Increasing Contraceptive Prescriptions in Adolescent Females With Documented Interest in Contraception: A Quality Improvement Project.

BACKGROUND: Adolescent pregnancy is a significant cause of morbidity and mortality among women and infants. Timely and comprehensive reproductive care in the medical home is essential in preventing unintended adolescent pregnancy. METHODS: This quality improvement (QI) project was completed within the Division of Primary Care Pediatrics at Nationwide Children's Hospital in Columbus, a large pediatric quaternary medical center. The population included female patients 15 to 17 years old from predominantly medically underserved communities receiving well care at 14 urban primary care sites. We identified 4 key drivers: 1) electronic health record, 2) provider training, 3) patient access, and 4) provider buy-in. The outcome measure of this QI project was the percentage of female patients 15 to 17 years old who received a contraceptive prescription within 14 days of answering "yes" to interest in starting contraception at a well-care visit. RESULTS: Female patients 15 to 17 years old with an interest in contraception documented increased from 20% to 76%. Etonogestrel subdermal implant placement plus referrals to the BC4Teens clinic increased from 28/month to 32/month. Females 15 to 17 years old interested in contraception who received contraception within 14 days of a visit increased from 50% to 70%. CONCLUSIONS: With this QI project, we increased the percentage of adolescents receiving contraceptive prescriptions within 14 days of indicating they were interested in starting a contraceptive. Improvement in the outcome measure was accomplished through improvements in 2 process measures: 1) increased documentation of interest in contraception and 2) improved access to referrals for contraceptive services and etonogestrel subdermal implant placement.

Quality Improvement to Eliminate Disparities in Developmental Screening for Patients Needing Interpreters.

Children from households with a preferred language other than English are less likely to receive timely identification and treatment for developmental delay than children of native English speakers. In dismantling this inequity, the role of primary care pediatrics is to establish equitable systems for screening and referral. This project, conducted in a network of twelve pediatric primary care centers, focused on eliminating a small but systematic disparity in developmental screening rates between families who did and did not require interpreters (86% versus 92%). The specific aim was to increase developmental screen completion among patients needing interpreters from 86% to 92% of age-appropriate well-child visits. Methods: Data were extracted from the electronic health record (EHR) to measure the proportion of 9-, 18-, 24-, and 30-month well-child visits at which developmental screens were completed, stratified by interpreter need (n = 31,461 visits; 7500 needing interpreters). One primary care center tested small changes to standardize processes, eliminate workarounds, and leverage EHR features using the Institute for Healthcare Improvement's Model for Improvement. The QI team plotted screen completion on control charts and spread successful changes to all 12 clinics. Statistical process control evaluated the significance of changes in screening rates. Results: For patients needing interpreters, screen completion rose across all clinics from 86% to 93% when the clinics implemented the new process. Screen completion for patients not needing interpreters remained at 92%. Conclusion: A standardized process supported by the EHR improved developmental screening among patients needing interpreters, eliminating disparities.

Quality Improvement Project to Increase Human Papillomavirus Two-Dose Vaccine Series Completion by 13 Years in Pediatric Primary Care Clinics.

PURPOSE: The human papillomavirus (HPV) causes genitourinary and oropharyngeal cancers. The HPV vaccine is safe and effective in preventing those diseases; however, vaccine series completion rates remain low in the United States. Our quality improvement (QI) project aimed to increase HPV-vaccination series completion rates to 70% from 2017 to 2020 for the 13-year patient population in an extensive academic pediatric primary care network that serves predominantly minority and Medicaid-insured children in Columbus, OH. METHODS: The outcome measure was the percentage of 13-years Nationwide Children's Hospital Primary Care Network patients who completed the two-dose vaccine series by their 13th birthday. Four QI implemented interventions were utilized. Electronic medical records alert informed providers when the HPV vaccines are due. We studied monthly data for the network and for individual clinics using statistical process control, displaying data on a control chart. We followed two process measures, captured opportunity rate, and the number of HPV vaccines given. RESULTS: We substantially increased HPV-vaccination series completion rates overall in the 13-year teen population from 27% to 65%, and three clinics reached the 70% goal for at least one quarter. Latino children had the highest completion rate of 80% and White children had the lowest completion rate at 64%. DISCUSSION: Our QI project used four measures to improve HPV-vaccination series completion rates in the 13-year patient population that serves minority and low-income teens predominantly. Further QI studies are needed to improve HPV vaccine completion rates in teens.

Quality Improvement to Engage General Pediatrics in Reducing Inaccurate Penicillin Allergy Labels.

OBJECTIVE: To remove inaccurate penicillin allergy labels in the general pediatric clinic setting. METHODS: From October 2017 through December 2021, this collaborative, quality improvement project used education, feedback, electronic health record alerts, and the introduction of oral amoxicillin challenges in a general pediatric clinic setting with the primary aim of decreasing the proportion of penicillin allergy labeled patients. Control charts were used to track the relationship between interventions and improvements in referral rates to allergy clinic, removal of the allergy label at clinic visits and the overall proportion of clinic patients labeled as PCN allergic. RESULTS: Referral rates to allergy clinic for penicillin allergy labeled patients increased from a baseline mean of 1.9% to 20.4%. The proportion of PCN allergy labeled patients who had the label removed during a pediatric clinic visit increased from a baseline of 1.1% to 6.6%. The overall proportion of penicillin allergy labeled clinic patients decreased from a baseline of 3.4% to 2.2%. CONCLUSION: With adequate education and collaboration with allergists, general pediatric practitioners can play a significant role in removing inaccurate penicillin allergy labels. Pediatricians can remove some of the burden placed on allergists by evaluating low risk patients in the primary care setting while referring higher risk patients to the specialist.

Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study.

