Vanessa K. Dalton

Understanding the Reasons Why Mothers Do or Do Not Have Their Adolescent Daughters Vaccinated Against Human Papillomavirus

PURPOSE The objective of this study was to compare the reasons why mothers do or do not have their adolescent daughters vaccinated against HPV. METHODS Mothers of vaccinated and unvaccinated 11- to 17-year-old girls seen during preventive care visits in outpatient family medicine or pediatric clinics underwent an audiotaped structured telephone interview that used open-ended questions to assess the reasons underlying maternal decisions about HPV vaccination. Qualitative methods categorized maternal responses into themes. RESULTS Interviews of 52 mothers (19 declining vaccination, 33 accepting) identified several distinct factors underlying their decisions about HPV vaccination. Lack of knowledge about HPV, age-related concerns, and low perceived risk of infection were commonly cited reasons for declining vaccination. Desire to prevent illness, physician recommendation, and a high perceived risk of infection were commonly identified motivating factors. Both groups of mothers had significant concerns about vaccine safety. Locus of control (e.g., mother or daughter) of health-related decisions arose as a novel factor influencing this decision that had not been previously described in the context of HPV vaccination. CONCLUSIONS Addressing safety concerns, educating parents about the age-specific risk of HPV infection, and promoting strong physician recommendation for vaccination may be the most useful targets for future interventions to increase HPV vaccine utilization.

Hospital Care for Parents After Perinatal Death

OBJECTIVE: To systematically review parent experiences with hospital care after perinatal death. DATA SOURCES: An evaluation of more than 1,100 articles from 1966 to 2006 was performed to identify studies of fetal death in the second or third trimester and neonatal death in the first month of life. METHODS OF STUDY SELECTION: Studies were limited to those that were in English, evaluated care in U.S. hospitals, and contained direct parent data or opinions. TABULATION, INTEGRATION, AND RESULTS: Results were compiled on five aspects of recommended care: 1) obtaining photographs and memorabilia of the deceased infant, 2) seeing and holding the infant, 3) labor and delivery of the child, 4) autopsies, and 5) options for funerals or memorial services. Sixty eligible studies with over 6,200 patients were reviewed. In general, parents reported appreciating time and contact with their deceased infant, being given options about labor, delivery, and burial, receiving photographs and memorabilia, and having appropriate hospital follow-up after autopsy. CONCLUSION: Although care after perinatal death often adheres to published guidelines, substantial room for improvement is apparent. Parents with perinatal losses report few choices during labor and delivery and inadequate communication about burial options and autopsy results. Hospitals, nurses, and doctors should increase parental choice about timing and location of delivery and postpartum care, encourage parental contact with the deceased infant, and facilitate provision of photos and memorabilia.

Worsening disparities in HPV vaccine utilization among 19–26 year old women

We evaluated the characteristics associated with uptake of HPV vaccine by 19-26 year old women seen in primary care university-based clinics. Of the 11,545 women analyzed only 18% had initiated the 3-dose vaccine series. Series completion among the sample overall was only 10% in the 30 month study period. Decreased series initiation was associated with older age, public insurance, white race and non-family medicine specialty. Decreased series completion was associated with public insurance and African American race. Utilization disparities by race and insurance worsened over time suggesting that the highest risk populations of women were not getting vaccinated.

Patient and clinic factors associated with adolescent human papillomavirus vaccine utilization within a university-based health system

We reviewed clinical and billing data from a university-based health system to assess HPV vaccine utilization among 9-18-year-old girls by individual, visit and medical specialty characteristics. Our sample included 10,082 adolescent patients with 27,928 visits to outpatient family medicine (FM), pediatric and gynecology clinics between January 2007 and March 2008. Vaccine series completion was low among eligible adolescents (15%), with important disparities in vaccine utilization by medical specialty, age, race and insurance status. Missed opportunities for vaccination were common. Our findings may help to target future interventions aimed at increasing adolescent HPV vaccine utilization.

Human papillomavirus vaccine intent and uptake among female college students

Abstract Objective: To examine human papillomavirus (HPV) vaccine intent and the effect of an educational intervention on vaccine uptake among female college students. Participants: Females aged 18 to 26 attending a university health service gynecology clinic (n = 256). Methods: Participants were randomized to receive either HPV-specific education with a mailed reminder or standard care. Predictors of HPV vaccine intent and uptake at 6 months following enrollment were identified. Results: At baseline, 41% intended to undergo HPV vaccination. Participants who were currently sexually active and lacked supplemental health insurance had decreased intent. Perceived parental approval regarding HPV vaccination, perceived vulnerability to HPV infection, and belief in health benefits of HPV vaccine were associated with increased intent. HPV vaccine uptake was low (5.5%) and did not differ by study group. However, baseline intent was significantly associated with HPV vaccine uptake. Conclusions: Interventions to increase HPV vaccine uptake in college students should address HPV-related beliefs and broader barriers to vaccination.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure.

