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Audubon Clinic Quality Improvement Project 2010 – 2011

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.

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Audubon Clinic Quality Improvement Project 2010 – 2011

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

  5. Background – HPV

  6. Background – HPV • 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

  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. Audubon Baseline Data - HPV • 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)

  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. Cycles of Change – Provider • 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

  12. Cycles of Change – Provider & Staff • 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

  13. Clinic Rooms

  14. Cycles of Change – Patient • 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

  15. Vaccination Rates – Hep A: 1/11 – 3/11 • 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% • 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 A HPV – 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 • Site Administrator • Kim Moore Steele • 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. OmolaraUwemedimo • Dr. Larry Williams • Nurses • Beverly Kim • Diana Decharo • Ernestina Amoah • Estela Padron • Jasmine Ortiz • Adora Brown • Vicki Bernstein • Medical Assistants • Doreen Pittman • HasseNolasco • Ivette Pinto-Velez • Jean Adedipe-Jonadu • Jessie Lyons • StacyannHalm

  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.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

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