HPV Vaccination in Primary Care Settings. in Middle Tennessee: An Environmental Scan

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1 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan May 1, 2016 This research was supported by National Institutes of Health (NIH) Grant 3P30CA S3 (administrative supplement) to Vanderbilt- Ingram Cancer Center, with partial support from grants CA163072, CA163066, CA163069, UL1TR and 1U54RR The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Meharry-Vanderbilt-TSU Cancer Partnership

2 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 1 Partner Organizations and Acknowledgments Vanderbilt- Ingram Cancer Center (VICC): VICC, the only National Cancer Institute (NCI)- designated comprehensive cancer center in Tennessee serving both adult and pediatric populations, is a matrix center within Vanderbilt University Medical Center (VUMC). Established in 1993, VICC earned its NCI- designated comprehensive cancer status in The VICC ranks 9 th in total NCI funding ($62.5M) among NCI- designated cancer centers (5 th among matrix cancer centers) and serves 6,000 new patients each year. In addition to the Henry Joyce Clinic at Vanderbilt, VICC has community- based clinical facilities in six other locations around Tennessee, and a formal research affiliation with Baptist Cancer Center (BCC) in Memphis. VUMC and VICC foster clinical affiliations with BCC and with other hospital systems in Tennessee and neighboring states through the Vanderbilt Health Affiliated Network. The VICC is dedicated to an integrated and patient- focused approach to cancer research, treatment, support, prevention, education and outreach throughout the cancer care continuum to positively impact persons in the VICC catchment area, throughout the southeast, and across the country. Jennifer Pietenpol, Ph.D. is the Director of VICC, and Debra Friedman, M.D., is Co- Leader of VICC s Cancer Health Outcomes and Control Program. Pamela Hull, Ph.D., VICC faculty, and Todd Lawrence, VICC s Community Engagement Specialist, served as the Cancer Control Coordinators for the administrative supplement grant that funded this environmental scan project and co- led the project. Cervical Cancer- Free Tennessee Coalition (CCFTN) CCFTN, an outgrowth of the Tennessee Cancer Coalition s (TC2) women s health committee and a member of the national Cervical Cancer- Free Coalition (CCFC), is a statewide coalition with the goal of eliminating cervical cancer in Tennessee by increasing HPV vaccination and increasing cervical cancer screening and early detection. CCFTN brings together representatives of multiple departments within the Tennessee Department of Health (TDH) and other state agencies as well as non- governmental partners such as VICC and Cumberland Pediatric Foundation. CCFTN is organized into five regional committees with 72 members total, half of which are in the Middle Tennessee region. Dr. Hull is Co- Chair, and all partners of this project are involved with CCFTN. Dr. Hull (VICC) and Kelly Moore, M.D., M.P.H. (TDH) are the statewide Co- Chairs of CCFTN. Todd Lawrence, M.A. (VICC), is the Chair of the Middle Tennessee regional committee. Kelly Luskin, M.S.N., and Anne Moore, D.N.P., of TDH have coordinated the CCFTN effort and the participation of TDH staff across the state, with the Middle Tennessee representatives contributing to this project. Tennessee Immunization Program (TIP), Tennessee Department of Health (TDH) TIP promotes proper vaccine use, tracks vaccine needs, provides educational outreach, and promotes public awareness of vaccine importance. TIP manages the Tennessee Immunization Information System (IIS), commonly known as vaccine registry, and the state s participation in the federal Vaccines for Children (VFC) Program. TIP spearheaded a 3- Star Report Quality Improvement initiative for local health departments to track and recognize staff performance at bundling adolescent vaccines for ages Visits are scored with one star each for Tdap, MCV4, and HPV vaccines given at the visit, with a goal of increasing the proportion of 3- Star visits (all three given at the visit) and HPV follow up 1- Star visits. LHD staff use the reports to track progress toward improving preteen immunization uptake at LHDs, with local incentives for staff excellence. Dr. Moore is the Director of TIP under the Tennessee Department of Health. Cumberland Pediatric Foundation (CPF) CPF is a non- profit organization founded in 1994 to promote the health care of children in 23 counties in Middle Tennessee and parts of Kentucky and Mississippi by improving the quality, increasing the efficiency, and lowering the cost of the delivery of pediatric health care services, including vaccination. Affiliated with Monroe Carrell Jr. Children s Hospital at Vanderbilt, CPF has 600+ physician members from over 80 pediatric practices. CPF develops best practice guidelines for the delivery of quality pediatric care and provides extensive educational resources for their implementation. CPF launched a quality improvement plan (QIP) in August 2014 focused on increasing uptake of adolescent vaccines, including HPV vaccine, among the Foundation s practice members, with 20 practices participating in the pilot phase of the QIP. Lora Harnack, M.S.N., the CPF Executive Director, Janet Cates, the CPF Research Coordinator, and Robert Lillard, M.D., the CPF Medical Director, assisted with this project. Meharry- Vanderbilt- TSU Cancer Partnership (MVTCP), Community Advisory Board The NCI- funded MVTCP brings together VICC with two Minority- Serving Institutions (Meharry Medical College and Tennessee State University (TSU), in order to generate and disseminate research aimed at reducing disparities in cancer incidence and its consequences. The MVTCP Cancer Outreach Core (COC) leads community engagement activities and supports the development and implementation of community- engaged research focused on reducing disparities related to cancer prevention and cancer control. The MVTCP s Community Advisory Board (CAB) includes representatives of organizations that

3 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 2 work with African American and Hispanic populations, cancer survivors, and a Teen and Parent Committee that has worked with an HPV vaccine pilot study. The CAB Chair, Navita Gunter, is a cervical cancer survivor, Director of the Cervical Cancer Coalition of Tennessee, and a member of CCFTN. The COC Co- Leaders are Maureen Sanderson, Ph.D. (Meharry), Elizabeth Williams, Ph.D. (TSU), and Pamela Hull, Ph.D. (VICC), and the COC Community Health Educator is Caree McAfee, MA, all of whom contributed to this project. Vanderbilt Health Affiliated Network (VHAN) The Vanderbilt Health Affiliated Network (VHAN) is the largest provider- organized network of doctors, regional health systems and other health care providers in Tennessee and surrounding states and currently includes 47 hospitals and over 3000 physicians. Within VHAN is a pediatric network of over 30 pediatric practices. Network providers collaborate to provide patients with high- quality, efficiently coordinated and cost- effective health care services. The network rewards providers for keeping people healthy, leading to overall cost savings and better patient outcomes. JoAnn Brundage and Dr. Elizabeth Pierce have served as representatives to CCFTN and contributed to this project. Suggested Reference: Vanderbilt- Ingram Cancer Center. HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan. Nashville, TN; Vanderbilt- Ingram Cancer Center 691 Preston Building Nashville, TN

