Insurance continuity and human papillomavirus vaccine uptake in Oregon and California federally qualified health centers

Abstract

Objectives: We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).

Methods: We analyzed retrospective electronic health record data for females, aged 9-26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%-32%, 33%-65%, 66%-99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.

Results: Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.

Conclusions: Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.

FIGURE 1—

Multivariable 2-level random intercept Poisson regression models for human papillomavirus (HPV) vaccine initiation, by age and race/ethnicity, for 100% insurance coverage vs (a) 0%, (b) 1%–32%, (c) 33%–65%, and (d) 66%–99%: Oregon and California, 2008–2010. Note: APR = adjusted prevalence ratio. Whiskers indicate 95% confidence intervals. The model included the following patient-level variables and interaction terms at level 1: insurance coverage, age, race/ethnicity, visit count, insurance coverage by age, insurance coverage by race/ethnicity, age by race/ethnicity, insurance coverage by age by race/ethnicity. Patients’ home clinic was modeled as a random intercept at level 2. Only patients with complete observations for all covariables were included in the model. The sample size was n = 15 614.