OBJECTIVE: To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure. METHODS: This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database. RESULTS: One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored “privacy,” “avoiding going to sleep,” and “previous experience” higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedures discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01). CONCLUSION: Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings. LEVEL OF EVIDENCE: II-2

The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance

Background:Long-acting reversible contraception (LARC) is highly effective but also has higher initiation costs than oral contraceptive methods, which may contribute to relatively low use. The Affordable Care Act requires most private insurance plans to cover contraceptive services without patient cost-sharing. Whether this mandate will increase LARC use is unknown. Objective:To assess the relationship between cost-sharing and use of LARC among privately insured women. Design:Cross-sectional analysis using Truven Health MarketScan data from January 2011 to December 2011. Subjects:Women aged 14–45 years with continuous insurance coverage enrolled in health plan products that covered branded and generic oral contraceptive pills (OCPs) and intrauterine devices (IUDs). We selected women using OCPs and IUDs as these are the most commonly used short-acting and long-acting reversible methods, respectively (N=1,682,425). Measures:Multivariable regression was used to assess the association of the level of out-of-pocket costs for IUDs for each patient’s plan and IUD initiation, adjusting for out-of-pocket costs for branded and generic OCPs and patient characteristics. Results:Overall, 5.5% of women initiated an IUD in 2011. After adjustment, IUD initiation was less likely among women with higher versus lower co-pays (adjusted risk ratio=0.65; 95% CI, 0.64–0.67). Women who saw an obstetrician/gynecologist during 2011 were more likely to initiate an IUD (adjusted risk ratio=2.49; 95% CI, 2.45–2.53). Conclusions:Rates of IUD use are low among privately insured women in the United States, and higher cost-sharing is associated with lower rates of IUD use. Together with other measures to promote LARC use, eliminating co-pays for contraception could promote the use of these more effective and cost-effective methods.

Characterization of Medicaid policy for immediate postpartum contraception

OBJECTIVE Long-acting reversible contraception (LARC) is safe, effective and cost-saving when provided immediately postpartum but currently underutilized due to nonreimbursement by Medicaid and other insurers. The objectives of this study were to (a) determine which state Medicaid agencies provide specific reimbursement for immediate postpartum LARC and (b) identify modifiable policy-level barriers and facilitators of immediate postpartum LARC access. STUDY DESIGN We conducted semistructured telephone interviews with representatives of 40 Medicaid agencies to characterize payment methodology for immediate postpartum LARC. We coded transcripts using grounded theory and content analysis principles. RESULTS Three categories of immediate postpartum LARC payment methodology emerged: state Medicaid agency (a) provides separate or increased bundled payment (n=15), (b) is considering providing enhanced payment (n=9) or (c) is not considering enhanced payment (n=16). Two major themes emerged related to Medicaid decision-making about immediate postpartum LARC coverage: (a) Health effects: States with payment for immediate postpartum LARC frequently cited improved maternal/child health outcomes as motivating their reimbursements. Conversely, states without payment expressed misinformation about LARCs clinical effects and lack of advocacy from local providers about clinical need for this service. (b) Financial implications: States providing payment emphasized overall cost savings. Conversely, states without reimbursement expressed concern about immediate budget constraints and potential adverse impact on existing global payment methodology for inpatient care. CONCLUSIONS Many states have recently provided Medicaid coverage of immediate postpartum LARC, and several other states are considering such coverage. Addressing misinformation about clinical effects and concerns about cost-effectiveness of immediate postpartum LARC may promote adoption of immediate postpartum LARC reimbursement in Medicaid agencies currently without it. IMPLICATIONS Medicaid policy for reimbursement of immediate postpartum LARC is evolving rapidly across the US. Our findings suggest several concrete strategies to remove policy-level barriers and promote facilitators of immediate postpartum LARC.

Moving toward patient-centered care: Women's decisions, perceptions, and experiences of the induction of labor process

BACKGROUND Patient preferences and clinician practices are possible causative factors to explain the increase in induction of labor, but scientific studies that demonstrate this link are limited. The purpose of this study is to identify factors that influence inductions from the perspective of women. METHODS A qualitative investigation using grounded theory methodology was conducted. Women were interviewed preinduction and postinduction. Analysis of the interviews was conducted using constant comparison to identify codes, categories, and themes. Through this process the complex intersection between women, their clinician, and the application of evidence-based care in clinical practice was explored. RESULTS Five major themes from the preinduction interview were identified; safety of baby, womens trust in their clinician, relief of discomfort and/or anxiety, diminish potential or actual risk, and lack of informed decision making. Five major themes were identified from the postinduction interview; lack of informed decision making, induction as part of a checklist, womens trust in their clinician, happy with induction, and opportunities to improve the experience. CONCLUSIONS Lack of informed decision making was cited as a barrier to optimal care. This study has important implications for patient-centered research and clinical care, requiring the inclusion of women and the salient concepts of care that they identify.

Counseling women with early pregnancy failure: Utilizing evidence, preserving preference

OBJECTIVES To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management. METHODS Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice. RESULTS Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management. CONCLUSION Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options. PRACTICE IMPLICATIONS Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.