Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program

Abstract

Objective Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals,[1] but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. Methods Practices with at least 50 patients 11–17 years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013–6/30/2014 and 7/1/2014–3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015–16. Results Among the cohort of 10,861 adolescent patients, 38% were 11–13 years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9 months, the intervention sites increased HPV initiation 10.2 PP compared with 7.3 PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96). Conclusions Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents.

Using the 4 Pillars™ Practice Transformation Program to increase adolescent human papillomavirus, meningococcal, tetanus-diphtheria-pertussis and influenza vaccination

“…These increases were higher than 10 PP increases in HPV initiation and 13 PP increases in HPV completion rates previously reported in the RCCT, in which these sites were the control group. 11 This may be explained in part, by the longer follow-up period in this study, as well as the significant HPV initiation increases observed among these practices during the RCCT. Having already increased the number of adolescents receiving the first or second dose of HPV in effect, gave these practices a year-long period in which to complete the remaining doses of the 3-dose series.…”

“…The sample size in this study precludes analyzing the effectiveness of specific strategies; however, in the RCCT related to this study, significant increases in vaccine uptake were related to adoption of >10 strategies. 6 Combinations of provider- and patient-based strategies may address previously observed barriers to HPV vaccination among adolescents. 14–18 Despite a Pennsylvania state mandate 19 for children to receive meningococcal and Tdap vaccines at ages 11–12 years, pre-intervention vaccination rates among participating practices were below 2015 Pennsylvania and U.S. averages (Figure 2).…”

“…Twenty practices participated in the RCCT, the methods and results of which have been previously published. 6 This pre-post study took place during 2015–2016, and reports on analysis of the 11 control sites that had waited a year to receive the intervention.…”

“…6 Control sites from that study were subsequently offered the intervention. This study reports the findings from the intervention offered to those eleven primary care control practices in a pre-post design.…”

Adolescent human papillomavirus vaccination in the United States: Opportunities for integrating pharmacies into the immunization neighborhood

“…55 Created by researchers at the University of Pittsburgh, this program has been used by over 50 primary care offices and focuses on 4 domains: convenience, communication, facilitation, and motivation. 56 In 2013, the inventors of program partnered with the Immunization Action Coalition (IAC) and conducted a randomized, cluster trial of 20 primary care practices with at least 50 11-17 y old patients. After 9 months of program implementation at intervention sites, HPV series initiation rates increased 10.2 percentage points vs. 7.3 in control sites (p < 0.001 for difference).…”