ISSN: 2377-4304OGIJ

Obstetrics & Gynecology International Journal
Research Article
Volume 3 Issue 3 - 2015
Quality Improvement Project on Ob/Gyn Ambulatory Clinic HPV Vaccination in a Tertiary Community Hospital
Shadi Rezai1, Sri Gottimakala1, Rula V Kanj2, Andres Molina3, Ray A Mercado1 and Cassandra E Henderson1
1Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, USA
2Department of Obstetrics and Gynecology, Weill Cornell Medical College, USA
3St. George’s Univierstiy, Grenada, West Indies
Received: October 21, 2015 | Published: December 3, 2015
*Corresponding author: Shadi Rezai, Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, Affiliated with Weill Cornell Medical Center, 234 East 149th Street, Bronx, New York, 10451, USA, Tel: 718-579-5835; Fax: 718-579-4699; Email:
Citation: Rezai S, Gottimakala S, Kanj RV, Molina A, Mercado RA et al. (2015) Quality Improvement Project on Ob/Gyn Ambulatory Clinic HPV Vaccination in a Tertiary Community Hospital. Obstet Gynecol Int J 3(3): 00083. DOI: 10.15406/ogij.2015.03.00083

Abstract

Background: Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with approximately half of new HPV infections occurring among persons aged 15–24 years. To improve HPV vaccination rate, a Quality Improvement (QI) Project was initiated in the OB/GYN ambulatory clinic and postpartum floor.
Methods: Data analysis was performed on the results of a Quality Improvement Project on HPV Vaccination for years 2011-14 at Lincoln Medical and Mental Health Center ambulatory OB/GYN clinic.
The following steps were implemented to improve the quality of care and increase rates of HPV vaccination:

  1. In-service training and meetings for OB/GYN staff members to discuss the importance of patient counseling on HPV vaccination, and associated issues and solutions.
  2. Enhancement of patient education on HPV vaccination by providing brochures and via use of wall panel and intra-hospital TV programs.
  3. Identification of patients eligible for HPV vaccination and follow-up to assure they receive all 3 doses of HPV vaccination.
  4. Implementation of standing postpartum orders for HPV vaccination for eligible patients and administration of one dose of HPV vaccine in postpartum unit.

Results: Data showed increased trend of vaccination from years 2011-14. For those quarters with a decreased number of patients that completed HPV vaccination series, there was a correspondent decrease in number of patients eligible for vaccine and/or an increase in number that refused vaccination.
Conclusion: Using the Quality Improvement Project in our hospital, we were able to increase the rate of HPV immunization rate among the young women and adolescent girls in our OB/GYN service.

Keywords: Centers for Disease Control and Prevention (CDC); Condyloma Acuminata; Efficacy; Efficacy of HPV Vaccine; Education; Gardasil; Genital Warts (Condyloma Acuminata); HPV; HPV QI; HPV Vaccine; HPV Vaccine Efficacy; Human Papillomavirus; Papillomavirus vaccines; QI; Quadrivalent HPV Vaccine; Quality Improvement (QI); Vaccination

Introduction

Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Two HPV vaccines are licensed in the United States for prevention of specific HPV types and HPV-associated outcomes.

  1. HPV- 4 (Gardasil) for use in male and females aged 9 –26 years for prevention of cervical cancer, cervical cancer precursors, vulvar and vaginal cancer precursors, and anogenital warts caused by HPV types 6, 11, 16, and 18 and
  2. HPV-2 (Cervarix) for use in females aged 9 –25 years for prevention of cervical cancer and cervical cancer precursors caused by HPV types 16 and 18 [1-5].

As of January 2015, U.S. Food and Drug Administration (FDA) approved the third HPV Vaccine; Human Papillomavirus 9-valent Vaccine (Gardasil 9) for vaccination against cervical, vulvar, vaginal, and anal cancer caused by Human Papillomavirus (HPV) types 16, 18, 31, 33, 45, 52, 58 and Genital warts (condyloma acuminata) caused by HPV types 6 and 11 [6].

