Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative

PURPOSE

Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities.

METHODS

Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2).

RESULTS

Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0).

CONCLUSIONS

Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.

Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative

PURPOSE

The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year.

METHODS

Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed.

RESULTS

At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration.

CONCLUSIONS

The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

A cost analysis for a community-based case management intervention program for pediatric asthma

OBJECTIVE

Evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) program through reduction of Emergency Department (ED) visits and hospitalizations and quality of life (QOL) for patients and their families due to reduced missed school days and work days.

METHODS

Cost-benefit analysis was used to determine an adjusted Return on Investment (ROI) for all 102 patients enrolled in the CAI program in the calendar year 2006 after controlling for changes in a comparable population without CAI intervention. A societal ROI (SROI) was also computed by including additional indirect benefits due to reduced missed school days for patients and work days for caregivers.

RESULTS

Adjusted cost savings from fewer ED visits and hospitalizations resulted in an adjusted ROI of 1.33 (adjusted Net Present Value, (NPV) of savings = $83,863) during the first 3 years after controlling for factors other than the CAI intervention. When benefits due to reduced missed school days and missed work days were added to adjusted cost savings, the SROI increased to 1.85 (Societal NPV of savings = $215,100).

CONCLUSIONS

Multidisciplinary, coordinated disease management programs offer the opportunity to prevent costly complications and hospitalizations for chronic diseases, while improving QOL for patients and families. This cost analysis supports the business case for the provision of proactive community-based asthma services that are traditionally not reimbursed by the fee-for-service health care system.

Assessing and referring adolescents' health-related social problems: qualitative evaluation of a novel web-based approach

We conducted a qualitative study to examine users' perceptions of a web-based screening and referral system for young adults with health-related social problems. The first 50 patients who used the system also took part in semi-structured interviews. There were 20 patients aged 15–17 years and 30 aged 18–25 years. Completing the web-based screening process took an average of 25 min. Ninety percent of participants reported at least one major health-related social problem and a total of 134 referrals were selected for further assistance. Ninety-six percent of participants said they would recommend the system to a friend or peer, and 80% supported its use for annual screening. Perceived strengths of the system were novelty, privacy, ease of use, relevance, motivation, variety and proximity of referrals, and clinic staff support. Perceived shortcomings were length, sensitivity, navigation challenges and agency availability. The system complemented provider visits and preserved privacy while improving attention to patient needs. Computerized screening and referral tools have potential to improve the quality of care in vulnerable young adults.

Evaluation of raising adolescent families together program: a medical home for adolescent mothers and their children

OBJECTIVES

This study described a medical home model for adolescent mothers and their children, and their 1- and 2-year preventive care, repeat pregnancy, and psychosocial outcomes.

METHODS

In this prospective, single cohort demonstration project, adolescent mothers (14-18 years old) and their children received care in a medical home. Demographic, medical and social processes, and outcomes data were collected at enrollment through 24 months. Change over time and predictors of repeat pregnancy were analyzed.

RESULTS

A total of 181 adolescents enrolled, with 79.6% participating for 2 years. At 2 years, 90.2% of children were completely immunized. Children and adolescent mothers met standards for health care visits, and adolescent condom use improved. Rates of cumulative repeat pregnancy were 14.7% and 24.6%, school attendance 77.6% and 68.7%, and employment 21.2% and 32.3% at 1 and 2 years, respectively.

CONCLUSIONS

A medical home model with comprehensive and integrated medical care and social services can effectively address the complex needs of adolescent parents and their children.

Randomized controlled trial of an immunization recall intervention for adolescents

OBJECTIVE

Determine if adolescent immunization rates can be improved by contacting the parents or by contacting both the parents and adolescents.

METHODS

Thirteen- to 17-year-olds overdue for at least 1 of 3 immunizations were randomized to (1) a control arm (Control), (2) telephone calls to the parent/guardian (Parent Only), or (3) telephone calls to the parent/guardian and the adolescent (Parent/Adol). Immunization records were assessed 4 weeks and 1 year after the intervention. Two-sided χ(2) tests and logistic regression models were used to compare receipt of immunizations by study arm.

