Early policy responses to the human papillomavirus vaccine in the United States, 2006-2010

The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care

Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.

Estimating the Effect of the New York State Nurse Practitioners Modernization Act on Care Received by Medicaid Patients

The demand for primary care services may surpass the supply of primary care providers, exacerbating challenges with access, quality, and cost in the U.S. health care system. Expanding the supply of, and access to, nurse practitioner (NP) care has been proposed as one method to alleviate these challenges. New York State (NYS) changed its regulatory environment for NPs in 2015. We estimate the impact of expanded NP scope of practice (SOP) regulations in NYS on total care days received by Medicaid beneficiaries from 2015 to 2018 using a model derived from national historical data from 1999 to 2011. We used a longitudinal data policy analysis framework and a generalized difference-in-differences model to identify the effect of changes in NP SOP regulations on total care days. The model included controls for state income and unemployment rates. Our results suggest that the policy change increased total care days provided to patients, but that this difference was not statistically significant and became negligible after computing the number of days per beneficiary. In addition, our results suggest that had NYS moved to a full practice environment, more care days could have been provided to Medicaid patients, and this difference was found to be statistically significant. Our results suggest that states should adopt full NP SOP practice environments to realize measurable benefits of expanded NP SOP.

The Intersection of Problems, Policy, and Politics: The Adoption of an HPV Vaccine School-Entry Requirement in Puerto Rico

Persistent human papillomavirus (HPV) infections can cause cancer (e.g., cervical/vaginal/penile/anal/oropharyngeal). The HPV vaccine prevents cancer, yet U.S. vaccination rates remain low. We explored sociopolitical factors in the adoption of Puerto Rico's HPV vaccine school-entry requirement. Multiple streams framework explains how the intersection of problems, policy, and politics streams influence policy adoption. Policy entrepreneurs work on joining these streams. Interviews (n = 20) were conducted with stakeholders (e.g., physicians/researchers/nonprofit organizations' leaders). Data were analyzed using applied thematic analysis. High incidence of HPV and HPV-related cancers in Puerto Rico were indicators of problems. Focusing events included Rhaiza's case and the HPV-Advisory Panel Report. During summer 2017, a policy window opened; the Department of Health (DOH) adopted the requirement in summer 2018. Stakeholders discussed policy initiatives. Political turnover positively influenced the process. Policy entrepreneurs created an extended period of intersection resulting in the adoption of the requirement. Findings can inform policy initiatives to improve HPV vaccination rates and reduce HPV-related cancers.

State policy change and organizational response: Expansion of nurse practitioner scope of practice regulations in New York State

BACKGROUND

In January of 2015, New York (NY) implemented a new policy, Nurse Practitioners Modernization Act, which removed the required written practice agreement between physicians and experienced nurse practitioners (NPs).

PURPOSE

We examined NP work environment in NY before (2012) and after (2018) the implementation of the new policy.

METHODS

Cross-sectional survey data on work environments were collected from NPs in NY in 2012 and 2018. Work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire. In 2012, 278 and in 2018, 348 NPs completed the tool. Regression analyses were used to examine the relationship between the study year and work environment.

FINDINGS

Controlling for individual and organizational characteristics, NPs reported significantly better work environments in 2018. Positive changes were observed both for experienced and less experienced NPs.

DISCUSSION

Removing state-level policy restrictions on NPs may promote a better work environment within health care organizations.

A multilevel analysis of factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status

BACKGROUND

Parental reports are commonly used for adolescent HPV vaccination status but may be subjected to bias. Guided by the Socioecological Framework, our study explores potential multilevel factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status.

METHODS

Data from parents of 19,683 adolescents with provider-verified data were analyzed using multilevel modeling. Correlates included adolescent characteristics, parent/household factors, number of providers seen, state-level median income, and state-level HPV vaccine policy. Outcomes included inaccuracy in reporting: vaccine initiation (≥1 dose), completion (3 doses), and number of doses.

RESULTS

24% and 25% of parents reported initiation and completion inaccurately; 28% under-reported and 11% over-reported number of doses. All adolescent characteristics, parent/household factors, and number of healthcare providers seen were associated with the outcomes. Of note, compared to parents of White adolescents, parents of racial/ethnic minority adolescents were more likely to inaccurately report all outcomes (aOR ranges from 1.43 to 1.76 for initiation, 1.45-1.75 for completion, 1.98-2.05 for under-reporting, and 1.17-1.41 for over-reporting). Households with higher maternal education (aOR = 0.70, 0.92, 0.79, and 0.80) and income (aOR = 0.54, 0.62, 0.50, and 0.70) were less likely to inaccurately report initiation, report completion, under-report, and over-report, respectively. Those having seen more providers were less likely to inaccurately report initiation and completion but more likely to over-report number of vaccine doses.

