March 2016

Using Doctors’ Certification Requirements to Increase HPV Vaccination

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Children’s health outcomes can improve, and pediatricians can be satisfied with the process, when the doctors participate in quality-improvement (QI) programs that are required to maintain their board certification. Researchers at The Children’s Hospital of Philadelphia demonstrated such success with a low-cost program designed to improve vaccination rates for human papillomavirus (HPV), a common sexually transmitted infection that can cause cervical and other cancers. The project results, reported in the journal Pediatrics, provide needed evidence for how such required programs can work effectively.

Several years ago, the American Board of Pediatrics changed its maintenance of certification (MOC) requirements for pediatricians to add required participation in certain QI activities. The move met with controversy, in part due to the limited evidence base for the impact of these physician-only programs.

“The evidence about how that requirement affects patients is lacking, as is information on how you really best do MOC in a way that respects clinicians’ other commitments and works in the context of the practice setting,” said Alexander Fiks, MD, MSCE, who led the CHOP study that now helps to fill some of that evidence gap.

Dr. Fiks is associate medical director for CHOP’s Pediatric Research Consortium; associate director of the Center for Pediatric Clinical Effectiveness; a founding member of the Department of Biomedical and Health Informatics; a PolicyLab faculty member; and an associate professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Co-authors included Xianqun Luan, MS, from CHOP’s Office of Clinical Quality Improvement and Stephanie Mayne, MHS, from the Center for Pediatric Clinical Effectiveness and PolicyLab.

A total of 27 primary care pediatricians in the CHOP Care Network from various locations in Pennsylvania and New Jersey participated in the QI program. Dr. Fiks and colleagues designed and led the program, focused on improving HPV vaccination rates, for pediatricians to meet MOC requirements. Elements of the program included an educational component delivered via webinar, personalized quarterly performance feedback reports summarizing individual and practice- and network-level vaccination rates, and quarterly teleconferences to discuss results of the feedback reports and plan improvement strategies for the next quarter.

Numerous national health authorities support the need to improve rates of HPV vaccination, which are low both in absolute terms and in comparison to other vaccines provided during adolescence. Earlier this year, the 68 National Cancer Institute-designated cancer centers issued a joint statement recognizing low HPV vaccination rates as a significant public health threat, and calling on parents, young adults, and healthcare providers all to contribute to preventing cancer by requesting or recommending this vaccine.

Overall, adolescents cared for by pediatricians participating in the CHOP MOC program received the HPV vaccine more often than those cared for by peer physicians who did not participate in the program. These rates were easy to measure and compare because both participating and non-participating pediatricians used the same type of electronic health records, which captured this data.

Participants in the MOC program increased their rates of offering eligible patients the first dose of HPV vaccine during preventive care visits by 10 percent, compared to a 4.2 percent increase during the same period by non-participating providers in the network. Participating pediatricians also had smaller statistically significant, measurable improvements relative to non-participants in offering the first or second dose of the vaccine during acute care visits.

Dr. Fiks noted a major value of his team’s study is that this program’s success informs the design of effective QI programs that are offered to fulfill MOC requirements. Participating physicians reported a high level of satisfaction with the program, with 96 percent agreeing that the effort they invested was warranted. Physicians reported appreciating group collaboration on improvement strategies, and they valued group accountability and competition among participants to improve their vaccination rates.

Dr. Fiks noted that elements of the program that made it easy and affordable to implement included the use of electronic health records for physician feedback, allowing participants to focus on improvement and not measurement, and the relatively low-cost setup of implementing the program through a webinar and conference calls.

The main barriers to the program’s success were that some physicians found it difficult to participate in scheduled group calls (and therefore listened to a recorded call later), and that some physicians remained reluctant to vaccinate children starting at age 11.

“The gains we saw were modest,” Dr. Fiks noted. “To see more blockbuster results, it may be important to go beyond engaging the physicians to engaging the administration and the rest of the care team. More work is needed to determine how to do that more effectively.”

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