RESULTS

The intention-to-treat analysis showed improved immunization rates at 4 weeks (adjusted odds ratio 2.27, 95% confidence interval 1.00-5.18), but not at 1 year, in the Parent/Adol group compared with controls. There was a trend toward increased immunization in the Parent Only group (odds ratio 2.02, 95% confidence interval 0.89-4.56). However, phone contact was not achieved for many parents and adolescents in the intervention groups. A post hoc analysis of the impact of actual phone contact showed significant improvement in immunization rates both 4 weeks and 1 year after the intervention among those who were reached successfully.

CONCLUSIONS

Improvement in immunization rates was seen in the short term but not the long term after contacting both the parent and adolescent. Although telephone interventions may be effective when rapid immunization is necessary, the difficulty in reaching parents and adolescents by phone highlights the importance of up-to-date contact information and a need to assess the effectiveness of alternative means of communication.

Community asthma initiative: evaluation of a quality improvement program for comprehensive asthma care

OBJECTIVES

The objective of this study was to assess the cost-effectiveness of a quality improvement (QI) program in reducing asthma emergency department (ED) visits, hospitalizations, limitation of physical activity, patient missed school, and parent missed work.

METHODS

Urban, low-income patients with asthma from 4 zip codes were identified through logs of ED visits or hospitalizations, and offered enhanced care including nurse case management and home visits. QI evaluation focused on parent-completed interviews at enrollment, and at 6- and 12-month contacts. Hospital administrative data were used to assess ED visits and hospitalizations at enrollment, and 1 and 2 years after enrollment. Hospital costs of the program were compared with the hospital costs of a neighboring community with similar demographics.

RESULTS

The program provided services to 283 children. Participants were 55.1% male; 39.6% African American, 52.3% Latino; 72.7% had Medicaid; 70.8% had a household income <$25 000. Twelve-month data show a significant decrease in any (≥1) asthma ED visits (68.0%) and hospitalizations (84.8%), and any days of limitation of physical activity (42.6%), patient missed school (41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatest functional impairment from ED visits, limitation of activity, and missed school were more likely to have any nurse home visit and greater number of home visits. There was a significant reduction in hospital costs compared with the comparison community (P < .0001), and a return on investment of 1.46.

CONCLUSIONS

The program showed improved health outcomes and cost-effectiveness and generated information to guide advocacy efforts to finance comprehensive asthma care.

Children's hospital boston community Asthma initiative: partnerships and outcomes advance policy change

PROBLEM

Rates of poorly controlled asthma among low-income children, particularly racial and ethnic minorities, remain disproportionately high. Comprehensive asthma programs, including education, case management and home environmental interventions have reduced disparities. Few sustainable payment models exist.

PURPOSE

The Children's Hospital Boston's Community Asthma Initiative (CAI) demonstrated dramatic reductions in hospitalizations and emergency department (ED) visits among African American and Latino patients with a return on investment (ROI) of 1.46. A strong coalition focused on sustainability plus CAI outcomes contributed to the state legislature's approving a bundled payment pilot for high-risk pediatric asthma patients on Medicaid/MassHealth.

KEY POINTS

Cost-effective, comprehensive asthma programs and policy makers' interest in new payment models created an opportunity for a new payment approach for pediatric asthma care.

CONCLUSION

A community coalition that successfully addresses asthma health disparities with a strong business case and program outcomes can be leveraged to persuade policy makers of the value of innovative financing strategies for asthma care.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses

PURPOSE

This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally.

METHODS

Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses.

RESULTS

The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites.

CONCLUSION

A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.

Malnutrition and hemodynamic status in adolescents hospitalized for anorexia nervosa

OBJECTIVE

To determine the effects of malnutrition on hemodynamic status of adolescents hospitalized for anorexia nervosa.

DESIGN

Longitudinal observational study.

SETTING

Tertiary care pediatric hospital. Patients Thirty-eight adolescents with anorexia nervosa, aged 13 to 21 years, with a mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 15.9 (1.8). Intervention Subjects received standard care, including bed rest and graded nutritional therapy. A subsample of subjects (n=19) returned 11 to 57 weeks following hospitalization for a second cardiac evaluation.

MAIN OUTCOME MEASURES

Results from a 15-lead electrocardiogram, echocardiogram, treadmill stress test, and spinal bone mineral density measurement.

