Implementing a multi-partner HPV vaccination assessment and feedback intervention in an integrated health system

Abstract

Context:

Human papillomavirus (HPV) vaccine initiation rates are persistently lower than rates for other adolescent-recommended vaccines. Assessment and feedback interventions are a recommended strategy for improving vaccination rates.

Objective:

Provide a guide for implementing a multi-partner intervention to increase HPV vaccine initiation rates.

Setting:

Nine primary care facilities within the Kaiser Permanente Northwest (KPNW) healthcare system.

Intervention:

In 2015–16 we implemented a system-wide assessment and feedback intervention to promote HPV vaccination. In partnership with the Centers for Disease Control and Prevention, the Oregon Immunization Program and KPNW's leadership, we developed an education session combining information on HPV infection, parental communication strategies, and facility-specific coverage data.

Results:

12 months post intervention, HPV dose 1 vaccination coverage increased from 71% to 72% among females; from 65% to 68% among males.

Conclusions:

A collaborative approach was critical to engaging leadership and enlisting support from providers, and to developing appropriate materials for clinical audiences.

Implications for Policy and Practice:

This is a detailed description of a collaborative assessment and Feedback approach, which walks through the process of engaging appropriate partners and developing the materials that were included in the intervention component. Information provided here can be used as a guide for conducting assessment and feedback interventions focused on HPV vaccination initiation.

Introduction

Human papillomavirus (HPV) vaccine uptake and coverage rates in the United States have improved in the past 10 years; however HPV vaccination rates remain far lower than rates for other vaccines recommended in adolescence.¹ In 2015, only 63% of teenaged girls and 50% of boys (aged 13–17 years) had initiated the HPV vaccine series. In comparison, 87% of all teenagers had received tetanus-diphtheria-acellular pertussis (Tdap) vaccine and 81% had received the meningococcal conjugate vaccine (MenACWY).²

Explanations for the discrepant vaccination rates have emphasized the challenges faced by providers when communicating with parents about the HPV recommendation. Several published studies have shown that providers lack reliable communication tools to adequately address the many concerns expressed by adolescents and their parents hesitant to receive HPV vaccination.^3–7

With these challenges in mind, researchers have explored the effect of various initiatives focused on improving provider communication concerning the HPV vaccine and have found that the strength of the individual provider’s recommendation does impact patient/parental vaccination decision-making.⁸ Efforts to educate providers on how best to deliver strong recommendations for receiving HPV vaccination have had some success,^8;9 and can be incorporated into Assessment and Feedback, interventions, which are proven to be an effective strategy for helping to improve vaccination rates.¹⁰

In an effort to help improve HPV vaccine initiation among adolescents enrolled in an integrated healthcare system, we developed and implemented a multi-partner assessment and feedback program. This brief report is intended to provide a useful guide for how to conduct an assessment and feedback intervention focused on HPV vaccine initiation.

Methods

The Center for Health Research (CHR) is the research division within Kaiser Permanente Northwest (KPNW). KPNW is an integrated healthcare system in NW Oregon and SW Washington that serves over 510,000 members. The research team at CHR was funded to implement an intervention to improve HPV vaccination rates that would complement existing quality improvement programs in place at KPNW. The intervention was implemented in nine primary care facilities in Oregon in 2015.

Best practices for vaccination already in place within KPNW at study onset included standing orders, walk-in or same-day appointments, electronic medical record (EMR) prompts, bi-directional data exchange with state Immunization Information Systems, vaccine coverage reports, and - for some facilities - patient reminders for past due vaccination (postcards or letters), all of which have been shown to positively influence vaccination coverage rates.^10–14

Given that many recommended practices were well established at KPNW, but that HPV coverage rates were still sub-optimal (3-dose HPV coverage range: 37–51% among females, 20–41% among males) the intervention was designed to engage healthcare teams in a participatory discussion about HPV.

Partnerships

Within KPNW, health plan leadership works closely with the healthcare teams and, through a clinical quality program manager, sets target goals for vaccination coverage. Prior to initiating this intervention, this manager agreed to help facilitate introductions between our research team and the department administrator (Pediatric and Family Medicine) for the healthcare teams in each facility. The research team also presented the planned intervention to health plan leadership to gain additional support from high-level clinical decision makers.

The Oregon Immunization Program (OIP), through its team of health educators, has vast experience in providing continuous quality improvement support to Oregon providers, including assessment and feedback for vaccination coverage rates, and agreed to collaborate with our team on this proposed project.

Content

The intent of this intervention was to ensure that all healthcare team members (administrative, Medical Assistance, Nurses, Medical Doctors) were given access to the same educational information about HPV, including facts about the disease and vaccine, but also about the lagging HPV rates in comparison to other adolescent-recommended vaccines. Using our ability to access timely data on defined patient populations within KPNW, our team developed a 2-part assessment report, adapted from a template used by our OIP partners. The first section included coverage rates for adolescent-recommended vaccines (including HPV initiation and series completion), for males and females, aged 11–18 and actively enrolled in each of the nine KPNW facilities. The second section detailed any recent (i.e. past 3 months) HPV vaccine-eligible preventive care visit where an adolescent had not received the HPV vaccine (termed a ‘missed opportunity’), with the purpose of demonstrating the frequency of missed opportunities for HPV vaccination specific to that facility’s adolescent population. (Supplementary appendix 1)

The content for HPV-related communication strategies was adapted from the CDC-developed presentation “You are the key to cancer prevention”,¹⁵ and was built on the premise that providers play a critical role in influencing decision-making around HPV vaccination. Communication themes stressed the importance of making strong recommendations for HPV vaccination, highlighting its role in cancer prevention, explaining the need for vaccine to be given as early as ages 11 or 12, and including personal statements of support for vaccination (when appropriate).¹⁶

Implementation

“Baseline” in-person sessions were scheduled during the month of April, 2015 at a total of 18 clinical team meetings (9 facilities; Pediatrics and Family Medicine department meetings) [see Figure 1]. One research team member paired with a health educator to deliver the intervention; research staff presented the HPV disease and vaccination information along with details on vaccine coverage and recent missed opportunities tailored to the facility where the presentation was scheduled. The health educator then engaged healthcare teams in a 20-minute participatory segment, reviewing communication strategies for discussing the HPV vaccine with questioning parents and adolescents. At sessions’ end, participants were invited to provide an evaluation of the presentation, specifically focusing on the perceived utility of the information provided and intentions to use any of the recommended approaches in future clinical encounters.