4 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 3 Table of Contents Executive Summary 4 Background 8 HPV Vaccine and Cancer Prevention 8 HPV Vaccination in the US & Tennessee 9 Environmental Scan Objectives and Methods 10 Objectives of Environmental Scan 10 Methods 10 Objective 1: Assess the feasibility of using existing data sources to measure 11 HPV vaccination initiation and completion in the VICC catchment area Data Sources Reviewed 11 Operationalization of Key Measures 11 Reported Data 12 Objective 2: Identify challenges and opportunities for conducting 14 implementation research on HPV vaccination in primary care settings Literature Review of Previous Research: Barriers and Facilitators for HPV Vaccination 14 Question #1: How familiar are providers with ACIP guidelines and to what extent 15 are they followed? Question #2: What are the barriers and facilitators for recommending HPV vaccination 16 at ages 11-12? Question #3: What quality improvement (QI) efforts or other strategies are currently being 18 used to address barriers to HPV vaccination? Question #4: What supports and changes could help facilitate vaccine recommendation? 20 Question #5: What types of education and training could increase vaccine uptake? 21 Objective 3: Recommendations for Future Research & Public Health Initiatives President s Cancer Panel Recommendations 22 Community Preventive Services Task Force: Increasing Appropriate Vaccination 22 Recommendations Related to Data Sources 23 Recommendations for Research to Increase HPV Vaccination 23 References 25

5 Executive Summary HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 4 In , the Vanderbilt- Ingram Cancer Center (VICC) collaborated with a number of partners to conduct an environmental scan and planning process to identify local priorities, challenges and opportunities for research focused on increasing HPV vaccine uptake in the VICC catchment area. Partners included the Cervical Cancer Free Tennessee Coalition, Tennessee Department of Health (TDH), Cumberland Pediatric Foundation (CPF), Meharry- Vanderbit- TSU Cancer Partnership Community Advisory Board, and Vanderbilt Health Affiliated Network. The purpose of this environmental scan was to guide planning of an implementation research agenda aimed at increasing HPV vaccination rates in primary care settings in the Middle Tennessee region. The key findings and recommendations are summarized below. Objective 1: Assess the feasibility of using existing data sources to measure HPV vaccination initiation and completion in the VICC catchment area We operationalized six key measures and assessed them in available data sources: 1. Prevalence of HPV Initiation, Ages (1+ doses) Substantially higher in the VUMC General Pediatrics clinic (87.6% for females, 85.3% for males) than the corresponding national and Tennessee rates reported for the National Immunization Survey- Teen Survey (NIS- Teen). 2. Prevalence of HPV Completion, Ages (3+ doses) Substantially higher in the VUMC General Pediatrics clinic (64.5% for females, 54.5% for males) than the respective national and Tennessee rates reported for the NIS- Teen. 3. Prevalence of HPV Initiation at Age 13 (1+ doses) Varied across the 19 community- based practices reporting data (range 0%- 59% for males and females combined), compared to 78% at VUMC General Pediatrics and 45% in the US (NIS- Teen). 4. Prevalence of HPV Completion at Age 13 (3+ doses) Ranged from 11% to 23.8% for females in 2014 across TennCare s eight Managed Care Organizations, compared to 34% for females and 31% for males at VUMC General Pediatrics, and 26% for females and 16% for males in the US (NIS- Teen). 5. Administration of Next Dose Due of HPV Vaccine (during a patient visit) During an eight- week time period during summer 2014: Practice A % given next dose due during year well child visits; Practice B % given next dose due during routine visits (excluding well- child visits). Practice B documented refusals (14.7% of visits), with the remaining 38.7% of visits representing missed opportunities. 6. Bundling of Adolescent Vaccines (HPV, Tdap, and meningococcal at the same visit) Practice A: During summer 2014, vaccines bundled in 4.3% of visits in which the patients received Tdap. VUMC General Pediatrics: Among all active patients in spring 2015, 68.1% had received bundled vaccines. Objective 2: Identify challenges and opportunities for conducting implementation research on HPV vaccination in primary care settings We collected a Provider Survey and Practice Administrator Survey among CPF pediatric practices. We collected 20 key informant interviews with stakeholders representing pediatric providers, practice administrators and practice networks, public health employees, healthcare professional associations, and health insurance payers. Question #1: How familiar are providers with ACIP guidelines and to what extent are they followed? Awareness: Some key informants observed high awareness of the ACIP guidelines for HPV vaccination among providers in their practice. Other key informants noted variation in levels of awareness across providers, pointing out that it is challenging for providers to keep up with frequent changes in the guidelines. Adherence: Many key informants observed partial adherence to guidelines by providers outside of local health departments and that some providers may not completely trust or agree with the guidelines. In the CPF Provider Survey, at least 18% of surveyed providers were not routinely following the guideline for girls and 27% were not following it for boys.