Improving HPV vaccination rate is an effective ways to promote the overall health of young women and adolescent boys and girls. Despite the counseling in our prenatal and Women’s Health clinics and high efficacy of the human papillomavirus (HPV) vaccine [7,8], many young mothers of our inner city population choose not to vaccinate. One of the main reasons is individual’s psychosocial perceived barriers to HPV vaccine uptake (e.g., safety concerns, vaccine adverse effects, vaccine cost, other HPV-related beliefs and not being sexually active) [7].

To improve HPV vaccination rate, this Quality Improvement (QI) Project was initiated to in the OB/GYN Ambulatory outpatient clinic and inpatient postpartum floor. We utilized our team of physicians, nursing and staffs with the goal of improvement of patients’ educations and HPV vaccination awareness leading to increase vaccination rate among our patients. This is an ongoing evolving process that has been started in 2011 and still going. We tailored each steps of this QI project based on our quarterly results for more improvement on the next upcoming quarters.

Methods

Analysis of collected Quarterly data on HPV Vaccination from Lincoln Medical and Mental Health Center, ambulatory OB/GYN clinic from years 2011 through 2014, while implementing the Quality Improvement (QI) Project for HPV vaccination.

In order to improve the quality of care and increase HPV vaccination among our patient, the following steps were implemented:

  1. In-service training for OB/GYN clinicians, nursing and staffs on importance of patient education and counseling on HPV vaccination on a monthly basis as well as review of the HPV QI results from the previous months on the performance improvement (PI) meeting.
  2. Enhancement of patient’s educations on HPV vaccination in both women’s outpatient clinic as well as postpartum floor and GYN inpatients, by providing brochures, use of wall panel and intra-hospital TV programs on importance of HPV vaccination and Gardasil. Information about vaccination (Taken from Centers for Disease Control and Prevention (CDC) handouts and other trusted resources) was also included as part of patient’s discharge instructions
  3. Setting the hospital computer system to ask a question about different type of vaccinations for each patient, mandating the clinicians to complete the vaccination part before moving to the next step of the patient evaluation in the patient’s chart and therefore identifying those patients who are eligible for vaccination.
  4. After identifying the eligible individuals (of 12 to 26 years of age) for HPV vaccination, we followed up on this targeted group to assure they receive the 2nd and third dose of HPV vaccination. Vaccination was offered through the prenatal, postpartum and GYN clinic as well as the postpartum inpatient and Gyn admissions. Vaccine was provided free of charge for the patient and repeat vaccination was performed on follow up visits. Reminder phone call for appointment was given to patients to improve patient follow up in clinic.
  5. Implementation of standing orders as part of routine postpartum orders for HPV vaccination for eligible patients:
    1. For those patient who did not receive the HPV vaccination prior to pregnancy, Administer first dose of HPV vaccine while patient is in post partum unit.
    2. This would followed by appointments and reminder calls from OB/GYN Clinic for 2nd and 3rd doses of HPV vaccination
  6. Formation of Quality improvement multidisciplinary Committee consist of administrative leadership personnel, physicians, nursing and staffs on HPV Vaccination with the review of quarterly performance improvement meeting to discuss the issues and solutions as well as for the evaluation of HPV vaccination results.

Results

HPV Vaccination Compliance (Ambulatory Quality Improvement report)

 

1st Quarter
(January – March)

2nd Quarter
(April – June)

3rd Quarter
(July – September)

4th Quarter
(October– December)

YTD

 

Year

2011

2012

2013

2014

2011

2012

2013

2014

2011

2012

2013

2014

2011

2012

2013

2014

2011

2012

2013

2014

Patients Screened

472

215

332

390

289

223

231

288

319

327

344

NA

387

433

716

NA

1467

1164

1623

678

Contraindication to Vaccine **/ Pregnant/ Previously Immunized

51

96

160

250

55

63

68

78

67

89

121

NA

86

165

92

NA

259

413

436

328

HPV Vaccination Series (# of Patients That Completed)

