South Dakota Systems Change to Increase HPV Vaccination Rates

PSE Change Real-World Example – Step 6: Implement
Authored by
Patient receiving vaccination

Problem: While over 7% of all cancers diagnosed between 2001 and 2014 in South Dakota were in a primary site that may have been caused by HPV1, HPV vaccination rates were lower than the national average.

1South Dakota Department of Health. (n.d.). South Dakota Cancer Registry. Retrieved from SD DOH website http://getscreened.sd.gov/registry/data/
2Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L.D., Curtis, C. R., MacNeil, J., … Singleton, J. A. (2016). National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States. MMWR Morbidity and Mortality Weekly Report, 65, 850–858. http://dx.doi.org/10.15585/mmwr.mm6533a4

PSE Change Solution: Sanford Health, in partnership with the South Dakota Department of Health Comprehensive Cancer Control Program, implemented systems changes, including client reminder and provider assessment and feedback processes to increase HPV vaccination rates in primary care clinics over a two-year project period. The percent of males and females ages 11 to 26 with zero doses of HPV vaccine administered decreased by 22%; the clinics also recorded a 15% increase in series completion over the two-year period. Year Two witnessed a 9% decrease in adolescents with zero doses of HPV vaccine administered and an 8% increase in series completion at the 39 clinic sites.

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Problem
In South Dakota, over 7% of all cancers diagnosed between 2001 and 2014 were in a primary site that may have been caused by HPV, and 4% of the total cancer deaths were from HPV-associated cancers. (SD Cancer Registry, n.d.). In 2015, the national averages of females and males ages 13-17 receiving the recommended three doses of HPV vaccine were 42% and 28%, respectively (Reagan-Steiner et al., 2016). Vaccination rates in South Dakota were lower: the state ranked 41st for females and 38th for males, with only 32% of females and 22% of males ages 13-17 receiving the recommended three doses (Reagan-Steiner et al., 2016).

PSE Solution
Sanford Health, in partnership with the South Dakota Department of Health Comprehensive Cancer Control Program, implemented systems changes, including client reminder and provider assessment and feedback processes to increase HPV vaccination rates over a two-year project period. Seven primary care clinics were included in Year One, with an additional 32 clinics added in Year Two. The intended patient population was males and females ages 11-26, representing over 46,000 adolescents and young adults.

Actions/Results
Actions

The South Dakota Cancer Coalition utilized a data driven decision-making process to prioritize HPV vaccination and create an implementation task force focused on increasing HPV vaccination rates. Once assembled, the task force developed an action plan that included a strategy focused on the development of a request for application (RFA) process (Step 1: Engage and Step 3: Assess). The RFA included funding and technical assistance to support implementation of systems change strategies and evidence-based interventions (Step 4: Review).

Sanford Health was awarded funding and began by educating clinical and administrative staff on the proposed plan (Step 5: Promote). Sanford Health implemented systems change strategies including a “no missed opportunities” culture that ensured HPV vaccine was offered the same way on the same day as other adolescent vaccines. Through this strategy, administrators used chart audits to capture missed opportunities and educate clinical staff on gaps in HPV reccomendation and adminstration practices.

Immunization protocol orders were disseminated to encourage nursing staff to be champions for vaccination rather than putting the sole emphasis on the physician and advanced practice providers. Additionally, mailed reminders and pre-recorded and personal phone calls were instituted to remind patients they were due for the first dose or subsequent doses of the HPV series. Lastly, HPV vaccination rates were tracked, shared and discussed with nursing staff, physicians, advanced practice providers and clinic leadership monthly in an un-blinded format. Rates were displayed by individual physician and advanced practice provider as well as stratified by clinic for comparison. Process and outcome indicators were tracked to measure effectiveness and identify opportunities for improvement (Step 7: Evaluate).

Results

Over the two-year period, 100,000 client reminders were distributed at the participating clinic sites. Staff administered 13,220 doses of HPV vaccine. The percent of males and females ages 11 to 26 with zero doses of HPV vaccine administered decreased by 22%, while the seven primary care clinics recorded a 15% increase in series completion over the two-year period. Year Two witnessed a 9% decrease in adolescents with zero doses of HPV vaccine administered and an 8% increase in series completion at the 39 clinic sites.

Success Factors and Key Questions Addressed
Was enough awareness about the PSE change established to ensure successful and seamless implementation? If so, how did you generate awareness?

Sanford Health educated administrative and clinical staff prior to implementation. Increasing awareness among all members of the provider teams at the 39 clinics, from the front desk staff to the clinicians, was critical to the success of these efforts.

Were stakeholders committed and engaged?

Executive leadership supported a program focused on increasing adolescent and young adult immunization rates. In-person education for clinical staff gave clarity regarding the need to engage frontline staff and improve system-level processes to increase HPV vaccination rates.

Describe how sufficient resources were secured to ensure successful implementation and sustainability of the PSE change.

Initial support for the project was provided by the South Dakota DOH Comprehensive Cancer Control Program implementation grant; however, practices have been integrated into the culture of Sanford Health and are now maintained independently.

How will you continuously engage stakeholders to keep momentum going?

Sanford Health continues to engage stakeholders through the creation of the Immunization Strategy Leader position. This role serves to plan, organize, develop and manage immunization practices throughout the organization. Sanford also created a formal curriculum termed VAX Champ, which trains nursing personnel on immunizations and establishes a trained vaccine expert within each clinic. The intent is to have VAX Champs readily available for questions, provide staff education and work at a clinic level to improve vaccination rates within their facility.

Additionally, a new platform for education was created, as in-person education is not timely or sustainable for a large organization that spans four states. Vaccine education is offered via Skype at various times throughout the year. Each educational topic is offered multiple times with different days and times each week. Lastly, clinic-level immunization data continues to be shared with leadership and clinical staff on a quarterly basis to effectively monitor progress and make adjustments as needed.

Related Resources
For additional data, please see NIS Teen Data, as well as CDC Success Story: Successful Partnership Increases South Dakota HPV Vaccination Rates (PDF).

References

Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L.D., Curtis, C. R., MacNeil, J., … Singleton, J. A. (2016). National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States. MMWR Morbidity and Mortality Weekly Report, 65, 850–858. http://dx.doi.org/10.15585/mmwr.mm6533a4

South Dakota Department of Health. (n.d.). South Dakota Cancer Registry. Retrieved from SD DOH website http://getscreened.sd.gov/registry/data/

Resources to Support Similar Evidence-Based Initiatives

Community Guide: 
•    Vaccination Programs: Provider Assessment and Feedback
•    Vaccination Programs: Client Reminder and Recall Systems

Evidence-Based Cancer Control Programs: 
•    DOSE HPV: Development of Systems and Education for HPV Vaccination
•    Give Teens Vaccines
 

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