6 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 5 Question #2: What are the barriers and facilitators for recommending HPV vaccination at ages 11-12? Summary of Barriers and Facilitators Identified in Key Informant Interviews and CPF Provider Survey Parent Level Provider Level Practice Level Barriers Barriers Barriers Varying degrees of acceptance and hesitancy Choosing to delay the decision, then not returning or eventually getting vaccinated Low compliance with returning for follow up shots Assuming parents will not want 3 shots in same visit (40%) Perceived difficulty to convince hesitant parents (31%) Lack of time during office visits Feeling uncomfortable with possibly having a conversation about sex with parents Tailoring recommendations based on assumptions about patients sexual activity or risk Lack of practice- level focus on increasing uptake of HPV vaccine and other adolescent vaccines Challenging to get all staff on board with HPV vaccination guidelines Costs of maintaining vaccine inventory Providers who are less likely to offer the HPV vaccine are also less likely to attend educational sessions on the topic Facilitators Facilitators Facilitators Higher demand for HPV vaccine from Hispanic parents Bundling adolescent vaccines at the same visit and treating HPV vaccine the same as other vaccines Mostly able to recommend bundled vaccines for year olds Mostly able to address questions about boys and link to sexual activity Usually have time to address questions Usually can convince hesitant parents Usually convince parents to bundle Usually influential in parents decisions Local public health department clinics have established protocols and standing orders, including incident reports whenever a nurse deviates from the protocol Question #3: What quality improvement (QI) efforts or other strategies are currently being used to address barriers to HPV vaccination? Provider Level: Four out of five surveyed providers tell parents when they should come back for the second and third doses of HPV vaccine, but only 42% order for appointments to be scheduled for these follow up doses. Over three- fourths of providers reported that they routinely recommend bundled vaccines for year olds. Only 12% routinely recommend vaccines to this age group outside of well- child visits. Practice Level: Most providers and practice administrators indicated that they do not have any QI efforts focused on HPV vaccine, other than participation in CPF s quality improvement project. The Tennessee Chapter of the American Academy of Pediatrics (TNAAP) has been conducting QI projects with several pediatric practices in East and West Tennessee, in collaboration with the national office of the American Academy of Pediatrics (AAP). Three- fourths of surveyed practices used their electronic health record (EHR) system or the state s immunization information system (TennIIS) in some way to inform the provider or nurse when patients are due for vaccines. Two- thirds of practices used some form of standing orders for nurses to administer vaccines, including nurse- only visits for the second and third doses of HPV vaccine. Less than half used the EHR or TennIIS to flag patients due for adolescent vaccines before scheduled appointments. Less than one- third of practices were tracking and reporting adolescent vaccine performance to providers. System Level: The Tennessee Department of Health s Immunization Program has been implementing a quality improvement program in local health departments called, 3- Star Report. Question #4: What supports and changes could help to facilitate vaccine recommendation? Patient Level: Communicate with families in advance with anticipatory guidance about adolescent vaccines. Printed materials in the exam room and waiting room and a link to a patient education website. Manual or automated reminders to patients about vaccines due and follow up doses. This requires a system to be established in the practice.

7 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 6 Provider Level: Improve provider communication to avoid offering the vaccine as optional, but rather part of a routine, bundled package of adolescent vaccines. Automated prompts from EHR to recommend 1 st, 2 nd, & 3 rd doses during patient visits. This requires a system to be established in the practice. Practice Level: Focus on the practice culture (all staff) to inculcate an opt- out mentality versus opt- in for HPV vaccine. Establish standing orders for nurses to administer vaccines consistently per guidelines. System Level: Ensure physicians are paid adequately for the vaccine and its administration. Require the vaccine as part of 7 th grade immunizations. Utilize pharmacies as ubiquitous, convenient locations to expedite and store follow- up doses of HPV vaccine. Include HPV vaccine indicators in the reporting requirements to the Uniform Data System (UDS) submission as a motivation for reimbursement (for federally- qualified health centers). Community Level: Disseminate public service announcements promoting HPV vaccination. Partner with faith- based leaders to promote HPV vaccination, given the strong influence of religion in Tennessee. Question #5: What types of education/training could help to increase vaccine uptake? Topics for continuing medical education (CME) or continuing education units (CEU) training, in order of provider interest: 1. Recently- approved 9- valent HPV vaccine. 2. HPV- related cancers. 3. Effective communication for making strong recommendations. 4. Talking points to explain why the vaccine is recommended at ages Training on quality improvement strategies and safety of the HPV vaccine. 6. Talking points for bundling adolescent vaccine recommendations at ages Key informant suggestions for education and training: Disseminate the talking points for providers on making effective recommendations for HPV vaccination produced by the Centers for Disease Control and Prevention (CDC). Focus training on senior providers and medical directors as standard- bearers and leaders within practices. Train all clinical and administrative staff so everyone is on the same page and communicating consistent messages to parents and patients. Insert HPV vaccine recommendation tips into CMEs on unrelated topics. Award CME credit and/or Maintenance of Certification credit for providers to implement quality improvement efforts in their practice and conducting periodic reviews of their own HPV vaccination rates. Objective 3: Make recommendations for future research and public health initiatives Many recommendations that emerged from our survey and key informant interviews echoed the 2014 President s Cancer Panel recommendations and the Community Preventive Services Taskforce s recommendations of evidence- based strategies for increasing appropriate vaccination. We recommend for coalition and organizational partners to continue building on the QI efforts that have recently been launched by CPF, TNAAP, and the TDH Immunization Program to improve the quality and efficiency of care in primary care settings related to all adolescent immunizations in general and HPV vaccination, in particular. Recommendations Related to HPV Vaccination Data: The National Immunization Survey- Teen (NIS- Teen) is currently the only source of population- level adolescent immunization data for the state of Tennessee. However, NIS- Teen only generates state- level estimates by gender, not for other population subgroups or smaller geographic areas. Since reporting to the state s immunization information system (TennIIS) is not mandatory, it does not cover the entire state population. Therefore, TennIIS cannot be used to generate population- level estimates of vaccination rates for the state or smaller geographic areas. Based on our review and assessment of existing data sources on HPV vaccination in Tennessee, we offer the following recommendations for collecting and reporting data related to HPV vaccination:

