Human Vaccines & Immunotherapeutics
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Non-preventive care: Challenges and opportunities for adolescent HPV vaccination Susan T Vadaparampil & Rebecca Perkins To cite this article: Susan T Vadaparampil & Rebecca Perkins (2014) Non-preventive care: Challenges and opportunities for adolescent HPV vaccination, Human Vaccines & Immunotherapeutics, 10:9, 2557-2558, DOI: 10.4161/21645515.2014.969620 To link to this article: http://dx.doi.org/10.4161/21645515.2014.969620
Published online: 30 Oct 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khvi20 Download by: [117.255.242.234]
Date: 05 November 2015, At: 19:27
COMMENTARY Human Vaccines & Immunotherapeutics 10:9, 2557--2558; September 2014; © 2014 Taylor & Francis Group, LLC
Non-preventive care: Challenges and opportunities for adolescent HPV vaccination Susan T Vadaparampil1,* and Rebecca Perkins2 Moffitt Cancer Center; Tampa, FL USA; 2Boston University; Boston, MA USA
Downloaded by [117.255.242.234] at 19:27 05 November 2015
1
Keywords: HPV vaccination, physician recommendation, primary care setting, specialty care setting Abbreviations: HPV, Human Papilloma Virus; CDC, Centers for Disease Control and Prevention. *Correspondence to: Susan T Vadaparampil; Email: susan.vadaparampil@moffitt.org Submitted: 07/31/2014 Accepted: 08/19/2014 http://dx.doi.org/10.4161/21645515.2014.969620 www.landesbioscience.com
Compared to other industrialized countries where Human Papillomavirus (HPV) vaccine is widely used,1 the United States has low levels of vaccine coverage. Nationally, »57% of females and »35% of males ages 13–17 y received 1 dose of HPV vaccine in 2013.2 The Centers for Disease Control and Prevention (CDC)3 and the President’s Cancer Panel4 strongly advocate increasing physician recommendations as a primary approach to improving HPV vaccine dissemination. Yet, national data suggest physicians most involved in adolescent health care delivery do not routinely and universally recommend HPV vaccination.5,6 While traditional preventive care settings serve as a solid foundation for efforts to increase provider recommendation and vaccine dissemination, it is important to consider that few adolescents (38% annually) visit doctors for preventive care.7 However, non-preventive care visits increase throughout adolescence from annually at age 11 to about 1.5 per year at age 17.8 Thus expanding clinical opportunities for recommending HPV vaccination beyond preventive visits to include other clinical encounters with adolescent patients could help realize the public health benefits of this vaccine. We consider different clinical scenarios and settings and discuss current barriers and possible solutions related to recommendation of HPV vaccination during these encounters. Problem visits to primary care providers in adolescent health care are typically short, focused visits that occur due to a specific health concern. Because primary care providers are knowledgeable about HPV vaccine, have readily available stock of vaccine, and dedicated office staff to administer vaccines, some providers and Human Vaccines & Immunotherapeutics
practices use problem visits as opportunities to provide catch-up vaccinations. However, its adoption varies dramatically. Thus, use of systems that support efficient review of patients records facilitate catchup vaccinations during problem visits. Electronic Health Records may automate identification by “flagging” patients not up to date for vaccination or trained medical assistants can review vaccinations and note missing vaccines in the patient chart. Without such systems, review relies on individual physicians who already struggle with the time limitations of busy clinical practices. Some providers may also be concerned that recommending HPV vaccination will add time to an already constrained visit. However, strong recommendations can be fast. For example, the statement “I see you are not up to date on the HPV vaccine, which prevents cervical and other cancers. Can we get started on that today?” may be sufficient for many parents to initiate vaccination. When additional discussion is needed, resources such as the CDC’s Tips and Timesavers talking points provide responses to commonly raised parental concerns regarding vaccination can be used (ref). Importantly, developing talking points for questions that may be asked during a non preventive care visit such as whether it is safe to vaccinate when an adolescent is ill may help physicians craft targeted recommendations and responses specific to problem visits. Increasing primary care provider utilization of problem visits is the simplest way to decrease missed vaccination opportunities. Expanding vaccination to other healthcare settings, such as those mentioned in the article by Hill and Okugo, has important potential benefits, but also 2557
Downloaded by [117.255.242.234] at 19:27 05 November 2015
