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Mukherjee G, Zhang C, Kandaswamy S, Gooding H, Orenstein E. Current Inpatient Screening Practices for Sexual History and STIs: An Opportunity to Seize. Clin Pediatr (Phila) 2024; 63:350-356. [PMID: 37424327 DOI: 10.1177/00099228231183501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually transmitted infection (STI) testing among adolescents admitted to a pediatric hospital medicine service. Retrospective cross-sectional study of adolescents (14-19 years old) admitted to the PHM service from 2017-2019 was performed at an academic children's health system. Patient (demographics, history of complex chronic condition, and insurance), hospitalization (length of stay, diagnosis, STI tests ordered/results), and physician (level of training and gender) characteristics were extracted for each encounter. A natural language processing algorithm identified the presence of SHxD. Univariate analysis and multivariable analysis were performed to detect factors associated with SHxD and STI screening. The prevalence of STIs was calculated for those who were tested. Out of 2242 encounters, SHxD and STI testing rates were 40.9% and 17.2%, respectively. Patient gender, race, lack of complex chronic condition, and resident involvement were predictive of SHxD and STI testing. SHxD increased the odds of STI testing significantly (OR 5.06, CI 3.90-6.58). Among those who were tested, the prevalence of STIs was highest for chlamydia (37/329, 11.2%). Overall, sexual health screening rates remain low in the hospital setting and future improvement initiatives are needed.
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Affiliation(s)
- Gargi Mukherjee
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta-Egleston Hospital, Atlanta, GA, USA
| | - Chao Zhang
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta-Egleston Hospital, Atlanta, GA, USA
| | - Swaminathan Kandaswamy
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta-Egleston Hospital, Atlanta, GA, USA
| | - Holly Gooding
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta-Egleston Hospital, Atlanta, GA, USA
- Department of Pediatrics, Emory University/Grady Memorial Hospital, Atlanta, GA, USA
| | - Evan Orenstein
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta-Egleston Hospital, Atlanta, GA, USA
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2
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The Hospitalized Adolescent. Pediatrics 2023; 151:190500. [PMID: 37184363 DOI: 10.1542/peds.2022-060647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 01/25/2023] Open
Abstract
This clinical report provides pediatricians evidence-based information on the developmentally appropriate, comprehensive clinical care for hospitalized adolescents. Included in this report are opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations. The companion policy statement, “The Hospitalized Adolescent,” includes detailed descriptions of adolescent hospital admission demographics, personnel recommendations, and hospital setting and design advice, as well as sections on educational services, legal and ethical matters, and transitions to adult facilities.
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Hunt JA, Randell KA, Mermelstein S, Miller MK, Masonbrink AR. Understanding the Sexual and Reproductive Health Needs of Hospitalized Adolescent Males. Hosp Pediatr 2022; 12:e387-e392. [PMID: 36300339 PMCID: PMC9647630 DOI: 10.1542/hpeds.2021-006489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe sexual behaviors and acceptability of receiving sexual and reproductive health (SRH) services among hospitalized adolescent males. METHODS We performed a cross-sectional survey of hospitalized adolescents. Eligible participants were males aged 14 to 20 years admitted at 2 academic medical centers. Outcome measures included reported healthcare utilization, sexual health behaviors (eg, sexual activity), contraception use, and acceptability of SRH discussions during a hospitalization. RESULTS Among 145 participants, 42% reported a history of vaginal sex, 27% current sexual activity, 12% early sexual debut, and 22% 4 or more prior sexual partners. At last sex, condom use was reported by 63% and use of reversible contraception by 36%. Nearly half (45%) agreed that hospital-based SRH discussions were acceptable, particularly among those with history of sexual activity (P < .01). Some (12%) reported they had not accessed care in the past year when they felt they should. CONCLUSIONS Hospitalized males in our study had similar rates of sexual activity as compared with the general population but had higher rates of early sexual debut and number of prior partners, which are independently linked with negative sexual health outcomes (eg, sexually transmitted infections). Our participants found SRH discussions to be generally acceptable. These findings reveal opportunities to screen for unmet SRH needs and provide SRH education and services for adolescent males in the hospital.
