1. “Our kids need the HPV vaccine” Insight from a UW Health Quality Improvement Initiative Nicholas Schmuhl, PhD HPV Vaccine Summits May 11 & 12, 2016

2. Current HPV Vaccine Recommendations  Girls  Vaccinate at ages 11-12 Earliest at age 9 Catch up vaccination until age 26  Boys  Vaccinate at ages 11-12 Earliest at age 9 Catch up vaccination recommended until age 21 May vaccinate until age 26 Petrosky E, Bocchini JA, Hariri S, Chesson H, Curtis CR, Saraiya M, et al. Use of 9-Valent Human Papillomavirus (HPV) Vaccine: Updated HPV Vaccination Recommendations of the Advisory Committee on Immunization Practices MMWR. 2015;64(11);300-304.

3. The HPV Vaccine is Effective and Safe... But Not Enough Kids are Getting It!

4. Barriers to Vaccination - Providers  Providers  Lack of information Efficacy, safety concerns Lack of knowledge about HPV-related cancers in men  Systems issues Time 3 shot series  Hesitancy to discuss the vaccine

5. Barriers to Vaccination – Parents/patients  General anti-vaccine sentiment  Lack of information/misinformation (media)  Lack of strong provider recommendation

6. UW HPV Vaccine Taskforce  Subgroup of UW Immunization Taskforce  Completed a quality improvement initiative to increase HPV vaccination rates  “Our Kids Need the HPV Vaccine”  Lunch and learn education series  May through October 2014

7. “Our Kids Need the HPV Vaccine”  Presentation by taskforce physician champions  Sarah Bradley, MD (Ob-Gyn) and Lindsay Geier, MD (pediatrics)  Over the lunch hour  Audience All UW Pediatric clinics High volume UW Family Practice clinics Providers (physicians, PAs/NPs) Clinic nursing staff

8. “Our Kids Need the HPV Vaccine”  Medical information  HPV  Cancer  Safety and efficacy of the vaccine Importance of vaccine for boys More effective the earlier given  Current rates of vaccination  Broken down by clinic/provider  Barriers to vaccination  Solutions

9. Baseline Vaccination Rates  Data pulled from the electronic medical record (AKA Epic, AKA Health Link)  Initial data pulls  Overall clinic vaccination rates 3 dose completion for females ages 13-15  Broken down by provider 1, 2, and 3 dose completion for each gender

10. “Our Kids Need the HPV Vaccine”  Emphasis on messaging  Strong provider recommendation  This is a cancer prevention vaccine

11. Data collection  Pre-test survey  Distributed to audience prior to the presentation  Knowledge and attitudes about vaccination  All sessions recorded, including question/answer portion  Follow up survey  6 months following the presentation  Knowledge and attitudes about vaccination  Was the presentation helpful?

12. Results  Vaccination rates  Pre and post survey data  Qualitative data

13. Denominator = Active Panel Patients with UW Health PCP (face to face touch within 3 years) age 11 through 13 y/o Numerator = 1 or 3 completed doses of HPV vaccination Patient population is not static (i.e. children can age in or out of the denominator) –February 2014 Datan = 11,370 –August 2014 Datan = 11,111 –November 2014 Datan = 11,426 –February 2015 Datan = 11,366 About the Data

14. Results: Vaccination Rates

18. WI Comprehensive Cancer Control Program HPV Environmental Scan

19. Design issues  Research design an afterthought  No random assignment of intervention, control clinics  difficult to compare  Intervention took place over >6 months  Problematic data  Confusing denominators  Age-in/-out  Natural cycles of adolescent appointments  Intervention really designed to promote initiation, vs. completion?  Etc. (see first bullet point)

20. Other people have the same problem  CDC Healthy People 2020 goal 80% 3 dose completion for all 13-15 year olds  HEDIS goal 3 dose completion for females by age 13  Etc.

21. Pre-test: knowledge, practice, perceptions (paper questionnaire)  Name (optional)*  Clinic role*  The HPV vax is recommended for:  Females ages _____ to _____ *  Males ages _____ to _____ *  How strongly do you recommend HPV vax for girls/boys? (1-7 scale)*  How well do patients/parents react to discussion of HPV vax? (1-7 scale)*  In your estimate, what % of patients/parents are receptive to HPV vax?  What % of your eligible patients receive the HPV vax?  What are the barriers to HPV vaccination in your practice? * Asked again in post-test, 6 months after session

22. Post-test: Online survey  Individual, anonymous link emailed six months after educational session  Reminders after one and two weeks; additional ad hoc reminders  All clinic staff at 15 clinics: attendees and non- attendees  160 post-test responses  56.3% had attended clinic talks (n=90)  26.3% had not attended  17.5% didn’t respond to attendance question

23. Post-test: Online survey  Name (optional)*  Clinic role*  The HPV vax is recommended for:  Females ages _____ to _____ *  Males ages _____ to _____ *  How strongly do you recommend HPV vax for girls/boys? (1-7 scale)*  How well do patients/parents react to discussion of HPV vax? (1-7 scale)*  Was the HPV provider education session helpful?  Have your practices regarding HPV vax changed? How?  What more could UW Health system do to facilitate HPV vax?  Would you like more info about HPV?  Any further comments?