8 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 7 1. Practices should be strongly encouraged and incentivized to report immunizations to TennIIS and to check patient immunization status in TennIIS. 2. Below the state level, HPV vaccination data should be reported at the practice level or health plan/health system- level where there is a clearly- defined denominator (i.e., which patients are included) in order to assess HPV vaccination rates over time and evaluate the impact of interventions to increase uptake. 3. Health information technology tools should be disseminated to primary care practices to facilitate the process of periodic auditing on key immunization measures with low personnel burden to inform quality improvement efforts. 4. Future efforts should focus on defining consistent measures that can be used across practices, health systems, research studies, and QI efforts to enhance the ability to compare across data sources. 5. All indicators for HPV vaccine performance should be expanded to include both females and males for reporting to Healthcare Effectiveness Data and Information Set (HEDIS) and the Uniform Data System (UDS), for federally- qualified health centers. Recommendations for Future Research and Public Health Initiatives Research, in collaboration with key stakeholders, is needed to compare and evaluate different approaches to implementing QI efforts in primary care settings targeting HPV vaccine together with other adolescent vaccines. Intervention approaches should be developed and tested that combine multiple strategies targeting the patient, provider, and practice/system levels. We recommend combinations of the following Intervention strategies to target more than one level simultaneously: Patient Level: Patient Education: Provide effective educational materials to parents/patients before appointments (anticipatory guidance) and during visits. Patient Reminder/Recall Systems: Use automated systems to remind parents (text, , phone, mail) about vaccines that are due/overdue and follow- up HPV vaccine doses. (Overlaps with practice level) Provider Level: Provider Education: Provide CME and CEU opportunities focused on strategies for improving HPV vaccine uptake, including inserting HPV vaccine content into trainings focused on broad pediatric topics. Provider Communication: Train providers to use effective communication skills for recommending HPV vaccine as a cancer prevention vaccine and bundled together with other adolescent vaccines. Provider Reminders: Use automated prompts in EHR, TennIIS, or other systems to remind providers when patients are due for HPV vaccine and other vaccines. (Overlaps with practice level) Practice Level: Practice Culture: Train all clinical and non- clinical staff on consistent messaging about HPV vaccination for cancer prevention and strategies for improving practice- level uptake. Standing Orders: Allow nurse- only visits for follow- up doses of HPV vaccine, and establish protocols for nurses to provide bundle adolescent vaccines. Quality Improvement: Support practice- level quality improvement efforts focused on HPV vaccination, with the incentive of providers earning CME and/or Maintenance of Certification credits for participation. System Level: Alternative Settings: Leverage local health departments, schools, and pharmacies as a complement to the medical home to increase access to HPV vaccination, in particular follow- up doses. Reimbursement: Ensure that payers cover all vaccines per ACIP guidelines so that providers are reimbursed adequately for the HPV vaccine and its administration. Community Level: Community Awareness: Disseminate public service announcements and mobilize influential community partners to promote HPV vaccination as routine adolescent vaccine and a cancer prevention vaccine.

9 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 8 Background In , the Vanderbilt- Ingram Cancer Center (VICC) conducted an environmental scan and planning process to identify local priorities, challenges and opportunities for research focused on increasing HPV vaccine uptake in the VICC catchment area. VICC conducted the environmental scan in collaboration with the partners listed below (see Appendix for details on each partner). Over the course of project, we also developed a new partnership with the Tennessee Chapter of the American Academy of Pediatrics (TNAAP) for future initiatives. Cervical Cancer Free Tennessee Coalition (CCFTN) Tennessee Immunization Program (TIP), Tennessee Department of Health Cumberland Pediatric Foundation (CPF) Vanderbilt Health Affiliated Network (VHAN) Meharry Medical College (MMC) Tennessee State University (TSU) Meharry- Vanderbilt- TSU Cancer Partnership (MVTCP), Community Advisory Board HPV Vaccine and Cancer Prevention th th 1 Tennessee ranks 15 nationally in terms of cancer incidence overall and 5 in mortality. While some cancers may not have 2 4 effective preventive strategies, this is not the case for cancers associated with the human papillomavirus (HPV). High- risk genital human papillomavirus (HPV) is a known cause for nearly all cervical cancers and anal cancers, two- thirds of 2 4 oropharyngeal and vaginal cancers, half of vulvar cancers, and one- third of penile cancers. Tennessee has a high incidence of cervical cancer (8.7/100,000) and oral cavity/pharynx cancer (6.3/100,000), both of which exceed the national averages 5 (7.8/100,000 and 6.1/100,000, respectively). Figure 1 shows the combined incidence of cervical and oropharyngeal cancers in the VICC catchment area, which extends into Kentucky and Alabama, and the locations of our partners, CPF and VHAN. Figure 1. Cervical/Oropharyngeal Cancer Incidence in VICC Catchment Area and TN; VHAN and CPF Networks The first HPV vaccines were approved for females in 2006 and males in 2010, with the 9- valent HPV vaccine approved in 2014 for males and females expanding protection to 9 high- risk types of HPV, including 2 that cause genital warts and 7 that are 4,6 8 responsible for 80-95% of cervical, vulvar, vaginal, and anal cancers and over half of oropharyngeal cancers in the US. 9 Current guidelines from the Advisory Committee on Immunization Practices (ACIP) recommend HPV vaccination (3 doses) for 10 all children ages 11-12, when immune response is the highest, with catch up recommended for all females through age 26 and males through age 21 (or optionally through age 26). Cost is not a significant barrier for children, given that the vaccine is free under most health insurance plans and available for a small administration fee to children under age 19 eligible for the federal Vaccines for Children (VFC) program. About 48% of children in the U.S. are eligible for VFC, primarily because they have Medicaid or lack insurance coverage for immunization.

10 HPV Vaccination in the US & Tennessee Despite lack of cost barriers and opportunities for co- administration with tetanus- diphtheria- pertussis (Tdap) and quadrivalent meningococcal conjugate (MCV4) vaccines, whose recommendation also started in 2006 for the same age group, uptake of HPV vaccine has lagged far behind the goal of 80%, according to surveillance data from the National Immunization Survey- Teen (NIS- Teen) (See Figure 2). In contrast, coverage for these ages was 87.6% for Tdap and 79.3% for MCV4 in In terms of age- appropriate vaccination at ages 11-12, the data are even more concerning, with only 26.2% of girls and 16.2% of boys having completed the 3- dose HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 9 % Vaccinated Healthy People 2020 Goal: 80% with 3 HPV doses Figure 2. HPV Vaccine Coverage in US & Tennessee Source: CDC, National Immunization Survey-Teen 9 1 HPV girls US 3 HPV girls US 1 HPV boys US 3 HPV boys US 1 HPV girls TN 3 HPV girls TN 1 HPV boys TN 3 HPV boys TN HPV vaccine series at age Tennessee ranked 49 th among states for initiation (47.8%) and ranked last for completion (20.1%) among females in 2014, while Tennessee s rates for Tdap and MCV4 were close to national rates. 11 Low rates of HPV vaccination mean that the full potential of the HPV vaccine to prevent six types of cancer is not being realized. If the U.S. achieved 90% HPV vaccine completion among females and males by age 12, cervical cancer could be virtually eliminated within one lifetime, 12 along with reductions in other HPV- associated cancers.

