Human Papillomavirus Prevalence and Vaccination Rates Among Users of Pre-Exposure Prophylaxis for Human Immunodeficiency Virus Prevention.

INTRODUCTION: Our study provides data on the prevalence of human papillomavirus (HPV) related disease and vaccination rates among users of pre-exposure prophylaxis (PrEP) in a primary care clinic. Results highlight an opportunity to partner HIV and HPV prevention efforts. METHODS: This is a retrospective chart review of PrEP patients in an urban Midwestern Family Medicine clinic. We conducted univariate analyses for HPV vaccination status and the prevalence of any HPV-related disease. We then examined bivariate relationships between vaccination status and insurance coverage, provider type, and age. RESULTS: Of all 78 PrEP patients identified, 21.8% (n = 17) were vaccinated. Of the 59 patients 45 years or younger, 28.8% (n = 17) were vaccinated. There was no association between insurance or provider type and vaccination status. Patients 26 years or younger were 3 times more likely to be vaccinated than those ages 27 to 45 (56.3% vs 18.6%, P = .0011). Three unvaccinated patients had HPV-related disease. CONCLUSIONS: Despite ongoing risk of HPV infection and frequent interaction with the medical system, this study found most PrEP users continue to be unvaccinated. This is a significant missed opportunity for HPV prevention. With the FDA approval of the HPV vaccine for individuals age 9 to 45, PrEP patients in this age range would benefit from clinicians partnering HPV vaccination with PrEP prescribing.

Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction.

IMPORTANCE: Inefficiency in the operating room (OR) is detrimental to the patient, the hospital, and the surgeon. Head and neck procedures requiring microvascular reconstruction are complex, lengthy operations in which prolonged operative time is associated with higher complication rates and increased costs. OBJECTIVE: To use Lean methodology to identify potential OR efficiency improvement opportunities for head and neck surgical cases involving free tissue transfer, to implement an intervention, the free flap plan of the day, and to evaluate OR times after implementation. DESIGN, SETTING, AND PARTICIPANTS: Phase 1: In 2015, with the assistance of the Lean Promotion Office at our institution, a tertiary academic medical center, we identified efficiency-improvement opportunities for 10 patients undergoing free flap reconstruction. Phase 2: A single intervention, the free flap plan of the day, was implemented on February 1, 2016. A retrospective medical record review of head and neck free flap reconstructions beginning 2 years before the implementation of the intervention and ending 2 years after the intervention was performed from February 1, 2014 until February 1, 2018 to analyze OR times, cost, and complications. Mean OR times were compared using the t test. MAIN OUTCOMES AND MEASURES: In-room-to-incision time and total OR time. RESULTS: Phase 1: The surgical procedures of 10 patients undergoing free flap reconstruction were observed by Lean specialists, and a time study with a process map was completed. Using this framework, major opportunities for decreasing intraoperative time waste were identified. Multiple communication breakdowns were seen to drive intraoperative time waste; therefore, a free flap plan of the day was created to improve communication between team members. Phase 2: 200 patients were included in the study and were categorized into 2 groups, no plan group (n = 104) and plan group (n = 96), based on whether the plan of the day was used or not. The age and sex distributions of the study participants were not collected. Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group (difference, 7.1 minutes; 95% CI, 3.8-10.4 minutes). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group (difference, 56.7 minutes; 95% CI, 23.6-89.6 minutes). CONCLUSIONS AND RELEVANCE: Lean methodology was used to identify efficiency-improvement opportunities for head and neck free flap reconstruction procedures and to design a focused intervention. A free flap plan of the day was used in this study to improve communication between the OR team and was found to improve efficiency and be associated with reduced OR times.