT

Objectives: To study the association of using an electronic health record (EHR)’s clinical reminder functionality with increased human papillomavirus (HPV) vaccine administration among US office-based physicians.

Study Design: National Ambulatory Medical Care Survey data from 2007-2012 were pooled together to determine if EHR systems that employ clinical reminders are associated with increased immunization rates in different populations.

Methods: The administration of HPV vaccine served as the dependent variable, with the EHR reminder being the primary independent variable of interest. Logit regression was used to assess the relationship between using EHR reminders and HPV vaccine administration.

Results: Analyses indicated that compared with physicians without clinical reminder functions, physicians with clinical reminder functions were more likely to order HPV vaccines. Clinical reminder functions were particularly effective at increasing HPV vaccine use among adolescent males.

Conclusions: Overall, physicians who report using clinical reminders were more likely to order HPV immunizations. However, the association of clinical reminders with HPV immunizations was not significant in the younger adolescent subpopulation. Further, given that HPV incidence decreases significantly even with small gains in vaccination rates, the increase in HPV immunizations found in the male population aged 11 to 21 years is promising. Therefore, targeting males to receive HPV vaccination immunizations through clinical reminders provides a positively disproportionate return on vaccination rates and disease burden.

Am J Manag Care. 2017;23(11):e353-e359
Takeaway Points

A significant amount of time, effort, and money has gone into increasing the meaningful use of electronic health records (EHRs). This study’s findings demonstrate that: 
  • Using clinical reminders is strongly associated with higher vaccination rates for human papillomavirus (HPV). 
  • The adolescent male population has an especially higher HPV vaccination rate in the presence of clinical reminders. 
  • EHR-driven clinical reminders have the potential to increase preventive care among at-risk, but often neglected, subpopulations.
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, causing genital warts and cervical and other cancers. It is estimated that 79 million people are currently infected and 14 million people acquire new HPV infections each year in the United States.1 Furthermore, 17,500 female and 9300 male Americans are affected by HPV-associated cancers annually.2 The widespread availability of an HPV vaccine has the promise to reduce the spread of many infectious diseases, including several that lead to cancers.3,4 Despite the efficacy of HPV vaccines, their use continues to lag behind that of other immunizations (eg, the tetanus, diphtheria, and pertussis vaccine and the first of 2 doses of quadrivalent conjugate meningococcal vaccine) among the targeted age groups.5,6 Moreover, differences in vaccination rates may be systematically linked to sociodemographic characteristics and represent an inequality in care delivery.7,8 Therefore, increasing HPV vaccine use to the levels of other commonly administered immunizations and across at-risk populations is desirable.9

One tool for improving primary care quality, particularly for routine tasks such as immunization administration, is the electronic health record (EHR). EHRs have the ability to provide clinical reminders that support evidence-based care; as such, there is an expectation that such systems will improve care processes and outcomes. Prior study results have shown that uses of EHR and clinical decision support are associated with improvements in preventive care services, such as health behavioral counseling, screening tests, prevention and management of chronic diseases (eg, cancer and cardiovascular diseases), preventive medications prescribed, and vaccination.10-21 The promise of improved care was foundational to the US government’s Meaningful Use program to increase physicians’ adoption and implementation of EHR systems.22 Within that context, one can empirically test the question of whether EHRs with clinical reminders have improved adherence to HPV immunization guidelines.

The purpose of this article is to explore the relationships among EHR adoption, clinical reminder use, and HPV immunization rates. Data from the 2007-2012 National Ambulatory Medical Care Survey (NAMCS) are analyzed using logit model regressions, with HPV immunization rates as the dependent variable. The results include analyses of HPV vaccination rates across sociodemographic groups; a discussion of the findings’ implications and areas of future research are promulgated. 

The study’s findings address an important interest area for public health officials, policy makers charged with promoting EHR Meaningful Use criteria, those seeking equity in healthcare provision, and clinicians. For public health advocates, any tool that increases effective immunization adherence in support of disease prevention is an important contribution to the well-being of communities. Additionally, policy makers responsible for the Meaningful Use program need meaningful measurements to assess whether increased EHR adoption leads to better treatment modalities. Mitigating care delivery disparities is an important aim for many government programs, including Meaningful Use. Lastly, for clinicians, evidence that EHRs can help them deliver better care is needed to more effectively assess the return on investment associated with owning and operating such a technology.

METHODS

Data Source and Sample

This study used the 2007-2012 iterations of the NAMCS to assess the use of clinical reminders in relation to HPV immunization rates in visits to office-based physicians. The NAMCS is a national probability sample survey administered by the National Center for Health Statistics on behalf of the CDC that collects data on patient visits to non–federally employed office-based physicians. For each visit, physicians or staff members complete a 1-page survey containing patient demographics, reasons for the visit, physician’s diagnoses, and medications ordered, supplied, administered, or continued during patient encounters. The NAMCS uses a multistage probability sampling design, which allows for the generation of nationally representative estimates. 

