A "Sense"-ational HPV Vaccination Quality Improvement Project in a Family Medicine Residency Practice.

BACKGROUND: Human papillomavirus (HPV) vaccination uptake for adolescents and young adults in the United States remains far from national goals. Using a multi-component intervention aligned with community-wide efforts, we implemented a quality improvement project to increase HPV vaccinations among 9-26 year-old male and female patients in an urban, low income, minority population family medicine residency practice. METHODS: The pre-intervention year was November 2, 2014 to October 31, 2015 and the intervention year was November 1, 2015 to October 31, 2016. Based on community input and published literature, the interventions were creative, practice-specific provider-, patient-, and system-level strategies. To compare pre- and post-intervention vaccinations, HPV vaccination data were extracted from an electronic medical record request for age-eligible patients seen in the practice during the intervention year. Chi-square, McNemar's and 2-tailed, 2-sample Z tests were used to test differences in vaccination initiation (≥1 dose) and completion (3 doses) across groups and over time. RESULTS: Despite high pre-intervention rates (58% and 75%), HPV vaccine initiation significantly increased 12.8 percentage points (PP) for males and 10.6 PP for females from pre- to post-intervention (P < 0.001). HPV vaccine completion also significantly increased 16 PP for males and 10.9 PP for females (P < 0.001). Young adult patients (18-26 years-old) had significant increases in completion rates (9.9 PP; P < 0.001), not observed among adolescents (20 PP; ns). CONCLUSIONS: Consistent and abundant positive HPV vaccination messaging, low-cost sensory rewards, process change, and community, clinician, and nonclinical staff engagement were associated with higher HPV vaccine initiation and completion, especially among young adults.

FitwitsTM Leads to Improved Parental Recognition of Childhood Obesity and Plans to Encourage Change.

INTRODUCTION: Brief tools are needed to help physicians and parents reach consensus on body mass index (BMI) categories for children and to discuss health-improving behaviors. This study tested the FitwitsTM intervention with interactive flashcards and before and- after surveys to improve parents' perceptions of children's BMI status. METHODS: We enrolled 140 parents and their 9- to 12-year-old children presenting for well child care, regardless of BMI status, scheduled with 53 Fitwits-trained physicians. The Fitwits tool guided a conversation with all parent-child dyads regarding understanding BMI, nutrition, activity, and portion sizes. A survey addressed BMI category perceptions before and after the intervention, requested 2 goal selections, and included open-ended comment areas. RESULTS: Fifty-three percent of children were overweight or obese. The primary outcome variable was the rate of correct parental identification of their child's weight status (underweight, healthy, overweight, or obese). The survey before the intervention resulted in 50.0% correct BMI category designations. This changed to 60.6% correct perceptions after the intervention, with movement between correct overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Secondary outcome variables included specific behavior change goals and the qualitative responses of parents, children, and physicians to the intervention. Parent-child dyads predominantly commented favorably and chose (75.8%) goals corresponding to Fitwits card suggestions. CONCLUSIONS: An improvement was observed in parental ability to identify the correct BMI category after the intervention during a preadolescent well child visit. Parent underrecognition of overweight/obese children was also observed. Most parent comments were appreciative of the physician interaction, Fitwits flashcards, and health improvement exchange.

Fitwits: preparing residency-based physicians to discuss childhood obesity with preteens.

OBJECTIVE: To evaluate the Fitwits MD office tool and games for obesity discussions with 9- to 12-year-olds. METHODS: A nonrandomized intervention study using pre- and posttest assessments in 2 residency programs compared 31 control group and 55 intervention physicians (34 previously trained, 21 newly trained to use Fitwits). Surveys addressed comfort and competence regarding: obesity prevention and treatment, nutrition, exercise, portion size, body mass index (BMI), and the term "obesity." We surveyed all groups at baseline and 5 months (post 1) and new trainees 3 months later (post 2). RESULTS: In post 1, prior trainees reported significantly increased comfort and competence for discussing obesity prevention, portion size, BMI, and "obesity." In post 2, new trainees reported significantly increased comfort and competence discussing obesity prevention and treatment, portion size, and BMI. CONCLUSIONS: Experience using Fitwits improved residency-based physician comfort and competence in obesity prevention and treatment, portion size, BMI, and "obesity" discussions with preadolescents.

Fitwits MD™: an office-based tool and games for conversations about obesity with 9- to 12-year-old children.

BACKGROUND: Physician feelings of ineffectiveness and family-related barriers hamper childhood obesity discussions. Physicians desire appealing, time-efficient tools to frame and sensitively address obesity, body mass index, physical activity, nutrition, and portion size. Our university design-led coalition codeveloped tools and games for this purpose. METHODS: In this feasibility study, we evaluated physician-level counseling of 9- to 12-year-old children and their parents/caretakers using Fitwits MD (Carnegie Mellon University School of Design, Pittsburgh, PA), a brief, structured intervention with flashcards and take-home games. Residency-based physicians in three low- to mid-level socioeconomic urban offices provided self-report data over 8 months through surveys, comment cards, and interviews. RESULTS: We recruited 33 physicians and 93 preadolescents and families. Child-centered key messages resulted in 7-minute conversations, on average. For those physicians who used Fitwits MD, 96% felt improved comfort and competence and 78% noted barrier reduction. CONCLUSIONS: Fitwits MD improved residency-based physician self-efficacy and emphasized important health education topics regarding office-based childhood obesity discussions with preadolescents and parents/caretakers.

Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers.

OBJECTIVES: To increase adult immunizations at inner-city health centers serving primarily minority patients. DESIGN: A before-after trial with a concurrent control. SETTING: Five inner-city health centers. PARTICIPANTS: All adult patients at the health centers eligible for influenza and pneumococcal vaccines. INTERVENTION: Four intervention sites chose from a menu of culturally appropriate interventions based on the unique features of their respective health centers. MEASUREMENTS: Immunization and demographic data from medical records of a random sample of 568 patients aged 50 and older who had been patients at their health centers since 2000. RESULTS: The preintervention influenza vaccination rate of 27.1% increased to 48.9% (P<.001) in intervention sites in Year 4, whereas the concurrent control rate remained low (19.7%). The pneumococcal polysaccharide vaccine (PPV) rate in subjects aged 65 and older increased from 48.3% to 81.3% (P<.001) in intervention sites in Year 4. Increase in PPV in the concurrent control was not significant. In logistic regression analysis, the likelihood of influenza vaccination was significantly associated with the intervention (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.77-2.41) and with age of 65 and older (OR=2.0, 95% CI=1.62-2.48) but not with race. Likelihood of receiving the pneumococcal vaccination was also associated with older age and, to a lesser degree, with intervention. CONCLUSION: Culturally appropriate, evidence-based interventions selected by intervention sites resulted in increased adult vaccinations in disadvantaged, racially diverse, inner-city populations over 2 to 4 years.

Impact of the 2004 influenza vaccine shortage on patients from inner city health centers.

In the fall of 2004, the FDA and British authorities suspended the license of one of only two manufacturers that provided the US supply of inactivated influenza vaccine. With a 50% reduction in supply, a severe vaccine shortage resulted. This situation necessitated the development of priority groups for vaccination including those > or =65 years, when ordinarily, influenza vaccine is recommended for those > or =50 years old. A sample of patients > or =50 years old (n = 336), who had been seen at one of four inner-city health centers, was interviewed in summer 2005 using computer-assisted telephone interviewing. Associations of survey responses were examined for three groups: those vaccinated in the 2003-2004 and 2004-2005 influenza seasons (n = 142), those vaccinated in 2003-2004 but not vaccinated in 2004-2005 because of the shortage (n = 63), and those unvaccinated in both seasons (n = 83). Bivariate and multivariate logistic regression analyses were used to determine factors significantly influencing the likelihood of vaccination status. A significantly larger proportion of patients 50-64 years of age were unvaccinated due to the shortage (73%) compared to those who were vaccinated during both seasons (36%, P < 0.001), but there were no racial disparities in vaccination rates. Compared with patients who were vaccinated during both seasons, those who were unvaccinated due to the shortage were more frequently employed, self-reported their health positively, saw their physician less frequently, rated the US government's response to the shortage as "terrible," and blamed the US government for the shortage. Vaccination during the influenza vaccine shortage appears to have followed preferential vaccination of the CDC-established priority group (> or =65 years) and did not result in racial disparities in inner-city health centers.