key: cord-0871329-gujejb0l authors: Yu, Hao; Klompas, Michael; Kofner, Aaron; Horvitz-Lennon, Marcela; Zhang, Fang; McKernan, Susan title: COVID-19 Vaccination: Concerning Trends in Primary Care Health Professional Shortage Areas date: 2022-02-09 journal: Am J Prev Med DOI: 10.1016/j.amepre.2021.12.024 sha: 992e853a42c6f968b197a8831a93a07b45095b47 doc_id: 871329 cord_uid: gujejb0l nan Widespread vaccination is the most promising way to control the coronavirus disease 2019 (COVID-19) pandemic. Unfortunately, U.S. vaccination rates have stagnated. The rates are particularly low among racial/ethnic minority groups 1 and rural residents. 2 Whereas much of the discussion about low vaccination centers on person-level factors, the role of healthcare system factors is not well understood. An important system factor is the availability of primary care physicians, who play an integral role in counseling patients regarding the risks and benefits of vaccination. The U.S., however, has a considerable shortage of primary care providers with >84 million (25%) Americans living in primary care health professional shortage areas (PC-HPSAs). 3 These are concentrated, but not exclusively located, in rural areas (61%) 4 and have complex demographic patterns. 5 Prior studies have reported higher rates of COVID-19 infection and deaths in full-county PC-HPSAs. 6 This study assesses the association between COVID-19 vaccination rates and county PC-HPSA status. The county-level data were from 2 sources: (1) the daily number of fully vaccinated people from the Centers for Disease Control and Prevention and (2) the 2020-2021 Area Health Resource Files from the Health Resources and Services Administration, which classifies all U.S. counties into 3 groups-full-county PC-HPSAs, partial-county PC-HPSAs, and non-PC-HPSAs. Prior research has confirmed the Area Health Resource Files data quality and value for workforce analysis. 7 Daily trends in COVID-19 vaccination rates were assessed by county PC-HPSA status between December 13, 2020 (the date of COVID-19 vaccine arriving in counties) and September 19, 2021. A negative binomial regression with state fixed effects was estimated to assess the association between vaccination rates on September 19, 2021 and county sociodemographic characteristics and health resources. Analyses were conducted using Stata/SE, version 16.0, with SEs clustered at the state level. Full-county PC-HPSAs trailed behind other counties in COVID-19 vaccination rates, and the gap widened over time ( Figure 1A ). Full-county PC-HPSAs within the bottom quartile of vaccination rates were concentrated in the South and Midwest ( Figure 1B ). Full-county PC-HPSAs had the lowest vaccination rate for each studied age group (12-17, 18-64, ≥65 years) ( Figure 1C -1E). The gap was especially pronounced for those aged 12-17 and 18-64 years. The regression analysis indicated that relative to non-PC-HPSAs, full-county PC-HPSAs had significantly lower vaccination rates (incidence rate ratio=0.88, 95% CI=0.80, 0.98), whereas there were no significant differences between partial-county and non-PC-HPSAs. Furthermore, vaccination rates were significantly higher in counties with greater non-White population, higher income, more hospitals and community health centers, and located in metropolitan counties (Appendix Table 1 ). This study identified growing disparities in COVID-19 vaccination rates in full-county PC-HPSAs. This effect was consistent across age groups. Recognizing the potential impact of primary care provider shortages on vaccination rates, the The finding of comparable vaccination rates between partial-county and non-PC-HPSA counties may be attributable to similar population-to-primary care physician ratios between the 2 groups. 10 By contrast, full-county PC-HPSAs have much lower ratios. 10 This study has limitations. The data did not have county-level information about vaccination rates among racial/ethnic groups, vaccine sites, local vaccine mandates, number of primary care physicians leaving their jobs, or share of physicians using telehealth. Future studies should examine the minimum level of primary care availability that is required to ensure sufficient vaccine uptake and whether telehealth may alleviate primary care workforce reduction during the pandemic and improve vaccination rates. Researchers should consider employing spatial autocorrelation to rigorously control for clustering and dispersion of vaccination rates in longitudinal analyses. All told, this study's findings suggest that further efforts to specifically target full-county PC-HPSAs are needed to improve COVID-19 vaccine coverage in those areas. Disparities in Reaching COVID-19 Vaccination Benchmarks: Projected Vaccination Rates by Race/Ethnicity as of Kaiser Family Foundation Disparities in COVID-19 vaccination coverage between urban and rural counties -United States Health Resources and Services Administration. Health Professional Shortage Areas Health Resources and Services Administration. Designated Health Professional Shortage Areas Statistics, Fourth Quarter of Fiscal Year 2021 Designated HPSA Quarterly Summary, as of The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health Associations between primary care provider shortage areas and county-level COVID-19 infection and mortality rates in the USA Society of General Internal Medicine. Area Health Resource Files (AHRF) Becerra Announces Expansion of COVID-19 Vaccine Program to All Community Health Centers Across the Country. HHS Expanding access to HPV vaccination in South Carolina through community pharmacies: a geospatial analysis Primary care health professional shortage area designations before and after the Affordable Care Act's shortage designation modernization project Conceptualization, Methodology, Original Draft Preparation and Revision Michael Klompas: Conceptualization, Writing-Reviewing and Editing Aaron Kofner: Data Visualization Marcela Horvitz-Lennon: Writing-Reviewing and Editing Fang Zhang: Statistical Supervision Susan McKernan: Writing-Reviewing and Editing