1. USING QI TO IMPROVE HPV VACCINATION RATES Nathan Boonstra, MD Pediatrician, Blank Children’s Hospital Vicki Hunting, BA Quality Improvement Advisor, Division of Child and Community Health, University of Iowa

2. Disclosures We have no relevant financial or nonfinancial relationships described, reviewed, evaluated or compared in this presentation.

3. Session Objectives 1. Outline use of quality improvement methodology to implement evidence-based strategies in the office practice 2. Recognize interventions around direct physician education, practice-level changes, public awareness strategies to increase immunization coverage 3. Identify ideas/interventions for strengthening office systems for delivery of the HPV vaccine and improvements in provider recommendation

4. Quality improvement: what & why What is it? A formal approach to the analysis of performance and systematic efforts to improve it. Focus on systems, not individuals. Ideas/changes from customers & front line staff Frequent ongoing measurement and data driven decision making Never ending process Why do it? 1. Increases customer satisfaction, efficient use of resources, measurable outcomes, community impact 2. Goes to organizational viability and competitiveness 3. Market & funders are demanding it 4

5. The Model for Improvement How will we know that a change is an improvement? What change can we make that will result in improvement? Aim Measures Ideas/Changes ActPlan StudyDo What are we trying to accomplish? Associates in Process Improvement, 2010 5

6. The PDSA Cycle for Learning and Improvement Act  What changes are to be made?  Next cycle?  Adopt, Adapt, Abandon Plan  Questions and predictions (why)  Plan to carry out the cycle (who, what, where, when)  Plan for data collection Study  Complete the analysis of the data  Compare data to predictions  Summarize what was learned Do  Carry out the plan  Document problems and unexpected observations  Begin analysis of the data Associates in Process Improvement, 2010 6

7. Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D D S P A Small Scale Testing Follow-up Tests Test new conditions Implementation of Change Learning and Improvement Evidence and Data AP SD 7

8. Overview; NIPA/NIPN and AAP NIPN/NIPA Cohort Collaboration Partnership; APA and NIPN, Cohort 2 Funding: CDC Focused on Primary Care; individual and practice Timeline: Feb-Nov 2016 74 practices/11 states; AL, AZ, IA, IN, VT, FL, ME, NH, NJ, TN, MA Iowa 5 practices; University of Iowa River Landing & Southeast Iowa City, Pediatrics Associates/Coralville, Pella Regional Health Center, Mercy Clinics AAP Cohort Sponsored by American Academy of Pediatrics (AAP) for District VI Funding: CDC Focused on Primary Care; individual and practice Timeline: Sept 2015-Sept 2016 27 practices/7 states/101 Physicians; IA, WI, MN, ND, SD, MO, KS Iowa – 2 practices; Blank Children’s Hospital - Peds Clinic & UIHC Children’s Hospital – Peds Clinic

9. IOWA AAP HPV Quality Improvement (QI) Program

10. Program Overview & Goals  Increase HPV immunization rates among adolescent boys and girls in Iowa  Expand age range to 11 and 12 year olds  Target Healthy People 2020 goal of 80% immunization rate among adolescents  Provide Quality Improvement (QI) training and experience for state’s pediatricians and allied healthcare providers  Expand age range to 11 and 12 year olds

11. AAP Program Activities  QI Training for Leadership – Summer 2015 Model for Improvement PDSA Cycle (Plan/Do/Study/Act)  Project Development  Learning Collaborative (District VI)  Data Collection Use of online tool – AAP’s QIDA Quality Improvement Data Aggregator  Data Collection Intervention  Learning Collaborative Participation

12. AAP Program Activities, continued  Data Collection Timeline – 3-month minimum: Month 1 - Baseline data collection and input into QIDA (Cycle 1) Month 2 - Intervention month 1 and data input into QIDA (Cycle 2) Month 3 - Intervention month 2 and data input into QIDA (Cycle 3)  Possible QI Interventions: Strong provider recommendation Reminder recall Physician education Patient and family education

13. AAP Current Work University of Iowa EMR “Best Practice Alert,” hard stop to order HPV vaccine or decline Blank Children’s Pediatric Clinic Strong provider recommendation Systematic workflow change for follow up

14. Adolescent Vaccination Coverage United States, 2006-2013

15. Strength of HPV Vaccine Recommendation for Female Patients, Pediatricians and Family Physicians (N=609)

16. Clinicians Underestimate the Value Parents Place on HPV Vaccine

17. Strong Provider Recommendation Successful recommendations group all of the adolescent vaccines Educating nurses and support staff may be just as important! The “HPV vaccine is cancer prevention” message resonates strongly with parents Cancer-focused, situation-appropriate language Parents may be interested in vaccinating, yet still have questions Why age 11 or 12? Why give to males? What about side effects?

18. Is she really too young? Take 1 Doctor: Meghan is due for some shots today: Tdap and the meningococcal vaccine. There is also the HPV vaccine… Parent: Why does she need an HPV vaccine? She’s only 11! Doctor: We want to make sure she gets the shots before she becomes sexually active. Parent: Well I can assure you Meghan is not like other girls- she’s a long way off from that! Doctor: We can certainly wait if that would make you feel more comfortable.

