OBJECTIVE: Human papillomavirus (HPV) infection is associated with a large burden of disease prevalence, morbidity, and known disparities. HPV vaccination rates remain lower than other childhood immunizations, despite vaccine safety and effectiveness. The objective of this quality improvement (QI) intervention was to improve HPV vaccination rate by 15% over 3-years through early initiation and analyze trends across health disparities. METHODS: QI study in ages 9 to 13 at Nemours Primary Care from 2019 to 2022, which includes rural and urban regions and diverse populations. Interventions included updating electronic health records to begin at age 9, practice-level feedback, and updated education. Primary outcome measure was the Healthcare Effectiveness Data Information Set (HEDIS) rate for HPV vaccination (proportion completed by age 13). Process measure was early HPV vaccine initiation rate (proportion aged 9-10 with at least one dose). Year-end early HPV vaccine initiation rates were analyzed to assess trends by race and ethnicity, geography, insurance, and Child Opportunity Index (COI). RESULTS: The number of eligible 9 and 10 year olds ranged from 16,466 to 17,925 annually. HEDIS rates improved over three years from 49.2% to 59.5% (P <
0.0001). Early initiation increased from 13.2% in 2019 to 42.2% in 2022 (P <
0.0001) and improved significantly across demographic variables (P <
0.0001). Groups with the lowest baseline early vaccination rates increased significantly. CONCLUSION: HPV vaccine completion by 13 increased significantly with QI supporting early initiation. Demographic analyses showed the highest degree of improvement in populations with the lowest baseline rates. This supports altering Centers for Disease Control and Prevention (CDC) recommendation for HPV vaccination initiation at ages 9-12.