Provider perspectives on multilevel barriers to HPV vaccination

Figures & data

Table 1. Demographic characteristics of family medicine physicians & pediatricians (n = 340).

	n(%) *age reported as mean and range
Age	52.2 (30–81)
Gender
Male	178 (52.4)
Female	162
Primary clinical specialty
Pediatrics	160 (47.9)
Family Medicine	148 (44.3)
Other	26 (7.5)
Practice type
Single specialty	238 (70.4)
Multi-specialty	83 (24.6)
Other	17 (5.0)
Patient load (patients per day)
Less than 15	29 (8.6)
15–19	74 (21.8)
20–29	159 (46.9)
30 or more	77 (22.7)
VFC provider
Yes	177 (51.3)
No	145 (42.0)
I don’t know	23 (6.7)
Provider race/ethnicity
White/Caucasian	199 (63.0)
Asian	36 (11.4)
Black/African-American	23 (7.3)
Other	58 (18.4)
Limit # of vaccines(‘Do you limit the number of vaccinations for those that are due for multiple vaccinations at a single visit?’)
Yes	60 (20.3)
No	236 (79.7)
Use of vaccine state registry (‘Have you ever tried to use FL. SHOTS to get data about HPV vaccination for patients?’)
Yes	192 (55.2)
No	149 (42.8)
Reminders from the healthcare team
Yes	135 (38.8)
No	213 (61.2)
Use of EHR/EMR
Yes	303 (88.3)
No	40 (11.7)
EMR-based reminders
Yes	122 (35.1)
No	226 (64.9)
Completion of residency training in Florida
Florida	105 (31.9)
All other regions	224 (68.1)

Table 2. Relationship between primary clinical specialty and level of engagement in recommendation practices.

Primary Clinical Specialty	Level of engagement in recommendation strategies
	Engage in 0 recommendation strategies	Engage in 1 type of recommendation strategy	Engage in 2 types of recommendation strategies	Engage in 3 types of recommendation strategies
Pediatrics	34 (23%) p = .0005*	26 (18%) p = .9681	38 (26%) p = .6100	48 (33%) p = .0015*
Family Medicine	41 (45%) p = .0005*	16 (18%) p = .9681	21 (23%) p = .6100	13 (14%) p = .0015*
Total	75 (32%)	42 (18%)	59 (25%)	61 (26%)

*significant at Bonferroni corrected p-value of .006

Figure 1. Physicians level of engagement in recommendation practices.

Engage in 0 types of recc.Engage in 1 type of recc.Engage in 2 types of recc.Engage in 3 types of recc.

Table 3. Factors associated with strong & consistent recommendation and presentation of HPV vaccine to 11–12 year old patients.