19. A Strong Recommendation at 11 Doctor: Meghan is due for some shots today: HPV, meningococcal vaccine, and Tdap. Parent: Why does she need an HPV vaccine? She’s only 11! Doctor: HPV vaccine will help protect Meghan from cancer caused by HPV infection. And I want to make sure Meghan receives all 3 doses and develops protection long before she becomes sexually active. Parent: But it just seems so young… Doctor: We don’t wait until exposure occurs to give any other routinely recommended vaccine. HPV vaccine is also given when kids are 11 or 12 years old because it produces a better immune response at that age. That’s why it is so important to start the shots now and finish them in the next 6 months.

20. NIPA/NIPN Improving HPV Immunization Rates in Practice- Based Settings

21. Project Aim & Goals Aim The overall aim of this QI project is to measurably increase HPV vaccination rates for adolescents within the practices participating in the 6-month intervention. Goals Goal 1: To support participating practices’ implementation of evidence-based strategies to improve their office systems delivery of the HPV vaccine and measurably improve their HPV vaccination rates. Goal 2: To strengthen strong provider recommendations for HPV vaccination among the practice team. Goal 3: To support the practice team in identifying office systems areas for improvement, planning and implementing changes, and studying changes made using the Plan/Do/Study/Act (PDSA) model of rapid-cycle improvement

22. Objectives Objective 1: To decrease rates of Missed Opportunities in patients eligible to receive any dose of HPV vaccine by 20% from baseline rate. Objective 2: To increase HPV vaccine initiation (1st dose) rates by 10% over baseline rate. Objective 3: To increase HPV vaccine series completion (3rd dose) rates by 10% over baseline rate

23. Background Cohort 1 40 practices/6 states; AL, ME, NH, NJ, TN, VT 9 month virtual Learning Collaborative Pre/post chart audit of 50 charts/practice to determine rates of HPV series initiation and completion and the rate of missed opportunities Monthly data submission of data on 10 patients and PDSA logs to monitor implementation of intervention and progress on reducing missed opportunities 9 monthly webinars

24. Barriers – Cohort 1 Push back from parents about HPV vaccine Time required to discuss HPV vaccination with families Lack of training in providing a strong provider recommendation for HPV vaccine

25. Baseline Cohort 1 FemalesMales Initiation of HPV vaccine series ≤12 y.o.48%34% 13-17 y.o.20%26% Total68%60% Completion of HPV vaccine series ≤12 y.o.22%12% 13-17 y.o.25%22% Total47%34% Missed Opportunities # of visits audited % MO by visit type Well visits149950% Acute/Chronic visits 276188% All visits484171% Reduction in missed opportunities at both well and acute visits Greater reduction in missed opportunities at acute visits 25% of missed opportunities were due to patient refusal/decline HPV vaccine.

30. Lessons Learned  Greater opportunity to impact missed opportunities at acute visits than well visits  Provider prompts are most effective when a variety of prompt types are used (e.g. electronic and verbal).  Practices need clear guidance and support to implement reminder-recall systems  Allow practices to use a variety of data sources (state immunization registries, electronic medical records, practice chart audits) to establish baseline HPV immunization rates  Access to recordings of Learning Collaborative webinars allows greater flexibility in participation and education of health care providers beyond those directly involved in the project.  Offering ABP MOC Part 4 credit and ABFM MC-FP Part IV credit is an important incentive for provider participation.

31. NIPA/NIPN Next Steps Expand reach of the project to include more states and different regions Target states with low rates of HPV vaccine coverage Broaden primary care practice types to include more family medicine practices, in addition to pediatric practices Convene relevant stakeholders to coordinate strategies, exchange information, and avoid duplication of efforts Offer continuing education credits for variety of heath care professionals Apply interventions to increase all adolescent immunization rates

32. WHAT WILL YOU DO BY NEXT TUESDAY?

33. Resources The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey- Bass Publishers., San Francisco, 1996. Institute for Healthcare Improvement, Knowledge Center, How to Improve. http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx National Immunization Partnership with the APA (NIPA): Improving HPV Immunization Rates in Practice-Based Settings, Virtual Toolkit http://www.academicpeds.org/NIPA/http://www.academicpeds.org/NIPA/ Accessing AAP EQUIP Modules for QI Basics: http://www.academicpeds.org/NIPA/assets/PDF/EQIPP_Access_Dire ctions.pdf http://www.academicpeds.org/NIPA/assets/PDF/EQIPP_Access_Dire ctions.pdf AAFP Basics of QI: http://www.aafp.org/practice- management/improvement/basics.htmlhttp://www.aafp.org/practice- management/improvement/basics.html

34. Contact Information Nathan Boonstra, MD  Pediatrician, Blank Children’s Hospital  Email: Vicki Hunting, BA  Quality & Operational Improvement Engineer, Division of Child and Community Health, Stead Family Department of Pediatrics, University of Iowa  Email: vicki-hunting@uiowa.edu vicki-hunting@uiowa.edu