11 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 10 Environmental Scan Objectives and Methods Objectives of Environmental Scan An environmental scan is a process of gathering and using information external to an organization to guide strategic planning of the organization s future course of action. 13 Environmental scans can utilize a variety of methodologies depending on the type of information that is needed, ranging from review of published literature to using secondary data reports to gathering primary qualitative or quantitative data. 14 The purpose of this environmental scan was to guide planning of an implementation research agenda aimed at increasing HPV vaccination rates in pediatric care settings in the Middle Tennessee region and the state of Tennessee. Based on the President s Cancer Panel recommendations, the objectives of the environmental scan were to: Methods 1. Assess the feasibility of using existing data sources to measure HPV vaccination initiation and completion in the VICC catchment area. 2. Identify challenges and opportunities for conducting implementation research on HPV vaccination in primary care settings. 3. Make recommendations for future research and public health initiatives. Assessment and Compilation of Existing Data Sources We reviewed a variety existing sources of data within the VICC catchment area to determine the feasibility of using each one to benchmark HPV vaccination rates for the state and Middle Tennessee region and potentially to evaluate future intervention studies. We operationalized the key measures that were available for each dataset and complied available data. Literature Review We reviewed scientific literature in order to identify existing knowledge and evidence related to barriers and facilitators for increasing HPV vaccine uptake in primary care settings at the parent/patient, provider, practice, and healthcare system levels. We summarized and consolidated this information into a table for easy reference. This literature review informed the questions that we asked in the key informant interviews and provider/practice administrator surveys, given that we aimed to explore questions that had not been answered yet in the existing literature. Key Informant Interviews We conducted 20 qualitative interviews with key informants from five stakeholder groups to gain detailed insights and perspectives on the challenges and opportunities for increasing HPV vaccination in primary care settings. After participants provided verbal consent, interviews were conducted over the phone and audio recorded. Interview recordings were summarized to capture key themes and quotes, without identifying individual participants. Below we list the number of participants in each stakeholder group. 8 pediatric providers (MDs, nurse practitioners) 4 practice administrators and representatives of practice networks 4 public health employees (state and local) 3 representatives of healthcare professional associations 1 representative of a payer organization (health insurance) Provider & Practice Administrator Surveys We invited the 79 CPF practices in the Middle Tennessee region to participate in an anonymous survey. We asked the practice administrator to complete a Practice Administrator Survey about the practice overall and to distribute a Provider Survey to each of the healthcare providers (physicians, nurse practitioners, and physician assistants) in the practice. The practice administrators received a gift card incentive for returning the completed surveys. We received completed surveys from 39 practice administrators and 159 providers. Stakeholder Engagement CCFTN and the MVTCP Community Advisory Board served as the primary vehicles to involve a range of stakeholders in the environmental scan process. During monthly CCFTN Middle Tennessee regional committee meetings and quarterly MVCTP CAB meetings, organizational partners and community members gave valuable input on each step of the environmental scan and research planning process.

12 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 11 Objective 1: Assess the feasibility of using existing data sources to measure HPV vaccination initiation and completion in the VICC catchment area Data Sources Reviewed Tennessee Immunization Information System (TennIIS) TennIIS records all vaccines given to Tennessee residents of all ages in local health departments (LHDs) and over 1,880 participating provider offices across the state that voluntarily report to the registry. However, since providers are not mandated to report to TennIIS, TennIIS does not have 100% coverage of all the vaccines provided in Tennessee and cannot be used to generate population- level estimates of vaccine coverage for the state. Individual practices can use TennIIS to pull data reports on their own patients, but our team could not have access to these practice- level reports without permission from individual practices and a formal approval process. Thus, we did not include TennIIS data in the environmental scan. Instead, we sought to assess the utility of other existing data sources to estimate patterns and changes in HPV vaccination in the VICC catchment area and the state. Cumberland Pediatric Foundation (CPF) In August 2014, CPF launched a pilot quality improvement plan (QIP) to enhance vaccine uptake among adolescents among member pediatric practices. The 20 participating practices were asked to submit baseline adolescent vaccination rates on active patients. HPV vaccine initiation was reported as the percentage of 13- year old patients (as of June 30, 2014) who had received at least one dose of HPV vaccine. CPF extended vaccine discounts to the participating practices as an incentive and organized provider/staff education sessions presented by VICC faculty. CPF is currently in the process of collecting follow- up data from the practices for Notably, most of the CPF practices reported that they struggled to pull the vaccination numbers from their EHR systems, highlighting low capacity of practices to implement periodic audit and feedback due to the limitations of reporting tools in EHR systems. Vanderbilt University Medical Center (VUMC) The General Pediatrics Clinic, located on the main medical center campus, is VUMC s largest primary care practice that serves pediatric patients, and it serves a large proportion of Medicaid- insured patients. General Pediatrics provided data on the immunization status of their adolescent patients in spring of General Pediatrics is part of CPF but not part of the QIP. Individual Pediatric Practices Two CPF pediatric practices participated in small QI pilot projects with our team during summer 2015 focused on adolescent immunizations and included assessment of baseline immunization data from summer Immunization histories had to be extracted from the electronic health record (EHR) systems then manually processed to generate data points. TennCare (Medicaid) Managed Care Organizations (MCO) TennCare is Tennessee s Medicaid program, which is administered through seven MCOs across the three regions of the state. Annually the MCOs submit a Healthcare Effectiveness Data and Information Set (HEDIS) performance measures to TennCare, which includes one measure on HPV vaccine series completion among females at their 13 th birthday. TennCare provided this HEDIS measure for 2013 for the seven MCOs and statewide. Operationalization of Key Measures Prevalence of HPV Vaccination for Ages 13-17: Percentage of adolescents ages in a specific geographic population or patient population (i.e., with a known denominator) who have received: (a) 1+ doses of HPV vaccine (initiation), and (b) 3+ doses of HPV vaccine (completion). Prevalence of HPV Vaccination at Age 13: Percentage of adolescents in a specific geographic population or patient population (i.e., with a known denominator) who have received (a) 1+ doses of HPV vaccine (initiation), and (b) 3+ doses of HPV vaccine (completion) by age 13. These measures assess age- appropriate vaccination at ages (prior to age 13). Administration of Next Dose Due of HPV Vaccine: Within a specific practice, percentage of patient visits during a specific time period and age range in which HPV vaccine was administered if a dose was due (any dose); may be assessed on well- child visits, other visits, or all visit types. Visits in which a patient was due for the HPV vaccine and did not receive it represent missed opportunities. Patient refusals may be excluded from the missed opportunity category where they are documented. Bundling of Adolescent Vaccines: Within a specific practice, percentage of patient visits during a specific time period and for a specific age range in which HPV vaccine was administered during the same visit with Tdap vaccine or with Tdap and meningococcal vaccines (if HPV and Tdap were due). This measure may be assessed on well- child visits, routine visits (not well- child visits), or all visit types.