24. Methodological difficulties  Can’t match pre- and post-test samples  Low post-test participation for some clinics

25. Sample: Clinical roles Clinic rolePre-testPost-test MD/DO16.1%29.4% APP7.0%6.3% RN30.2%30.8% LPN/MA24.6%15.4% CMA21.1%17.5% Other1.0%0.7%

26. Pre-test: Perceived uptake among patients MD, DO, APPRN, LPN, MA, CMA Estimated % of eligible patients who receive HPV vax 53.96%**61.0%** In Feb ‘14, no clinic’s rate was above 45% for first dose.

27. Knowledge: Recommended age Pre-test (MD, DO, APP) Pre-test (RN, LPN, MA, CMA) Post-test (MD, DO, APP) Post-test (RN, LPN, MA, CMA) Female start10.2810.5310.2310.43 Female stop24.96**25.66**25.0925.25 Male start10.41*10.94*10.15*10.85* Male stop25.3525.1324.3923.98 *significant difference ( p<0.05) between MD/DO/APP and RN/LPN/MA/CMA ** p<0.1

28. Knowledge: Ranges in age recommendations Pre-test (MD, DO, APP) Pre-test (RN, LPN, MA, CMA) Post-test (MD, DO, APP) Post-test (RN, LPN, MA, CMA) Female start9 – 128 – 18 9 – 12 (9 – 15) 9 – 13 (9 – 13) Female stop12 – 2812 – 40 21 – 26 (11 – 28) 12 – 28 (12 – 30) Male start9 – 128 – 18 9 – 12 (8 – 14) 9 – 13 (9 – 13) Male stop13 – 2812 – 40 21 – 26 (11 – 28) 12 – 26 (12 – 30) Attended clinic talk (Full sample)

29. Knowledge: Within acceptable age range Pre-testPost-test Female start (9-11 yrs)90%95% Female stop (21-26 yrs)91%93% Male start (9-11 yrs)83%89% Male stop (21-26 yrs)93%

30. Strength of recommendation Pre-test (MD, DO, APP) Pre-test (RN, LPN, MA, CMA) Post-test (MD, DO, APP) Post-test (RN, LPN, MA, CMA) Recommend female 6.72*6.38*6.92*6.45* Recommend male 6.536.266.79*6.42* *significant difference ( p<0.05) between MD/DO/APP and RN/LPN/MA/CMA

31. Perception of parent attitudes Pre-test (MD, DO, APP) Pre-test (RN, LPN, MA, CMA) Post-test (MD, DO, APP) Post-test (RN, LPN, MA, CMA) Openness to discussion of HPV vax 5.24*4.64*5.60*4.74* *significant difference ( p<0.05) between MD/DO/APP and RN/LPN/MA/CMA

32. Perception of parent attitudes  In both pre- and post-tests, perception that parents react more positively to discussions of HPV vaccination correlated with stronger recommendations for females and males (significant at p<0.01)  Also related to higher estimates of overall HPV vaccination rate in practice (p<0.05)

33. Pre-test: Provider-reported barriers  Themes most often mentioned by providers (in order)  Parent hesitancy—especially “sex stigma”  Lack of information  Unfavorable media coverage  Adverse reactions

34. Q&A/discussion session: Qualitative analyses  Recorded, transcribed, categorized, coded by UW Ob-Gyn grad assistant  Reported barriers (in order)  Parent hesitancy—especially “sex stigma”  Adverse reactions  Issues with electronic health records  Unfavorable media coverage

35. Comments on parent hesitancy/sex stigma “How do you handle the parent that just says ‘you know my son is not having sex until he is fifteen, I don’t even want to talk about this now,’ that is the most common issue with me that there is some sort of moral stance.” “Often parents feel that it gives their children license to have sex…”

36. Comments on lack of information “My biggest barrier is when parents aren’t particularly familiar with the vaccine, they come in at age eleven and you know it’s a concept that’s tough to get your head around because these are kids that are often prepubescent and so they’re faced with making decisions about preventative measures that may not be important for years to come…” “Patients are not very educated on HPV …it’s not as well known as other vaccines.”

37. Q&A/discussion session: Qualitative analyses  Provider questions (in order)  Age recommendations  Vaccine series  How to recommend  Adverse reactions  Questions related to data from educational talk  Vaccine durability  Protection provided by vaccine

38. Questions related to the vaccine series “I’ve had parents concerned that it’s been you know two years since they had their first one and should they really complete it, does it really mater at this point?”

39. Q&A/discussion session: Qualitative analyses  Provider suggestions for increasing rates  More/better information for parents and patients  System issues—especially better follow-up for 2 nd, 3 rd shot

40. Conclusions  HPV vaccination rates rose at intervention clinics during and after educational talks  Other system-wide changes  Limitations of the data

41. Next steps  Dissemination and implementation work  Fix the bugs in Q.I. initiative  Translate in-person talk to video?  Offer CME credit? Some other incentive?  Patient/parent education  D&I of educational video 1-2-3 Pap, Minnesota Health Department  Focus groups

42. Thank you!