RESULTS

On admission, 26 subjects (68%) had sinus bradycardia. Bradycardia was less common in participants with a longer duration of illness (P=.04). Left ventricle mass was lower than predicted for age (Z score<-1.0) in 11 subjects (31%). Exercise tolerance was normal by all measures. Both heart rate and QT interval were predictors of spinal bone mineral density. In those who returned for follow-up, absolute measures of left ventricle mass did not change (P=.27). However, the corresponding Z scores declined over time (mean [SD] change, -0.9 [1.3]; P=.02).

CONCLUSIONS

In acutely malnourished adolescents with anorexia nervosa, few truly pathologic cardiac findings were identified. Sinus bradycardia was observed in most cases. Mild reductions in left ventricle mass and left ventricle function were seen both at baseline and at follow-up, suggesting early sparing of cardiac muscle in the face of moderate malnutrition as well as a relative delay of cardiac muscle restoration. The association of hemodynamic status with altered spinal bone mineral density emphasizes the range of systems affected by malnutrition in anorexia nervosa.

Assessing youth risk behavior in a clinical trial setting: lessons from the infant health and development program

PURPOSE

The purpose of this article was to describe the use of the Youth Risk Behavior Surveillance System (YRBSS) with known 17-18-year-old patients in follow-up of a multisite randomized clinical trial, and to develop a new scoring algorithm indicating the degree of risk-taking behavior for between-group analyses.

METHODS

Seventy-five questions from the YRBSS were incorporated into the study questionnaire, with the development of safety plans to guide the disposition of participants. The YRBSS questions were grouped into two categories (with three subdomains each) named problem behaviors (conduct problems, sexual behavior, and suicide/hopelessness) and substance use (cigarettes, alcohol, and marijuana use), with scores for each subdomain indicating high, moderate, and low risk.

RESULTS

Of the 677 participants, the safety plan was activated 215 times for 199 (29.4%) of participants. Risk behaviors included binge drinking (149), alcohol/substance use and driving (41), depression (22), hopelessness (37), and suicidal ideation (13; all in the past). No emergency room evaluations were required. The subdomain scaling was analyzed by demographic characteristics, and findings were consistent with the literature; for example, higher rates of conduct problems in males, more suicidal ideation in females, greater sexual risk in African Americans, more substance use in males and whites, and more alcohol use in youth with mothers with higher levels of education.

CONCLUSIONS

YRBSS can be administered in a research setting with appropriate safety precautions. These results should provide a useful guide to the application of the YRBSS to other adolescent populations in the future.

Depression, parenting attributes, and social support among adolescent mothers attending a teen tot program

OBJECTIVE

To investigate the associations between depressive symptoms in adolescent mothers and their perceived maternal caretaking ability and social support.

PATIENTS AND METHODS

Subjects were participants enrolled in a parenting program that provided comprehensive multidisciplinary medical care to teen mothers and their children. Baseline data of a prospective cohort study were collected by interview at 2 weeks postpartum and follow-up, and standardized measures on entry into postnatal parenting groups. Demographic data included education, social supports, psychological history, family history and adverse life events. Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale for Children short version (CES-DC). The Maternal Self-report Inventory (MSRI) measured perceived maternal self-esteem, and Duke-UNC Functional Social Support Questionnaire measured social support. Data were analyzed with bivariate analyses and linear regression modeling focusing on depressive symptoms as the outcome variable.

RESULTS

In the 168 teen mothers, mean age 17.6 +/- 1.2 years, African American (50%), Latina (31%) or Biracial (13%), the prevalence of depressive symptoms was 53.6%. In the linear model, controlling for baby's age, teen's age, ethnicity, Temporary Aid for Families with Dependent Children (TAFDC), and previous suicidal gesture, increased depressive symptoms were associated with decreased perceived maternal caretaking ability (P = 0.003) and lower social support (P < 0.001). In a linear model controlling for the same variables, MSRI total score (P = 0.001) and social support (P < 0.001) contributed significantly to the model as did the interaction term (MSRI x Social Support, P = 0.044).

CONCLUSIONS

Depression is associated with decreased maternal confidence in their ability to parent and decreased perceived maternal social support, with a possible moderating effect of social support on the relationship of maternal self-esteem and depression.

Do-not-resuscitate orders and/or hospice care, psychological health, and quality of life among children/adolescents with acquired immune deficiency syndrome

OBJECTIVE

The frequency of do-not-resuscitate (DNR) orders and hospice enrollment in children/adolescents living with acquired immune deficiency syndrome (AIDS) and followed in Pediatric AIDS Clinical Trials Group (PACTG) Study 219C was examined, and evaluated for any association with racial disparities or enhanced quality of life (QOL), particularly psychological adjustment.