13 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 12 Table 1. Key Measures Reported from Each Data Source Measures CPF QI Pilot VUMC General Individual Pediatric TennCare Practices Pediatrics Practices 1. Prevalence of HPV Initiation, Ages X 2. Prevalence of HPV Completion, Ages X 3. Prevalence of HPV Initiation at Age 13 X X 4. Prevalence of HPV Completion at Age 13 X X 5. Administration of Next Does Due of HPV Vaccine X 6. Bundling of Adolescent Vaccines X X Reported Data Overall, among adolescents ages 13-17, HPV vaccine initiation and completion rates (Figure 3) in the VUMC General Pediatrics clinic (87.6% and 64.5% for females, 85.3% and 54.5% for males, respectively) were substantially higher than the corresponding national and Tennessee rates reported for the NIS- Teen Survey. HPV vaccine initiation at age 13, with males and females combined, varied substantially across the 19 community- based CPF practices reporting data (range 0%- 58.8%), with a weighted average initiation rate at age 13 of 33.1% (Figure 4). Initiation was higher at VUMC General Pediatrics, with 79.2% for females and 77.7% for males. These compare to approximately 45% initiation by age 13 for the U.S. (averaging 51.1% for females and 39.9% for males). 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60.0% 39.7% US: NIS- Teen 2014 Females 41.7% US: NIS- Teen 2014 Males HPV Vaccine Inimamon (1+ dose) HPV Vaccine Complemon (3+ doses) 47.8% 21.6% 20.1% TN: NIS- Teen 2014 Females 30.5% VUMC=Vanderbilt University Medical Center 14.0% TN: NIS- Teen 2014 Males 87.6% 85.3% 64.5% VUMC General Pediatrics 2015 Females Figure 3: Prevalence of HPV Vaccine Coverage for Ages % VUMC General Pediatrics 2015 Males 100% 90% 80% 79.2% 77.7% 70% 60% 50% 40% 30% 20% 10% 0% 0.0% 7.0% 55.0% 58.8% 47.6% 31.2% 33.1% 34.9% 36.5% 38.0% 39.2% 42.4% 40.0% 22.2% 18.0% 18.0% 19.3% 14.2% 15.2% 51.1% 38.9% CPF=Cumberland Pediatric Foundation ; VUMC=Vanderbilt University Medical Center General Pediatrics 2015 Figure 4. Prevalence of HPV Initiation (1+ doses) at Age 13 (both genders combined, except where noted)

14 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 13 TennCare MCO s reported HPV vaccine completion at age 13 among females, which ranged from 11% to 23.8% in 2014 (Figure 5). This compares to national rates of 26.2% for females and 16.2% for males at age 13. At VUMC General Pediatrics, completion at age 13 was notably higher, with 33.9% for females and 31.3% for males. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 17.5% 16.1% Statewide Weighted TennCare (Medicaid) Managed-Care Organizations, Females 2014 BC West 11.0% UHC West 16.1% 16.8% 16.5% BC Middle UHC Middle AG Middle 23.8% BC East 20.0% UHC East 33.9% VUMC Females 31.3% VUMC Males 26.2% US Females 16.2% US Males UCH=United Health Care Plan of the River Valley, Inc., BC=BlueCare/TennCare Select/Volunteer State Health Plan, Inc., AG=Amerigroup Community Care, Inc., VUMC=Vanderbilt University Medical Center General Pediatrics, VEHP=Vanderbilt Employee Health Plan Figure 5. Prevalence of HPV Vaccine Completion (3+ doses) at Age 13 Only two practices were able to report data on administration of next dose due of HPV vaccine during patient visits for an eight week time period during 2014 (Figure 6). For Practice A, only 16.7% of year olds seen for well child visits were given the next dose due, while 81.8% of the patients were due but not vaccinated. Since patient refusals were not documented, it is not known what proportion of the unvaccinated were offered but declined the vaccine. Practice B reported that the next dose due of HPV vaccine was administered in 41.5% of routine visits (excluding well- child visits) with year olds. Refusals were documented for 14.7% of these visits, with the remaining 38.7% representing missed opportunities. Only two practices were able to report data on bundling of adolescent vaccines at the same visit, focusing on children who were due for HPV vaccine when they received the Tdap vaccine (Figure 7). Practice A examined all year old well child visits in summer 2014, revealing that the three adolescent vaccines were administered simultaneously in only 4.3% of visits in which they received Tdap. In contrast, VUMC General Pediatrics examined the immunization history of all active patients in spring 2015 and reported that 68.1% of their patients had received all three vaccines on the day that they received Tdap. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 81.8%** 16.7% 1.5% * Practice A: Well-Child Visits Already up to date (not due) Next dose due given at visit Patient refused Due but not given at visit 41.5% 38.7% 14.7% 5.1% Practice B: Non-Well Child Visits 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 95.7% 4.3% 0.0% Practice A: Year Old Well- Child Visits (Summer 2014) Tdap given but not HPV Tdap+HPV given Tdap+MCV4+HPV given 29.3% 2.6% 68.1% VUMC General Peds (All visits, 2015) Note: Practice A: Well-Child Visits, N = 66 Note: Practice B: Non-Well Child Visits, N = 217 *Not collected **Includes refusals Figure 6. Next Dose Due: HPV Vaccination during Visits for Year-Olds in Two CPF Practices, Summer 2014 Note: Practice A: Year Old Well Child Visits (Summer, 2014) = 47 Note: VUMC General Pediatrics (All visits, 2015) = 2,265 Figure 7. Bundling Adolescent Vaccines