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Affiliation(s)
- Jane Alyce Hunt
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kimberly A Randell
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Sarah Mermelstein
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Melissa K Miller
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Abbey R Masonbrink
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- University of Kansas School of Medicine, Kansas City, Kansas
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Robertson C, Mukherjee G, Gooding H, Kandaswamy S, Orenstein E. A method to advance adolescent sexual health research: Automated algorithm finds sexual history documentation. Front Digit Health 2022; 4:836733. [PMID: 35937421 PMCID: PMC9354080 DOI: 10.3389/fdgth.2022.836733] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background:We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings.MethodsWe iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation. We validated this algorithm with inpatient admission notes for adolescents. We calculated the sensitivity, specificity, negative predictive value, positive predictive value, and F1 score of the tool in each environment using manual chart review as the gold standard.ResultsIn the ED test cohort with abdominal or GU complaints, 97/179 (54%) provider notes had a sexual history documented, and the NLP algorithm correctly classified each note. In the inpatient validation cohort, 97/321 (30%) admission notes included a sexual history, and the NLP algorithm had 100% sensitivity and 98.2% specificity. The algorithm demonstrated >97% sensitivity and specificity in both settings for detection of elements of a high quality sexual history including protection used and contraception. Type of sexual practice and STI testing offered were also detected with >97% sensitivity and specificity in the ED test cohort with slightly lower performance in the inpatient validation cohort.ConclusionThis NLP algorithm automatically detects the presence of sexual history documentation and its key components in ED and inpatient settings.
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Affiliation(s)
- Caryn Robertson
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Gargi Mukherjee
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
- *Correspondence: Gargi Mukherjee
| | - Holly Gooding
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
- Grady Memorial Hospital, Atlanta, GA, United States
| | - Swaminathan Kandaswamy
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Evan Orenstein
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
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Goldstein RL, Keppler H, Pineda N, Weng Y, Carlson JL. Implementation of an Inpatient Reproductive Health Screening Consult Service. Hosp Pediatr 2022; 12:303-310. [PMID: 35165737 DOI: 10.1542/hpeds.2021-006178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Reproductive health is an important issue in the care of adolescents and young adults (AYA). Unfortunately, many AYAs, particularly those with chronic medical conditions, may not regularly access primary care to address these issues. This study evaluates the impact of an inpatient reproductive health consult service on reproductive health care. METHODS A reproductive health-focused screening consult service was initiated in June 2017 at an academic teaching hospital. Patients aged 15 to 26 admitted to pediatric ward teams were eligible for screening. A retrospective chart review was conducted from December 2016 to June 2019 to determine the effect of the consult service on the primary outcome, documentation of a psychosocial assessment, and reproductive health concerns. RESULTS Nine hundred twenty-nine encounters were analyzed (345 preintervention and 584 during intervention), representing 675 patients. The proportion of encounters with a documented psychosocial assessment increased from 14.8% to 41.3% during the intervention (P < .001); a reproductive health screening consult was responsible for 37.3% (109 of 292) of the documented assessments. There were high self-reported rates of sexual activity (38%), substance use (47%), and mood concerns (48%) among hospitalized AYA; all behaviors were documented at statistically significant increased frequencies (P < .001) during the intervention compared with preintervention. CONCLUSIONS Initiation of an inpatient reproductive health screening consult service led to increased documentation of psychosocial assessments, including increased documentation of sexual health history and other risk factors. With improved screening of reproductive and psychosocial needs, targeted interventions can meet underrecognized needs among hospitalized AYA.
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Affiliation(s)
| | - Hannah Keppler
- Department of Pediatrics, Albert Einstein College of Medicine, New York, New York
| | | | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alta, California
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McFadden V, Bauer SC, Porada K, Mehta S, Pickett ML. Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care. Hosp Pediatr 2022; 12:53-61. [PMID: 34918092 DOI: 10.1542/hpeds.2021-006038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service. METHODS We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions. RESULTS From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected. CONCLUSIONS The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception.
