Audubon Clinic Quality Improvement Project

2010 – 2011Hepatitis A and Human Papillomavirus Vaccine

Rates

Amie Dave, MDMay 18, 2011

Project SelectionCBC Screening

Chart review showed that of eligible patients

1 year olds 100% had screening

2 year olds90% had screening

Hepatitis A&

Human Papillomavirus (HPV)

Vaccine rates

Background – Hepatitis A

Vaccine Licensed

Hepatitis A in the US 1966-2007

cdc.gov

Background – HPV

Most effective prior to exposure to HPVPrior to first sexual encounter

Three dose series: 0, 2, and 6 months

GardasilLicensed in 2006 for girls/womenLicensed in 2009 for boys/men

Only HPV vaccine approved for boys/menQuadrivalent vaccine

Against HPV 6, 11, 16, 18 IM injection

Background – HPV

Audubon Baseline Data – Hep A

Quarterly Review from 7/10 – 9/10

Hepatitis A vaccine rates 13 – 23 months old

1 dose: 85%2 doses: 24%

24 – 35 months old1 dose: 94%2 doses: 71%

Quarterly Review from 7/10 – 9/10

166 patients, 11 – 13 years seen during this time

27 (16%) had already initiated first HPV vaccineFemales: 24/27Males: 3/27

Of remaining 139, 42 (30%) initiatedFemales: 39% (27/69) Males: 21% (15/70)

Overall, 41% (69/166) patients initiated Females 54% (51/93)Males 24% (18/73)

Audubon Baseline Data - HPV

Aim StatementWe aim to improve

Hepatitis A vaccine completion rates (2 doses) for 24 to 36 month olds

From 71% 85%

&

Initiation of the first dose of HPV vaccine by age 13 years

For girls from 73%* 80% [54%]For boys to above 30% [24%]

by April 2011

Framework

July – September 2010 Baseline data – Hep A & HPV vaccination rates

October 2010 - presentCycles of Change/

Increase Awareness

January – March 2011Reassessment of vaccination rates

Provider

Staff

Patient

Didactic presentations October On Hep A and HPV vaccines/guidelines given each

day at clinic for residents and attendings

Surveying doctors October/November Online survey of practitioners about preferred

vaccine scheduleHep A: Given personal preferences given

administration between 1 and 2 years of age, recommendation of 12 & 18 or 15 & 24 month visits

HPV: Should be given at 11 year old visit to both boys and girls

Cycles of Change – Provider

Posting of vaccine schedulesDecember: Vaccine schedules highlighting Hep A and

HPV placed in exam rooms, nurses station, and MA room

Large posters – not used April: New schedules posted that were larger to draw

more attention

Staff educationNovember/DecemberSpoke with nurses about project and encouraged

them to remind providers to order vaccines for appropriate patients

Cycles of Change – Provider & Staff

Clinic Rooms

Information in waiting roomPosting information - not done given issues revolving

around needing approval for postings

Patient vaccine information sheets January: Info re HPV vaccine in Spanish and English

provided in exam rooms Feb/March: Encouraged MAs to provide information

sheet to parents to review while waiting for doctorSheets placed in MAs room as wellLimitations:

Biggest barrier: not having enough time to hand out the HPV information sheet

Not finding the sheets in the same place when they run out Forgetting to give them to patients in that age group

Cycles of Change – Patient

Quarterly Review from 1/11 – 3/11

Vaccination Rates:13 – 23 months old

1 dose: 80% (85%)*2 dose: 20% (24%)• Quarterly data from 7/10 – 9/10

• Vaccine Rates at other Clinics:• 24 – 35 months old, 2 doses• ACNC 68%• Farrell 67%, WHFHC 65%, Broadway 67%, Rangel 64%

Vaccination Rates – Hep A: 1/11 – 3/11

24 – 35 months old1 dose: 95% (94%)2 doses: 74% (71%)

Goal: 85%

Vaccination Rates - HPV: 1/11 – 3/11

152 patients, 11 – 13 years seen during this time

61 (40%) had already initiated first HPV vaccine Females: 44/61 Males: 17/61

Of remaining 91 patients; 38 (42%) had initiation of HPV vaccine Females: 48% (18/37) (39% in 7/10 – 9/10) Males: 37% (20/54) (21% in 7/10 – 9/10)

Overall, 65% initiated (41% in 7/10 – 9/10) Females: 76% (62/81) (54% in 7/10 – 9/10) Males: 52% (37/71) (24% in 7/10 – 9/10)

Hep A

HPV – Overall

HPV – Initiatio

n

ConclusionsProvider behavior changes needed to increase Hep A

vaccination rates Challenge to create system changes

Staff participation can help improve awareness and improve vaccination ratesMedical assistants can help initiate patient educationNurses help serve as safety net to catch patients that may

have been missed and remind providerNurses are a resource to remind us of missed opportunities

– WIC visit, non-febrile sick visit

Patient information in room serves as reminder to provider to help initiate conversation

Acknowledgements

Residents

Dr. Jackie Baker

Dr. Jillian Borman

Dr. Kelly Burke

Dr. Amie Dave

Dr. Valerio Dorrello

Dr. Wendy Chang

Dr. Jennifer Guimbellot

Dr. Melissa Landis

Dr. Michele Levin

Dr. Elaine Lin

Dr. Genevieve London

Dr. Ryan Morgan

Dr. Matthew O’Rourke

Dr. Neha Patel

Dr. Erin C. Qualter

Dr. Zoe Shamash

Dr. Shawndip Sen

Dr. David Sparling

Dr. Rebecca Turcotte

Dr. Bram Welch – Horan

Dr. Ronald Zviti

Attendings

Dr. Connie Kostacos

Dr. Melissa Stockwell

Dr. Mariellen Lane

Dr. Annika Hofstetter

Dr. Christine Krause

Dr. Amy Lief

Dr. Valerie Niketakis

Dr. Betsy Pfeffer

Dr. Karen Soren

Dr. Nikki Timko

Dr. Betsy Wedemeyer

Dr. Omolara Uwemedimo

Dr. Larry Williams

Nurses

Beverly Kim

Diana Decharo

Ernestina Amoah

Estela Padron

Jasmine Ortiz

Adora Brown

Vicki Bernstein

Medical Assistants

Doreen Pittman

Hasse Nolasco

Ivette Pinto-Velez

Jean Adedipe-Jonadu

Jessie Lyons

Stacyann Halm

Site Administrator

Kim Moore Steele

References Vaccine Information:

http://www.cdc.gov/vaccines/

www.gardasil.com

Images:

Dead End sign: http://en.wikipedia.org/wiki/File:Dead_End_sign.svg

Detour sign:http://www.rockytoptalk.com/2008/12/1/676484/talking-points-the-lane-ki

Vaccine Schedule 1: http://pediatrics.aappublications.org/cgi/data/125/1/195/DC1/1

Hep A graph: www.cdc.gov/vaccines/pubs/pinkbook/downloads/.../HepA11.ppt

Vaccine Schedule 2: http://www.healthychildren.org/Documents/tips-tools/ Immunization%20Schedules/IZSchedule_Adolescent.pdf