Electronic Health Record Alerts for Early Human Papillomavirus Vaccination

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Importance: Despite recommendations to begin human papillomavirus (HPV) vaccination as early as 9 years of age, uptake remains low. Objectives: To compare early HPV vaccine initiation between 2 interventions, compare vaccine completion rates between youths initiating HPV vaccination at 9 to 10 vs 11 to 14 years of age, and identify factors associated with early HPV vaccination initiation and series completion. Design, Setting, and Participants: This retrospective quality improvement study was conducted from January 1, 2019, to December 31, 2023. The study analyzed a quality improvement project using descriptive statistics and survival analyses. Youths aged 9 to 14 years with no prior HPV vaccination, who had at least 1 in-person visit, and who had complete electronic health record (EHR) data were included. The study took place at 21 US outpatient primary care sites within a large health system. Site assignments were based on patient volume and geographic location (urban and rural). Exposures: An EHR best practice alert (BPA) recommending HPV vaccination beginning at 9 years of age implemented with or without an added clinician education component. Main Outcomes and Measures: The primary outcome was HPV vaccine initiation at 9 to 10 years of age. Secondary outcomes included vaccine series completion within 2 years after initiation and factors associated with early initiation and completion. Outcomes were measured using EHR-recorded vaccination status and timing. Results: A total of 15 743 eligible patients (mean [IQR] age, 9.9 [9.0-11.0] years; 7946 [50.5%] male; 1260 [8.0%] Asian, 5082 [32.3%] Black or African American, 7621 [48.4%] White, 420 [2.7%] unknown race, and 1360 [8.6%] other race, including American Indian or Alaska Native, Guamanian or Chamorro, and Native Hawaiian or Other Pacific Islander) participated in the study. Overall, 10 102 (64.2%) initiated and 5198 (33.0%) completed the vaccine series. In the group aged 9 to 10 years, the BPA plus education arm had a significantly higher likelihood of initiating vaccination than the BPA-only arm (adjusted hazard ratio, 1.39; 95% CI, 1.17-1.65; P < .001) compared with the group aged 11 to 14 years. Completion increased from 16 (2.2%) to 464 (19.6%) among youths aged 9 to 10 years and from 183 (13.9%) to 323 (66.6%) among youths age 11 to 14 years. By year 3, the group aged 9 to 10 years had a higher cumulative completion rate than the group aged 11 to 14 years (3899 [33.9%] vs 1299 [30.7%], P < .001). Black or African American race and public insurance were associated with HPV vaccine initiation and completion. Conclusions and Relevance: In this quality improvement study of early HPV vaccine initiation, an EHR BPA combined with education was associated with a higher likelihood of early HPV vaccination. Delayed but meaningful improvements in series completion were observed among early initiators.

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