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Affiliation(s)
| | | | | | | | - Michelle L Pickett
- Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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7
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Can a Clean Catch Urine Sample Be Used to Diagnose Chlamydia and Gonorrhea in Adolescent Females? J Adolesc Health 2021; 69:574-578. [PMID: 33846057 DOI: 10.1016/j.jadohealth.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Clean catch urine samples may be an alternative specimen to test for chlamydia and gonorrhea infections. The aim of this study was to determine the sensitivity and specificity of clean urine for chlamydia and gonorrhea in women. METHODS This was a noninferiority prospective cohort study of women aged 14-22 years requiring chlamydia and gonorrhea testing. Patients provided a vaginal swab (gold standard), clean urine (test sample), and dirty urine (usual care). All samples were analyzed using Hologic's Aptima Combo2 Assay, a second-generation nucleic acid amplification test. The sensitivity and specificity of the clean and dirty urine were calculated and compared. RESULTS Three hundred and twenty-three females were included, mean age 17.0 ± 1.6 years. For chlamydia, 59 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose chlamydia was 86.2% (95% CI: 74.8%-93.1%) and specificity was 98.8% (95% CI: 96.5%-99.8%). The sensitivity of dirty urine to diagnose chlamydia was 89.8% (95% CI: 79.2%-95.6%), and the specificity was 99.6% (95% CI 97.6%-100%). For gonorrhea, 18 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose gonorrhea was 94.4% (95% CI: 72.4%-100%) and specificity was 99.7% (95% CI: 98.0%-100.0%). The sensitivity of dirty urine to diagnose gonorrhea was 100% (95% CI: 79.3%-100%) and specificity was 99.7% (95% CI: 98.0%-100%). Specificity of clean urine was noninferior compared with dirty urine for diagnosing chlamydia (p = .0004) and gonorrhea (p < .0001). CONCLUSIONS Clean urine samples may be an alternative option to diagnose chlamydia and gonorrhea in women.
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Hunt JA, Randell KA, Mermelstein S, Miller MK, Sherman AK, Philipose S, Masonbrink AR. Sexual Health Behaviors and Pregnancy Risk Among Hospitalized Female Adolescents. Hosp Pediatr 2021; 11:1129-1136. [PMID: 34518336 DOI: 10.1542/hpeds.2021-005810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe sexual health behaviors, contraceptive use, and pregnancy risk among hospitalized female adolescents. METHODS We conducted a cross-sectional survey of hospitalized female patients aged 14 to 21 years at 2 academic medical centers to assess sexual health behaviors, contraceptive use, contraceptive counseling receipt, and factors associated with pregnancy complications (eg, diabetes, teratogenic exposure). We calculated the validated Pregnancy Risk Index (PRI) (number per 100 who will become pregnant in the next year). RESULTS Among 177 participants (mean age 16 years, SD 1.5), 75 (43%) were sexually active. At last vaginal sex, 65% reported condom use; 49%, reversible contraception; and 12%, long-acting reversible contraception (LARC). Past-year contraceptive counseling was reported by 73% of sexually active female participants and was associated with increased use of reversible (P = .001) and dual contraception (P = .03) but not LARC (P = .24). The mean PRI among all participants was 4.75. Nearly three-quarters (73%) had a medical comorbidity or teratogenic exposure. Those with teratogenic medication use had the lowest PRI of 0.32 (P < .05), with 88% using reversible contraception and 31% using LARC. CONCLUSIONS Hospitalized female adolescents had a PRI similar to that of adolescents in the general population. However, nearly three-quarters had a medical comorbidity and/or teratogenic exposure, which increased risk for pregnancy complications. Contraceptive counseling was associated with increased reversible and dual contraception use but not LARC use. Efforts to improve comprehensive contraceptive counseling, highlighting LARC, are critically needed in this population.
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Affiliation(s)
- Jane Alyce Hunt
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Kimberly A Randell
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Departments of Pediatrics
| | - Sarah Mermelstein
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Melissa K Miller
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Departments of Pediatrics
| | - Ashley K Sherman
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
| | - Shirene Philipose
- Department of Internal Medicine, School of Medicine, University of Kansas, Kansas City, Kansas
| | - Abbey R Masonbrink
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Departments of Pediatrics
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9
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Brookmeyer KA, Coor A, Kachur RE, Beltran O, Reno HE, Dittus PJ. Sexual History Taking in Clinical Settings: A Narrative Review. Sex Transm Dis 2021; 48:393-402. [PMID: 33093285 DOI: 10.1097/olq.0000000000001319] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to explore gaps between Centers for Disease Control and Prevention's clinical guidelines for obtaining a sexual history and regular clinical practice. We examine how patient, provider, and setting characteristics may influence the likelihood of obtaining comprehensive sexual histories and examine patient outcomes linked to sexual history taking. METHODS We performed a narrative review to identify studies that examined clinical practice and sexual history taking via 8 databases. A 2-level inclusion protocol was followed, wherein the abstract and full text of the article were reviewed, respectively. Data were abstracted using a standardized tool developed for this study. RESULTS The search yielded 2700 unique studies, of which 2193 were excluded in level 1, and 497 were excluded in level 2, leaving 10 studies for data abstraction. None of the studies reported comprehensive sexual history taking, and 8 studies reported differences in how providers obtain a sexual history when patient and provider demographics are considered. Three studies found a positive link between providers who discuss sexual history and provider sexually transmitted disease testing. CONCLUSIONS When sexual histories are obtained, they are not comprehensive, and providers may discuss sexual history differentially based on patients' demographic characteristics. Providers who discuss patients' sexual history may be more likely to also provide sexual health preventive care.
