Implementation Challenges and Opportunities Related to HPV Vaccination Quality Improvement in Primary Care Clinics in a Rural State

Efforts to understand low human papillomavirus vaccine coverage led us to explore quality improvement (QI) decision-making programs and processes to increase vaccine uptake. These QI programs often include interventions recommended by the AFIX (Assessment Feedback Incentives eXchange) Program that supports Vaccines for Children (VFC) clinics. However, little is known about decision-making around intervention selection or extent of implementation. In collaboration with the state public health department in the rural Midwestern, investigators developed a survey to explore vaccine-related QI in VFC clinics. The survey was distributed via email to all VFC clinics (n = 605); results presented are from the primary care clinics (n = 115). Respondents (VFC liaisons) reported decisions about vaccine QI were made by multiple actors within their own clinics (45.1%), by a clinic manager in charge of multiple clinics (33.0%) and/or at a centralized administrative office (35.2%). Additionally, the majority of respondents considered external actors, like insurance companies (52.7%) or Medicaid/Medicare (50.5%), important to the decision-making process. Most commonly implemented interventions focused on provider knowledge and patient education. Least commonly implemented interventions required systematic changes, such as reminder/recall and follow-up after missed appointments. This preliminary research indicates there are multiple points of decision-making within clinics and health care systems, and therefore change agents at all points need to be involved. The most commonly implemented interventions focus on providers and patients, with an emphasis on education. Interventions requiring system-level changes and use of electronic health records are less common and more attention should be directed towards such interventions.