more logistical challenges. Specialty providers who see adolescents such as sports medicine physicians, dermatologists, allergists, and pediatric dentists may also offer vaccination opportunities. Many adolescents who do not have a preventive healthcare visit do see these other types of providers. Providing vaccinations in these alternative venues could be powerful mechanism for raising rates. However, several barriers must be overcome to expand vaccination services to these settings. First, many specialty providers are less knowledgeable about HPV or other vaccinations, and will require targeted training and education that addresses the unique clinical situations in which they see adolescent patients. In addition, many specialty practices do not routinely stock vaccines, and require sufficient vaccination volume to make adding this capacity financially feasible. However, in situations where vaccine is not be readily available in the specialty care setting, even recommending vaccination and follow up with the adolescent’s primary care provider may reinforce the importance of HPV vaccination to adolescent patients and parents. Tracking vaccinations, both to determine if doses were previously administered and to ensure vaccine series completion is another important consideration. The routine use of statewide vaccine registries could greatly facilitate tracking if all providers reported into these systems. Finally, hospital-based healthcare entry points into healthcare, such as emergency room or labor-and-delivery visits, may provide access for adolescents with limited healthcare insurance and few healthcare options. As described in the article by Hill and Okugo, these venues may be an important avenue to vaccinate the most vulnerable populations. However, the
2558
barriers are likely the greatest in this context. Providers attending to patients in acute care settings must triage other important health concerns before considering vaccination. They also may lack training in vaccine education and/or lack capacity to stock and administer vaccinations. Record-keeping and tracking patient vaccine series initiation and completion to ensure appropriate administration of vaccination is also challenging in acute settings that lack longitudinal health records. Finally, current insurance reimbursement methods negatively incentivize providing additional healthcare services at the time of a hospitalization. Most emergency and obstetric visits are paid with a single “global fee” based on the primary diagnosis. This requires that the hospital absorb the cost of any other services provided during that visit, such as vaccination or contraception. Many hospitals, especially those serving the most vulnerable patients, cannot afford to provide preventive care during acute visits. As healthcare systems evolve, fractionated healthcare and payment systems that penalize provision of preventive care in acute settings should be reviewed and possibly adapted to consider a holistic view of patients’ wellbeing. Therefore, using hospital-based points of entry requires shifts across the provider, practice paradigm, payer, and policy levels. Despite the efficacy of vaccination in the prevention HPV-related disease, series initiation and completion rates remain suboptimal. Innovative approaches to increase vaccination require moving beyond physician recommendation exclusively in the primary care preventive visit to consider other visit types, physician specialties and clinical care settings.
Human Vaccines & Immunotherapeutics
However, supporting physicians in vaccine recommendation requires careful consideration of the unique opportunities, barriers, and facilitators in these nontraditional contexts. Disclosure of Potential Conflicts of Interest
There were no potential conflicts of interest. References 1. Nelson B. Lagging HPV vaccination rates dampen outlook in US: cloudy prospects for overcoming multiple barriers. Cancer Cytopathol 2010; 118:113-4; PMID:20544704; http://dx.doi.org/10.1002/cncy.20084 2. Elam-Evans LD, Yankey D, Jeyarajah J, Singleton JA, Curtis RC, MacNeil J, Hariri S, Immunization Services Division, National Center for Immunization and Respiratory Diseases; Centers for Disease Control and Prevention (CDC). National, regional, state, and selected local area vaccination coverage among adolescents aged 1317 years - United States, 2013. MMWR Morb Mortal Wkly Rep 2014; 63:625-33; PMID:25055186 3. Dorell C, Stokley S, Yankey D, Jenny Jeyarajah J, MacNeil J, Markowitz L. National and state vaccination coverage among adolescents aged 13-17 years – United States, 2011. MMWR 2012; 61:671-7; PMID: 22932301 4. Rimer B, Harper H, Witte O. Accelerating HPV vaccine uptake: urgency for action to prevent cancer. A Report to the President of the United States from the President’s Cancer Panel. Bethesda, MD: National Cancer Institute; 2014. 5. Vadaparampil ST, Malo TL, Kahn JA, Salmon DA, Lee JH, Quinn GP, Roetzheim RG, Bruder KL, Proveaux TM, Zhao X, et al. Physicians’ human papillomavirus vaccine recommendations, 2009 and 2011. Am J Prev Med 46:80-4, 2014; PMID:24355675; http://dx.doi. org/10.1016/j.amepre.2013.07.009 6. Malo TL GA, Kahn JA, Zimet GD, Lee JH, Zhao X, Vadaparampil ST. Physicians’ human papillomavirus vaccine recommendations in the context of permissive guidelines for male patients: a national study. Cancer Epidemiol, Biomar Prevent 2014; 10:2126-35; PMID:25028456; http://dx.doi.org/10.1158/10559965/EPI-14-0344 7. Irwin CE, Adams SH, Park MJ, Newacheck PW. Preventive care for adolescents: few get visits and fewer get services. Pediatrics 2009; 123:e565-72; PMID:19336348; http://dx. doi.org/10.1542/peds.2008-2601 8. Nordin JD, Solberg LI, Parker ED. Adolescent primary care visit patterns. Ann Family Med 2010; 8:511-6; PMID:21060121; http://dx.doi.org/10.1370/afm.1188
Volume 10 Issue 9
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Non-preventive care: Challenges and opportunities for adolescent HPV vaccination Susan T Vadaparampil & Rebecca Perkins To cite this article: Susan T Vadaparampil & Rebecca Perkins (2014) Non-preventive care: Challenges and opportunities for adolescent HPV vaccination, Human Vaccines & Immunotherapeutics, 10:9, 2557-2558, DOI: 10.4161/21645515.2014.969620 To link to this article: http://dx.doi.org/10.4161/21645515.2014.969620
Published online: 30 Oct 2014.