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Affiliation(s)
- Kathryn A Brookmeyer
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alexandra Coor
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rachel E Kachur
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Oscar Beltran
- The United States-Mexico Foundation for the Sciences, Washington, DC
| | - Hilary E Reno
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Patricia J Dittus
- From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Pfaff N, DaSilva A, Ozer E, Vemula Kaiser S. Adolescent Risk Behavior Screening and Interventions in Hospital Settings: A Scoping Review. Pediatrics 2021; 147:peds.2020-020610. [PMID: 33785635 DOI: 10.1542/peds.2020-020610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Risky behaviors are the main threats to adolescents' health; consequently, evidence-based guidelines recommend annual comprehensive risk behavior screening. OBJECTIVE To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings. DATA SOURCES Our data sources included PubMed (1965-2019) and Embase (1947-2019). STUDY SELECTION Studies were included on the basis of population (adolescents aged 10-25 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents. DATA EXTRACTION Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention. RESULTS Forty-six studies were included; most (38 of 46) took place in the ED, and a single risk behavior domain was examined (sexual health [19 of 46], mood and suicidal ideation [12 of 46], substance use [7 of 46], and violence [2 of 46]). In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (∼10%) but significant increases with clinician reminder implementation. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Reported barriers were time constraints and limited resources. LIMITATIONS Only 1 included study was a randomized controlled trial, and there was large heterogeneity of included studies, potentially limiting generalizability. CONCLUSIONS Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Our findings outline promising tools for improving screening and intervention, highlighting the critical need for continued development and testing of interventions in these settings to improve adolescent care.
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Affiliation(s)
| | | | - Elizabeth Ozer
- Division of Adolescent and Young Adult Medicine.,Office of Diversity and Outreach, and
| | - Sunitha Vemula Kaiser
- Departments of Pediatrics and.,Epidemiology and Biostatistics.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
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11
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Pfaff N, Pantell MS, Kaiser SV. High-risk Behavior Screening and Interventions in Hospitalized Adolescents. Hosp Pediatr 2021; 11:293-297. [PMID: 33568420 DOI: 10.1542/hpeds.2020-001792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Risky behaviors are the main threats to adolescents' health. Consequently, guidelines recommend adolescents be screened annually for high-risk behaviors. Our objectives were to (1) determine rates of physician-documented risk behavior screening of hospitalized adolescents, (2) determine rates of positive screening results, and (3) evaluate associations between risk behavior screening and provision of risk behavior-related health care interventions. METHODS We conducted a cross-sectional study of patients aged 12 to 24 years admitted to the pediatric hospital medicine service at an urban tertiary children's hospital from January to December 2018. Exclusion criteria were transfer to a different service, nonverbal status, or altered mental status. We reviewed 20 charts per month. Outcomes included (1) documentation of risk behavior screening (mood, sexual activity, substance use, abuse and/or violence, and suicidal ideation), and (2) risk behavior-related health care interventions (eg, testing for sexually transmitted infections). We determined associations between screening and risk behavior-related interventions using χ2 tests. RESULTS We found that 38% (90 of 240) of adolescents had any documented risk behavior screening, 15% (37 of 240) had screening in 4 of 5 risk behavior domains, and 2% (5 of 240) had screening in all 5 domains. The majority of screened adolescents had a positive screening result (66%), and most with positive results received a risk behavior-related health care intervention (64%-100% across domains). Adolescents with documented screening were significantly more likely to receive a risk behavior-related health care intervention. CONCLUSIONS We found low rates of risk behavior screening documentation among hospitalized adolescents. There was a high rate of positive screen results, and those who were documented as screened were more likely to receive risk behavior-related interventions.
