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Audubon Clinic Quality Improvement Project 2010 – 2011. Hepatitis A and Human Papillomavirus Vaccine Rates. Amie Dave, MD May 18, 2011. Project Selection. CBC Screening Chart review showed that of eligible patients 1 year olds 100% had screening 2 year olds 90% had screening. - PowerPoint PPT Presentation
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Audubon Clinic Quality Improvement Project
2010 – 2011Hepatitis A and Human Papillomavirus Vaccine
Rates
Amie Dave, MDMay 18, 2011
Project SelectionCBC Screening
Chart review showed that of eligible patients
1 year olds 100% had screening
2 year olds90% had screening
Hepatitis A&
Human Papillomavirus (HPV)
Vaccine rates
Background – Hepatitis A
Vaccine Licensed
Hepatitis A in the US 1966-2007
cdc.gov
Background – HPV
Most effective prior to exposure to HPVPrior to first sexual encounter
Three dose series: 0, 2, and 6 months
GardasilLicensed in 2006 for girls/womenLicensed in 2009 for boys/men
Only HPV vaccine approved for boys/menQuadrivalent vaccine
Against HPV 6, 11, 16, 18 IM injection
Background – HPV
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 old1 dose: 94%2 doses: 71%
Quarterly Review from 7/10 – 9/10
166 patients, 11 – 13 years seen during this time
27 (16%) had already initiated first HPV vaccineFemales: 24/27Males: 3/27
Of remaining 139, 42 (30%) initiatedFemales: 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
Aim StatementWe 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
Framework
July – September 2010 Baseline data – Hep A & HPV vaccination rates
October 2010 - presentCycles of Change/
Increase Awareness
January – March 2011Reassessment of vaccination rates
Provider
Staff
Patient
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 scheduleHep 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
Posting of vaccine schedulesDecember: 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 educationNovember/DecemberSpoke with nurses about project and encouraged
them to remind providers to order vaccines for appropriate patients
Cycles of Change – Provider & Staff
Clinic Rooms
Information in waiting roomPosting 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 doctorSheets placed in MAs room as wellLimitations:
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
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 old1 dose: 95% (94%)2 doses: 74% (71%)
Goal: 85%
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)
Hep A
HPV – Overall
HPV – Initiatio
n
ConclusionsProvider behavior changes needed to increase Hep A
vaccination rates Challenge to create system changes
Staff participation can help improve awareness and improve vaccination ratesMedical assistants can help initiate patient educationNurses help serve as safety net to catch patients that may
have been missed and remind providerNurses 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
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
References Vaccine Information:
http://www.cdc.gov/vaccines/
www.gardasil.com
Images:
Dead End sign: http://en.wikipedia.org/wiki/File:Dead_End_sign.svg
Detour sign:http://www.rockytoptalk.com/2008/12/1/676484/talking-points-the-lane-ki
Vaccine Schedule 1: http://pediatrics.aappublications.org/cgi/data/125/1/195/DC1/1
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.pdf