This study analyzed visits by adolescents recommended to receive HPV vaccines to all office-based physicians, including primary care physicians, pediatricians, internists, obstetricians/gynecologists, and other specialists. Detailed descriptions of physician specialties are available from the authors and on the NAMCS website. HPV vaccination is recommended for both girls and boys at age 11 or 12 years. Females aged 13 to 26 years and males aged 13 to 21 years who have not been vaccinated previously are also recommended to receive HPV vaccines.2 To estimate the influence of clinical reminders on HPV vaccines ordered or administered in the ambulatory setting during adolescent visits, the study analyzed 3 adolescent visit samples during 2007-2012: 1) visits with patients aged 11 to 12 years (3388 visits), 2) visits with patients aged 11 to 18 years (14,354 visits), and 3) visits with female patients aged 11 to 26 years and male patients aged 11 to 21 years (25,573 visits).

Measures

HPV vaccine immunization. The NAMCS contains data on medications ordered, supplied, administered, or continued during patient encounters. The outcome of interest in this study was a dichotomous measure that identifies whether the physician ordered, supplied, administered, or continued HPV vaccine immunizations during adolescent patient visits.

Clinical reminder use. In the NAMCS survey, physicians reported whether their practices used an EHR system and, if so, which functionalities their EHR included. Based on physician-reported information regarding specific EHR functionalities used in their practices, the key independent variable of this study was related to physicians’ use of the clinical reminder function of the EHR. The clinical reminder was coded by examining physicians’ response to the question, “Does your practice have computerized capabilities of providing reminders for guideline-based interventions or screening tests and how often is the capability used?” “Clinical reminder” was coded as "1" if the response was “Yes” and coded as "0" for those who responded “No,” “Unknown,” or “Yes, but turned off or not used.” In 2012, the NAMCS changed questions on specific EHR functionalities to differentiate between “routine use” and “nonroutine use” of specific functions such as clinical reminders.

Statistical Analysis

A cross-sectional analysis of pooled survey data was conducted. We used weighted multivariable logit regression to estimate the association of clinical reminder use with HPV vaccine immunization rates at adolescent visits. In each regression, we included interaction terms between a dichotomous indicator for patients’ sex (female) and clinical reminder use to examine how the association of clinical reminder use with HPV vaccine immunization rates varies between male and female adolescent patients. All of the regressions controlled for potential confounders, including patient demographic characteristics (race/ethnicity), visit characteristics (ie, preventive care visits, patient’s own primary care physician), and other covariates, such as metropolitan statistical area status and survey year. Instead of adjusted odds ratios, marginal effects of coefficients in logit regressions were estimated and presented in the subsequent result section because odds ratio interpretation of interaction terms in nonlinear models, such as logit models, are problematic.23,24

RESULTS

HPV Vaccine Immunization Rates by Clinical Reminder Use (unadjusted)

Survey-weighted descriptive statistics for HPV vaccine immunizations, clinical reminder use, and other covariates are reported in Table 1. From 2007 to 2012 in the United States, there were 89.1 million office-based physician visits by adolescents aged 11 to 12 years, 381.6 million ambulatory clinic visits by those aged 11 to 18 years, and 672.7 million visits by female adolescents aged 11 to 26 years and male adolescents aged 11 to 21 years. In ambulatory clinic visits by adolescents aged 11 to 18 years, approximately 40% were with clinical reminders. 

Table 2 presents survey-weighted rates of HPV vaccine immunizations by clinical reminder use in the different samples of adolescent visits. The rate of HPV vaccine immunizations varied by the use of clinical reminder function. Compared with physicians without clinical reminder functions, physicians with clinical reminder functions were more likely to order HPV vaccines. The pattern holds consistently across patients’ sex and age-group samples. For example, in female patients aged 11 to 12 years, HPV vaccines were ordered in 6.44% of encounters where a clinical reminder function was present and 5.24% when it was not. In visits by male patients aged 11 to 12 years, HPV vaccines were ordered in 1.50% of encounters with clinical reminders and 0.61% without. The subsequent section will detail further analysis on the statistical significance of these patterns, controlling for patient and visit characteristics.

Estimated Association Between Clinical Reminder Use and HPV Vaccine Immunization

Table 3 presents the differential estimated association of clinical reminder use with HPV vaccine immunizations by patient sex. Logit coefficients are presented in odd columns and marginal effects are presented in even columns. No statistically significant associations were found between clinical reminder use and HPV vaccine immunization in the samples of: 1) visits with patients aged 11 to 12 years and 2) visits with patients aged 11 to 18 years. In visits with female patients aged 11 to 26 years and male patients aged 11 to 21 years, use of clinical reminders was associated with a higher rate of HPV vaccine immunizations for male and female patients. Furthermore, the coefficients for the interaction term (Clinical reminder use × Female) were negative (marginal effect, –0.0136; P <.1), and the magnitude of the coefficients on the interaction is less than the magnitude of coefficients on clinical reminder use (marginal effect, 0.0164; P <.01). This indicates that the association of clinical reminder use with HPV vaccines ordered is greater in male encounters than in female encounters. 

Compared with male patients aged 11 to 21 years who visited physicians who did not adopt clinical reminders, male patients in the same age group who visited physicians who did use clinical reminders received more HPV vaccines, by 1.64 percentage points. This represents a relative increase of 146% from the mean probability of HPV vaccine immunizations (1.12%). Compared with female patients aged 11 to 26 years who visited physicians who did not adopt clinical reminders, female patients in the same age group who visited physicians who did use clinical reminders received more HPV vaccines, by 0.28 percentage points. This represents a relative increase of 10.7% from the mean probability of HPV vaccine immunizations (2.61%).

 
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