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Affiliation(s)
- Nora Pfaff
- Benioff Children's Hospital and University of California San Francisco, San Francisco, California
| | - Matthew S Pantell
- Benioff Children's Hospital and University of California San Francisco, San Francisco, California
| | - Sunitha V Kaiser
- Benioff Children's Hospital and University of California San Francisco, San Francisco, California
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12
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Clary K, Cortright L, Tumin D, Buckman C, Eldridge D. Primary Care Use and Assessment of Adolescents' Sexual Health During Hospitalization. Hosp Pediatr 2020; 10:963-968. [PMID: 33067349 DOI: 10.1542/hpeds.2020-0050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hospitalization provides an opportunity to address sexual health needs of adolescents who may not otherwise receive regular medical care. We investigated documentation of a sexual health discussion with adolescents hospitalized at our medical center to determine if previous primary care physician (PCP) visits in the same health system were associated with sexual health documentation during the hospital admission. METHODS We retrospectively identified adolescents aged 13 to 17 years discharged from the pediatric general ward. Documented discussion of sexual health was reviewed in the electronic medical record. Previous PCP visits were identified from the affiliated primary care clinics within 12 months before hospitalization. We also queried follow-up PCP visits within 90 days of discharge to determine if a sexual health discussion during hospitalization was followed-up in the outpatient setting. RESULTS We analyzed 394 patients (49% girls; median age 15 years), of whom 122 (31%) had documentation of a sexual health discussion while hospitalized and 75 (19%) had previous PCP visits in our health system. On multivariable analysis, older age (P < .001), female sex (P = .016), admission from the emergency department (P < .001), and a genitourinary primary problem at admission (P = .007), but not previous PCP visits, were associated with increased likelihood of sexual health documentation. CONCLUSIONS Although discussion of sexual health was uncommon overall for hospitalized adolescents, we noted that nearly 4 in 5 adolescents for whom this was documented had not recently visited a PCP in our health system. These findings highlight hospitalization as a unique opportunity for sexual health intervention among adolescents who may not regularly see a PCP.
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Affiliation(s)
- Kathryn Clary
- Brody School of Medicine, East Carolina University, Greenville, North Carolina
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13
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Feller DJ, Bear Don't Walk Iv OJ, Zucker J, Yin MT, Gordon P, Elhadad N. Detecting Social and Behavioral Determinants of Health with Structured and Free-Text Clinical Data. Appl Clin Inform 2020; 11:172-181. [PMID: 32131117 DOI: 10.1055/s-0040-1702214] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Social and behavioral determinants of health (SBDH) are environmental and behavioral factors that often impede disease management and result in sexually transmitted infections. Despite their importance, SBDH are inconsistently documented in electronic health records (EHRs) and typically collected only in an unstructured format. Evidence suggests that structured data elements present in EHRs can contribute further to identify SBDH in the patient record. OBJECTIVE Explore the automated inference of both the presence of SBDH documentation and individual SBDH risk factors in patient records. Compare the relative ability of clinical notes and structured EHR data, such as laboratory measurements and diagnoses, to support inference. METHODS We attempt to infer the presence of SBDH documentation in patient records, as well as patient status of 11 SBDH, including alcohol abuse, homelessness, and sexual orientation. We compare classification performance when considering clinical notes only, structured data only, and notes and structured data together. We perform an error analysis across several SBDH risk factors. RESULTS Classification models inferring the presence of SBDH documentation achieved good performance (F1 score: 92.7-78.7; F1 considered as the primary evaluation metric). Performance was variable for models inferring patient SBDH risk status; results ranged from F1 = 82.7 for LGBT (lesbian, gay, bisexual, and transgender) status to F1 = 28.5 for intravenous drug use. Error analysis demonstrated that lexical diversity and documentation of historical SBDH status challenge inference of patient SBDH status. Three of five classifiers inferring topic-specific SBDH documentation and 10 of 11 patient SBDH status classifiers achieved highest performance when trained using both clinical notes and structured data. CONCLUSION Our findings suggest that combining clinical free-text notes and structured data provide the best approach in classifying patient SBDH status. Inferring patient SBDH status is most challenging among SBDH with low prevalence and high lexical diversity.