METHODS

A cross-sectional analysis of children with AIDS enrolled in this prospective multicenter observational study between 2000 and 2005 was conducted to evaluate the incidence of DNR/hospice overall and by calendar time. Linear regression models were used to compare caregivers' reported QOL scores within 6 domains between those with and without DNR/hospice care, adjusting for confounders.

RESULTS

Seven hundred twenty-six (726) children with AIDS had a mean age of 12.9 years (standard deviation [SD]=4.5), 51% were male, 60% black, 25% Hispanic. Twenty-one (2.9%) had either a DNR order (n=16), hospice enrollment (n=7), or both (n=2). Of 41 children who died, 80% had no DNR/hospice care. Increased odds of DNR/hospice were observed for those with CD4% less than 15%, no current antiretroviral use, and prior hospitalization. No differences by race were detected. Adjusted mean QOL scores were significantly lower for those with DNR/hospice enrollment than those without across all domains except for psychological status and health care utilization. Poorer psychological status correlated with higher symptom distress, but not with DNR/hospice enrollment after adjusting for symptoms.

CONCLUSIONS

Children who died of AIDS rarely had DNR/hospice enrollment. National guidelines recommend that quality palliative care be integrated routinely with HIV care. Further research is needed to explore the barriers to palliative care and advance care planning in this population.

Relationship of STD-related shame and stigma to female adolescents' condom-protected intercourse

PURPOSE

Shame and stigma associated with sexually transmitted diseases (STDs) are barriers to adolescents seeking prompt and appropriate diagnosis and treatment. However, little is known about how these constructs are related to STD-protective behaviors, such as condom-protected intercourse. Thus, we prospectively examined the relationship between shame and stigma and condom use in adolescent females.

METHODS

There were 192 African American females age 17.4 +/- 1.7 years (range 15-21 years) recruited for the study from local teen-oriented health clinics. At baseline, participants completed demographic and psychosocial measures (including STD-related shame and stigma), and chart- or laboratory-confirmed history of STDs was obtained. At 6 months follow-up, rate of condom-protected intercourse in past 14 days was assessed. Participants' baseline shame and stigma scores, prior history of STDs, and select demographic and theoretically important psychosocial variables were entered into a hierarchical linear regression model to predict condom-protected intercourse in the 14 days prior to the 6-month follow-up assessment.

RESULTS

After controlling for variables identified in bivariate correlations, STD-related shame was significantly predictive of condom-protected intercourse in the 14 days prior to follow-up, with higher shame predicting higher rates of condom-protected intercourse.

CONCLUSIONS

Future prevention efforts attempting to reduce adolescents' risks for STDs and HIV may benefit from addressing STD-related shame and stigma in addition to explicitly linking health-promoting behavior changes (condom use) to a decreased likelihood of future infection with STDs.

The impact of state policies on vaccine coverage by age 13 in an insured population

PURPOSE

To determine the impact of state policies on vaccine coverage among adolescents with managed care insurance.

METHODS

We used the 2003 Health Plan Employer Data and Information Set to determine state-specific hepatitis B and varicella vaccine coverage among children with managed care insurance who turned 13 years in 2002. Our outcomes of interest were receipt of hepatitis B and varicella vaccines by age 13. Utilizing weighted least-squares methods, multiple linear regression models were developed to evaluate the relationship between hepatitis B and varicella vaccine coverage and state policies, while controlling for state sociodemographic variables.

RESULTS

Across 28 states, adolescent hepatitis B vaccine coverage ranged from 35.3% to 80.5% (mean = 55.3%) and varicella vaccine coverage ranged from 22.9% to 7.6% (mean = 42.3%). In separate multiple regression models, after adjusting for potentially confounding sociodemographic variables, middle school mandates were significantly associated with hepatitis B vaccine coverage (p = .002) and varicella vaccine coverage (p = .024). Other policies, including universal purchase of vaccines and availability of philosophic exemptions, were not associated with vaccine coverage in this insured population.

CONCLUSIONS

In this population of insured adolescents, middle school vaccine mandates were the only state policy associated with improved hepatitis B and varicella vaccine coverage. Mandates are an effective method for promoting adolescent immunization.