	Bivariate OR [95% CI]	Multivariable aOR [95% CI]
Outcome: Recommendation Strength
VFC provider	4.99 [2.82–8.84]*	2.62 [1.23–5.59]*
Limit # of vaccines	.211 [.098-.457]*	.283 [.111-.722]*
Use of vaccine state registry	2.71 [1.61–4.56]*	1.67 [.861–3.22]
Reminders from the healthcare team	2.81 [1.71–4.63]*	1.59 [.868–2.93]
Primary clinical specialty	2.37 [1.41–3.98]*	.891 [.425–1.87]
Use of EHR/EMR	.966 [.473–1.97]
EMR-based reminders	1.98 [1.19–3.29]*	1.80 [.953–3.38]
Daily patient load
Less than 15 patients per day	.368 [.130–1.04]
15–19 patients per day	.956 [.452–2.02]
20–24 patients per day	.844 [.436–1.63]
25–29 patients per day	.607 [.292–1.26]
30 or more patients	ref
Provider age
Age 30–44	1.45 [.745–2.84]
Age 45–54	1.46 [.842–2.52]
Age 55+	ref
Provider gender: Males*Females used as reference category	.705 [.434–1.14]
Provider race/ethnicity
White/Caucasian	1.56 [.793–3.08]
Asian	1.08 [.428–2.72]
Black/African-American	1.29 [.420–3.99]
Other	ref
Completion of residency training in Florida	1.25 [.741–2.12]
Outcome: Recommendation Consistency
VFC provider	6.85 [3.69–12.71]*	2.84 [1.26–6.39]*
Limit # of vaccines	.124 [.046-.332]*	.210 [.066-.673]*
Use of vaccine state registry	2.52 [1.49–4.27]*	1.09 [.535–2.20]
Reminders from the healthcare team	2.95 [1.79–4.86]*	2.26 [1.23–4.16]*
Primary clinical specialty	3.91 [2.27–6.74]*	1.49 [.707–3.15]
Use of EHR/EMR	.834 [.525–2.22]
EMR-based reminders	1.50 [.909–2.47]
Daily patient load
Less than 15 patients per day	.465 [.172–1.26]
15–19 patients per day	.611 [.291–1.28]
20–24 patients per day	.756 [.392–1.46]
25–29 patients per day	.574 [.278–1.18]
30 or more patients	ref
Provider age
Age 30–44	1.31 [.674–2.54]
Age 45–54	1.23 [.715–2.13]
Age 55+	ref
Provider gender: Males*Females used as reference category	450 [.275-.735]**	563 [.305–1.04]
Provider race/ethnicity
White/Caucasian	1.09 [.550–2.15]
Asian	.894 [.346–2.31]
Black/African-American	1.57 [.503–4.91]
Other	ref
Completion of residency training in Florida	.847 [.501–1.43]
Outcome: Presentation of Vaccine
VFC provider	2.76 [1.52–5.00]*	1.90 [.882–4.07]
Limit # of vaccines	.434 [.196-.962]**	.801 [.305–2.11]
Use of vaccine state registry	2.12 [1.22–3.69]*	1.86 [.941–3.67]
Reminders from the healthcare team	1.54 [.938–2.52]
Primary clinical specialty	1.47 [.863–2.49]
Use of EHR/EMR	.743 [.359–1.54]
EMR-based reminders	1.67 [1.01–2.77]*	2.00 [1.11–3.61]*
Daily patient load
Less than 15 patients per day	.862 [.318–2.34]
15–19 patients per day	.821 [.384–1.76]
20–24 patients per day	1.13 [.591–2.17]
25–29 patients per day	.479 [.218–1.05]
30 or more patients	ref
Provider age
Age 30–44	1.04 [.526–2.06]
Age 45–54	.932 [.532–1.63]
Age 55+	ref
Provider gender: Males*Females used as reference category	.711 [.433–1.17]
Provider race/ethnicity
White/Caucasian	2.22 [1.05–4.69]*	1.77 [.760–4.14]
Asian	2.55 [.954–6.79]	1.60 [.536–4.76]
Black/African-American	2.40 [.725–7.97]	1.82 [.504–6.56]
Other	ref	ref
Completion of residency training in Florida	.734 [.427–1.26]

*significant at p < .05

Table 4. Multinomial factors associated with level of engagement in recommendation strategies.

Outcome: Engagement in all 3 types of recommendation practices (strength, consistency, & presentation of vaccine)*engage in none of these 3 types used as ref. category for multinomial model	Engages in at least 1 type of recommendation practice	Engages in at least 2 types of recommendation practices	Engages in all 3 types of recommendation practices
	Multinomial aOR [95% CI]	Multinomial aOR [95% CI]	Multinomial aOR [95% CI]
VFC Provider	.254 [.061–1.06]	4.11 [1.02–16.64]*	12.61 [1.89–82.20]*
Receiving reminders from the healthcare team to discuss vaccination	1.31 [.389–3.57]	2.66 [.958–7.39]	2.47 [.861–7.08]
Limit number of vaccinations administered during visit	.614 [.144–2.62]	.230 [.039–1.36]	.112 [.010–1.20]
EMR-based reminders for subsequent doses	2.06 [.627–6.79]	1.05 [.350–3.16]	4.02[1.28–12.63]*
Use of state vaccine registry to obtain data on patient vaccination rates	2.10 [.662–6.63]	2.02 [.710–5.76]	1.97 [.627–6.20]
Primary Clinical Specialty	3.29 [.733–14.74]	.690 [.193–2.47]	1.25 [.292–5.38]
Completion of residency training in Florida	.428 [.130–1.41]	1.02 [.355–2.96]	.703 [.226–2.19]
Use of an EHR/EMR in clinical practice setting	.391 [.086–1.78]	.955 [.192–4.76]	.289 [.063–1.32]
Patient load: # of patients seen daily
Less than 15 patients per day	3.20 [.364–28.14]	2.04 [.202–20.62]	.906 [.090–9.10]
15–19 patients per day	.514 [.069–3.85]	2.64 [.553–12.59]	.631 [.130–3.07]
20–24 patients per day	2.77 [.610–12.60]	4.79 [1.18–19.56]*	2.22 [.556–8.84]
25–29 patients per day	3.14 [.726–13.62]	2.17 [.518–9.08]	.544 [.122–2.42]
30 or more patients	ref	ref	ref
Provider Age
Age 30–44	.612 [.131–2.87]	2.91 [.767–11.07]	1.34 [.316–5.65]
Age 45–54	1.02 [.319–3.25]	1.71 [.552–5.30]	1.97 [.636–6.07]
Age 55+	ref	ref	ref
Provider race/ethnicity
White/Caucasian	1.35 [.330–5.52]	1.83 [.462–7.21]	4.74 [1.05–21.43]*
Asian	.763 [.124–4.69]	.309 [.049–1.96]	1.72 [.261–11.38]
Black/African-American	.414 [.026–6.64]	.260 [.031–2.22]	2.90 [.364–23.14]
Other	ref	ref	ref
Provider Gender: Males *females as ref category	.310 [.102-.946]**	.393 [.139–1.11]	.511 [.178–1.46]

