Provider-based interventions may increase human papillomavirus vaccination rates

by Molly Munsell, Alex Gipsman, MD

Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In a meta-analysis of studies on provider-based interventions aimed at promoting human papillomavirus (HPV) vaccination, the rate of HPV vaccine initiation was 3.7% higher after the intervention.

2. Provider-based interventions were diverse, ranging from provider training to automated reminders, with heterogeneity in outcome measures between studies.

Evidence Rating Level: 2 (Good)

Study Rundown:

Though vaccination against human papillomavirus (HPV) in adolescence or young adulthood is effective in preventing cervical cancer, vaccine uptake remains low in the United States. While vaccine hesitancy and refusal among patients and parents play a role, some individual studies have shown that intervening on providers increases vaccination. This study aimed to assess the strength of this evidence for the US population using a systematic review and to estimate the effect of provider-based interventions using meta-analysis. A total of 32 studies examining a variety of interventions, from automated reminders in electronic medical records to provider training sessions on vaccine conversations to regular updates on provider- or clinic-level vaccination rates, were included. Interventions including provider assessment and feedback were used in 18 of these studies, usually in combination with other strategies. The systematic review showed mixed results for each type of intervention. However, a meta-analysis showed a statistically significant pooled 3.7% increase in HPV vaccine initiation in the intervention compared to control groups and a 9.4% increase in patients receiving their next needed vaccine dose. Very high levels of heterogeneity between the included studies limit the interpretation of these findings. The results suggest that interventions focused on nudging providers to recommend HPV vaccination may be effective, at least in the short term. However, the modest pooled effect sizes highlight the complexity of vaccine promotion efforts. Future studies combining provider-focused with parent- or community-focused interventions could help illuminate the role of the intervention itself.

In-Depth [systematic review and meta-analysis]:

Randomized controlled trials and pre/post studies were included if they quantitatively measured differences in HPV vaccination uptake before and after intervention in patients aged 9-26 in the United States. Cochrane risk-of-bias assessment was performed and showed that 6 of 15 randomized studies had a risk of bias, and 3 of 17 nonrandomized studies had a serious risk of bias. In the primary meta-analysis including 10 controlled studies, the pooled increase in HPV vaccine initiation rate after the intervention was 3.7% (95% CI 1.2-6.2%, p<0.01%), although the I2 statistic was 97.5%, indicating high heterogeneity. Among 5 studies reporting vaccine series completion rates in both intervention and control groups, the pooled effect size was not statistically significant. Across 4 studies, an intervention was associated with an increase of 9.4% in patients receiving their next needed vaccine dose (95% CI 4.8-14.0%, p<0.01), also with high heterogeneity.

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