Scientific Papers

HPV Vaccine Completion by 13: a Quality Improvement Initiative in a Large Primary Care Network


Human papillomavirus (HPV) causes >90% of cervical and anal cancers, >70% of oropharyngeal cancers and >60% of vulvar and penile cancers.1 An HPV vaccine that is safe and effective in reducing the incidence of these cancers has been available in the United States since 2006 for girls and since 2011 for boys. The Centers for Disease Control and Prevention routinely recommends HPV vaccination at age 11 or 12 years;2 per the Advisory Committee on Immunization Practices (ACIP), vaccination can be given starting at age 9.3 However, in 2019, only 27-32% of children with commercial insurance and 40% with public insurance completed the series by age 13,4 a Healthcare Effectiveness Data and Information Set (HEDIS) measure. Moreover, there has been a widening gap over the last decade between initiation and completion before age 13.5

Drivers of successful HPV vaccination include a strong provider recommendation,6 patient reminders that vaccination is due,7 effective clinical decision support (CDS) in the electronic health record (EHR) to prompt providers to order vaccine,8, 9 data audit and feedback,10, 11 and standing orders.12 The American Academy of Pediatrics (AAP)13 and American Cancer Society14 recommend starting HPV vaccination at age 9. Earlier initiation of HPV vaccine has multiple benefits, including increased immunogenicity,15 higher completion rate of the vaccine series,16 and improved prevention by completing vaccination before HPV exposure through sexual activity.17, 18, 19 Multicomponent interventions that combine both patient-focused and provider-focused strategies demonstrate the greatest increase in HPV vaccination rates.20, 21

Examining data from April 2017 to April 2019 in our large pediatric primary care network of 30 practices, we found that only 30% of patients had completed HPV vaccination by age 13, with tremendous variation in rates across practices, ranging from 10%-65%. We hypothesized that a phased approach incorporating both multicomponent network-wide and iterative practice-specific interventions would be an effective strategy to enact change and improve outcomes. Applying our institution’s quality improvement (QI) framework, which combines elements of multiple improvement methodologies (Lean,22 Six Sigma,23 Model for Improvement24), our SMART aim was to increase the proportion of patients across our network who complete HPV vaccination by their 13th birthday by 15% above the two-year baseline (from 30% to 45%) by December 2020. In parallel with our primary aim, a corresponding goal was to increase HPV vaccine initiation rates for patients between 9 and 12.99 years old by 15% above baseline (from 10% to 25%). Due to the COVID-19 pandemic, we extended this timeframe to December 2021.

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