Abstract：
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.
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.
摘要：
背景：评估和反馈是提高医疗保健提供者对临床指南的保真度的常见实施策略。对于免疫指南，保真度通常在符合条件的访视期间使用剂量进行测量。添加患者拒绝度量更完全地捕获提供者保真度(即，提供者推荐疫苗的所有实例，导致疫苗接种或拒绝)，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特定疫苗的多个拒绝实例，现有的拒绝账单代码不是疫苗特异性的。这项研究评估了在一项针对人乳头瘤病毒（HPV）疫苗的研究中使用的新型拒绝记录方法的可行性。
方法：观察性，描述性比较，混合方法研究设计用于实施-有效性试验的次要数据分析.家长试验比较了基于教练的实践和基于网络的实践促进，包括评估和反馈，在21个社区私人儿科诊所中增加HPV疫苗接种。指示提供者在EHR的免疫表格中记录最初的HPV疫苗拒绝，并使用虚拟程序代码记录随后的拒绝。用于评估和反馈报告。本分析检查了在合格的井访问期间采用和维持拒绝文件方法，确定了文档的障碍和促进者，并描述了拒绝患者的人口统计模式。
结果：七种做法采用了拒绝文件法。在采用者的做法中，记录在案的拒绝始于基线时符合条件的井访视的2.4%，开始实施时增加到14.2%，峰值为24.0%，然后下降到18.8%。拒绝文件的障碍包括低优先级，工作流集成和计费过程的复杂性。调解人包括高动机，文档说明和教练支持。在采用者的做法中，与11-12岁相比，15-17岁的患者拒绝HPV疫苗的几率高出25%，男性比女性低18%。
结论：我们证明了患者拒绝文档对测量HPV疫苗接种指南保真度的价值，以及在未来研究中可以改进的方法。创建疫苗特定的拒绝账单代码或EHR改编以能够记录特定疫苗拒绝的多个实例将有助于一致的拒绝文档。试验注册NCT03399396于2018年1月16日在ClinicalTrials.gov注册。
方法：观察性，描述性比较，混合方法研究设计用于实施-有效性试验的次要数据分析.家长试验比较了基于教练的实践和基于网络的实践促进，包括评估和反馈，在21个社区私人儿科诊所中增加HPV疫苗接种。指示提供者在EHR的免疫表格中记录最初的HPV疫苗拒绝，并使用虚拟程序代码记录随后的拒绝。用于评估和反馈报告。本分析检查了在合格的井访问期间采用和维持拒绝文件方法，确定了文档的障碍和促进者，并描述了拒绝患者的人口统计模式。
结果：七种做法采用了拒绝文件法。在采用者的做法中，记录在案的拒绝始于基线时符合条件的井访视的2.4%，开始实施时增加到14.2%，峰值为24.0%，然后下降到18.8%。拒绝文件的障碍包括低优先级，工作流集成和计费过程的复杂性。调解人包括高动机，文档说明和教练支持。在采用者的做法中，与11-12岁相比，15-17岁的患者拒绝HPV疫苗的几率高出25%，男性比女性低18%。
结论：我们证明了患者拒绝文档对测量HPV疫苗接种指南保真度的价值，以及在未来研究中可以改进的方法。创建疫苗特定的拒绝账单代码或EHR改编以能够记录特定疫苗拒绝的多个实例将有助于一致的拒绝文档。试验注册NCT03399396于2018年1月16日在ClinicalTrials.gov注册。
