Effect of provider prompts on adolescent immunization rates: a randomized trial.
OBJECTIVE
Adolescent immunization rates are suboptimal. Experts recommend provider prompts at health care visits to improve rates. We assessed the impact of either electronic health record (EHR) or nurse- or staff-initiated provider prompts on adolescent immunization rates.


METHODS
We conducted a randomized controlled trial, allocating practices in 1 of 2 practice-based research networks (PBRN) to provider prompts or standard-of-care control. Ten primary care practices participated, 5 intervention and 5 controls, each matched in pairs on urban, suburban, or rural location and practice type (pediatric or family medicine), from a PBRN in Greater Rochester, New York (GR-PBRN); and 12 practices, 6 intervention, 6 controls, similarly matched, from a national pediatric continuity clinic PBRN (CORNET). The study period was 1 year per practice, ranging from June 2011 to January 2013. Study participants were adolescents 11 to 17 years attending these 22 practices; random sample of chart reviews per practice for baseline and postintervention year to assess immunization rates (n = 7,040 total chart reviews for adolescents with >1 visit in a period). The intervention was an EHR prompt (4 GR-PBRN and 5 CORNET practice pairs) (alert) that appeared on providers' computer screens at all office visits, indicating the specific immunizations that adolescents were recommended to receive. Staff prompts (1 GR-PBRN pair and 1 CORNET pair) in the form of a reminder sheet was placed on the provider's desk in the exam room indicating the vaccines due. We compared immunization rates, stratified by PBRN, for routine vaccines (meningococcus, pertussis, human papillomavirus, influenza) at study beginning and end.


RESULTS
Intervention and control practices within each PBRN were similar at baseline for demographics and immunization rates. Immunization rates at the study end for adolescents who were behind on immunizations at study initiation were not significantly different for intervention versus control practices for any vaccine or combination of vaccines. Results were similar for each PBRN and also when only EHR-based prompts was assessed. For example, at study end, 3-dose human papillomavirus vaccination rates for GR-PBRN intervention versus control practices were 51% versus 53% (adjusted odds ratio 0.96; 95% confidence interval 0.64-1.34); CORNET intervention versus control rates were 50% versus 42% (adjusted odds ratio 1.06; 95% confidence interval 0.68-1.88).


CONCLUSIONS
In both a local and national setting, provider prompts failed to improve adolescent immunization rates. More rigorous practice-based changes are needed.
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY. Electronic address: p_szilagyi@mednet.ucla.edu.
Peter G
PG
Szilagyi
Department of Pediatrics, Johns Hopkins University, Baltimore, Md.
Janet R
JR
Serwint
Division of Emergency and Urgent Care, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Mo.
Sharon G
SG
Humiston
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Cynthia M
CM
Rand
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Stanley
S
Schaffer
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Phyllis
P
Vincelli
Academic Pediatric Association, Atlanta, Ga.
Nui
N
Dhepyasuwan
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Aaron
A
Blumkin
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Christina
C
Albertin
Centers for Disease Control and Prevention, Atlanta, Ga.
C Robinette
CR
Curtis
D000293:Adolescent; D002648:Child; D004165:Diphtheria / Q000517:prevention & control; D022681:Diphtheria-Tetanus-acellular Pertussis Vaccines / Q000627:therapeutic use*; D057286:Electronic Health Records; D005194:Family Practice; D005260:Female; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data*; D007252:Influenza Vaccines / Q000627:therapeutic use*; D007251:Influenza, Human / Q000517:prevention & control; D008297:Male; D008589:Meningococcal Infections / Q000517:prevention & control; D022401:Meningococcal Vaccines / Q000627:therapeutic use*; D030361:Papillomavirus Infections / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000627:therapeutic use*; D010372:Pediatrics; D011320:Primary Health Care; D058996:Quality Improvement; D017010:Reminder Systems; D013742:Tetanus / Q000517:prevention & control; D014917:Whooping Cough / Q000517:prevention & control
D022681:Diphtheria-Tetanus-acellular Pertussis Vaccines; D007252:Influenza Vaccines; D022401:Meningococcal Vaccines; D053918:Papillomavirus Vaccines
EHR; HPV; Tdap; adolescent immunization; influenza; meningococcal; outreach; provider prompt