*significant at p < .05

Table 5. Qualitative themes and exemplar quotes.

Question: What are your top 3 suggestions for improving HPV vaccination rates in the United States?
Most Common Themes	Sub-code & Definition	Exemplar Quotes
Education	Adolescent education	“Education for teens regarding vaccine benefits” “Patient handouts in waiting rooms” “Ads in magazines that parents and teens are reading”
	Parent education	“Improve or create online resources that present accurate information for families who are considering the vaccine.” “Educate parents on [HPV vaccine] efficacy and side effects”
	Provider education	“Educate doctors on these 2 factors (I always tell my patients this): -HPV affects 80% of men & women by age 50. – The younger you give it, the more effective it is.” “Better – educative seminars/roundtables about HPV4 & HPV9 similarities, differences, coverage, etc.”
	Education source/location	“Endorsement of HPV vaccine by school system – even if it’s not required for school entry, schools could consider recommending to students to receive it” “Middle school and high school education in health/wellness classes” “More scientific authorities speaking in favor of HPV vaccination on TV/internet”
System-level practices	Availability of the vaccine	“Office doesn’t buy vaccine” “Better supply through VFC” “Improved cooperation with offices having vaccine on hand to administer”
	Integration of EMR with FL. Shots records	“EMR integration with Florida SHOTS” “FL shots notifying when patient completes series”
Financial aspect	Cost	“Tell Medicaid not to make physicians pay for the shots, a better …. in arrangements” “Make it cost effective for a small practice.” “Patients may or may not get vaccinated due to cost of vaccines is very high insurance reimbursement very low-we refer them to DOH to get or write script” “Decrease cost”
	Reimbursements for the vaccine	“Provide physicians with direct vaccine distribution and better prices (HPV vaccine is costly)” “Reimbursements for practice – low/poor payments for shots” “HPV is expensive – I can’t afford to buy them – Also reimbursements are very poor – Also Medicaid doesn’t pay us a fair amount.”
	Insurance coverage	“Improving automatic coverage so it doesn’t need to be verified” “Improved coverage for HPV9” “Expanding VFC coverage for patients over 18 who are eligible for HPV vaccination” “Improve insurance payment for preventive services, Legislature help in forcing insurance companies for adequate payment for preventative treatment rendered during sick visits. Why do I have to prove HPV vaccine is medically necessary in case patient is a teenage male?”
Patient & provider reminder systems	Patient/parent reminders	“Reminding via text/email to get complete HPV vaccinations” “Using text prompts to patients as reminders” “Reminder letters”
	Physician reminders	“EMR reminders” “Put in EHR even for sick visits”
Vaccine mandate	Mandate for school entry	“Consider making it mandatory for school entrance (many parents only want mandatory shots)” “Make mandatory for 9th grade and college admission” “Require for 7th grade”