15 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 14 Objective 2: Identify challenges and opportunities for conducting implementation research on HPV vaccination in primary care settings Literature Review of Previous Research: Barriers and Facilitators for HPV Vaccination Table 2. Summary of Known Barriers and Facilitators for HPV Vaccination Level Barriers Facilitators Parent/Patient Level Lack of information, Unaware or forgetting about 2 nd /3 rd doses, Concerns about vaccine safety, Concerns about sexual behavior, Provider recommendation, Regular medical home, Frequent doctor visits Provider Level 17,19,20 Practice and System Levels 16,20 22 Perceive child too young, Irregular preventive care Knowledge gaps, Preference for vaccinating at older ages, Lack of time, Forgetting, Perceptions of parental hesitancy, Low self- efficacy for recommending, Safety concerns, Low perceived severity, Financial concerns Vaccine availability, Cost/insurance reimbursement, Immunization information system (IIS) not compatible with electronic health record (EHR) system, Not required for school Clinical routines related to immunizations, Co- administration with other vaccines, Perceived safety and benefits, Incentives Policies allowing co- administration of vaccines, Reminders/prompts via EHR, Use of IIS Previous research has identified numerous barriers to and facilitators of HPV vaccination at the parent/teen, provider, and practice/system levels (See Table 2). Given that parental lack of knowledge, misinformation, and concerns about safety are common barriers to vaccination, the content of provider- patient communication and patient education materials are very important. 23,24 Our previous social marketing research found that parents are more hesitant about the HPV vaccine when it is presented or perceived as different from other routine vaccinations, and more accepting when presented as a routine component of the adolescent vaccine platform (Tdap, MCV4, HPV). 25 CDC reported findings that bundling adolescent vaccine recommendations at the same year old visit may be more effective than singling out HPV. 24 Many providers are concerned about parents being hesitant about HPV and often experience low self- efficacy in their own ability to persuade hesitant parents to initiate the vaccine, pointing to the need for provider training in communication skills and talking points. 19 Healthcare provider recommendation is consistently reported to be the most important determinant of HPV vaccination, 16,17,26 which points to the primary care setting as a top priority for developing interventions aimed to increase HPV vaccination. Missed clinical opportunities also represent a critical factor, with the vast majority of adolescents having a health care visit each year and two- thirds of 11- and 12- year old girls receiving Tdap or meningococcal (MCV4) vaccines but not HPV vaccine According to a CDC estimate, 91% initiation of HPV vaccine by the 13 th birthday could have already been achieved among females born in 2000 if the HPV vaccine had been co- administered with another vaccine at the same visit. 27 Failing to complete the 3- dose series is often due to poor communication from clinical staff to parents of the need to return or a lack of reminders to return for subsequent doses, in addition to typical access to care barriers. 17 EHR- based reminder systems have contributed to practices having higher rates of series completion. 22 Furthermore, slow translation of evidence- based recommendations and guidelines for preventive services such as immunizations has been a perennial challenge for healthcare providers and primary care practices in the U.S. 30,31 Based on the findings of this literature review, we identified the following five overarching research questions for the environmental scan that addressed knowledge gaps in the existing literature and would be useful to inform the development of a new intervention to increase HPV vaccination in primary care settings. We explored these questions in the key informant interviews and provider/practice administrator surveys. Key findings are summarized below for each question.

16 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 15 Question #1: How familiar are providers with ACIP guidelines and to what extent are they followed? SURVEY FINDINGS Adherence to Guidelines: In the CPF Provider Survey, pediatric providers (N=159) self- reported their perception of how often they recommend the HPV vaccine to 11 and 12 year- old patients, per ACIP guidelines, in the past 12 months. The percentage of providers reporting that they always followed this guideline (greater than 75% of the time) was 82.3% for female patients and 73.4% for male patients. In other words, at least 17.7% of providers were not routinely following the guideline for girls and 26.6% were not following it for boys. However, given the low rates of HPV vaccination reported among pediatric practices and in surveillance data for Tennessee, providers may overestimate their own adherence, so the frequency of non- adherence is likely higher. Notably, 26.6% of providers also indicated that they did not routinely recommend the HPV vaccine (less than 75% of the time) for year old patients they perceived to be at low risk of initiating sexual activity. This also represents non- adherence to the guidelines, since the guidelines indicate that the vaccine should be recommended universally to all year olds. Table 3. Pediatric Provider Self- Reported Frequency of Recommending HPV Vaccine per ACIP Guidelines, CPF Provider Survey, 2015 Never Rarely Sometimes Often Always In the past 12 months, how often did you do the following? (0%) (1-25%) (26-50%) (51-75%) (>75%) Recommend HPV vaccine for year- old girls 0.6% 3.2% 3.2% 10.8% 82.3% Recommend HPV vaccine for year- old boys 0.6% 5.7% 5.7% 14.6% 73.4% Recommend HPV vaccine for year- olds who I felt were at low risk of starting sexual activity soon KEY INFORMANT INTERVIEW FINDINGS Awareness of Guidelines: 2.6% 5.8% 4.5% 13.5% 73.5% Some observed high awareness among providers in their practice, while others noted variation across providers. o We have the ACIP guidelines posted on our refrigerator. (Provider) o Providers are aware of the guidelines; adhering to them is different. (Practice Administrator) It is challenging for providers to keep up with frequent changes in the guidelines. Some providers still believe HPV is meant only for girls and cervical cancer, and not also for boys. Family practitioners may not be as familiar with guidelines as pediatricians. Public health department employees are pretty familiar with the guidelines. Adherence to Guidelines: Many observed partial adherence to guidelines by providers: o Starting to recommend HPV vaccine at ages older than years. o Starting recommendations for Tdap and meningococcal at age 11 but starting recommendations HPV at age 12 or later, in case parents may think three shots are too many to get at once. o Basing recommendation on the provider s judgment of the patient s risk of initiating sexual activity. o Nobody in my practice is holding providers to the guidelines; it s up to each provider. (Provider) o Providers are still feeling out the climate for how receptive parents will be to the vaccine. (Public Health Employee) Some providers may not completely trust or agree with the guidelines. o Some providers may have issues with the HPV vaccine based on religious beliefs. o One provider indicated needing to see more data on the vaccine before recommending it regularly. o One practices routinely waits until 13 to start recommending HPV vaccine. o I don t think there is any difference when the vaccine is given in terms of the immune response. (Practice Administrator) Local public health department clinics have high adherence.