Although recommended, adolescent depression screening with appropriate initial management is challenging. This project aimed to improve adolescent depression screening rates during preventive care visits in 12 primary care clinics from 65.4% to 80%, increase the proportion of documented initial management for those with a positive screen from 69.5% to 85%, then sustain improvements for 12 months. Methods: This quality improvement project involved 12 urban primary care clinics serving >120,000 mostly Medicaid-enrolled patients and targeted adolescents 12-17 years. Interventions included standardized depression screening using tablets with electronic health record (EHR) capture and automated scoring, embedding screening results and initial management actions into the EHR, provider education, and individual clinician and clinic performance feedback. Results: After standardizing the approach to screening, the process mean depression screening rate was 91.9%. However, after adopting tablets into the clinic flow, there was an unexpected initial decrease in proportion with appropriately documented initial management plans, from 89.7% to 67.6%. In response to this special cause variation, there was additional provider feedback and education, and a redesign of the EHR flow related to the presentation of results and prompts for action after a positive screen. As a result, the proportion with appropriately documented initial management was 87.3% by project completion. Conclusions: Tablet-based screening with EHR scoring capture effectively increased depression screening rates but required significant additional work to improve initial management after a positive screen. A full system approach, including EHR modification, clinician education, and performance feedback, is needed to make meaningful, sustained improvements in comprehensive adolescent depression screening.

Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Primary Care.

OBJECTIVES: Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services. METHODS: In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly. RESULTS: Between November 1, 2016, and December 31, 2019, 6 practices serving >7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P < .001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions per month increased from 0 to 8.5 (P < .001). CONCLUSIONS: Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.

Improving Patient-Provider Continuity in a Large Urban Academic Primary Care Network.

OBJECTIVE: Although patient-provider continuity improves care delivery and satisfaction, poor continuity with primary care providers (PCP) often exists in academic centers. We aimed to increase patient empanelment from 0% to 90% and then increase the percent of well-child care (WCC) visits scheduled with the PCP from 25.6% to 50%, without decreasing timely access that might result if patients waited for PCP availability. METHODS: Nationwide Children's Hospital Primary Care Network cares for >120,000 mostly Medicaid-enrolled patients across 13 offices. Before 2017, patients were empaneled to an office, not individual PCPs. We empaneled patients to PCPs, reduced provider floating, implemented continuity-promoting scheduling guidelines, scheduled future WCC visits for patients ≤15 months during check-in for their current one, and encouraged online scheduling. We tracked the percentage of all WCC visits that were scheduled with the patient's PCP and the percentage of subsequent WCC visits for patients ≤15 months that were scheduled during the current visit, and provided feedback to schedulers. We followed emergency department (ED) utilization and visit show rates. WCC visit completion rates were tracked using HEDIS metrics. RESULTS: Patient empanelment increased from 0% to >90% (P < .001). Patient-provider WCC continuity increased from 25.6% to 54.7% (P < .001). A 20.5% decrease in ED utilization rate was associated with continuity project initiation. Empaneled patients demonstrated higher show rates (76.9%) versus unempaneled patients (71.4%; P < .001). WCC completion rates increased from 52.6% to 60.7%. CONCLUSIONS: WCC continuity more than doubled after interventions and was associated with decreased ED utilization, higher show rates, and increased timely WCC completion.

Fostering Quality Improvement Capacity in a Network of Primary Care Practices Affiliated With a Pediatric Accountable Care Organization.

OBJECTIVES: Quality improvement (QI) methodologies are not widely implemented in primary care practices. As an accountable care organization serving pediatric Medicaid recipients in Ohio, Partners For Kids (PFK) sought to build QI capacity in affiliated primary care practices to improve organizational performance on key quality measures. METHODS: A team of QI specialists developed a comprehensive training program focused on pediatric QI initiatives. From 2014 to 2017, community-based, primary care practices affiliated with PFK were recruited to participate in QI. The primary outcome, assessed yearly, was the proportion of eligible PFK patients accessing care at a practice with ≥1 active QI project. The proportion of QI projects that demonstrated moderate improvement, defined as the implementation of ≥1 intervention and observed improvement in process measures, within 12 months of initiation was also calculated for 2017. RESULTS: Over the study period, the PFK QI team supported 72 projects in 33 primary care practices throughout central and southeast Ohio. In 2017, 26 practices were engaged in ≥1 active QI project, reaching 26% of all eligible PFK patients. Of the 21 projects active as of January 2017, 11 (52%) showed moderate improvement within 12 months. CONCLUSIONS: The PFK QI team successfully supported QI capacity building in primary care practices throughout Ohio using a systematic approach to recruitment, training, and QI resource support. New, multilevel interventions are needed to promote the uptake of preventive services among patients.

Pharmacist Involvement in Population Health Management for a Pediatric Managed Medicaid Accountable Care Organization.

Accountable care organizations (ACOs) have emerged as an effective healthcare delivery model for managing quality and cost at a population level. Within ACOs, pharmacists are critical for the delivery of high-value health care, offering patients and health care providers medication-related training, resources, and guidance that can improve quality of care at lower costs. Partners For Kids (PFK), one of the oldest and largest pediatric ACOs in the country, has successfully leveraged pharmacists to provide population health management and medication management to promote health outcomes for individual patients and the overall population it serves. This review explores how the inclusion of pharmacists in the development and execution of various quality improvement initiatives within PFK has positively impacted outcomes for patients while also lowering overall spend. A catalog of interventions is provided to offer various ways that pharmacists can intersect as providers in the triad of patient/family, payor, and provider. By providing enhanced training and education, on-site guidance, medication management, and population-level data analysis, pharmacists are able to identify and improve inefficiencies in care. Moving forward, ongoing engagement of pharmacists in health care operations will be a necessary feature to maximize health care value.