Use of human immunodeficiency virus postexposure prophylaxis in adolescent sexual assault victims

OBJECTIVES

To describe the use of human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) in adolescent survivors of sexual assault and to explore barriers to PEP completion in this population.

DESIGN

Chart review.

SETTING

Two academic medical centers in Boston, Mass, between July 1, 2001, and June 30, 2003.

PARTICIPANTS

Adolescents presenting to 2 urban pediatric emergency departments within 72 hours of a penetrating sexual assault. Of 177 charts reviewed, adequate documentation of the sexual assault and medical management was available for 145 patients.

INTERVENTION

Provision of HIV PEP.

MAIN OUTCOME MEASURE

Documented completion of a 28-day course of PEP.

RESULTS

Among the 145 patients, 96% were female, 38% were black, and 14% were Hispanic. Many patients were uncertain regarding their exposures: 27% were unsure whether a condom had been used, 54% were unsure whether ejaculation had occurred, and 21% had blacked out during the assault. One hundred ten (76%) received HIV PEP. Of the 97 patients referred for follow-up at the academic centers, 37 returned for at least 1 visit and 13 completed a 28-day course of PEP. Sixteen (46%) of those taking PEP who returned for follow-up developed an adverse reaction to medication. Forty-seven percent of adolescent sexual assault survivors had carried a psychiatric diagnosis before the assault; adherence to PEP was lower among these adolescents.

CONCLUSIONS

We observed low rates of PEP completion among adolescent sexual assault survivors. Potential difficulties of using PEP in this population include uncertainties regarding exposure, high rates of psychiatric comorbidity, and low rates of return for follow-up care.

Effects of creating visual illness narratives on quality of life with asthma: a pilot intervention study

PURPOSE

To determine whether self-examination through video, by creating visual illness narratives of living with asthma, is associated with improved disease-specific quality of life.

METHODS

Nineteen children and adolescents (aged 8-19 years) with moderate or severe asthma by 1992 National Heart, Lung, and Blood Institute criteria were administered the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) twice before (T1 and T2) and once immediately after (T3) they made Video Intervention/Prevention Assessment (VIA) visual narratives of their lives with asthma. The PAQLQ is a previously validated scale (range 1-7) that measures asthma-specific quality of life in three domains: activity limitation, symptoms, and emotional function. Overall and domain-specific PAQLQ scores were compared using general linear model repeated measures analysis. Participant exit interviews about the VIA experience were analyzed using grounded theory.

RESULTS

The mean PAQLQ score did not change between T1 and T2, but significantly increased from 4.78 at T1 to 5.30 at T3 (p = .045). The activity level domain score increased from a mean of 4.08 at T1 to 5.08 at T3 (p < or = .001). Qualitative data indicated that VIA was associated with increased disease-awareness and more confident self-management for most participants.

CONCLUSIONS

The results of this pilot study suggest that creating visual illness narratives is associated with improved quality of life for children and adolescents with asthma. Research with larger numbers and a control group is needed to evaluate VIA as an intervention and to further quantify its impact on health-related quality of life.

Development of a new Adolescent Patient-Provider Interaction Scale (APPIS) for youth at risk for STDs/HIV

PURPOSE

Although an adult model of patient-provider mutual exchange of information has been proposed, there is no guiding model for adolescents or measurement methodology. Our purpose was to develop a new scale of patient-provider interaction for adolescents accessing reproductive health care and at risk for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV), and assess the reliability and validity of the scale.

METHODS

The Adolescent Patient-Provider Interaction Scale (APPIS) was developed from the Roter and Hall theory of doctor-patient relationships, previously validated adolescent satisfaction and communication scales, and focus group and individual elicitation interviews. To assess construct validity, the new nine-item APPIS was compared with the satisfaction scale used by the Young Adult Health Care Survey (YAHCS), and Kahn's Provider Communication Scale. Pearson correlation coefficients were used to examine convergence across scales, and factor analysis of the APPIS was performed.

RESULTS

The study recruited 192 African American girls aged 17.9 +/- 1.7 years (range 15-21 years) from three sites: a county STD clinic (n = 51), urban adolescent clinic (n = 99), and a family planning clinic (n = 42). Most participants (85%) rated their overall health care highly (> or = 7 on a 10-point scale); 49% felt that both the provider and patient were "in charge" of the visit, and 88% "strongly agreed" or "agreed" that there was an equal "exchange of information" during the visit. The APPIS showed good internal consistency (Cronbach alpha = .75), and moderate convergence with the six-item YAHCS scale (r = .57, p < .001) and seven-item Kahn scale (r = .48, p < .001). Three factors emerged from exploratory factor analyses, supporting our conceptualization of patient-provider interaction as being multi-dimensional.