DISCUSSION

Being parents of females, older adolescents, and racial/ethnic minority adolescents, having lower material education, and poverty status were associated with higher odds of inaccurately reporting HPV vaccination status. These results have implications for estimates drawn from self-reports. Future research can examine sources of inaccuracies (e.g., social desirability or health literacy); they could also explore solutions (e.g., access to vaccine records) that can help parents accurately report vaccination status. State policy does not appear to have an impact on report accuracy.

Legislative activity related to the human papillomavirus (HPV) vaccine in the United States (2006-2015): a need for evidence-based policy

State-based policies to mandate HPV vaccination are politically challenging and have received broad criticisms. There is a critical need to understand the legislative activities that underpin subsequent policy implementation. The objective of this policy analysis was to analyze state legislation that focused on HPV vaccination from 2006–2015. A content analysis was conducted among primary sources of legislative data from HPV vaccine-related bills, including using the National Conference of State Legislatures as a search-source. Findings reveal that much of the legislative activity occurred early after the HPV vaccination was introduced, and focused on increased information for parents, public financing, awareness campaigns, etc. Far fewer states focused on voluntary or mandatory vaccination. Understanding the barriers to achieving mandatory vaccination policy and implementation of such policies for HPV vaccines remains a public health priority.

Impact of Louisiana's HPV Vaccine Awareness Policy on HPV Vaccination Among 13- to 17-Year-Old Females

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) immunization for 11- to 12-year-old adolescents. In 2008, Louisiana required the school boards to distribute HPV vaccine information to parents or guardian of students in Grades 6 to 12. This article investigates the impact of this policy on HPV vaccination among 13- to 17-year-old female adolescents using National Immunization Survey-Teen (NIS-Teen) data. Drawing on the data from the 2008 to 2012 NIS-Teen, we compared the difference in proportions of females who have been vaccinated before and after the policy. Using difference-indifference estimation, we explored the change in vaccination rates before and after the policy implementation in Louisiana compared with Alabama and Mississippi, two states that did not have such a policy in place. The difference-in-differences estimates for HPV vaccination were not significant. Physician recommendation for HPV vaccination was significantly associated with vaccination among females in Louisiana and Alabama (adjusted odds ratio [aOR] = 7.74; 95% confidence interval [CI; 5.22, 11.5]), and for those in Louisiana and Mississippi (aOR = 7.05; 95% CI [4.6, 10.5]). Compared to the proportion of female adolescents who had received physician recommendation in Alabama or Mississippi, the proportion in Louisiana did not increase significantly in the postpolicy period. HPV vaccination rates did not increase significantly in Louisiana compared to Alabama or Mississippi following the implementation of the policy. Despite Louisiana's policy, physician recommendation remains the key determinant of HPV vaccination. HPV vaccine awareness does not necessarily result in HPV vaccination.

Parents' Support for School-Entry Requirements for Human Papillomavirus Vaccination: A National Study

BACKGROUND

The number of states proposing school-entry requirements for human papillomavirus (HPV) vaccination has increased over the last decade. However, data are currently limited regarding parents' support of such laws. We sought to obtain the first national estimates of parents' support of HPV vaccination school-entry requirements.

METHODS

A national sample of 1,501 parents of 11- to 17-year-old children completed a web-based survey between November 2014 and January 2015. Analyses used multivariable logistic regression to assess correlates of support for school-entry requirements for HPV vaccination.

RESULTS

Overall, 21% of parents agreed that laws requiring HPV vaccination for school attendance "are a good idea," and 54% disagreed. If school-entry requirements included opt-out provisions, agreement increased to 57%, and only 21% disagreed. Parents more often agreed with requirements without opt-out provisions if they were Hispanic [OR = 1.53; 95% confidence interval (CI), 1.05-2.22], believed HPV vaccine was as or more important than other adolescent vaccines (OR = 2.76; 95% CI, 1.98-3.83), or believed HPV vaccine was effective for preventing cervical cancer (OR = 2.55; 95% CI, 1.93-3.37). Parents less often agreed if they resided in Midwest states or believed that HPV vaccine was being pushed to make money for drug companies (both P < 0.05).

CONCLUSION

Opt-out provisions almost tripled parents' support for HPV vaccine school-entry requirements. Our findings suggest that race/ethnicity, attitudes about HPV vaccine, and region of residence may influence support for requirements without opt-out provisions.

IMPACT

Opt-out provisions greatly increase parent support of school-entry requirements for HPV vaccination but may make them ineffective. Cancer Epidemiol Biomarkers Prev; 25(9); 1317-25. ©2016 AACR.