17 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 16 Question #2: What are the barriers and facilitators for recommending HPV vaccination at ages 11-12? SURVEY FINDINGS In the CPF Provider Survey, pediatric providers rated their perceptions of a list of barriers and facilitators in their ability to successfully recommend and administer the HPV vaccine to patients, with responses ranging from 1=Strongly Disagree to 5=Strongly Agree and 3=Neutral. The average (mean) score for each item is presented in Figure 8. Barriers Providers opinions were split as to whether parents are concerned that receiving three adolescent vaccines in one visit is too many, with about 40% agreeing and 40% disagreeing (not shown), making the average score 3 (neutral). Thus, this assumption about parents concerns was a barrier for 40% of providers. Most providers disagreed or were neutral on the statement that there was not much they can do to change the mind of parents who wanted to delay or refuse HPV vaccination (average=2.8), but this was a barrier for the 30.8% of providers who agreed with this statement (not shown). Facilitators Most providers strongly agreed that they were confident in their ability to recommend bundled vaccines for year olds and to address questions about vaccinating boys and whether HPV vaccine increases sexual activity (averages=4.6 to 4.8). There was slightly less agreement on confidence in the ability to overcome parental concerns about HPV vaccine safety, with most responding agree rather than strongly agree (average=4.2). Most providers agreed that they had time to discuss reasons for parental hesitancy, that they were influential in parental decisions, and that they could usually convince hesitant parents to get the HPV vaccine and to get all three vaccines at the same visit (average= ). I think parents are concerned that getting HPV, Tdap, and Meningococcal is too many shots for the same visit When parents wish to delay or refuse HPV vaccination, there is not much I can say to change their minds I am confident that I can strongly recommend for year-olds to get HPV, Tdap, and Meningococcal at the same visit I am confident that I can address parental questions about getting the HPV vaccine for boys I am confident that I can overcome parental concerns about HPV vaccine safety 4.2 I am confident that I can address parental questions about whether HPV vaccine increases sexual activity 4.8 I have enough time during visits to probe parents about their reasons for wanting to refuse or delay HPV vaccine 3.8 I am influential in parents final decision about whether to get the HPV vaccine for their adolescent child 4.3 I am usually able to convince hesitant parents to get the HPV vaccine I am usually able to convince parents of year-olds to get HPV, Tdap, and Meningococcal at the same visit Mean Score (Strongly Disagree to Strongly Agree) Figure 8. Barriers and Facilitators to Recommending and Administering HPV Vaccine, CPF Provider Survey, 2015

18 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 17 KEY INFORMANT INTERVIEW FINDINGS: Barriers Parent Level Varying degrees of acceptance and hesitancy o Parents are the problem, not the provider. (Provider) o Parental concerns about side effects, pain, newness of vaccine. o Some parents concerned that the vaccine grants permission to have sex, not considering cancer prevention. o Some parents already have their mind made up before seeing the doctor. Choosing to delay the decision, then not returning or eventually getting vaccinated o Thinking their child does not need the vaccine because not going to be sexually active for a long time. o Parents often cannot accurately predict when their children will become sexually active. Low compliance with returning for follow up shots o Some patients will not come to the clinic just for a vaccine. Provider Level Lack of time during office visits. Feeling uncomfortable with possibly having a conversation about sex with parents. o Providers realize they re putting parents in an uncomfortable position talking about sex at an early age. (Provider) o Providers may associate moral/ethical conduct and HPV vaccine, but not with other adolescent vaccines. Tailoring recommendations based on assumptions about patients sexual activity or risk. o Some providers reserve HPV vaccination for more sexually active patients only. o Others do not offer the vaccine to patient who they assume have already been exposed to HPV. Some providers (not only child s primary care doctor) telling families that they do not need to get HPV vaccine. Feeling hesitant to give the HPV vaccine because if the patient becomes infected with HPV later, families may wrongly associate HPV exposure with the vaccine. Having to remind parents they are not just testing vaccines on kids. Practice Level Lack of practice- level focus on increasing uptake of HPV vaccine and other adolescent vaccines. o It s just kind of up to me whether to give the HPV vaccine. We don t get much specific direction from clinical leadership. (Provider) Challenging to get all staff on board with HPV vaccination guidelines. Costs of maintaining vaccine inventory. Providers who are less likely to offer the HPV vaccine are also less likely to attend educational sessions on the topic. Facilitators Parent Level Higher demand for HPV vaccine from Hispanic parents. Provider Level Bundling adolescent vaccines at the same visit and treating HPV vaccine the same as other vaccines. o I don t tell them it s [HPV vaccine] optional; rather, it s part of a series of three. (Provider) Practice Level Local public health department clinics have established protocols and standing orders, including incident reports whenever a nurse deviates from the protocol.

19 HPV Vaccination in Primary Care Settings in Middle Tennessee: An Environmental Scan 18 Question #3: What quality improvement (QI) efforts or other strategies are currently being used to address barriers to HPV vaccination? SURVEY FINDINGS According to the CPF Practice Administrator Survey (N=39 practices) (Figure 9), two- thirds used some form of standing orders for nurses to administer vaccines, including nurse- only visits for the second and third doses of HPV vaccine. Less than half of practices used the EHR or TennIIS to flag patients due for adolescent vaccines before scheduled appointments, but three- fourths of practices used the EHR or TennIIS in some way to inform the provider or nurse when patients are due for vaccines. Two- thirds used phone, mail, or to some extent to remind parents when adolescent patients are due for vaccines. Only 28.9% of practices were tracking and reporting adolescent vaccine performance to providers. Use standing orders for nurses to offer and administer recommended vaccines to adolescents* 65.8% Use EHR or TennIIS to flag patients due for adolescent vaccines before scheduled appointments 48.7% Use EHR or TennIIS to prompt provider/nurse to offer vaccines to adolescent patients during a visit if they are due Use phone calls/postcards/ s to remind parents when adolescent patients are due for vaccines 65.8% 74.4% Track and review with providers their performance on providing adolescent vaccine for quality improvement 28.9% 0% 20% 40% 60% 80% 100% Percent Reported Currently Doing *Includes standing orders for nurse to administer the 2 nd and 3 rd dose of HPV at a nurse-only follow up visit Figure 9. Strategies Currently Being Used, Practice Administrator Surveys, 2015 In the Provider Survey (N=159 providers) (Figure 10), over three- fourths of providers reported that they recommend the three adolescent vaccines at the same visit for year olds routinely (more than 75% of the time). However, only 12.3% said that they routinely recommend vaccines to this age group outside of well- child visits. Nearly 80% of providers reported that they tell parents when they should come back for the second and third doses of HPV vaccine, but only 42% said that they order for appointments to be scheduled for these follow up doses. Recommend HPV, Tdap, and Meningitis at the same visit for year-olds 78.3% Recommend vaccines for year-olds during routine non-well child visits 12.3% Tell parents suggested dates to return for 2nd and 3rd doses of HPV vaccine when giving 1st dose 79.0% Order for appointments to be scheduled for 2nd and 3rd doses of HPV vaccine when giving 1st dose 42.0% 0% 20% 40% 60% 80% 100% Percent Report Doing Always (>75% of Time) Figure 10. Strategies Currently Being Used, CPF Provider Survey, 2015