1. HPV Vaccination Practices: A National Survey of Physicians 18 Months Post-Licensure
April 1, rd National Immunization Conference Matthew F. Daley, MD Associate Professor, Pediatrics University of Colorado Denver

2. Disclosures The authors have no relevant
financial relationships with any
commercial interests to disclose
Presentation may include discussion of HPV vaccine use for patients >26 years of age; otherwise no reference will be made to the use of medications in manners not licensed by
the Food and Drug Administration

3. Timeline-Vaccination Recommendations and Current Study
for HPV Vaccination
Published in MMWR
National Survey
Regarding HPV Vaccination Practices
Quadrivalent HPV
Vaccine Licensed
Jun
Mar
Jan -Mar
2006
2007
2008
ACIP Voted to
Recommend
HPV Vaccine

4. Study Objectives
To assess, in a nationally representative sample of family medicine physicians (FM) and pediatricians (Peds):
Knowledge, attitudes, current practices regarding HPV vaccination
Perceived barriers to HPV vaccination
Factors associated with strongly recommending HPV vaccine to year old female patients

5. Methods Conducted in existing sentinel physician network
Recruited from random samples of AAP and AAFP
Quota sampling done to ensure networks similar to overall AAP and AAFP memberships
Prior work: network participants compared with physicians randomly sampled from AMA
Network participants similar to AMA sample:
Demographic characteristics
Practice attributes
Range of vaccine-related attitudes
Conducted in an already-existing sentinel physician network.
This study was conducted roughly 18 months after HPV vaccine was licensed in the U.S.
Ref: Crane LA, Eval & Health Prof, 2008

6. Survey Design and Administration
Survey pilot-tested in advisory committee of FM and Peds physicians from across country
Administered by internet and standard mail
Survey period: January to March 2008

7. Results: Survey Response
80% response rate overall
FM: 79% (331 of 419)
Peds: 81% (349 of 431)
Respondents not significantly different from non-respondents (with respect to gender, graduation year, urban/rural location, practice type)
For FM, respondents less likely from South, more likely from West

8. Respondents’ Knowledge about HPV
Statements (Correct response)
% Correct, FM
% Correct, Peds
Most genital HPV infections symptomatic (False) 86 85
Almost all cervical cancers caused by HPV (True) 95
Genital warts caused by same HPV types as cervical cancer (False) 58 43

9. Knowledge about HPV Vaccination
Statements (Correct response)
% Correct, FM
% Correct, Peds
Sexually active women should be tested for HPV before starting HPV vaccination (False) 85 91
Women diagnosed with HPV should not be given HPV vaccine (False) 81 77
Pregnancy test should be performed prior to giving HPV vaccine (False) 69 86
Invalid contraindications

10. Attitudes about HPV Vaccination
% Strongly/ Somewhat Agree FM
Peds
Necessary to discuss sexuality prior to recommending HPV vaccine 54 42
Parents concerned that vaccination against STI may encourage earlier or riskier sexual behavior 49
Physician concerned that vaccination against STI may encourage earlier or riskier sexual behavior 6 4

11. HPV Vaccination Practices
Currently administering HPV vaccine to female patients in practice:
88% of FM
98% of Peds
Difference statistically significant (p<0.001)

12. FM: Percentage Recommending HPV Vaccine to Female Patients, by Age Group
The remaining group is “do not recommend”
Note: Recommendations are among providers seeing patients in this age group

13. Peds: Percentage Recommending HPV Vaccine to Female Patients, by Age Group
Note: Recommendations are among providers seeing patients in this age group

14. Perceptions about HPV Vaccine Safety
% Strongly/ Somewhat Agree FM
Peds
Concerned that syncope more likely after HPV than other vaccines 13 33
Concerned that Guillain-Barré syndrome may occur after HPV vaccination 9 8

15. Refusal and Deferral of HPV Vaccination
More reported parent/patient deferral than refusal of HPV vaccine among FM and Peds
More reported refusal at y. than y.
Reporting that at least 25% of parents of year olds refused HPV vaccine when offered
29% of FM
18% of Peds
Refusal defined as outright refusal with no consideration of vaccination later
Deferral defined as postponing vaccination, but parent will consider later

16. Most Common Reported Reasons for Vaccine Refusal/Deferral
The second most common reported reason for vaccine refusal/deferral among FM was that insurance did not cover HPV vaccine for the patient.

