Effect of decision support on missed opportunities for human papillomavirus vaccination

Am J Prev Med. 2014 Dec;47(6):734-44. doi: 10.1016/j.amepre.2014.08.010. Epub 2014 Nov 18.


Background: Missed opportunities for human papilloma virus (HPV) vaccination are common, presenting a barrier to achieving widespread vaccine coverage and preventing infection.

Purpose: To compare the impact of clinician- versus family-focused decision support, none, or both on captured opportunities for HPV vaccination.

Design: Twelve-month cluster randomized controlled trial conducted in 2010-2011.

Setting/participants: Adolescent girls aged 11-17 years due for HPV Dose 1, 2, or 3 receiving care at primary care practices.

Intervention: Twenty-two primary care practices were cluster randomized to receive a three-part clinician-focused intervention (educational sessions, electronic health record-based alerts, and performance feedback) or none. Within each practice, girls were randomized at the patient level to receive family-focused, automated, educational phone calls or none. Randomization resulted in four groups: clinician-focused, family-focused, combined, or no intervention.

Main outcome measures: Standardized proportions of captured opportunities (due vaccine received at clinician visit) were calculated among girls in each study arm. Analyses were conducted in 2013.

Results: Among 17,016 adolescent girls and their 32,472 visits (14,247 preventive, 18,225 acute), more HPV opportunities were captured at preventive than acute visits (36% vs 4%, p<0.001). At preventive visits, the clinician intervention increased captured opportunities by 9 percentage points for HPV-1 and 6 percentage points for HPV-3 (p≤0.01), but not HPV-2. At acute visits, the clinician and combined interventions significantly improved captured opportunities for all three doses (p≤0.01). The family intervention was similar to none. Results differed by practice setting; at preventive visits, the clinician intervention was more effective for HPV-1 in suburban than urban settings, whereas at acute visits, the clinician intervention was more effective for all doses at urban practices.

Conclusions: Clinician-focused decision support is a more effective strategy than family-focused to prevent missed HPV vaccination opportunities. Given the persistence of missed opportunities even in intervention groups, complementary strategies are needed. This study is registered at clinicaltrials.gov NCT01159093.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Decision Support Systems, Clinical*
  • Female
  • Humans
  • Medical Order Entry Systems*
  • Papillomavirus Infections / prevention & control*
  • Papillomavirus Vaccines / administration & dosage*
  • Physician-Patient Relations
  • Preventive Health Services / methods*
  • Primary Health Care / methods
  • Professional-Family Relations
  • Staff Development / organization & administration*
  • United States
  • Vaccination* / methods
  • Vaccination* / psychology
  • Vaccination* / statistics & numerical data


  • Papillomavirus Vaccines

Associated data

  • ClinicalTrials.gov/NCT01159093