Submit your article to this journal
Article views: 49
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khvi20 Download by: [117.255.242.234]
Date: 05 November 2015, At: 19:27
COMMENTARY Human Vaccines & Immunotherapeutics 10:9, 2557--2558; September 2014; © 2014 Taylor & Francis Group, LLC
Non-preventive care: Challenges and opportunities for adolescent HPV vaccination Susan T Vadaparampil1,* and Rebecca Perkins2 Moffitt Cancer Center; Tampa, FL USA; 2Boston University; Boston, MA USA
Downloaded by [117.255.242.234] at 19:27 05 November 2015
1
Keywords: HPV vaccination, physician recommendation, primary care setting, specialty care setting Abbreviations: HPV, Human Papilloma Virus; CDC, Centers for Disease Control and Prevention. *Correspondence to: Susan T Vadaparampil; Email: susan.vadaparampil@moffitt.org Submitted: 07/31/2014 Accepted: 08/19/2014 http://dx.doi.org/10.4161/21645515.2014.969620 www.landesbioscience.com
Compared to other industrialized countries where Human Papillomavirus (HPV) vaccine is widely used,1 the United States has low levels of vaccine coverage. Nationally, »57% of females and »35% of males ages 13–17 y received 1 dose of HPV vaccine in 2013.2 The Centers for Disease Control and Prevention (CDC)3 and the President’s Cancer Panel4 strongly advocate increasing physician recommendations as a primary approach to improving HPV vaccine dissemination. Yet, national data suggest physicians most involved in adolescent health care delivery do not routinely and universally recommend HPV vaccination.5,6 While traditional preventive care settings serve as a solid foundation for efforts to increase provider recommendation and vaccine dissemination, it is important to consider that few adolescents (38% annually) visit doctors for preventive care.7 However, non-preventive care visits increase throughout adolescence from annually at age 11 to about 1.5 per year at age 17.8 Thus expanding clinical opportunities for recommending HPV vaccination beyond preventive visits to include other clinical encounters with adolescent patients could help realize the public health benefits of this vaccine. We consider different clinical scenarios and settings and discuss current barriers and possible solutions related to recommendation of HPV vaccination during these encounters. Problem visits to primary care providers in adolescent health care are typically short, focused visits that occur due to a specific health concern. Because primary care providers are knowledgeable about HPV vaccine, have readily available stock of vaccine, and dedicated office staff to administer vaccines, some providers and Human Vaccines & Immunotherapeutics
practices use problem visits as opportunities to provide catch-up vaccinations. However, its adoption varies dramatically. Thus, use of systems that support efficient review of patients records facilitate catchup vaccinations during problem visits. Electronic Health Records may automate identification by “flagging” patients not up to date for vaccination or trained medical assistants can review vaccinations and note missing vaccines in the patient chart. Without such systems, review relies on individual physicians who already struggle with the time limitations of busy clinical practices. Some providers may also be concerned that recommending HPV vaccination will add time to an already constrained visit. However, strong recommendations can be fast. For example, the statement “I see you are not up to date on the HPV vaccine, which prevents cervical and other cancers. Can we get started on that today?” may be sufficient for many parents to initiate vaccination. When additional discussion is needed, resources such as the CDC’s Tips and Timesavers talking points provide responses to commonly raised parental concerns regarding vaccination can be used (ref). Importantly, developing talking points for questions that may be asked during a non preventive care visit such as whether it is safe to vaccinate when an adolescent is ill may help physicians craft targeted recommendations and responses specific to problem visits. Increasing primary care provider utilization of problem visits is the simplest way to decrease missed vaccination opportunities. Expanding vaccination to other healthcare settings, such as those mentioned in the article by Hill and Okugo, has important potential benefits, but also 2557
Downloaded by [117.255.242.234] at 19:27 05 November 2015