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Affiliation(s)
- Daniel J Feller
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
| | | | - Jason Zucker
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York, United States
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York, United States
| | - Peter Gordon
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York, United States
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
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Walston JM, Foster BA, Gardner TA, Benchbani H, Noelck M, Austin JP. Sexual History and Contraception Documentation in Hospitalized Adolescents: Are Technology-Dependent Patients Overlooked? Hosp Pediatr 2019; 9:967-973. [PMID: 31685520 DOI: 10.1542/hpeds.2019-0113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Adolescents are at high-risk for sexually transmitted infections and pregnancy, yet many do not receive regular preventive care. Hospitalization represents an opportunity for providing sexual and contraception counseling for this high-risk population. Our aim in this study was to assess the frequency of sexual and contraception history documentation in hospitalized adolescents and identify subgroups that may benefit from more vigilant screening. METHODS A retrospective chart review of adolescent patients 11 years of age and older who were discharged from the pediatric hospitalist service at an urban, academic children's hospital from July 2017 to June 2018 was conducted. Patient and admission characteristics were analyzed for presence of sexual and contraception history documentation. Technology-dependent patients were analyzed separately. In addition, technology-dependent patients were assessed by chart review for developmental appropriateness for screening. RESULTS Twenty-five percent of patients (41 of 165) had a sexual history documented, and 8.5% (14 of 165) had a contraception history documented. Among patients with any technology dependence, 0 had a sexual history documented and only 1 had a contraception history documented, whereas 31.5% (12 of 38) were deemed developmentally appropriate for screening. Female and older patients were more likely to have sexual and contraceptive histories documented than male and younger patients. Patients transferred from the PICU had lower rates of sexual history documentation compared with direct admissions. CONCLUSIONS Hospitalized adolescents, especially those with technology dependence, did not have adequate sexual and contraception histories documented. Improving documentation of these discussions is an important step in providing adolescents with preventive medicine services while hospitalized.
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Riese A, Houck C, Abdullahi N, Davies AC, Baird J, Alverson B. An Electronic Sexual Health Module for Hospitalized Adolescent Girls. Hosp Pediatr 2019; 9:880-887. [PMID: 31597670 DOI: 10.1542/hpeds.2018-0276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the acceptability and feasibility of an electronic sexual health module for inpatient adolescent girls and assess the preliminary effect on uptake of sexual health services. METHODS We recruited girls 14 to 18 years old admitted to the hospitalist service of 1 academic children's hospital from January 2016 to October 2016. Participants completed an electronic sexual health module that included a sexual health assessment, tailored feedback (randomized for half of the participants only), and a questionnaire to request sexual health services. Participation and completion rates, along with effects of tailored feedback, risk perception, age group, and sexual activity on uptake of services, were examined. RESULTS Seventy-seven percent of eligible participants who were approached enrolled in the study (n = 66 of 86). The completion rate was 100%. Fifty-three percent (n = 35) requested some form of sexual health service; of these, 83% (n = 29) requested to watch a contraception video. There was no statistically significant difference in the frequency of requests for those who received tailored feedback and for those who did not (57% vs 48%; P = .48). Younger teens and those without sexual experience made requests similar to older and sexually experienced girls except regarding sexually transmitted infection testing, which was significantly higher in the latter populations. CONCLUSIONS This pilot study demonstrated reasonable feasibility and acceptability of a standardized sexual health module for adolescent girls admitted to the general pediatric wards. Videos focused on adolescent health were of particular interest to this population. Further study should examine the impact of such a module on long-term sexual health behaviors.