National- and state-level impact and cost-effectiveness of nonavalent HPV vaccination in the United States

Every year in the United States more than 12,000 women are diagnosed with cervical cancer, a disease principally caused by human papillomavirus (HPV). Bivalent and quadrivalent HPV vaccines protect against 66% of HPV-associated cervical cancers, and a new nonavalent vaccine protects against an additional 15% of cervical cancers. However, vaccination policy varies across states, and migration between states interdependently dilutes state-specific vaccination policies. To quantify the economic and epidemiological impacts of switching to the nonavalent vaccine both for individual states and for the nation as a whole, we developed a model of HPV transmission and cervical cancer incidence that incorporates state-specific demographic dynamics, sexual behavior, and migratory patterns. At the national level, the nonavalent vaccine was shown to be cost-effective compared with the bivalent and quadrivalent vaccines at any coverage despite the greater per-dose cost of the new vaccine. Furthermore, the nonavalent vaccine remains cost-effective with up to an additional 40% coverage of the adolescent population, representing 80% of girls and 62% of boys. We find that expansion of coverage would have the greatest health impact in states with the lowest coverage because of the decreasing marginal returns of herd immunity. Our results show that if policies promoting nonavalent vaccine implementation and expansion of coverage are coordinated across multiple states, all states benefit both in health and in economic terms.

Global Delivery of Human Papillomavirus Vaccines

Worldwide, cervical cancer is the fourth most common cancer among women. Human papillomavirus (HPV) vaccination, if broadly implemented, has the potential to significantly reduce global rates of morbidity and mortality associated with cervical and other HPV-related cancers. More than 100 countries around the world have licensed HPV vaccines. As of February, 2015, there were an estimated 80 national HPV immunization programs and 37 pilot programs. This article discusses global implementation of HPV vaccination programs and issues such as vaccine financing and different approaches to HPV vaccine delivery.

Human papillomavirus vaccine trials and tribulations: Clinical perspectives

Human papillomavirus (HPV) affects hundreds of millions of people worldwide and is associated with both benign and malignant neoplasms in men and women. It is a double-stranded DNA virus with an icosahedral capsid. Forty HPV types are known to infect mucosal keratinocytes. If not cured by the immune system, the infection can lead to genital warts, mucosal dysplasia, or cancer. The most common oncogenic types are 16 and 18. The vaccine to prevent HPV and its associated morbidity and mortality has existed since 2006. Several variations protect against an increasing number of HPV types. The recommended vaccination age is before sexual exposure; administration of the vaccine to children has been controversial. This continuing medical education review evaluates the current HPV vaccines available to clinicians. Part I focuses on the debate over who should be vaccinated, at what age, and in which populations.

Summer Peaks in Uptake of Human Papillomavirus and Other Adolescent Vaccines in the United States

BACKGROUND

Seasonality in human papillomavirus (HPV) vaccination could have a large impact on national cancer prevention efforts. We hypothesized that uptake of HPV vaccine and other adolescent vaccines in the United States would be highest in the summer.

METHODS

Data came from health care provider-verified vaccination records for 70,144 adolescents (ages 13-17 years) from the 2008 to 2012 versions of the National Immunization Survey-Teen. Using the Edwards method for testing annual trends, we examined seasonal patterns in the uptake of HPV and other recommended adolescent vaccines [tetanus, diphtheria, and pertussis (Tdap) booster and meningococcal vaccine]. HPV vaccine initiation (receipt of the first of the three-dose series) data were for female adolescents.

RESULTS

Uptake for HPV and other adolescent vaccines peaked in the summer across years and states (all P < 0.001). Uptake was five times as frequent at the peak as at the trough for HPV vaccine, and HPV vaccine initiation was highest in June, July, and August (percent of doses delivered in these months: 38.7%). The same pattern existed for Tdap booster and meningococcal vaccine. Concomitant (same-day) vaccination of HPV vaccine with other adolescent vaccines also demonstrated summer peaks each year nationally (all P < 0.001).

CONCLUSION

Uptake of adolescent vaccines increased dramatically in summer months. These summer peaks are an important opportunity for interventions focused on concomitant vaccination.

IMPACT

The potential cancer prevention impact of HPV vaccination programs could be increased, for example, by delivering messages about concomitant vaccination during the summer, when adolescents and their parents might be most open to them.

HPV vaccination series completion and co-vaccination: Pairing vaccines may matter for adolescents

Very little is known about the effect of concurrent co-vaccination on HPV series completion. This study utilized a retrospective review of a Clinical Data Repository to assess whether concurrent vaccination had an impact on HPV vaccination series completion, and whether there were differences based on age. 3371 patients who received the HPV vaccine at a single academic medical center between the years 2009-2013 were included in this analysis. The adjusted odds ratio (aOR) for effect of concurrent vaccination on series completion for the age group 9-18 was 1.32 (95% CI 1.09, 1.60). Although not statistically significant, the aOR for effect of concurrent vaccination on completion changed direction for the 19-25 age group and was 0.44 (95% CI 0.17, 1.12). This study provides preliminary evidence that pairing the HPV vaccine with one or more co-vaccines may yield a higher HPV vaccination completion rate among adolescents age 9-18.