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Saving Lives from Preventable Cancer: Solutions for Geographic Disparities in HPV Vaccination
This blog post is the first of a three-part series exploring the disparities related to human papilloma virus (HPV) vaccination rates across the US. In this post, we examine geographic disparities in HPV vaccination, with the goal of understanding the causes of these disparities to inform recommendations for policy makers, payers, health care providers, and patients. In subsequent posts, we will address racial/ethnic disparities in HPV vaccination and conduct a case study examining the highest- and lowest-performing states (Rhode Island and Mississippi, respectively).
HPV is a highly prevalent infection in the US, with the probability of infection exceeding 80% for women and 90% for men across their lifetime. HPV is responsible for various types of cancers, including cervical, anal, penile, and oropharyngeal. Vaccination against the high-risk HPV types (types 16 and 18) commonly associated with these cancers is a promising primary prevention strategy that could significantly reduce the incidence and burden of these cancers. Since the introduction of HPV vaccination in 2006, infections with HPV types that cause most HPV cancers and genital warts have declined 88% among teen girls and 81% among young adult women. The HPV vaccine has demonstrated sustained protection against HPV infections for at least 10 years after vaccination.
Evidence of Geographic Disparities in HPV Vaccination Rates
In 2020, the national rate of HPV vaccination (≥1 dose) among adolescents in the US was 75% and has remained consistent through 2022. While on the whole this may seem to be a respectable achievement, when considered as a range, this statistic greatly from the poorest-performing state (Mississippi ~48%) to the highest-performing state (Rhode Island ~89%). In the final post of this series, we will examine the likely reasons behind the variation in HPV vaccination rates between these two states. Recent evidence shows that uneven HPV vaccination across the US may be contributing to continued geographic disparities in HPV‐related cancers among unvaccinated young women and men, as emerging herd immunity may not be as strong in regions with lower vaccination rates.
Disparities in HPV vaccination rates have been observed among the various regions across the US, with southern states and mountain states generally having lower rates. Provider recommendation of the HPV vaccine for adolescents is less common in southern and rural regions compared to other areas, likely contributing to lower vaccination rates in these regions; as such, recommendations are among the most important strategies to increase HPV vaccination coverage. The majority of southern and mountain states with low rates of HPV vaccination are also those that have not adopted Medicaid expansion. Given adolescents with Medicaid have the highest rates of HPV vaccine completion, there is a correlation between state Medicaid expansion and HPV vaccination, as several studies have concluded.
Disparities in HPV vaccination across states may be tied to varying levels of poverty, health care infrastructure, and HPV education. In areas with higher poverty rates, access to health care services, including vaccinations, is often limited due to financial constraints and lack of health insurance, which could contribute to lower HPV vaccination rates. Areas with limited health care infrastructure may not have sufficient resources to implement and promote vaccination programs. Public health education also plays a significant role in HPV vaccination rates, as areas with lower education levels may have less awareness about the importance of the vaccine, leading to lower uptake. Further, eligibility criteria for publicly-funded vaccination programs and the amount of public funds available for these programs differ by state, and thus likely contribute to these disparities.
Initiatives to Address Geographic Disparities
Identifying and addressing geographic disparities in HPV vaccination is crucial for achieving the goal of eliminating HPV infections and associated preventable cancers within the population. There are a range of factors at play when considering geographic disparities.In terms of patient circumstances, there are likely many confounding factors that lead to the geographic disparities we see in HPV vaccination rates, including income, education, and insurance coverage, for instance. Other factors include, but are not limited to, health care infrastructure, provider recommendations and attitudes, and public policy and funding.
Medicaid beneficiaries have the highest rate of HPV vaccination when compared with those covered by other payers, so it is useful to understand what Medicaid programs are doing to encourage HPV vaccination. Medicaid programs may be more proactive in their approach to member outreach, sending communication to members encouraging them to become vaccinated or providing an incentive to do so. Given the HPV vaccine is part of the HEDIS (Healthcare Effectiveness Data and Information Set) Immunization for Adolescents measure, and more than 90% of health plans use HEDIS to measure performance and serve as a comparison with other health plans, commercial/Medicaid payers should be motivated to improve their measured immunization rates. The immunization measure is also part of the Medicaid Child Core Set and is therefore particularly relevant to Medicaid plans.
While there are few widely available, evidence-based HPV vaccination interventions focused on rural communities, there are initiatives addressing known barriers that have demonstrated success. For instance, school- and pharmacy-based vaccination programs have demonstrated success improving vaccination rates, particularly among individuals in underserved areas. State-enacted laws may require school-entry HPV vaccination and enable pharmacist-administered vaccines, so advocating for these state policies is critical.
Interventions that have successfully increased HPV vaccination rates require the active involvement of health care providers. Their role in educating patients, addressing concerns, and promoting vaccination is vital. This is especially important in the context of providers based in rural settings, given underserved populations residing in rural areas are the least likely to report collaborative communication with their provider about HPV vaccination. Rural clinics face shortages of medical providers, especially pediatricians, which has been well documented and is the focus of several workforce enhancement initiatives.
Conclusion
It is important to acknowledge and address the geographic disparities associated with HPV vaccination and ensure that all eligible individuals, regardless of where they live, have equal access to this lifesaving vaccine. To promote equitable access to HPV vaccination and reduce unwarranted variation in HPV vaccination rates, stakeholders must take action to address specific geographic disparities. This may involve leveraging provider performance measures such as HEDIS to monitor and improve vaccination rates, implementing interventions tailored to the specific needs of underserved communities, advocating for policy change that addresses health care infrastructure gaps and improves access to vaccination programs, and improving access to providers and provider education. By informing stakeholders about the importance of HPV vaccination, the associated barriers, and initiatives that can make an impact, we can protect the health and well-being of our communities and pave the way for the elimination of HPV-related cancer.
About the Quality Outlook Commentary Series
Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Real Chemistry will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.
Anne Disalvo
Anne DiSalvo, MPH, MBA, is a Director at Real Chemistry. She has a background in Medicaid policy and quality improvement, and currently applies her passion for public health and business within Real Chemistry’s Market Access Strategy division. Anne helps clients convey the value of their therapeutics by leading the development of payer value propositions and crafting access strategies. She also oversees and conducts work related to state-level analysis of trends in access, policy, and health inequities.
Kendall Logan
Kendall Logan, MPH, a Manager at Real Chemistry, brings a public health and health equity perspective to her work. In her role, she manages and supports client projects in the quality and value-based care space across a variety of therapeutic areas. Her recent work involved analyses of the oncology quality landscape and quality measurement, utilizing her experience in qualitative research and stakeholder engagement. With a commitment to client success, Kendall strives to provide comprehensive support and guidance to meet clients’ unique needs within the value-based marketplace.
Erik Muther
Erik Muther, a Senior Vice President at Real Chemistry, is a thought leader and subject matter expert in value-based care and healthcare performance measurement. Erik leads strategy and implementation projects related to primary care transformation, real-world evidence generation, provider engagement, quality measurement and multi-stakeholder collaboration with clients in the health and life sciences industry.
Tom Valuck
Tom Valuck, MD, JD, is a Partner at Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Real Chemistry includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Clinical Pathways or HMP Global, their employees, and affiliates.
