Human Papillomavirus Vaccine Completion by 13: A Quality Improvement Initiative in a Large Primary Care Network.

OBJECTIVE: Fewer than 40% of U.S. children complete the human papillomavirus (HPV) vaccine series before their 13th birthday. In our large pediatric primary care network, HPV vaccine completion rate by age 13 was 30%. We hypothesized that a phased quality improvement (QI) initiative would increase rates of HPV vaccine completion by age 13 across our network. METHODS: This QI initiative was conducted in a network of 30 practices located across two states, in urban and suburban settings, consisting of teaching and non-teaching clinics, and ranging in size from three to 50 providers per office. We used a phased approach incorporating multicomponent network-wide and iterative practice-specific interventions. Key interventions included: updating clinical decision support to default order HPV vaccine due at preventive visits starting at age nine instead of 11, data audit and feedback to providers and practices, encouraging use of a strong provider recommendation, and standing orders. RESULTS: From April 2019 to October 2022, HPV vaccine completion by age 13 across our network increased from 30% to 55% and met criteria for special cause variation on statistical process control charts. A gap in median HPV vaccine completion by age 13 between patients with public insurance and patients with private or commercial insurance decreased from 9% to 1%. CONCLUSION: A QI initiative was associated with a sustained increase in HPV vaccine series completion by age 13 and reduced variation in care across a large network of 30 primary care practices.

Improving surveillance for hyperammonemia in the newborn.

OBJECTIVE: Prompt ascertainment is crucial for the management of hyperammonemic infants. Because these patients are rare and recognition of hyperammonemia is often delayed, we designed and implemented an electronic medical record (EMR)-based tool to assist physicians in the detection of hyperammonemia. METHODS: We retrospectively evaluated the hospitalizations of prior hyperammonemic infants to identify codable elements that could trigger an EMR-based warning. An alert was designed and implemented and its utilization was prospectively analyzed. RESULTS: Blood gas studies were obtained universally and early in the retrospectively evaluated infants (x¯=26h before ammonia level). Prompting physicians to evaluate ammonia after ordering blood gas studies would have accelerated the initial ammonia order in 89% of retrospective cases. The alert has activated 184 times over the first six months of operation leading to 63 laboratory evaluations and detection of one hyperammonemic infant. CONCLUSION: Implementation of an EMR-based warning system can improve surveillance for hyperammonemia in a susceptible population.