HPV Vaccine Delivery Practices by Primary Care Physicians

Abstract

Background and objectives: To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

Methods: We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

Results: The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) (P < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

Conclusions: Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.

Figure 1:. Strength of Physician Recommendation for HPV Vaccine by Patient Age and Gender (Peds n=302; FP n=228).

Figure 2:. Proportion of Physicians Reporting Patients/Parents Refusal/Deferral of HPV Vaccine, by Patient Age and Gender (Peds n=302; FP n=228).

Figure 3:. Physician Experiences with HPV Vaccine Discussions (Peds n=302, FM n=228)

Figure 4:. Physicians’ Perceived Barriers to HPV Vaccination (Peds n=302, FM n=228)

Barriers reported as “Major” by <12% by both specialties: Parent concerns that vaccination may encourage their sons to have earlier sexual behavior, vaccination may encourage their sons to have riskier sexual behavior, vaccine could cause infertility in their daughters/sons, their child will suffer immediate short-term effects from the HPV vaccine, about the efficacy of the HPV vaccine, about waning immunity if the HPV vaccine is given too early; physician concern about giving too many vaccines in one visit, it will result in an uncomfortable conversation with the parent, about the safety of the HPV vaccine for females, about the efficacy of the HPV vaccine for males/females; physician belief that HPV infection is not common enough in males/females to justify a vaccination, pap smears are an adequate way to prevent cerivical cancer, HPV-associated diseases are not severe enough in males/females to justify a vaccination; parents wanting to wait to begin the HPV series until after menarche for girls; failure of some insurance companies to cover HPV vaccination; the ‘up-front’ costs for my practice to purchase the vaccine; Lack of adequate reimbursement for vaccination, the time it will take me to discuss HPV vaccination with my patients and their parents.

Figure 5:. Physician Knowledge Regarding 2-dose HPV Vaccine Schedules (Peds n=302, FP n=228)

Figure 6:. Primary Care Physicians’ Attitudes Regarding 2-dose HPV Vaccine (Peds n=302, FM n=228)