HPV Vaccination Quality Improvement: Physician Perspective Discussion of efforts to raise HPV vaccine coverage using quality improvement from a physician’s perspective Alix Casler, M.D., F.A.A.P. Chief of Pediatrics Medical Director of Outpatient Pediatrics Orlando Health Physician Associates Director, Quality Improvement Curriculum University of Florida Pediatrics Residency at Orlando Health Assistant Professor of Pediatrics UCF and FSU Colleges of Medicine
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Disclosures Speaker and consultant: Merck ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA I ~ O R L A N D O 1-IEALTH
Educational Goals Participants in this conversation will: • Understand the relevant principles behind an effective zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA QI project in medical practice. • Become familiar with methods applied to a successful QI project to increase HPV vaccination rates in a large, multi-office pediatric group in Central Florida. • Recognize relevant barriers to QI in primary care pediatrics. • Develop strategies to assist busy primary care pediatric ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA practices in their QI efforts to increase HPV vaccination rates. I ~ O R L A N D O 1-IEALTH
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HPV Is Widespread • Approximately 79 million people in the United States are currently zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA infected with HPV 1,a – ~14 million people become newly infected with HPV each year in the United States 1,a • Most HPV infections clear on their own; however, persistence of certain HPV types can lead to clinically significant diseases 1 • For HPV-associated cervical disease, it cannot be reliably predicted which patients with infection or abnormal cytology will zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA progress to clinically significant disease versus spontaneously regress 1,2 ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA a Estimates are for 2008 and reflect persons with detectable infection with any of 37 different HPV types, not just Types 6, 1 1, 16, 18, 31, 33, 45, 52, and 58. 3 HPV=human papillomavirus. 1. Centers for Disease Control and Prevention (CDC). Epidemiology and Prevention of Vaccine-Preventable Diseases . 13th ed. Chapter 11: Human Papillomavirus. cdc.gov/vaccines/pubs/pinkbook/hpv.html. Accessed December 5, 2016. 2. Woodman CB et al. Nat Rev Cancer . 2007;7:11–22. 3. Satterwhite CL et al. Sex Transm Dis . 2013;40(3):187–193. I ~ O R L A N D O 1-IEALTH
~ ~ ~ HPV Causes Cancer cancer probably caused by HPV type S8 - _ _______ can be prevented by bivalent -- --------- ---- .. and quadrivalent vaccines .,, _ tin be prevented by 9•v.ilent vaccine Sex/ cancer Site Ce,v ix vaeina Vulva u. Anus Rectum Oropharynx Pen is Anus Reetum Oropharynx O 1, 000 2, 000 3, 000 4, 000 S, 000 6, 000 7, 000 8,000 9, 000 10 , 000 11,000 12, 000 13, 000 14, 000 Avera1e number of cases per year https://www.cdc.gov/cancer/hpv/statistics/cases.htm March 2017 /~ ORLANDO HEALTH
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA The National Problem: Inadequate HPV Vaccination • An average of 38,793 HPV-associated cancers (11.7 per 100,000 persons) were diagnosed annually in the United States during 2008– 2012, including 23,000 (13.5) among females and 15,793 (9.7) among males. Among these cancers, CDC estimates that 30,700 (79%) can be attributed to HPV, and 28,500 of these are attributable to HPV types that are preventable with the 9-valent HPV vaccine. • HPV vaccination coverage for ≥1 dose could easily have reached 92.6% by 2015. ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA • Every year that increases in coverage are delayed, another 4,400 women will go on to develop cervical cancer. MMWR July 26, 2013 / 62(29);591-595, MMWR July 31, 2015 / 64(29);784-792, MMWR: NIS teen data 2011-2015, MMWR July 8, 2016 / 65(26);661–666 . I ~ O R L A N D O 1-IEALTH
✓ Estimated HPV Vaccine Coverage for Adolescents Age 13 Years (NIS-Teen, 2015) 1–3 Per ACIP recommendations this age group should be routinely vaccinated with HPV vaccine at 11 or 12 years of age 100 Healthy People 2020 Objective (80%) a 80 accinated (%) 56.4 60 48.7 • Females Males 40 29.5 V 24.9 20 0 ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA HPV-1 HPV-3 a The Healthy People 2020 goal is to increase the vaccination coverage level of 3 doses of HPV vaccine for males and females to 80% by 13 to 15 years of age. ACIP=Advisory Committee on Immunization Practices; HPV=human papillomavirus; HPV-1=1 or more doses of HPV vaccine; HPV-3=3 doses of HPV vaccine; NIS=National Immunization Survey. 1. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep . 2016;65(33):850–858. 2. CDC. MMWR Morb Mortal Wkly Rep . /~ 2016;65(49):1405–1408 3. Healthy People 2020 . healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious- diseases/objectives. ORLANDO HEALTH Accessed December 5, 2016.
