A quality improvement collaborative to increase human papillomavirus vaccination rates in local health department clinics.

Human papillomavirus (HPV) vaccination rates are well below the Healthy People 2020 goal of 80%. Vaccinating in settings other than primary care, such as local health departments (LHDs), may help achieve higher HPV immunization rates. We tested the effect of a quality improvement (QI) collaborative to reduce missed opportunities (MOs) for HPV vaccine in LHDs. Between 2016 and 2019, we conducted four consecutive cohorts of a virtual QI collaborative at 24 LHDs across multiple states. Participants were trained on topics including how to provide an effective recommendation for HPV vaccine, strategies to reduce MOs, and motivational interviewing. Throughout the 6-month project implementation, LHDs tested strategies to reduce MOs through Plan-Do-Study-Act cycles, performed chart reviews to identify and characterize MOs, and received feedback reports to assess progress on MOs. HPV vaccination rates were assessed pre- and post-intervention. LHDs reduced MOs for HPV vaccine in all four cohorts with aggregated data showing a 25.3 percentage point reduction in MOs. Modified Poisson regression analysis found a 44% reduction in the relative risk of missing the opportunity for an HPV vaccine at a visit (RR = 0.56, 0.46-0.68, p < .001). This project shows that strategies effective in reducing MO for HPV vaccine in primary care settings are also effective in LHD settings. Training LHD staff on these strategies may help the U.S. approach national goals for HPV vaccine coverage.

Identifying Strategies to Reduce Missed Opportunities for HPV Vaccination in Primary Care: A Qualitative Study of Positive Deviants.

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system-level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

Identifying Barriers to Access and Utilization of Preventive Health-Care Services by Young Adults in Vermont.

PURPOSE: The objective of this study was to examine barriers to accessing and utilizing routine preventive health-care checkups for Vermont young adults. METHODS: A population-based analysis was conducted using aggregated data from the 2011-2014 Behavioral Risk Factor Surveillance System (BRFSS) surveys of Vermont young adults aged 18-25 years (N = 1,329). Predictors analyzed as barriers were classified county of residence, health-care coverage, and annual household income level, as well as covariates, with the outcome of the length of time since the last routine checkup. RESULTS: A total of 81.1% of Vermont young adults reported having a routine checkup in the past 2 years. Health-care coverage was a predictor of undergoing routine checkups within the past 2 years, with 85.2% of insured respondents undergoing checkups compared with 56.3% of uninsured respondents (p < .001). Additionally, 81.9% of respondents from Vermont counties classified as mostly rural reported undergoing a checkup within the past 2 years (p < .05). A total of 80.8% of respondents from the middle level (p < .05) and 89.0% of respondents from the highest level (p < .001) of annual household incomes reported undergoing a checkup in the past 2 years. Finally, age (p < .001) and sex (p < .01) were shown to indicate receipt of routine preventive checkups more often. CONCLUSIONS: For Vermont young adults, health-care coverage, classified county of residence, and household income level were shown to be indicators of undergoing routine preventive health care more often. Further investigation is needed to examine how these barriers may impede preventive screenings, thereby contributing to the ongoing development of health-care guidelines and policies for young adults in rural settings.

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

OBJECTIVE: Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. METHODS: Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. MEASURES: outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. INTERVENTION: providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. ANALYSES: chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. RESULTS: MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). CONCLUSIONS: Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery.