Improving HPV Immunization: A Review of Best Practices in South Texas

Transcription

1 Improving HPV Immunization: A Review of Best Practices in South Texas Cherise Rohr-Allegrini, PhD, MPH The Immunization Partnership Cancer Prevention & Research Institute of Texas (PP160042; PP160080).

2 In Collaboration With Raquel Romero, MD UT SPH, Institute for Health Promotions Deborah Parra-Medina, MPH, PHD Director, UT Latino Initiative Professor, Mexican-American and Latino (a) Studies, UT Austin Daisy Morales-Campos, PhD Research Assistant Professor, Mexican American and Latina/o Studies Latino Research Initiative UT Austin Laura Covarrubias Crocker UT Austin

3 Disclosures I have no relevant financial relationships with commercial interests to disclose.

4 Objectives 1. Discuss the cervical cancer rates in South Texas 2. Recognize gaps in knowledge re HPV 3. Discuss outreach and education efforts in two South Texas studies 4. Utilize evidence-based interventions to improve HPV rates in their clinics

5 HPV-Related Cancers Cervical Cancer Incidence (per 100,000) Bexar County 10.4 Hidalgo County 10.9 Rest of Texas 9.0 Hispanic Women are most at risk Bexar County 11.5 Hidalgo County % of Hispanic Girls in Texas initiate the HPV Vaccine 41.9% of these girls complete the series

6 HPV Vaccination dose Girls 58.3% Bexar 54.5% All of Texas 1 dose Boys 48.5% Bexar 38.3% All of Texas 3 Doses Girls 41.2% Bexar 36.1% All of Texas 3 Doses Boys 29.3% Bexar 20.9% All of Texas 2016 National Immunization Survey

7 Previous studies on HPV-Disease in South Texas Entre Madre e Hija (EMH) Daisy Morales-Campos, PhD UT Health Science Center at San Antonio Colonias Program, Texas A&M University Kappa Delta Chi Sorority, UT-Pan American

8 Entre Madre e Hija (EMH) A cervical cancer prevention program delivered by promotoras (community health workers) and student peer educators Promotoras are trained to provide outreach, health education, referral, and navigation support for HPV immunization to Hispanic mothers and their daughters in Cameron and Hidalgo counties in the LRGV

9 Flow Diagram of Promotora Responsibilities Recruit potential participants and determine eligibility. Administer baseline surveys and distribute EMH educational brochure. Promotoras and peer educators deliver EMH group educational sessions and administer follow-up surveys. Refer mothers to no/low-cost HPV vaccine services and offer navigation support. Call mothers to confirm daughter s receipt of the HPV vaccine (3 doses).

10 EMH Brochure (English/Spanish)

11 Example of Bilingual EMH Flipchart

12 Screened (N=944) Enrollment & Follow-Up Rates Eligible (n=607; 64.3%) Baseline Assessment & Brochure (n=372; 61.3%) Ineligible (n=337; 35.7%) EMH Program (n=257; 68.1%) Brochure Only (n=115; 30.9%) 6 month Follow-up (n=208; 80.9%) 6 month Follow-up (n=80; 69.6%)

13 Methods EMH Study Design Single group, pre- and post- surveys Measures Knowledge of HPV and cervical cancer screening Attitudes on HPV vaccine HPV Vaccination (selfreport)

14 Data Collection 10/ /2013 Sample: 372 mothers with unvaccinated daughter yrs Survey: Interviewer-administered Electronic/Web-based tools: Secured online database, netbooks, wireless Internet

15 HPV Knowledge Gaps 93.5% believed HPV is detected through a Pap test 62.8% believed HPV is cured with antibiotics 72.5% believed condoms protect from HPV

16 HPV Vaccine Attitudes 43.7% agreed the vaccine is safe 7.5% agreed getting the vaccine encourages girls to become sexually active 9.4% agreed if a woman gets the vaccine, everyone will assume she is having sex 83.3% agreed they would vaccinate their daughter if their daughter s doctor recommended it

17 Vaccine Status at 6 months by group 90 Percentage of participants Initiated Vaccine Status Completed EMH Program Brochure Only * Chi-square test for EMH program versus Brochure only (p<.001)

18 Conclusions Observed knowledge gaps regarding how HPV is detected, cured prevented and how its effects on the body. EMH improved knowledge among education program participants Over 80% of patients initiated vaccine (both EMH and Brochure) 58% Texas and 65% US More EMH program patients (71%) completed the vaccine series compared to Brochure only (45%) 35% Texas and 42% US Patients in the EMH program compared to those in the brochure only group were two times more likely to complete the vaccine. Patients who spoke English, had health insurance, and were employed had lower odds of completing the vaccine.

19 Next Steps Continuation/Expansion grant from CPRIT Entre Familia & UTHSCSA/South Texas Rural Health Include males Combines public education with clinic in-reach Clinic partner (Nuestra Clinica del Valle & STRH) Verification of vaccination status in EMR & ImmTrac

20 Improving HPV Vaccination Rates Best Practices Using Best Practices to increase vaccination rates South Texas Entre Familia: Evidencedbased Services Program in the Rio Grande Valley Medina Dimmitt LaSalle Frio Cancer Prevention & Research Institute of Texas (PP160042; PP160080).

21 Partners Best Practices in South Texas The Institute for Health Promotion Research (IHPR), UT Health San Antonio South Texas Rural Health Services (STRHS) The Immunization Partnership (TIP) Area Health Education Centers (AHECs) South Central and Mid Rio Grande Border Entre Familia, RGV The University of Texas at Austin, Latino Research Initiative Nuestra Clinica del Valle The Immunization Partnership Texas A&M University Colonias Program AHEC Lower Rio Grande Valley

22 Using Best Practices to increase vaccination rates in South Texas Increase HPV vaccination (initiation and completion) among adolescent male and female patients ages from six clinics in rural south Texas Entre Familia: Evidencedbased Services Program in the Rio Grande Valley To increase HPV vaccination (initiation and completion) among adolescent male and female patients ages residing in Hidalgo County

23 Projects Implementation Plan Strong HPV vaccine recommendation from providers Healthcare professionals Implement health systems-based interventions to support HPV vaccination Parents/caregivers, adolescents & young adults Provider directed intervention Educate to increase knowledge of HPV, cancer prevention benefits, efficacy, and safety of HPV vaccines. Community education and outreach

24 Community Component: Area Health Education Center (AHEC) County-wide outreach Education sessions in groups and one-on-one with parents and their adolescents Educate and train and community health workers Flyers, health fairs, media (incl. social media)

25 Community Component: AHEC

26 Using Best Practices to increase vaccination rates in South Texas Community Outreach March 2016 May 2017 Reached 18,097 adult residents Educated 3,797 adult residents evidence-based education sessions and brochures Educated 452 healthcare professionals

27 Entre Familia: Evidenced-based Services Program in the Rio Grande Valley Community Outreach Mar-May 2017 Reached 1,157 adult residents of Hidalgo County through outreach Educated 349 adult residents of Hidalgo County using EF s evidence-based education sessions and brochures Educated 109 healthcare professionals Served 46 vaccine-eligible clinic patients

28 Clinic Component: Clinic Coordinator Educate and train Immunization Champions Implement healthcare systems-based interventions Patient Education Reminder/Recall Noting missed opportunities Update providers on evidencebased strategies to make strong recommendations

29 Assessing HPV Vaccination Rates at the Clinic Level Assessment and Feedback: The AFIX Process

30 What is AFIX? AFIX identifies immunization rates, opportunities for improving immunization delivery practices, and ensuring that providers are: Aware of and knowledgeable about their immunization rates and missed opportunities to vaccinate Motivated to incorporate changes to their current practices Ready to try new immunization service strategies Capable of sustaining these new behaviors. Source: Centers for Disease Control and Prevention,

31 What is AFIX? Assess providers vaccination rates and immunization practices Assessment Follow-up with providers to monitor and support exchange AFIX Incentives Feedback Let providers know their rates and recommendations on how to improve Recognize and reward those providers who are doing well and/or improve their rates and practices

32 Assessment Data-driven Purpose is two-fold: Figure out how providers are doing Vaccination rates Vaccine delivery practices Identify areas for improvement

33 Chart-based Assessments For this kind of assessment, the CDC recommends: Reviewing charts for the same age group. If >50 charts are available for an age group, pull a sample. If <50 charts are available for an age group, review ALL available charts for that age group.

