University of Michigan
Health System
Adolescent HPV Vaccination:
Experience of the First Year
Amanda F. Dempsey, MD, PhD, MPH
Assistant Professor, Division of General Pediatrics
Child Health Evaluation and Research (CHEAR) Unit
University of Michigan
National Immunization Conference
Dallas, TX 2009
What do we Know about
HPV Vaccine Uptake in the U.S. So Far?
NIS-Teen
• ~25% of 13-17 yo females initiated
vaccination in 2007
– 17% second dose
– 6% third dose
• No significant differences by year of age
Smaller populations
• ~5-25% vaccine initiation depending on
population studied
MMWR (2008), 57(40): 1100; Kahn et al Obstet Gyn (2008), 111(5): 1103; Rosenthal et al. J Adol Health (2008),
43(3): 239
Many Unanswered Questions
• What are the under-vaccinated
subpopulations (race, geography,
religion)?
Understanding more detail about the who,
• Who
is when
providing
vaccines?
what,
and the
where
is critical for
beginning effective vaccination outreach
• In what settings is the vaccine being
activities.
provided?
• What proportion initiate the series, but do
not complete it?
Study Goals
1. What proportion of eligible females received
doses 1, 2 and 3 and what were their
characteristics?
2. By whom and at what types of visits was the
vaccine being administered?
3. Were there any diagnoses preferentially
associated with vaccine delivery?
4. What proportion and type of visits were
“missed opportunities” for vaccination?
Study Design
• Retrospective medical record review
– January 2007 – March 2008
– Females ages 9-18
– Outpatient visit in Peds, Fam. Med or Ob/Gyn
• Variety of data retrieved from electronic
medical records
– Claims data
– Vaccination Records
– Demographics
– Scheduling/clinic data
Sample Characteristics - Patients
Characteristic
N
(Total =10,082)
%
Race
White
African American
Other
7,416
1,369
1,297
73%
14%
13%
Age
9-10
11-12
13-15
16+
2,421
2,035
2,951
2,675
24%
20%
29%
27%
Insurance
Private
Public
No Insurance
7,867
2,124
91
78%
21%
1%
Sample Characteristics – Eligible Visits
Characteristic
Specialty
Pediatrics
Family Medicine
Ob/Gyn
Visit Type
Preventive
Problem-focused
Immunization Only
N
N=27,928
%
21,105
5,920
903
76%
21%
3%
5,781
18,301
3,846
20%
66%
14%
Receipt of Vaccines by Eligible
9-18 year olds
Dose
# Eligible - Dose
% Vax
1
10,082
28%
2
2,625
78%
3
1,515
75%
Compliance with Dosing Schedule
• Up-to-date via recommended schedule (6
months after 1st dose)
– Out of 1865, 521 received = 28%
• Up-to-date within a year after first dose
– Out of 585 eligible, 406 received = 69%
For those initiating the series, vaccination with
second and third doses is remarkably high, however
most girls who do get started with vaccination and
do not get their doses within the recommended 6month time frame.
Associated Patient Characteristics
Characteristic
% Eligible Girls Vaccinated
Dose 1
Dose 2
Dose 3
Race
White
African American
Other
28%
34%
25%
82%
60%
76%
77%
61%
71%
Age
9-10
11-12
13-15
16+
2%
32%
38%
39%
75%
77%
79%
77%
72%
74%
77%
73%
Insurance
Private
Public
No insurance
27%
35%
24%
81%
67%
70%
78%
63%
30%
Study Goals
1. What proportion of eligible women received
doses 1, 2 and 3 and what were their
characteristics?
2. By whom and at what types of visits was
the vaccine being administered?
3. Were there any diagnoses preferentially
associated with vaccine delivery?
4. What proportion and type of visits were
“missed opportunities” for vaccination?
Visit Types
• Immunization-Only Visit
– Shots but no contact with doctor/provider
• Preventive Visit
– Well child exams, sports physicals, annual
Paps
• Problem-focused Visit
– All other types of visits
Vaccination by Type of Visit
100%
90%
80%
70%
% of
60%
dose
50%
provided 40%
30%
20%
10%
0%
Problemfocused
Immunizationonly
Preventive
1st
Dose
2nd
Dose
3rd
Dose
Vaccination by Medical Specialty
Specialty
Of Eligible Girls in that
Specialty, % Vaccinated
Dose 1
Dose 2
Dose 3
Pediatrics
29%
78%
76%
Family Medicine
29%
78%
72%
Ob/Gyn
17%
71%
72%
Conclusions
• Initiation of the HPV series seems critical.
Once the series is begun, the majority of
girls complete it.
• Most girls who complete the series do so
in 1 year rather than the recommended 6
months
• There are important disparities in series
completion by race and insurance which
has implications for the population-level
effect of HPV vaccination campaigns.
Limitations
• Generalizability to other populations
• Misclassification of visits/patients
• Exclusion of important populations
– older females
– girls seen in other clinical settings
– girls within the system who should have been
vaccinated but made no visits during the
study period.
Putting it All Together –
How well are we doing with HPV vaccination?
•High proportion those
initiating complete the
series
•All three specialties able to
complete the series once
begun
+
•Disparities in vaccine use
•Ob/Gyn least likely to initiate
•11-12 year olds less likely to
get vaccinated than older
•Older girls vaccination less
linked to preventive visits
-
University of Michigan
Health System
Thank You!
Special thanks to my collaborators at the University of
Michigan
•
Lisa Cohn, CHEAR
•
Vanessa Dalton, Ob/Gyn
•
Mack Ruffin, Family Med
•
Lynn Holevinski, HSDW
•
Judy Habelter, Billing
Qualifying Visits
“Immunization only”:
– Procedure code for an immunization (not
always HPV)
– No associated visit code
– Same for Peds, FM and Ob/Gyn
• “Problem-focused Visit”:
– Defined by having an office visit procedural
code (99201-05, 99211-15)
– May or may not have an associated
immunization
– Same for Peds, FM and Ob/Gyn
Relationship Between Patient Factors and Visit
Type – 1st Dose
100%
90%
80%
70%
% of
dose
60%
provided 50%
40%
30%
20%
10%
0%
Problemfocused
Immunizationonly
Preventive
9 to 10
11 to 12 13 to 15
Age
*p<.0001
16+
Qualifying Visits – cont’d
• “Preventive Visit”:
– Peds, FM:
• “Comprehensive Exam” visit procedural code
– For Ob/Gyn:
• “Annual Exam” procedural code
– For all:
• Level 3 or 4 office visit procedural code PLUS
• Pap smear/cervical cx screening proc. Code PLUS
• No associated ICD-9 code of “hx abnormal Pap”