Total Received Vaccine

261

119

172

140

234

160

163

210

252

238

223

NA

301

268

624

NA

1048

751

1182

350

Percentage Change Compared to Previous Year

NA

–54.4%

+44.54%

–18.6%

NA

–31.6%

+1.88%

+28.83%

NA

–5.6%

–6.3%

NA

NA

–10.96%

+232.84%

NA

NA

–28.34%

+157.39%

–70.4%

Percentage Change Compared to Year 2011

NA

–54.4%

–34.1%

–46.4%

NA

–31.6%

–30.34%

–10.26%

NA

–5.6%

–11.51%

NA

NA

–10.96%

+107.31%

NA

NA

–28.34%

+112.79%

–6.6%

Table 1: HPV Vaccination Compliance and Vaccination Rate from years 2011–2014.

**/ Contraindication to Vaccine: Individuals who develop symptoms indicative of hypersensitivity to the active substances or to any of the components of either vaccine after receiving a dose of vaccine should not receive further doses of the product [3].

  1. 4th quarter 2012: October – December 2012: 28 % Decrease in # of patients that completed HPV vaccination series - Less patients eligible or refused vaccination.
  2. 4th quarter 2013: October – December 2013: 43% increase in # of patients that completed HPV vaccination series.
  3. 2nd Quarter of 2014: April – June 2014: From month of April and June 2014, HPV Compliance rates increased. 23% increase in # of patients that completed HPV vaccination series as there were less eligible patients for the vaccine in the 2nd quarter of 2014 compared to 2013.

Discussion

An estimated 14 million persons are newly infected with HPV each year; approximately half of new HPV infections occur among persons aged 15-24 years [1]. Although the majority of HPV infections are asymptomatic and resolve, persistent infections can cause disease, including cervical cancers [1-3]. No cure exists for HPV infection; treatments can be directed only at HPV-associated lesions (e.g., warts, precancerous lesions, and cancers). Annual costs of cervical cancer screening and treatment of HPV-associated health outcomes have been estimated at $8 billion U.S. dollars in 2010 [1]. Almost all cervical cancers and many vaginal, vulvar, anal, penile, and oropharyngeal cancers are attributable to persistent, oncogenic HPV infections [1]. HPV-associated cancers in males include some anal, penile, and oropharyngeal cancers caused primarily by HPV16 [5].

Published studies consistently indicate that HPV vaccination of girls [1,2] and boy [8] aged 12 years in the United States is cost-effective [1,2]. For those not vaccinated against HPV at the target age, catch-up vaccination is recommended up to age 26 years.

Centers for Disease Control and Prevention (CDC) recommends HPV vaccination for men as following [9]:

  1. All boys at age 11 or 12 years [9,10].
  2. Older boys through age 21 years, if they did not get vaccinated when they were younger [9].
  3. Gay, bisexual, and other men who have sex with men through age 26 years, if they did not get vaccinated when they were younger [9].
  4. Men with HIV or weakened immune systems through age 26 years, if they did not get vaccinated when they were younger [9].

Educational interventions and increase knowledge about vaccine awareness [11] as well as tailoring intervention materials to women and each individual barriers to HPV vaccination are potentially promising strategy for increasing HPV vaccination among young adult women [12,13].

Obstetrician–gynecologists have the opportunity to intervene by:

  1. Educating mothers about the importance of vaccinating their children at the recommended age and catch up period.
  2. Educating those who are between 13-26 prior to the onset of sexual activity.
  3. While HPV vaccination in pregnancy is not recommended [2,14];
  4. Lactating women can receive HPV vaccine and should be offered this intervention [2,14].

Human papillomavirus (HPV) vaccination is a safe and effective primary prevention strategy for cervical cancer [8,12]. Increase awareness about susceptibility to HPV infection and the high efficacy of the vaccine, along with peer interventions to increase acceptability, are all important factors in increasing HPV vaccination rate [7].