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Affiliation(s)
- Alison Riese
- Departments of Pediatrics and
- Lifespan Injury Prevention Center, Rhode Island Hospital, Providence, Rhode Island
| | | | - Najma Abdullahi
- School of Public Health, Brown University, Providence, Rhode Island; and
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Riese A, Tarr E, Baird J, Alverson B. Documentation of Tobacco, Alcohol, and Drug Screening in Hospitalized Adolescents. Hosp Pediatr 2019; 9:719-723. [PMID: 31413069 DOI: 10.1542/hpeds.2018-0252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To examine the frequency of documented screening for tobacco, alcohol, and drug use in hospitalized adolescents on the pediatric hospitalist service. PATIENTS AND METHODS This was a retrospective chart review of adolescents aged 14 to 17 years hospitalized at a large urban academic children's hospital in the Northeast from 2013 to 2015. Only patients admitted directly to the hospitalist service and only the first admission (if multiple occurred) were included. Patients presenting for psychiatric illness, ingestions, or impaired neurologic functioning were excluded. Admission history and physical (H&P) notes were reviewed to identify documented screening for tobacco, alcohol, and drug use. χ2 tests and 95% confidence intervals (CIs) were used to compare screenings for each substance and assess for associations of patient and encounter characteristics. RESULTS A total of 443 charts met criteria for inclusion. The majority of adolescents were girls (n = 286; 64.6%), and mean age was 15.6 years (SD: 1.1). The H&P notes included notation of screening for tobacco use in 75.4% (95% CI: 71.1%-79.3%), alcohol use in 56.4% (95% CI: 51.7%-61.1%), and drug use in 37.9% (95% CI: 33.4%-42.6%) of charts. Girls were 1.4 times more likely to have of documented screening for alcohol use than boys. The admission diagnosis category was significantly associated with documentation of alcohol screening. Tobacco and drug screening frequency did not differ on the basis of sex, age, or diagnosis category. CONCLUSIONS Documentation of substance use screening was not universal in admission H&P notes. These discrepancies suggest a need for improvements in screening protocols and documentation methods.
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Affiliation(s)
- Alison Riese
- Warren Alpert Medical School, Brown University, Providence, Rhode Island; and .,Lifespan Injury Prevention Center, Rhode Island Hospital, Providence, Rhode Island
| | - Elizabeth Tarr
- Warren Alpert Medical School, Brown University, Providence, Rhode Island; and
| | - Janette Baird
- Lifespan Injury Prevention Center, Rhode Island Hospital, Providence, Rhode Island
| | - Brian Alverson
- Warren Alpert Medical School, Brown University, Providence, Rhode Island; and
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Addressing Reproductive Health in Hospitalized Adolescents-A Missed Opportunity. J Adolesc Health 2019; 64:721-724. [PMID: 30878183 DOI: 10.1016/j.jadohealth.2019.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents' reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting. METHODS Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception. RESULTS Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females). CONCLUSIONS Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents.
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Masonbrink AR, Miller MK. Caring for Hospitalized Adolescents: Opportunities to Identify and Address Unmet Reproductive Health Needs. J Adolesc Health 2019; 64:689-690. [PMID: 31122502 DOI: 10.1016/j.jadohealth.2019.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Abbey R Masonbrink
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Melissa K Miller
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Masonbrink AR, Stancil S, Reid KJ, Goggin K, Hunt JA, Mermelstein SJ, Shafii T, Lehmann AG, Harhara H, Miller MK. Adolescent Reproductive Health Care: Views and Practices of Pediatric Hospitalists. Hosp Pediatr 2019; 9:100-106. [PMID: 30622112 DOI: 10.1542/hpeds.2018-0051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Many hospitalized adolescents are at increased risk for pregnancy complications due to an underlying medical condition, however sexual risk assessment is not consistently performed in this setting. While adolescents and their parents are supportive of sexual health discussion in the inpatient setting, a thorough understanding of factors that influence provision of this care among pediatric hospital physicians is lacking. This formative information is needed to facilitate efforts to improve and standardize clinical care provision. Our objective is to assess the frequency and factors that influence the provision of adolescent sexual and reproductive care by pediatric hospitalists. METHODS We performed a cross-sectional computerized survey of hospitalists at 5 pediatric hospitals who cared for ≥1 adolescent (14-21 years old) in the past year. Sexual and reproductive care practices were assessed by using a 76-item novel survey informed by the theory of planned behavior. We used descriptive statistics to summarize the data. RESULTS Sixty-eight pediatric hospitalists participated (49% response rate): 78% were women and 65% were aged <40 years. Most (69%) reported treating >46 adolescents annually, including many who are at an increased risk for pregnancy complications due to teratogenic medication use or a comorbid condition. A majority felt that sexual and reproductive services are appropriate, although many endorsed barriers, including concern about follow-up after emergency contraception (63%) and time constraints (53%). Most reported insufficient knowledge regarding contraception (59%), desired contraception education (57%), and were likely to increase contraceptive provision if provided education (63%). Hospitalists rarely provided condoms or referral for an intrauterine device. CONCLUSIONS Pediatric hospitalists frequently care for adolescents who are at risk for pregnancy complications and generally agree that reproductive care is appropriate in the inpatient setting. With these findings, we highlight the critical need for effective comprehensive reproductive health service interventions that are tailored to address the numerous actionable barriers identified in this study.
