1. Audubon Clinic Quality Improvement Project 2010 – 2011 Hepatitis A and Human Papillomavirus Vaccine Rates Amie Dave, MD May 18, 2011

2. Project Selection CBC Screening Chart review showed that of eligible patients 1 year olds 100% had screening 2 year olds 90% had screening Hepatitis A & Human Papillomavirus (HPV) Vaccine rates

3. Background – Hepatitis A

4. Vaccine Licensed Hepatitis A in the US 1966- 2007 cdc.gov

5. Background – HPV

6. Most effective prior to exposure to HPV Prior to first sexual encounter Three dose series: 0, 2, and 6 months Gardasil Licensed in 2006 for girls/women Licensed in 2009 for boys/men Only HPV vaccine approved for boys/men Quadrivalent vaccine Against HPV 6, 11, 16, 18 IM injection Background – HPV

7. Audubon Baseline Data – Hep A Quarterly Review from 7/10 – 9/10 Hepatitis A vaccine rates 13 – 23 months old 1 dose: 85% 2 doses: 24% 24 – 35 months old 1 dose: 94% 2 doses: 71%

8. Quarterly Review from 7/10 – 9/10 166 patients, 11 – 13 years seen during this time 27 (16%) had already initiated first HPV vaccine Females: 24/27 Males: 3/27 Of remaining 139, 42 (30%) initiated Females: 39% (27/69) Males: 21% (15/70) Overall, 41% (69/166) patients initiated Females 54% (51/93) Males 24% (18/73) Audubon Baseline Data - HPV

9. Aim Statement We aim to improve Hepatitis A vaccine completion rates (2 doses) for 24 to 36 month olds From 71%  85% & Initiation of the first dose of HPV vaccine by age 13 years For girls from 73%*  80% [54%] For boys to above 30% [24%] by April 2011

10. Framework July – September 2010 Baseline data – Hep A & HPV vaccination rates October 2010 - present Cycles of Change/ Increase Awareness January – March 2011 Reassessment of vaccination rates Provider Staff Patient

11. Didactic presentations October On Hep A and HPV vaccines/guidelines given each day at clinic for residents and attendings Surveying doctors October/November Online survey of practitioners about preferred vaccine schedule Hep A: Given personal preferences given administration between 1 and 2 years of age, recommendation of 12 & 18 or 15 & 24 month visits HPV: Should be given at 11 year old visit to both boys and girls Cycles of Change – Provider

12. Posting of vaccine schedules December: Vaccine schedules highlighting Hep A and HPV placed in exam rooms, nurses station, and MA room Large posters – not used April: New schedules posted that were larger to draw more attention Staff education November/December Spoke with nurses about project and encouraged them to remind providers to order vaccines for appropriate patients Cycles of Change – Provider & Staff

13. Clinic Rooms

14. Information in waiting room Posting information - not done given issues revolving around needing approval for postings Patient vaccine information sheets January: Info re HPV vaccine in Spanish and English provided in exam rooms Feb/March: Encouraged MAs to provide information sheet to parents to review while waiting for doctor Sheets placed in MAs room as well Limitations: Biggest barrier: not having enough time to hand out the HPV information sheet Not finding the sheets in the same place when they run out Forgetting to give them to patients in that age group Cycles of Change – Patient

15. Quarterly Review from 1/11 – 3/11 Vaccination Rates: 13 – 23 months old 1 dose: 80% (85%)* 2 dose: 20% (24%) Quarterly data from 7/10 – 9/10 Vaccine Rates at other Clinics: 24 – 35 months old, 2 doses ACNC 68% Farrell 67%, WHFHC 65%, Broadway 67%, Rangel 64% Vaccination Rates – Hep A: 1/11 – 3/11 24 – 35 months old 1 dose: 95% (94%) 2 doses: 74% (71%) Goal: 85%

16. Vaccination Rates - HPV: 1/11 – 3/11 152 patients, 11 – 13 years seen during this time 61 (40%) had already initiated first HPV vaccine Females: 44/61 Males: 17/61 Of remaining 91 patients; 38 (42%) had initiation of HPV vaccine Females: 48% (18/37) (39% in 7/10 – 9/10) Males: 37% (20/54) (21% in 7/10 – 9/10) Overall, 65% initiated (41% in 7/10 – 9/10) Females: 76% (62/81) (54% in 7/10 – 9/10) Males: 52% (37/71) (24% in 7/10 – 9/10)

17. Hep AHPV – Overall HPV – Initiation

18. Conclusions Provider behavior changes needed to increase Hep A vaccination rates Challenge to create system changes Staff participation can help improve awareness and improve vaccination rates Medical assistants can help initiate patient education Nurses help serve as safety net to catch patients that may have been missed and remind provider Nurses are a resource to remind us of missed opportunities – WIC visit, non-febrile sick visit Patient information in room serves as reminder to provider to help initiate conversation

19. Acknowledgements Residents Dr. Jackie Baker Dr. Jillian Borman Dr. Kelly Burke Dr. Amie Dave Dr. Valerio Dorrello Dr. Wendy Chang Dr. Jennifer Guimbellot Dr. Melissa Landis Dr. Michele Levin Dr. Elaine Lin Dr. Genevieve London Dr. Ryan Morgan Dr. Matthew O’Rourke Dr. Neha Patel Dr. Erin C. Qualter Dr. Zoe Shamash Dr. Shawndip Sen Dr. David Sparling Dr. Rebecca Turcotte Dr. Bram Welch – Horan Dr. Ronald Zviti Attendings Dr. Connie Kostacos Dr. Melissa Stockwell Dr. Mariellen Lane Dr. Annika Hofstetter Dr. Christine Krause Dr. Amy Lief Dr. Valerie Niketakis Dr. Betsy Pfeffer Dr. Karen Soren Dr. Nikki Timko Dr. Betsy Wedemeyer Dr. Omolara Uwemedimo Dr. Larry Williams Nurses Beverly Kim Diana Decharo Ernestina Amoah Estela Padron Jasmine Ortiz Adora Brown Vicki Bernstein Medical Assistants Doreen Pittman Hasse Nolasco Ivette Pinto-Velez Jean Adedipe-Jonadu Jessie Lyons Stacyann Halm Site Administrator Kim Moore Steele

20. References Vaccine Information: http://www.cdc.gov/vaccines/ www.gardasil.com Images: Dead End sign: http://en.wikipedia.org/wiki/File:Dead_End_sign.svghttp://en.wikipedia.org/wiki/File:Dead_End_sign.svg Detour sign:http://www.rockytoptalk.com/2008/12/1/676484/talking-points-the-lane-kihttp://www.rockytoptalk.com/2008/12/1/676484/talking-points-the-lane-ki Vaccine Schedule 1: http://pediatrics.aappublications.org/cgi/data/125/1/195/DC1/1http://pediatrics.aappublications.org/cgi/data/125/1/195/DC1/1 Hep A graph: www.cdc.gov/vaccines/pubs/pinkbook/downloads/.../HepA11.ppt Vaccine Schedule 2: http://www.healthychildren.org/Documents/tips-tools/ Immunization%20Schedules/IZSchedule_Adolescent.pdfhttp://www.healthychildren.org/Documents/tips-tools/