more logistical challenges. Specialty providers who see adolescents such as sports medicine physicians, dermatologists, allergists, and pediatric dentists may also offer vaccination opportunities. Many adolescents who do not have a preventive healthcare visit do see these other types of providers. Providing vaccinations in these alternative venues could be powerful mechanism for raising rates. However, several barriers must be overcome to expand vaccination services to these settings. First, many specialty providers are less knowledgeable about HPV or other vaccinations, and will require targeted training and education that addresses the unique clinical situations in which they see adolescent patients. In addition, many specialty practices do not routinely stock vaccines, and require sufficient vaccination volume to make adding this capacity financially feasible. However, in situations where vaccine is not be readily available in the specialty care setting, even recommending vaccination and follow up with the adolescent’s primary care provider may reinforce the importance of HPV vaccination to adolescent patients and parents. Tracking vaccinations, both to determine if doses were previously administered and to ensure vaccine series completion is another important consideration. The routine use of statewide vaccine registries could greatly facilitate tracking if all providers reported into these systems. Finally, hospital-based healthcare entry points into healthcare, such as emergency room or labor-and-delivery visits, may provide access for adolescents with limited healthcare insurance and few healthcare options. As described in the article by Hill and Okugo, these venues may be an important avenue to vaccinate the most vulnerable populations. However, the
2558
barriers are likely the greatest in this context. Providers attending to patients in acute care settings must triage other important health concerns before considering vaccination. They also may lack training in vaccine education and/or lack capacity to stock and administer vaccinations. Record-keeping and tracking patient vaccine series initiation and completion to ensure appropriate administration of vaccination is also challenging in acute settings that lack longitudinal health records. Finally, current insurance reimbursement methods negatively incentivize providing additional healthcare services at the time of a hospitalization. Most emergency and obstetric visits are paid with a single “global fee” based on the primary diagnosis. This requires that the hospital absorb the cost of any other services provided during that visit, such as vaccination or contraception. Many hospitals, especially those serving the most vulnerable patients, cannot afford to provide preventive care during acute visits. As healthcare systems evolve, fractionated healthcare and payment systems that penalize provision of preventive care in acute settings should be reviewed and possibly adapted to consider a holistic view of patients’ wellbeing. Therefore, using hospital-based points of entry requires shifts across the provider, practice paradigm, payer, and policy levels. Despite the efficacy of vaccination in the prevention HPV-related disease, series initiation and completion rates remain suboptimal. Innovative approaches to increase vaccination require moving beyond physician recommendation exclusively in the primary care preventive visit to consider other visit types, physician specialties and clinical care settings.
Human Vaccines & Immunotherapeutics
However, supporting physicians in vaccine recommendation requires careful consideration of the unique opportunities, barriers, and facilitators in these nontraditional contexts. Disclosure of Potential Conflicts of Interest
There were no potential conflicts of interest. References 1. Nelson B. Lagging HPV vaccination rates dampen outlook in US: cloudy prospects for overcoming multiple barriers. Cancer Cytopathol 2010; 118:113-4; PMID:20544704; http://dx.doi.org/10.1002/cncy.20084 2. Elam-Evans LD, Yankey D, Jeyarajah J, Singleton JA, Curtis RC, MacNeil J, Hariri S, Immunization Services Division, National Center for Immunization and Respiratory Diseases; Centers for Disease Control and Prevention (CDC). National, regional, state, and selected local area vaccination coverage among adolescents aged 1317 years - United States, 2013. MMWR Morb Mortal Wkly Rep 2014; 63:625-33; PMID:25055186 3. Dorell C, Stokley S, Yankey D, Jenny Jeyarajah J, MacNeil J, Markowitz L. National and state vaccination coverage among adolescents aged 13-17 years – United States, 2011. MMWR 2012; 61:671-7; PMID: 22932301 4. Rimer B, Harper H, Witte O. Accelerating HPV vaccine uptake: urgency for action to prevent cancer. A Report to the President of the United States from the President’s Cancer Panel. Bethesda, MD: National Cancer Institute; 2014. 5. Vadaparampil ST, Malo TL, Kahn JA, Salmon DA, Lee JH, Quinn GP, Roetzheim RG, Bruder KL, Proveaux TM, Zhao X, et al. Physicians’ human papillomavirus vaccine recommendations, 2009 and 2011. Am J Prev Med 46:80-4, 2014; PMID:24355675; http://dx.doi. org/10.1016/j.amepre.2013.07.009 6. Malo TL GA, Kahn JA, Zimet GD, Lee JH, Zhao X, Vadaparampil ST. Physicians’ human papillomavirus vaccine recommendations in the context of permissive guidelines for male patients: a national study. Cancer Epidemiol, Biomar Prevent 2014; 10:2126-35; PMID:25028456; http://dx.doi.org/10.1158/10559965/EPI-14-0344 7. Irwin CE, Adams SH, Park MJ, Newacheck PW. Preventive care for adolescents: few get visits and fewer get services. Pediatrics 2009; 123:e565-72; PMID:19336348; http://dx. doi.org/10.1542/peds.2008-2601 8. Nordin JD, Solberg LI, Parker ED. Adolescent primary care visit patterns. Ann Family Med 2010; 8:511-6; PMID:21060121; http://dx.doi.org/10.1370/afm.1188
Volume 10 Issue 9
