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Are HPV vaccination rates in the pediatric office reflective of the quality of adolescent care that an office gives?
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HPV vaccination rates in the pediatric office are certainly reflective of the overall quality of adolescent care given.
HPV vaccination is just one element of adolescent vaccination, which is just one element of adolescent preventive care. However, HPV vaccination rates represent true quality of overall adolescent care due to the unique skill sets and processes required to attain excellent HPV vaccination rates. Practitioners who engage in the processes necessary to achieve excellent HPV vaccination rates are more likely to meet other metrics necessary for superb adolescent care. First, achieving excellence in HPV vaccination rates requires a system to ensure contact with patients both to initiate and to complete the series. This provides for completion of other vaccinations, wellness visits, critical screenings, and disease-state follow-up. Second, we all know that the HPV vaccine carries a stigma in many parents’ minds. Discussion of this vaccine leading to acceptance and series completion requires commitment and refined skills from pediatrician and staff. In most cases, it also requires providers to leave their comfort zones. It is much easier to discuss diet, exercise and injury prevention, all absolutely necessary parts of adolescent wellness visits. In light of limited time and a loaded agenda, tougher conversations, such as sexual safety, cancer risks (tobacco, HPV), depression, self-mutilation and eating disorders, may seem daunting. It is easier, given our workload, for a provider to acquiesce to a parent’s vaccine refusal than to sit down and have the conversation that leads to vaccination, just as it is easier to just refer a depressed teen out and move on with the visit than to take time to discuss teen depression, do a suicide risk assessment and then follow up to ensure that the patient indeed got in to see a counselor. Clearly HPV vaccination rates can be optimized only if pursuit of all preventive adolescent measures is the defined goal, and if practice processes are honed to ensure achievement of all of these missions.
Alix Casler, MD, FAAP, is chief of pediatrics at Orlando Health Physician Associates, medical director of quality at the University of Florida Pediatric Residency Program at Orlando Health, and assistant clinical professor at Florida State University College of Medicine and the University of Central Florida College of Medicine. Disclosure: Casler reports serving on the Merck speakers bureau and the Merck advisory board. She also consults for the CDC.
The HPV vaccine may indeed be a cancer prevention vaccine, but there is so much more to quality adolescent care.
What does it take to deliver quality health care to adolescents in 2016? How do we measure this? “My pediatrician has better HPV vaccination rates than yours, so mine must be better, right?” Just making sure children “have their shots’” does not mean that we have done our job as pediatricians. And what about parent’s rights to refuse this vaccine even though we have talked and talked and talked about it — does that mean that we are giving poor care? The National Center for Health Statistics reported in 2010 that 43% of teen deaths were from accidental injuries, with motor vehicle accidents being the leading cause. Talking with our patients about risk-taking behaviors, seat belt use, texting while driving, and decisions to ride in a car with someone who may be impaired from alcohol or substance abuse, can have a positive immediate impact on prevention of death or injury. These same data reveal that 11% of deaths are attributed to suicide — might depression screening be a better measure of quality care if you insist on a single measure? But there is not a single measure. Administering the HPV vaccine alone does not protect against STDs or unwanted pregnancy. The CDC reported in 2015 that 41% of high school students were sexually active. Counseling and discussion about “safe sex” will impact HPV infection as well as other STDs and unwanted pregnancy. Gender issues, date rape and abuse all affect daily life and health. Shouldn’t these be part of quality care? Or do we just give the HPV vaccine and say we did a good job? We need to screen for lipid abnormalities and help our teens avoid obesity to prevent type 2 diabetes and heart disease, which will be an inevitable negative health result in early adulthood — just like HPV. These are all important and are all a part of quality health care in adolescents. Any single piece of data regarding adolescent health care, although it may be very important, does not tell the whole story.
Thomas A. Lacy, MD, is medical director at Nemours Children’s Primary Care, Orlando, Florida. Disclosure: Lacy reports no relevant financial disclosures.
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