A Quality Improvement Project to Increase Hepatitis A and B Vaccination in Adults with Hepatitis C in a Federally Qualified Health Center

A Quality Improvement Project to Increase Hepatitis A and B Vaccination in Adults with Hepatitis C in a Federally Qualified Health Center Virginia M. Selanik Problem Statement Despite long-standing recommendations for vaccination against hepatitis A virus (HAV) and hepatitis B (HBV) in persons with chronic liver disease and hepatitis C virus (HCV) infection and the life-threatening complications suffered from cirrhosis and hepatocellular cancer (HCC), vaccination rates for HAV and HBV in adults are suboptimal in clinical practice. Theoretical FrameworkBased upon published clinical guidelines and performance measures for optimal care of HCV-infected persons, a quality improvement project was implemented guided by Kotter’s eight-step change model. Strategies adopted from the 4 PillarsTM Practice Transformation Program, including staff/provider education, standing orders, immunization champions, open access/walk-in vaccination during office hours, posters promoting vaccination electronic medical record (EMR) reminders, patient post card reminders, and weekly charts to track progress were used. Project Description Retrospective EMR reviews from patients with a detectable HCV viral load (HCV RNA) were conducted at the start of the project and three months following the intervention. Demographic data along with HCV RNA, HAV total antibody (HAV Ab), HBV surface antibody (HBsAb), and vaccination against HAV and HBV were derived from EMR reports, comparing vaccination rates before and after the intervention. A secondary goal included increasing provider and staff knowledge related to hepatitis and clinical guideline recommendations for immunization against HAV and HBV in persons with chronic liver disease and HCV infection. Using a quasi-experimental, one group pretest-posttest design, health care providers’ and staff members’ knowledge related to hepatitis and clinical guideline recommendations for immunization against HAV and HBV were evaluated before and after the educational intervention using 20-items from a pretest-posttest questionnaire. Findings and Implications The educational intervention significantly increased the providers’ and staff knowledge about hepatitis C. There was an average gain of 16.76 points (95% confidence interval, 13.32, 20.20) on a knowledge test after the educational presentation. This gain was statistically significant at p ≤ . 05 by the paired t-test (two-tailed). Improvements were seen for Havrix (16.9% pre-intervention, 19.7% post-intervention); Engerix-B (2.3% preintervention, 3.5% post-intervention); and Twinrix (20.8% pre-intervention, 21.4% postintervention). Overall vaccination rates were increased by 4.6% in a predominantly publicly insured patient population. The goal of increasing vaccination rates by 20% was not met. However, multi-strategy, evidence-based interventions were an effective means of increasing HAV and HBV vaccinations in a community health center and led to increased access to vaccination services, increased community demand for vaccines, and improved system-based performance. HEPATITIS VACCINATION IN ADULTS WITH HEPATITIS C iii Dedication I dedicate this work to my patients, without whom this project would not have been possible and to my mother, Virginia E. Selanik, who taught me the value of lifelong learning, just because. you can and want to. HEPATITIS VACCINATION IN ADULTS WITH HEPATITIS C iv.