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Affiliation(s)
- Abbey R Masonbrink
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; .,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Stephani Stancil
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Kathy Goggin
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Division of Health Services and Outcomes Research and
| | - Jane Alyce Hunt
- Department of Pediatrics, St Louis Children's Hospital and School of Medicine, Washington University, St Louis, Missouri
| | - Sarah J Mermelstein
- Department of Pediatrics, St Louis Children's Hospital and School of Medicine, Washington University, St Louis, Missouri
| | - Taraneh Shafii
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Amber G Lehmann
- Department of Pediatrics, East Carolina University, Greenville, North Carolina; and
| | - Haleema Harhara
- Department of Pediatrics, Children's Hospital of San Antonio, San Antonio, Texas
| | - Melissa K Miller
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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Masonbrink AR, Richardson T, McCulloh RJ, Hall M, Bettenhausen JL, Walker JM, Johnson MB, Queen MA, Markham JL, Goyal MK. Sexually Transmitted Infection Testing in Adolescents: Current Practices in the Hospital Setting. J Adolesc Health 2018; 63:342-347. [PMID: 30072303 PMCID: PMC6269275 DOI: 10.1016/j.jadohealth.2018.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Adolescents are disproportionately affected by sexually transmitted infections (STIs), and evidence supports expanding sexual health services to the hospital setting. Because STI testing practices in the hospital setting are poorly understood, we sought to describe current STI testing practices among adolescents seen in children's hospitals. METHODS We performed a retrospective analysis of adolescents (14-18 years old) from 45 children's hospitals in 2015-2016, excluding visits with a billing code for sexual abuse/assault. We calculated rates of STI testing and investigated differences in STI testing by patient and hospital characteristics using generalized linear mixed modeling. RESULTS Of the 541,714 adolescent encounters, 59,158 (10.9%) underwent STI testing. After adjusting for demographic characteristics, those with an STI test were more likely to be female (adjusted odds ratio [aOR] 1.61; 95% confidence interval [CI] 1.58-1.64), of non-Hispanic black race/ethnicity (aOR 1.20; 95% CI 1.17-1.23), or from the lowest median household income quartile (aOR 1.21; 95% CI 1.17-1.24). There was substantial inter-hospital variation in adjusted rates of STI testing (3%-24%), but strong correlation was observed between STI testing rates in the ED and inpatient settings within individual hospitals (adjusted R2 .99). CONCLUSIONS Only one in ten adolescents seen in children's hospitals underwent STI testing with wide variation in testing patterns across hospitals. There are critical opportunities to increase adolescent STI testing in this setting. Our findings highlight potential disparities in STI testing rates and patterns that warrant further exploration from the patient, provider, and health system perspective.
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Affiliation(s)
- Abbey R. Masonbrink
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Troy Richardson
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA,Children’s Hospital Association, 16011 College Blvd., Suite 250, Lenexa, KS 66219, USA
| | - Russell J McCulloh
- Department of Pediatrics, Children’s Hospital & Medical Center, 8200 Dodge Street, Omaha, Nebraska 68114, USA,Division of Emergency Medicine, Children’s National Medical Center, 2141 K St NW, Washington DC 20037, USA,Affiliation at the time work was completed: Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Matt Hall
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA,Children’s Hospital Association, 16011 College Blvd., Suite 250, Lenexa, KS 66219, USA
| | - Jessica L. Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Jacqueline M. Walker
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Matthew B. Johnson
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Mary Ann Queen
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO 2401 Gilham Rd, Kansas City MO 64108, USA
| | - Monika K. Goyal
- Division of Emergency Medicine, Children’s National Medical Center, 2141 K St NW, Washington DC 20037, USA
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Blackwell CW. Preventing HIV Infection in High-Risk Adolescents Using Preexposure Prophylaxis (PrEP). J Assoc Nurses AIDS Care 2018; 29:770-774. [PMID: 30146018 DOI: 10.1016/j.jana.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/04/2018] [Indexed: 11/29/2022]
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Affiliation(s)
- Carly E Guss
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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