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Huang E, Filograna K, Lockwood KK, Crossette J, Jenssen BP. Human Papillomavirus Vaccine Completion by 13: A Quality Improvement Initiative in a Large Primary Care Network. Acad Pediatr 2024; 24:293-301. [PMID: 37907128 DOI: 10.1016/j.acap.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023]
Abstract
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.
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Affiliation(s)
- Elena Huang
- Children's Hospital of Philadelphia, Primary Care (E Huang, K Filograna, KK Lockwood, J Crossette, and BP Jenssen), Philadelphia,Pa; Department of Pediatrics (E Huang, KK Lockwood, and BP Jenssen), University of Pennsylvania Perelman School of Medicine, Philadelphia,Pa.
| | - Kathleen Filograna
- Children's Hospital of Philadelphia, Primary Care (E Huang, K Filograna, KK Lockwood, J Crossette, and BP Jenssen), Philadelphia,Pa
| | - Katie K Lockwood
- Children's Hospital of Philadelphia, Primary Care (E Huang, K Filograna, KK Lockwood, J Crossette, and BP Jenssen), Philadelphia,Pa; Department of Pediatrics (E Huang, KK Lockwood, and BP Jenssen), University of Pennsylvania Perelman School of Medicine, Philadelphia,Pa
| | - Jonathan Crossette
- Children's Hospital of Philadelphia, Primary Care (E Huang, K Filograna, KK Lockwood, J Crossette, and BP Jenssen), Philadelphia,Pa
| | - Brian P Jenssen
- Children's Hospital of Philadelphia, Primary Care (E Huang, K Filograna, KK Lockwood, J Crossette, and BP Jenssen), Philadelphia,Pa; Department of Pediatrics (E Huang, KK Lockwood, and BP Jenssen), University of Pennsylvania Perelman School of Medicine, Philadelphia,Pa
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Perkins RB, Humiston S, Oliver K. Evidence supporting the initiation of HPV vaccination starting at age 9: Collection overview. Hum Vaccin Immunother 2023; 19:2269026. [PMID: 37824444 PMCID: PMC10572037 DOI: 10.1080/21645515.2023.2269026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | | | - Kristin Oliver
- Departments of Environmental Medicine and Public Health, Pediatrics, Icahn School of Medicine, New York, NY, USA
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Kohler RE, Wagner RB, Careaga K, Btoush R, Greene K, Kantor L. Mothers' perceptions and attitudes about HPV vaccination initiation among 9- and 10-year-olds. Hum Vaccin Immunother 2023; 19:2270842. [PMID: 37955127 PMCID: PMC10653617 DOI: 10.1080/21645515.2023.2270842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.
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Affiliation(s)
- Racquel E. Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Rachel B. Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Katherine Careaga
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Rula Btoush
- School of Nursing, Rutgers University, New Brunswick, NJ, USA
| | - Kathryn Greene
- School of Communication & Information, Rutgers University, New Brunswick, NJ, USA
| | - Leslie Kantor
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
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Christensen T, Zorn S, Bay K, Treend K, Averette C, Rhodes N. Effect of immunization registry-based provider reminder to initiate HPV vaccination at age 9, Washington state. Hum Vaccin Immunother 2023; 19:2274723. [PMID: 37929936 PMCID: PMC10629428 DOI: 10.1080/21645515.2023.2274723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023] Open
Abstract
Human papillomavirus (HPV) vaccination rates are lower than Tetanus-diphtheria-pertussis (Tdap) and Meningococcal conjugate (MenACWY) rates, although the Advisory Committee on Immunization Practices recommends all three vaccines be given routinely at age 11-12. Evidence is mounting that children who initiate HPV vaccination starting at age 9 are more likely to complete the series on time. Washington state implemented a provider reminder through its immunization information system (WAIIS) in January 2023 to increase HPV vaccine initiation at 9-years-old by updating the forecasted recommended age for HPV from age 11 to 9. The effectiveness of provider reminders when implemented via an immunization information system (IIS) is poorly understood. We evaluated the impact of this forecast update using a seasonally adjusted interrupted time series regression of weekly HPV initiations at 9-years-old before and after implementation. We also examined time series trends of vaccine administration between 2018 and 2023 for HPV initiation at age 9, as well as Tdap, MenACWY and HPV initiation at age 11. The WAIIS forecast update doubled the weekly rate of HPV initiation among 9-year-olds in Washington state, although the weekly count of initiation at 9 remains far lower than initiations at 11. Jurisdictions wanting to increase HPV vaccine initiation at earlier ages should consider updating their forecast algorithm and investing in complementary evidence-based strategies such as provider and parent education, and clinic-based quality improvement efforts. The reach of IIS forecaster updates may be enhanced by working with administrators of electronic medical record systems to ensure parity of provider prompts with IIS.
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Affiliation(s)
| | - Sherri Zorn
- Washington State HPV Free Task Force, Tumwater, Washington, USA
| | - Kathy Bay
- Washington State Department of Health, Tumwater, Washington, USA
| | - Katherine Treend
- Washington State Department of Health, Tumwater, Washington, USA
| | | | - Nicole Rhodes
- Washington State Department of Health, Tumwater, Washington, USA
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Brewer NT, Kahn BZ, Kritikos KI, Heisler-MacKinnon JA, Young JD, Gilkey MB. How to make effective HPV vaccine recommendations starting at age 9. Hum Vaccin Immunother 2023; 19:2216117. [PMID: 37246871 PMCID: PMC10305488 DOI: 10.1080/21645515.2023.2216117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023] Open
Abstract
This article provides best and promising practices for recommending HPV vaccination at age 9 as a way to ensure high uptake. An effective method for recommending HPV vaccination is the Announcement Approach, which consists of 3 evidence-based steps. The first step, Announce, involves noting that the child is 9 years old, saying they are due for a vaccine that prevents 6 HPV cancers, and saying you'll vaccinate today. This adapted version of the Announce step simplifies the bundled approach used at ages 11-12 that emphasizes the prevention of meningitis and whooping cough in addition to HPV cancers. For hesitant parents, the second step, Connect and Counsel, involves finding common ground with the parent and communicating the value of starting HPV vaccination at the first opportunity. Finally, for parents who decline, the third step is to Try Again at a later visit. Using the Announcement Approach at age 9 stands to increase HPV vaccine uptake, save time, and lead to high family and provider satisfaction.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Benjamin Z Kahn
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine I Kritikos
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer A Heisler-MacKinnon
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Jessica D Young
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Melissa B Gilkey
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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