Paul M. Darden

To test the effectiveness of a comprehensive team-based intervention to improve human papillomavirus (HPV) vaccination completion rates and reduce missed opportunities to vaccinate in rural Oregon. Stepped-wedge cluster randomized trial. Forty family physicians and pediatricians who are members of the Oregon Rural Practice-based Research Network. Tailored to individual practice needs, components will include (1) practice facilitation with clinicians, nurses, front office staff, and others who have patient contact to redesign patient care and communication strategies to optimize HPV vaccine series completion; (2) workflow mapping adapted to practice context to support HPV vaccine delivery; (3) a practice improvement model designed to firmly establish reminder and recall systems and then standing orders; (4) education for patients and parents that underscores HPV vaccination is safe, effective, and an important approach for reducing cancer risk; and (5) partnering with community organizations to plan and implement a social marketing campaign on HPV vaccination. Initiation and completion of the HPV vaccine series as well as reduction in rates of missed opportunities to vaccinate derived from Oregon Immunization Program data. ClinicalTrials.govPRS, NCT03604393 : .Trial was registered on July 11, 2018. The first participant was enrolled on September 11, 2018.

Oklahoma ranked 43rd in the 2017 America's Health Rankings largely due to health behaviors such as adult obesity, lack of physical activity and smoking. Oklahoma children also suffer from adverse childhood experiences that contribute to poor health outcomes. Community engagement, a process that involves people affiliated by geographic location and shared interest working together to address issues affecting community wellbeing, is a common model that has had some success in Oklahoma communities addressing child health. Factors that contribute to poor health in Oklahoma include not only health behaviors such as obesity and smoking, but also lack of access to care created by a lack of health insurance and primary care providers, compounded by the largely rural nature of the state. The National Institutes of Health is committed to funding research aimed at improving the health of rural and disadvantaged populations. Historically, these populations are difficult to reach and may not be interested in the national health research initiatives, but rather want to focus on health issues important to their communities. In this article we discuss some of Oklahoma's most pressing pediatric health needs, community engagement efforts to address these issues and a newly funded NIH grant at OUHSC aimed at supporting and learning from these efforts.

National data on vaccine up-to-date (UTD) suggest that insufficient numbers of adolescents receive needed vaccines. This study analyzed public use data of the National Immunization Survey-Teen (NIS-Teen) from 2010 through 2013 for South Carolina (SC) adolescents and compared immunization rates to those of United States (US) adolescents. We also examined trends for each vaccine recommended for adolescents for both SC and US adolescents. UTD rates in SC adolescents for the quadrivalent meningococcal conjugate vaccine (MCV4) and the tetanus- diphtheria, acellular pertussis (Tdap) vaccine lag those of US adolescents, despite demonstrating a trend of improvement in SC adolescents from 45% to 69% for MCV and from 48% to 72% for Tdap. Human papillomavirus (HPV) vaccine UTD rates for SC adolescents demonstrated improvement over a 4 year period. HPV vaccination for SC girls improved when compared to the US, however UTD rates for both the SC and US were still well below the Healthy People 2020 goal of 80%. For all three vaccines, parental recall for a provider recommendation to vaccinate their adolescent was around or below 50%, except for HPV in females where it reached 65% in SC and 69% in the US. Differences between state and national rates may help SC providers focus on specific interventions needed to improve UTD rates.

Because adolescents make relatively few visits to clinics for preventive care, their vaccination rates suffer. We examined rates among Minnesota youths to see how they compared with those among teens throughout the United States. We used National Immunization Survey-Teen (NIS-Teen) data to estimate vaccination rates for 13- to 17-year-olds in Minnesota from 2008 through 2013 and compared them to national rates for MCV4, Tdap and HPV vaccines. We also examined rates of provider recommendation for each of the three vaccines and rates of parental intention to vaccinate against HPV. We found rates for all three vaccinations increased between 2008 and 2013, but they continue to be low for both MCV4 (69%) and HPV (38% of females and 9% of males completed the three-dose series in 2013). Fortunately, the percentage of Minnesota clinicians recommending those vaccines is increasing (the percentage recommending HPV vaccination for females increased from 55% in 2008 to 74% in 2013; however, only 44% recommended it for males in 2013). The percentage of parents in Minnesota reporting intent to vaccinate their female children against HPV rose from 52% in 2008 to 58% in 2013; the percentage intending to vaccinate their male children rose from 16% in 2010 to 47% in 2013. Clinicians and public health officials must address how we can improve HPV vaccination rates among adolescents.

Primary care practice-based research has become more complex with increased use of electronic health records (EHRs). Little has been reported about changes in study planning and execution that are required as practices change from paper-based to electronic-based environments. We describe the evolution of a pediatric practice-based intervention study as it was adapted for use in the electronic environment, to enable other practice-based researchers to plan efficient, effective studies. We adapted a paper-based pediatric office-level intervention to enhance parent-provider communication about subspecialty referrals for use in two practice-based research networks (PBRNs) with partially and fully electronic environments. We documented the process of adaptation and its effect on study feasibility and efficiency, resource use, and administrative and regulatory complexities, as the study was implemented in the two networks. Considerable time and money was required to adapt the paper-based study to the electronic environment, requiring extra meetings with institutional EHR-, regulatory-, and administrative teams, and increased practice training. Institutional unfamiliarity with using EHRs in practice-based research, and the consequent need to develop new policies, were major contributors to delays. Adapting intervention tools to the EHR and minimizing practice disruptions was challenging, but resulted in several efficiencies as compared with a paper-based project. In particular, recruitment and tracking of subjects and data collection were easier and more efficient. Practice-based intervention research in an electronic environment adds considerable cost and time at the outset of a study, especially for centers unfamiliar with such research. Efficiencies generated have the potential of easing the work of study enrollment, subject tracking, and data collection.

OBJECTIVE: To determine the reasons adolescents are not vaccinated for specific vaccines and how these reasons have changed over time. METHODS: We analyzed the 2008–2010 National Immunization Survey of Teens examining reasons parents do not have their teens immunized. Parents whose teens were not up to date (Not-UTD) for Tdap/Td and MCV4 were asked the main reason they were not vaccinated. Parents of female teens Not-UTD for human papillomavirus vaccine (HPV) were asked their intent to give HPV, and those unlikely to get HPV were asked the main reason why not. RESULTS: The most frequent reasons for not vaccinating were the same for Tdap/Td and MCV4, including “Not recommended” and “Not needed or not necessary.” For HPV, the most frequent reasons included those for the other vaccines as well as 4 others, including “Not sexually active” and “Safety concerns/Side effects.” “Safety concerns/Side effects” increased from 4.5% in 2008 to 7.7% in 2009 to 16.4% in 2010 and, in 2010, approaching the most common reason “Not Needed or Not Necessary” at 17.4% (95% CI: 15.7–19.1). Although parents report that health care professionals increasingly recommend all vaccines, including HPV, the intent to not vaccinate for HPV increased from 39.8% in 2008 to 43.9% in 2010 (OR for trend 1.08, 95% CI: 1.04–1.13). CONCLUSIONS: Despite doctors increasingly recommending adolescent vaccines, parents increasingly intend not to vaccinate female teens with HPV. The concern about safety of HPV grew with each year. Addressing specific and growing parental concerns about HPV will require different considerations than those for the other vaccines.

Objectives.: We assessed whether extra-immunization can serve as a clinical indicator for fragmentation of care. Methods.: Using public-use files of the 1999–2003 National Immunization Survey, we classified children 19–35 months of age by their vaccination providers for the degree of fragmentation of care as ordered from lowest with one vaccine provider, to increasing fragmentation with multiple providers in one facility type, to multiple providers in more than one facility type. Extra-immunization was defined conservatively based on the year-specific recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunizations due before 18 months of age. Of note, 1999–2003 transitioned from oral to inactivated poliovirus vaccines. Results.: The rate for extra-immunization was 9.4% (95% confidence interval [CI] 9.2, 9.7). Of single vaccines, the rate for polio vaccine was highest (5.7%, 95% CI 5.5, 6.0). Extra-immunization was lowest for the 69% of children with only one vaccination provider (6.4%, 95% CI 6.1, 6.7), was higher in children who had more than one vaccination provider with one vaccination facility type (13.9%, 95% CI 13.2, 14.6), and highest with more than one facility type (24.1%, 95% CI 22.5, 25.6). Logistic regression (including race/ethnicity, language, provider type, survey year, and a parent-held immunization record) confirmed that multiple providers (adjusted odds ratio [AOR] = 2.30), multiple facility types (AOR=4.67), Spanish language (AOR=1.29), and race/ethnicity (black AOR=1.16, Hispanic AOR=1.31) were each associated with extra-immunization. Excluding poliovirus vaccine from the analysis, AORs for multiple providers and multiple facility types increased to 3.64 and 8.95, respectively. Conclusions.: Extra-immunization is associated with receiving immunizations from multiple providers and multiple facility types.