Figure 1. Project Timeline.

¹ In-person clinic visits: Assessment and Feedback sessions including presentation of current facility- and department-level HPV, Tdap, and MCV vaccine coverage rates, including HPV vaccine initiation and series completion rates, as well as HPV vaccine missed opportunities for most recent quarter. Examples of how to approach HPV vaccine communication with parents and teens provided and discussed.

² Quarterly mailings: Assessment reports with current facility- and department-level HPV, Tdap, and MCV vaccine coverage rates, including HPV vaccine initiation and series completion rates, as well as HPV vaccination missed opportunities for most recent quarter.

Following each session, the department administrator was given electronic copies of all materials, including assessment reports at the facility-, department-, and provider levels, so that clinical teams could share reports with team members. Thereafter, on a quarterly basis, facilities were sent (by email and mail) updated coverage reports, to reflect the coverage and missed opportunity rates for the most recent quarter [Figure 1]. In January, 2016, a second round of in-person sessions was conducted at each site to review coverage and missed opportunity data for the full calendar year of 2015, and to discuss coverage trends for initiation and completion HPV vaccination rates for boys and girls. [Supplementary appendix, Figures 1 and 2] Health care teams were also asked to share any experiences where they employed a strategy that was discussed during the initial educational session.

Figure 2.

≥1-dose and 3-dose coverage among all adolescents aged 11 through 17 paneled to a PEDIATRICS provider at XXX clinic as of each assessment date

Results

Following the “baseline” in-person session, 87% of clinical staff reported, via self-administered surveys immediately following the session, they planned to implement the strategies discussed at the sessions. At the January 2016 follow-up session, several clinical staff mentioned that clear, succinct ‘sound bites’ (i.e. HPV-associated cancer rates for males and females) are very effective in convincing parents to consent to HPV vaccine for their child. Some staff had even posted slides from our presentation in their exam rooms. During the follow-up in-person sessions, several clinical staff volunteered they were more confident discussing the importance of HPV vaccination for boys after attending our “baseline” session. The fact that some staff used our resources in the exam room suggests that even within large systems where many best vaccination practices are in place there is room for additional educational initiatives targeted to a specific topic, such as HPV vaccination. Reviewing best practices for vaccination may also be a useful strategy, particularly in settings where quality improvement activities are not routinely updated.

Assessment report data, as well as information on HPV infection, and HPV vaccine safety, were each rated “4” or “5” on a usefulness scale of 1–5 (5 being the most useful), by >85% of respondents. As noted in the self-administered evaluations, use of recent clinical encounter data also allowed us to share data on rates of missed HPV vaccination opportunities during preventive care visits (rather than sick or urgent care visits), which helped to generate discussion with providers on possible reasons for those missed opportunities.

Little change was observed in HPV vaccine initiation rates for females aged 11–18 years in the 12 months following the initial intervention session (increase from 71% to 72% among females); male vaccination initiation rates increased from 65% to 68%. These rates are notably higher than national averages for adolescents 13–17 years and suggest that KPNW has had some success with vaccinating even young (11–12 year old) adolescents; likely due to the many vaccination best-practices already in place prior to this intervention. There were some challenges to the implementation of this initiative, particularly involving coordination of presentations to the facility healthcare teams, given their many competing priorities. Some clinical staff contested that missed opportunities were usually due to parental declination of vaccination rather than lack of provider recommendation. Other feedback from healthcare teams focused heavily on the need for automated, system-wide reminders for receiving doses 2 and 3, once the HPV series had been initiated. The main study limitation was that we were unable to determine if the intervention resulted in coverage improvements; however even without significant improvements in coverage, the intervention was still well received as it provided healthcare teams with information to help them with engaging in fact-based conversations with parents and teens about HPV vaccine.

Conclusions

Integrated healthcare systems have multiple leadership teams, representing either the health plan and/or the clinical staff. Identifying and engaging these respective teams is critical in garnering support for systems-based initiatives. Securing time on each teams’ monthly agenda to present our educational intervention would not have been possible without that support.

Relying on the experience and skills of health educators from the state, along with CDC expertise, to help us develop the content and materials for our education intervention demonstrated to the health care teams that we were bringing them current information on best practices around HPV vaccination. Utilization of materials already developed and readily available was both time-saving and helped to ensure consistent delivery of HPV-related messaging.

This project is one example of how to work collaboratively with healthcare system and state partners to develop an intervention around improving HPV vaccination coverage. By closely examining vaccination patterns among an insured and actively enrolled population, we were able to focus our conversation on a population being directly served by the healthcare team in attendance and provide new tools for approaching discussions on HPV vaccination. Limited improvements in coverage may mean that HPV vaccination poses new challenges that current recommended strategies do not fully address.

Figure 3.

Quarterly rates of missed opportunities for 1^st dose HPV administration among adolescents aged 11 through 17 at preventive care visits in this department