34 CoCASA software Comprehensive Clinic Assessment Software Application (CoCASA) Tool for assessing immunization rates and practices at clinics and practices Designed to be used hand-in-hand with AFIX

35 2 DOSES / DOSIS 6-12 months after Adolescents years 2 dose series Adolescentes años serie de 2 dosis 6-12 meses después 6-12 months/meses* *Minimum interval between the first and second dose in a 2 dose schedule is 5 months *Intervalo mínimo entre la primera y la segunda dosis en 2 dosis es de 5 meses 3 DOSES / DOSIS 2 months after 2 meses después 4 months after 4 meses después Young adults years 3 dose series Adultos jóvenes años serie de 3 dosis 6 months/meses

36 AFIX Baseline Data STRHS Feb patients from 6 clinics randomly sampled 15 patients (4.5%) initiated the series 1 (0.3%) 3 doses 3 (0.89%) 2 doses 26 (7.7%) Missed Opportunities Entre Familia March patients from 2 clinics randomly sampled 48 patients (48%) initiated the series 23 (23%) completed the series (based on new criteria) 22 needed 2 more doses 3 needed 1 more dose 36 Missed Opportunities

37 AFIX Baseline Data Entre Familia March patients from 2 clinics 12 patients initiated the series 9 completed the series 2 needed 2 more doses 1 needed 1 more dose 9 missed opportunities Note: This age group has much lower rate of Men B (25%) and Tdap (20%) Compare age group Men B (62%), Tdap (58%)

38 Entre Familia: Evidenced-based Services Program in the Rio Grande Valley Clinic implementation goals Educate 60 health care providers on evidencebased HPV vaccination practices Increase over baseline the proportion of healthcare providers that routinely offer the HPV vaccine Meet or exceed Texas vaccine initiation (39%/16%) and completion (20%/8%) rates for adolescents and young adults

39 How Do We Make This Happen? The Immunization Champion

40 Reminder/Recall Identify and contact patients who have upcoming vaccine doses (reminder) or have missed doses (recall) PROS: Doesn t rely on patients being in the clinic already

41 Reminder/Recall CHALLENGES: Can be time-intensive, especially if on paper charts TIPS: Use Tickler files Ask parents to fill out reminder post cards for subsequent doses before leaving a clinic visit Conduct recall in batches

42 Immunization Information Systems Texas uses ImmTrac, a statewide immunization registry PROS: Can fill in the gaps of immunization history by desegregating vaccination records

43 Immunization Information Systems CHALLENGES: ImmTrac is opt-in and unidirectional so is not as complete as other states systems; Often diverts resources to input data TIPS: Reference shot records for patients daily or in small batches so that clinics don t fall behind

44 Provider Reminders Alerts providers that a patient is in need of a vaccine dose PROS: Helps to reduce missed opportunities

45 Provider Reminders CHALLENGES: Only works for patients who are in the clinic; Screening adds an additional step to work flow; Competing priorities TIPS: Review patients charts for the next day and flag those that needs vaccines Can be simple: place a colored dot sticker on the front of the chart to indicate to the provider that a vaccine is needed

46 Standing Orders Gives non-physician healthcare personnel (ex. physician assistants, nurses and medical assistants) directive to administer vaccines without a prescription to eligible patients PROS: Allows more flexibility and opportunity to administer vaccines

47 Standing Orders CHALLENGES: Only works for patients who are in the clinic; Sometimes difficult to enforce TIPS: Buy-in from provider is critical; it s important that they enforce the standing orders Use in conjunction with reminder/recall and/or vaccine-only visits to increase effectiveness

48 Interventions Used in Combination Uses 2+ interventions in a healthcare setting PROS: Often more effective than any one intervention used alone

49 Interventions Used in Combination CHALLENGES: Depending on the interventions, can be very time and personnel intensive; Difficult to adapt protocol and norms to accommodate new processes TIPS: Leadership buy in and staff training is critical Identify overlap with existing protocols to ease transition (ex. Well-Child Visits)

50 RESULTS

51 Using Best Practices to increase vaccination rates in South Texas Results Mar 2016 January Records Reviewed 29 patients (8.61%) initiated the series. This is 2x the baseline 9 (2.67%) received their second dose 3 (0.89%) completed the series Missed opportunities dropped from 7.7% to 2.1% 77% of the Target population has not been to the clinic in more than 12 months

52 Conclusions Preliminary data from both studies indicate that Reminder/Recall is working to bring patients back to complete the series Improved communication between providers and patients has shown an increase in HPV vaccine initiation Community outreach efforts in both locations have also resulted in more initiation of vaccination

53 Recommendations for Clinics Continue Community Outreach at public events Determine Baseline Rates in your clinic Educate Providers on Communication Tools Identify a Champion in the clinic to: conduct reminder/recall Flag charts to avoid missed opportunities Provide education and outreach to patients

54 Texas Immunizations Conference November Hyatt Regency San Antonio