CONCLUSIONS

A new theory-based scale of adolescent patient-provider interaction compares favorably with previous scales of health care satisfaction and communication. The new APPIS may be useful for evaluating approaches to improve health care outcomes for adolescents at-risk for STDs and HIV.

Early intervention in low birth weight premature infants: results at 18 years of age for the Infant Health and Development Program

OBJECTIVE

To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age.

METHODS

This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001-2499 g) and lighter low birth weight (LLBW; < or = 2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status.

RESULTS

We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (-0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2).

CONCLUSIONS

The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

Parental acceptance of the human papillomavirus vaccine

We conducted focus groups and individual interviews to explore parental views on the human papillomavirus (HPV) vaccine. Parents were generally positive about the HPV vaccine. Some participants perceived their children were not at risk for acquiring HPV and questioned vaccinating young adolescents against HPV. Vaccine education should target parental beliefs about HPV and the optimal age for HPV vaccine administration.

An algorithm using reticulocyte hemoglobin content (CHr) measurement in screening adolescents for iron deficiency

PURPOSE

To evaluate whether the use of an algorithm including reticulocyte hemoglobin content (CHr), a new hematologic parameter, in addition to the screening complete blood count (CBC), improves detection of iron deficiency and iron deficiency anemia in healthy adolescents.

METHODS

After initiation of an algorithm using CHr in addition to CBC results for identifying iron-deficient patients in a primary care hospital-based adolescent clinic, we reviewed results of all hematological tests performed in the clinic during an 8-month period. Electronic medical records were screened for health status and inclusion criteria. We determined the number of patients with low hematocrit values, low mean cell volume (MCV), and low CHr. To evaluate the impact of the protocol, we calculated the percentage of cases in which the CHr results suggested a management plan different from that which would have been formulated using the CBC results only.

RESULTS

A total of 381 patients (mean age 16.8 +/- 3.1 years) were included in the study. Anemia was diagnosed by the Centers for Disease Control (CDC) guidelines in 63 patients (16.5%), low MCV in 170 patients (44.6%), and a low CHr in 80 (21%) patients. In 68% of anemia cases, a normal CHr suggested that iron deficiency was not the cause of the anemia. Although low MCV values were found in 38 (60.4%) of all anemic cases, mean MCV was significantly (p < 0.001) lower in the 19 cases with a low CHr as well. In 19% of 318 patients with a normal hematocrit (HCT), a low CHr suggested the need for treatment of early iron deficiency. In 103 (27%) cases, CHr suggested a different treatment plan from that which would have been formulated using the screening CBC only.

CONCLUSIONS

The use of an algorithm including CHr to screen for iron deficiency anemia may increase the accuracy of diagnosis, enabling early detection and treatment of iron deficiency in adolescents without the need for additional costly iron studies.

Youth preferences for prenatal and parenting teen services

STUDY OBJECTIVE

Parenting teens served by a teen-tot program and teens from a prenatal clinic participated in focus groups to explore their perceptions of medical care, social services, and psycho-educational parenting groups.

DESIGN

The teens met in four focus groups, two prenatal and two postnatal.

SETTING

Teens receiving care from a teen-tot program and associated prenatal clinic in a large metropolitan area in New England.

PARTICIPANTS

A total of 16 pregnant (n=6) and parenting (n=10) teens ages ranging from 16 to 21 years (13 African American, 2 Latina, and 1 Haitian) participated in the four focus groups.

METHODS

A qualitative focus group study was performed. Structured, culturally sensitive questions guided the discussion based on a hypothetical case scenario. Themes were identified through grounded theory with three coders and differences were reconciled.

RESULTS

The groups revealed prenatal and postnatal mothers valued medical and social services provided in a teen-focused hospital clinic. Prenatal teens looked to providers for health education services and group support. Parenting teens requested consistent doctors for their children and social supports for themselves. Both groups desired assistance with social services, education, housing, and finances as well as educational services for fathers.

CONCLUSIONS

Teen parents' perceptions and suggestions for services are critical to program development that meets the needs of participants.