AT THE NATIONAL IMMUNIZATION CONFERENCE
ATLANTA (FRONTLINE MEDICAL NEWS) – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
Her practice is a large multispecialty health care group with 22 pediatricians, 2 pediatric advanced registered nurse practitioners, 80 pediatric staff, and 11 offices that serve 57,000 pediatric patients, about 40% of whom are at least 11 years old. In 2013, only 23% of their female patients and 12% of their male patients ages 13-17 years had received any doses of the HPV vaccine, far below the 54% and 21% nationally. Fourteen percent of girls and 3% of boys in their practice had received all three doses, Dr. Casler said at a conference sponsored by the Centers for Disease Control and Prevention.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment… so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.