Provider perspectives on clinical decision support to improve HIV prevention in pediatric primary care: A mixed methods study

Abstract

Abstract Background: Clinical decision support (CDS) is a promising implementation strategy for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting. Methods: Cross-sectional mixed methods study utilizing surveys and in-depth interviews with pediatricians to 1) assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, 2) assess optimal timing and contextual barriers and facilitators to CDS implementation, and 3) develop an Implementation Research Logic Model to conceptualize implementation determinants, mechanisms, and outcomes of potential CDS use. Interview scripts were grounded in the Consolidated Framework of Implementation Research. Qualitative analysis utilized a mixed inductive and deductive approach, and quantitative and qualitative data were merged to develop the logic model. Results: Participants (n=26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a five-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow; standardized to promote universal testing yet adaptable to the level of patient’s HIV risk; and addressed providers knowledge gaps and bolstered self-efficacy in providing HIV prevention services. Conclusions: This mixed methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate strategy for improving the reach and equitable delivery of HIV screening and PrEP. Design considerations for CDS in this setting should include deploying interventions early in the visit workflow, and prioritizing standardized but flexible designs.