JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
missed opportunities.
Themes Appointment
Child Codes Patient given appointment for vaccination during current visit
The findings of this study included the use of reminder calls and text messages and scheduling appointments for subsequent doses at the time of the first dose to increase adherence to series completion. While moving to a two-dose series should facilitate completion, further investigation is warranted on systems changes including alternative hours and sites for vaccination to overcome the barriers to completing the series. While insurance coverage was not mentioned frequently by those interviewed, informing parents about their coverage could reduce hesitancy related to financial burdens. According to the 2015 Louisiana Health Insurance Survey, 59.6% of children in Louisiana are covered by Medicaid, which covers vaccination at no cost to parents. 22 Of children in Louisiana, in 2016 less than 4% had no health insurance and less than 7.5% and dropping were covered by grandfathered plans and could be expected to have out of pocket expenses for vaccination. 23 This leave approximately 90% of children in Louisiana fully covered for HPV vaccination. There are some limitations to this study. The sample size is small and involves clinics with a large population of patients under 200% FPL and covered by Medicaid. Therefore, the same strategies may not be applicable to providers with patients who are above the federal poverty level, are largely covered by private insurance, have significantly smaller or larger patient populations or are located in rural or suburban area. The practices are summarized in Figure 2. The next steps in this process will be to design ways to allow other providers to practice these behaviors and monitor the effectiveness of such practices. To that end, the Louisiana Immunization Work Group has been formed with the mission of improving immunization rates through coordinated activities and sharing of information. The partnership includes the Louisiana Department of Health Immunization Program, medical society chapters including the Louisiana Chapter of the American Academy of Pediatrics, cancer programs such as the American Cancer Society and the Louisiana Cancer Prevention and Control Programs, immunization partners, health systems, and insurance partners.
• Informational Posters • Nursing Staff
•Talking • Tape (video)
Education
• Cards
• Drug Rep • Handouts
• Pictures
Insurance
Insurance is seen as a barrier or facilitator to receiving vaccines HPV vaccine is offered as an adolescent vaccine or along with other adolescent vaccines (Meningitis or Tdap)
Adolescent Vaccines
• 11 yr. old vaccine
• 12 yr. old vaccine
• Meningitis
Prevent Cancer
Reason for getting HPV vaccine is cancer prevention HPV vaccine is seen as protection against cancer or genital warts
Protect
Recommendation • Offer vaccine during current office visit
• Recommend vaccine during current office visit Building a relationship with patient aids in HPV vaccination
Relationship
Reminders
• Calls
• Postcard
• Text Message
Sexual Activity Shot Records
HPV vaccine is associated with sexual activity
Clinic checks shot records to determine what vaccines patient is eligible for during visit Standing Orders Clinic has standing orders for vaccines, may or may not include HPV
Table 1. Common themes Well Visit
HPV vaccine is talked about, offered or given during well visit
DISCUSSION
Studies have shown that a physician recommendation may be the most important factor in HPV vaccination adherence, 15,16 and according to Reiter, et al., vaccine initiation is higher among parents who receive such recommendations. 17 At least one study has found that pediatricians and family physicians are reluctant to recommend the vaccine because of the perceived necessity to discuss sexual activity in children. 18 However, one systematic review found that only 6-12%of parents indicated a concern that the vaccine would promote sexual activity across the studies reviewed. 16 Another study, a systematic review of European studies, found that parents of children who had received prior vaccines had higher rates of acceptance of the HPV vaccine in all 23 studies reviewed. 19 Along with these studies, our findings support the idea that physicians may be more successful by including the vaccine in their general recommendations for vaccines and limiting such discussion only to those families who ask. In fact, the CDC suggests recommending the HPV vaccine in the same way that other child and adolescent vaccines are offered, that is without lengthy discussions on transmission. 20 Many physicians miss the opportunity to recommend and administer the vaccine at crucial 11 or 12-year wellness visits. 21 This study discovered several approaches to reducing these missed opportunities. This includes having standing orders for HPV vaccination and making that recommendation at every visit, well or sick. Other successful providers simply included the vaccine in the list of recommendations for the 11 or 12-year well visit. Combining both approaches should significantly decrease
CONCLUSION
This study uncovered successful and widely used methods among high performing providers in Louisiana. The majority of these strategies require simple system changes within the practice that should be easily reproducible to improve HPV vaccination rates. Further, these practices require minimal resources and most if not all can easily be implemented in any practice. Collaborative efforts are underway in Louisiana to disseminate these and other practices.
J La State Med Soc VOL 169 MAY/JUNE 2017 65
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