Conclusion

HPV vaccination has the potential to decrease substantial health and economic burdens caused by HPV-associated diseases, including cancers. If health-care reform implementation expands adolescents’ access to primary care and vaccination services, it could ultimately, reduce the substantial burden of HPV-associated diseases and cancers in the U.S. population [1,2,11]. Using the Quality Improvement Project in our hospital, we were able to increase the rate of HPV immunization rate among the young women and adolescent girls in our OB/GYN service.

Future Directions

Our goal is to continue our vaccination educations based on each individual’s level of understanding and raise public awareness about HPV and therefore increase in health care service utilization and HPV vaccine acceptance for both male and female. Social media (including TV, radio, newspaper, Internet, advertisements), school, peer counseling and parental guidance should educate the children about benefits of HPV vaccination. In medical field, Multidisciplinary teams from pediatrics, adolescent medicine, Obstetrics and Gynecology, family medicine and internal medicine should address HPV vaccination to all their eligible patients. These tools should be promoted to reduce the cervical cancer burden on vulnerable populations [7].

References

  1. Curtis CR, Dorell C, Yankey D, Jeyarajah J, Chesson H, et al. (2014) Centers for Disease Control and Prevention (CDC); National human papillomavirus vaccination coverage among adolescents aged 13-17 years-National Immunization Survey – teen, United States, 2011. MMWR Surveill Summ 63(Suppl 2): 61-70.
  2. Committee on Adolescent Health Care of the American College of Obstetricians and Gynecologists; Immunization Expert Work Group of the American College of Obstetricians and Gynecologists (2014) Committee opinion no. 588: human papillomavirus vaccination. Obstet Gynecol 123(3): 712-718.
  3. Committee on Practice Bulletins – Gynecology (2012) ACOG Practice Bulletin Number 131: Screening for cervical cancer. Obstet Gynecol 120(5): 1222-1238.
  4. Fu LY, Bonhomme LA, Cooper SC, Joseph JG, Zimet GD (2014) Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine 32(17): 1901-1920.
  5. Dunne EF, Markowitz LE, Chesson H, Curtis C, Saraiya M, et al. (2011) Centers for Disease Control and Prevention (CDC). Recommendations on the use of quadrivalent human papillomavirus vaccine in males Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 60(50): 1705-1708.
  6. US Food and Drug Administration (FDA) (2015) Approved Vaccines: Human Papillomavirus Vaccine.
  7. Manhart LE, Burgess-Hull AJ, Fleming CB, Bailey JA, Haggerty KP, et al. (2011) HPV vaccination among a community sample of young adult women. Vaccine 29(32): 5238-5244.
  8. Giuliano AR, Palefsky JM, Goldstone S, Moreira ED Jr, Penny ME, et al. (2011) Efficacy of quadrivalent HPV vaccine against HPV Infection and disease in males. N Engl J Med 364(5): 401-411.
  9. Centers for Disease Control and Prevention (CDC) (2015)HPV and Men - Fact Sheet.
  10. Centers for Disease Control and Prevention (CDC) (2014) HPV Vaccine is Recommended for Boys.
  11. Foley OW, Birrer N, Rauh-Hain JA, Clark RM, Di Tavi E, et al. (2015) Effect of Educational Intervention on Cervical Cancer Prevention and Screening in Hispanic Women. J Community Health 40(6): 1178-1184.
  12. Gerend MA, Shepherd MA, Lustria ML (2013) Increasing human papillomavirus vaccine acceptability by tailoring messages to young adult women's perceived barriers. Sex Transm Dis 40(5): 401-405.
  13. Patel DA, Zochowski M, Peterman S, Dempsey AF, Ernst S, et al. (2012) Human papillomavirus vaccine intent and uptake among female college students. J Am Coll Health 60(2): 151-161.
  14. Quadrivalent HPV Vaccine – ACOG Recommendations - Omnia Education.
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