Article Title

Changes in Adolescent HPV Vaccination Following Incorporation Into California’s Pay-for-Performance Program

Publication Date



cancer prevention, performance incentives


Background/Aims: Pay-for-performance programs (P4P) are intended to improve care by aligning incentives with targeted outcomes; however, findings regarding their impact are mixed. Adolescent female human papillomavirus (HPV) vaccination was added to the measures reported by California’s P4P program in 2012. Using electronic health record data from a mixed-payer, multispecialty health care organization in northern California, we examined on-time completion of the three-dose vaccination series by the recommended age of 13 before and after P4P implementation among 10,020 adolescent females.

Methods: We included all eligible female patients who turned 13 years old two years before (2010–2011 cohort) and two years after P4P implementation (2012–2013 cohort), excluding those patients with documented history of any adverse vaccine reaction. We used hierarchical logistic regression models to account for patient clustering within primary care providers. We estimated odds ratios (OR) associated with on-time vaccination completion with 95% confidence intervals (CI) based on robust estimation of standard errors, adjusting for patient race, insurance type and length of patient-provider relationship as well as provider experience (in years), gender, specialty and location.

Results: We found a positive association between on-time completion of HPV vaccination and P4P reporting of HPV vaccination. Patients who turned 13 after P4P implementation had 27% higher odds of completing vaccination by age 13 than those who turned 13 before (OR: 1.27, 95% CI: 1.12–1.45), adjusting for all covariates. Compared with other groups, African-American and Asian Indian patients had significantly lower odds of on-time vaccination, and patients with public or HMO insurance had significantly higher odds of on-time vaccination. Despite increases, the proportion of patients who completed the series on time remained remarkably low (12.5% [538/4,312] in the 2010–2011 cohort and 15.0% [855/5,708] in the 2012–2013 cohort).

Conclusion: Although further research is needed to establish any causal effects of P4P implementation on HPV vaccination uptake, these findings provide support for the continued use of incentive programs as a means to help improve health care quality and outcomes. On-time vaccination completion rates, however, remain suboptimal. Additional efforts, such as quality improvement initiated by this health care system in early 2014, may be needed to encourage parents and providers to vaccinate by age 13.