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA If An Opportunity to Vaccinate Is Missed, the Preteen Patient May Not Be Seen Next Year According to IMS data for ~4.9 million commercially insured 11- to 12-year-old patients who had well-visits from 2012 to 2014 (data do not include vaccine-only visits) a : Only 23% Only 48% had a well-visit had a well-visit each year in a in 2012 3-year period 48% (2012–2014) 23% ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA (n=2,357,934) (n=1,122,362) a Research was conducted by IMS Health, Inc., for Merck from January 1, 2012 through December 31, 2014. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Data consisted of health claims from a database of commercial health plans and managed Medicaid. Data were collected for “well-visits” only, not for vaccine-only visits. Commercially insured patients (who had a “well- visit”) between 2012 and 2014 included 11- to 12-year-olds (n=4,940,805), 13- to 14-year-olds (n=5,360,708), and 15- to 16-year-olds (n=5,370,393). /~ 1. Data available on request from Merck Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004. Please specify ORLANDO HEALTH information package VACC-1163821-0000.
What is Quality? Transition in Health Care MACRA ACO METRICS ORL~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA u ~ t S tJ\t~S c.o~t ~ ALTH
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Improving Medical Care Requires System Redesign ,---------- _, "Change is possible if we have the desire a n d commitment to ma, ke it hap, pen.' - Mohandas Gandhi ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA "All improvement will require "Every system is perlectly ll"" ~j change 1 but not all change will ~ ------ -- -~ ;;;;;;;; - _ _ _ designed to achieve the result in improvement !" results that it gets." - T. Nolan -Paul Batalden The definition of Insanity is doing the same thing over and over I ~ and expecting to get a different result ORLANDO 1-IEALTH www.ihi.org
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA The Science of Improvement A Model for Learning and Change Model for Improvement When you What are we trying to accomplish? combine the How will we know that a change is an improvement? 3 questions f What change ca n we make with the ... that will res ult in improvement? What will happen ifwe What's try something • Re ad y to next? different? im plement? predictions • Try somet hi ng • Plan to carry out: else? Who?When? ... the Model for • Next cycle How? Where? Study Do Improvement. PDSA cycle, • Complete data • Carry out plan analysis • Document you get. .. • Compare to ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Did it Let's try it! predictions work? • Summarize H • J Langley, et al, The Improvement Gwde, 2009 On the basis of what is learned from any PDSA cycle, a change might be: Implemented (adopt) Dropped (abandon) /~ Modified (adapt) ORLANDO HEALTH Increased in scope (expand) Tested under other conditions
The TRIPLE AIM Definition m1Triplefu.m • System designs that simultaneously improve three dimensions: ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA - Improving the health of the populations; - Improving the patient experience of care (including quality and satisfaction); and - Reducing the per capita cost of health care. /~ www.ihi.org ORLANDO HEALTH
The QUADRUPLE AIM - ~ issi - g Aim ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA I ~ O R L A N D O 1-IEALTH
Question 1: What are We Trying to Accomplish? zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA I D What are we trying to accomplish? The project AIM is: Not just a vague desire to do better ~ zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA A commitment to achieve measured improvement in a specific system with a definite timeline with numeric goals I ~ www.ihi.org O R L A N D O 1-IEALTH
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