17. Factors Reported as Definitely/Somewhat a Barrier to HPV Vaccination

18. 25% or more of respondent’s patients have public health insurance 0.4
Factors Associated with Not Strongly Recommending HPV Vaccine to y.o. Female Patients
Adjusted ORs
(95% CIs)
Considering it necessary to discuss sexuality prior to recommending HPV vaccine
1.6
( )
Reporting that parents of y.o. have been more likely to refuse than parents of y.o.
4.0
( )
Believing that the time it takes to discuss HPV vaccination is definitely/somewhat a barrier
1.9
( )
25% or more of respondent’s patients have public health insurance
0.4
( )
Adjusting for specialty, region of country, and all other factors listed in table

19. Limitations
Respondents may have differed from non-respondents (but high survey response rate)
Sentinel physicians may differ from physicians overall (prior work suggests not)
Survey results represent reported practice; actual practice not observed
Results may not be generalizable to all settings

20. Summary of Findings Knowledge Vaccination practices
Most FM and Peds aware of several key aspects of HPV epidemiology
Some knowledge gaps regarding HPV vaccination
Vaccination practices
High adoption overall: 88% of FM, 98% of Peds administering HPV vaccine in practice
More physicians strongly recommended HPV vaccine to patients 13 years and older vs years
Misunderstanding about HPV vaccination relates to prior diagnosis of HPV, and about whether pregnancy testing is needed prior to vaccination.

21. Summary, continued Reported parent refusal
Vaccine “too new”
Adolescent too young/not sexually active
Insurance not covering
Perceived barriers to HPV vaccination
For both specialties, top 3 barriers were financial
Parent opposition a moderate barrier
Responses about vaccine safety
Parent vaccine refusals not explicitly safety-related
Moderate provider concern about syncope, esp. Peds

22. Implications-Financial
Potential consequences of financial barriers
Does this reflect more underinsured patients?
Increased referrals public health clinics
Financial concerns more prevalent in FM
How much do financial considerations factor in when FM physicians decide not to offer HPV vaccine at all?
Further studies of vaccine cost and reimbursement issues in FM
It may be that insurance coverage for HPV vaccine has improved since this survey was fielded.

23. Implications-Missed Opportunities
Risk for missed vaccination opportunities
Physicians not strongly recommending at y.
Parents deferring at y.
Knowledge gaps
Will missed opportunities stay “missed?”
Interventions to reduce missed opportunities
Potential data source for studying missed opportunities: sentinel registries, large linked databases such as the VSD, NIS-Teen

24. Vaccine Policy Collaborative Initiative
University of Colorado Denver
Principal Investigator - Allison Kempe, MD, MPH
Matthew F. Daley, MD
Brenda L. Beaty, MSPH
L. Miriam Dickinson, PhD
Jennifer Barrow, MSPH
Sandra Black, DVM, MSPH
Christine Babbel, MSPH
Lori A. Crane, PhD, MPH
Christina Kim, MD
CDC Collaborators
Lauri E. Markowitz, MD
Nicole Liddon, PhD
Shannon Stokley, MPH
Sami Gottlieb, MD, MSPH
Funding
CDC, through Rocky Mountain Prevention Research Center

25. Additional Slides

26. Strongly Recommending HPV Vaccine: Comparison of FM and Peds
Note: Recommendations are among providers seeing patients in this age group

27. Family Medicine: Reported Barriers to HPV Vaccination

28. Pediatricians: Reported Barriers to HPV Vaccination

29. Knowledge and Use in Females > 26 Years Old
Knew HPV vaccine not licensed > 26 y.o.
FM: 79%
Peds: 78%
Recommend or strongly recommend vaccine for females > 26 y.o.
FM: 32%
Peds: don’t see this age group
Most FM (62%) who recommended vaccine for > 26 y.o. knew not licensed in this age group

30. Perceived Implications of Having 2 Different HPV Vaccines Available
Statements
Strongly Agree, %
Somewhat Agree, %
Most parents will understand difference between these 2 vaccines 5 20
I will use whichever HPV vaccine is less expensive 4 16
Parents will not think protection against genital warts is very important 3 19
Note: FM and Peds Combined

31. FM: Factors Associated with Not Using HPV Vaccine in Practice
Adjusted ORs
(95% CIs)
Male physician gender (ref: female)
3.79 ( )
Region of country (ref: West)
Midwest
0.69 ( )
Northeast
1.71 ( )
South
3.33 ( )
Factors tested but not significant in multivariate analysis: year of graduation; urban vs. rural location; number of providers; participates in VFC vs. does not