A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care

"A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery."

A strong recommendation by a trusted health care professional is cited as an important factor in parents' vaccination decisions. Yet many physicians recommend human papillomavirus (HPV) vaccine inconsistently, tepidly, or for older adolescents because they fear parental hesitancy and prolonged office visits discussing HPV vaccination. Furthermore, missed opportunities (MOs) for adolescent vaccination are common. For these and other reasons, United States (US) HPV vaccination rates have lagged behind those for other adolescent vaccines. This study was conducted to explore whether quality improvement (QI) learning collaboratives (LCs) might help clinicians implement HPV vaccination interventions by sharing expertise and knowledge among similar practice sites.

The researchers conducted a 9-month QI project in 33 community practices and 14 paediatric continuity clinics. Participants were trained via webinar to deliver strong provider recommendations about HPV vaccination at the project's initiation. All practices were encouraged to implement provider prompts, and participants received training on reducing MOs for HPV vaccine at all visit types. They also received monthly feedback reports on MOs.

Each practice was encouraged to form a QI team, which was responsible for educating other nurses and providers in their respective practice. Before rooming the patient, staff were expected to review the patient's immunisation history and to prompt the physician to order HPV vaccine using cues such as a vaccine information statement, sticker, or electronic health record (EHR) prompt. During monthly LC calls, practices sharing successes and barriers they encountered.

The study found that MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03).

Practices also reported significant improvements in office systems to reduce MOs. By the study's end, more practices posted a common schedule (from 42% to 71%), educated staff on valid doses (from 50% to 83%), and had an office policy to vaccinate at all visits (from 50% to 85%; P < .01 for each). Strong recommendations for the vaccine for 11- to 12-year-old patients were almost universal at baseline and postintervention for continuity clinics, but community practices improved from 65% to 85% (P = .06) for female patients and 56% to 82% (P = .02) for male patients. (Baseline vaccination rates for male patients were lower than that for female patients, allowing more opportunity to improve.)

Qualitative data indicate that the main practice barriers included concerns related to prompts, time constraints, reaching parents for reminders, systems issues, and parent education and refusal. Regarding the latter, some practices overcame the challenge of parent refusal, in part, by educating staff to talk to parents and by giving patients printed material before seeing the physician.

In conclusion: "This QI study shows that a multicomponent intervention, which includes training in giving a strong HPV vaccination recommendation, with provider prompts as well as feedback on MOs can reduce MOs for HPV vaccination in community practices as well as continuity clinics and improve HPV vaccination rates."