Preventive care for adolescents: few get visits and fewer get services

Examining provider anticipatory guidance for adolescents' preventive health: A latent class approach

BACKGROUND

Low rates of anticipatory guidance (AG) are reported across studies with adolescents, and little is known about how these conversations differ across early versus middle adolescence. This study explored adolescent-provider AG conversations for preventive health skills; the study objectives were to (1) identify patterns of provider-adolescent AG conversations across early and middle adolescence and (2) determine socio-demographic characteristics associated with these AG conversations.

DESIGN AND METHOD

Data from the 2019 National Survey of Children's Health were used to identify patterns of provider-adolescent AG conversations. The sample included 5500 early and 6730 middle adolescents (Mage = 14.67 years old, SD = 1.71, 51.7% boys, 79% White). Multiple group latent class analysis and multinomial regressions were estimated using four indicators of AG conversations (i.e., skills to manage health and healthcare, changes in healthcare that happen at 18, making positive choices about health, and receiving a medical history summary).

RESULTS

Three types of AG conversations were identified: high AG, low AG, and parent unaware. Among early and middle adolescents, adolescents that were older, girls, had private health insurance, and a personal provider were less likely to receive high AG compared to other types of AG.

CONCLUSIONS

Policies and strategies to engage adolescents in AG conversations during and outside of the medical appointment are needed.

PRACTICE IMPLICATIONS

Tools, such as brief screeners, can be used to ensure all adolescents are receiving high AG. School-based health centers, community centers and organizations, and telehealth appointments with medical professionals may be additional opportunities for adolescents to receive AG.

Current Inpatient Screening Practices for Sexual History and STIs: An Opportunity to Seize

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.

Adolescent Healthcare Access: A Qualitative Study of Provider Perspectives

INTRODUCTION

Adolescent access to quality healthcare is key to prevention and early intervention for health risk behaviors. This paper provides a healthcare provider perspective on barriers and facilitators to youth accessing care.

METHODS

Five focus groups were conducted from November to December 2020 with providers from a variety of healthcare settings. Participants were asked to describe their respective adolescent patient populations, adolescent-specific health concerns, and organizational accommodations specific for youth services. Transcripts were analyzed using Inductive Thematic Analysis and themes were grouped using a social-ecological framework.

RESULTS

At an individual level, providers noted that an adolescent's knowledge and ability to navigate services varied greatly across settings. Providers identified provider trust and parent/guardian support as key interpersonal factors that support adolescents' access to services. Organizational factors included bureaucratic barriers and the clinic's reputation among youth. Community factors centered on mistrust within healthcare systems and stigmatization of seeking certain types of services. Participants also described how state-level policies influence parent/guardian consent requirements, which can limit adolescents' access to care.

CONCLUSION

Adolescent access to and utilization of healthcare in the United States is a complex problem requiring systems-level change. Healthcare organizations and providers have the opportunity and capacity to positively influence adolescents' healthcare access and experiences, however a lack of standardized, clinic-level priorities and guidelines can limit adolescent-centered care.

A qualitative assessment of adolescent perspectives on patient education in the outpatient setting

Objective

To explore adolescent perspectives on the content and delivery of anticipatory guidance (AG), both during and after outpatient visits, in order to develop targeted resources and educational material for adolescent patients.

Methods

Semi-structured phone interviews among patients ages 12 to 21 seen between May-July 2021 at four outpatient sites of NewYork Presbyterian Hospital were recorded, transcribed and analyzed using thematic analysis. Content domains included attitudes toward and preferences around AG, discharge instructions and patient education resources.

Results

Twenty-eight of 156 recruited patients completed interviews; 52% received an After Visit Summary (AVS); of the 48% who did not receive it, half of them expressed interest in receiving one. Themes included positive perceptions of the AVS, patient-physician communication, multimodal delivery of educational materials, and critical discussion topics such as mental health and nutrition.

Conclusion

Adolescents value the AVS and prefer multimodal materials and topics that are specifically geared towards them, rather than their caregivers.

Innovation

This study is the first to explore adolescent perspectives on AG and after-visit informational materials. These findings may help more effectively reach, educate and engage adolescent patients in the primary care setting by guiding the focused development of patient-centered instructions and resources.

The Development of a Systems-Level Approach to Address Adolescent Access to Health Care: A Novel Confidentiality Policy Intervention

Most evidence-based interventions in adolescent sexual and reproductive health and mental health remain largely aimed at individual-level outcomes and do not conceptualize adolescent health within a social-ecological model. Interventions to affect policy, systems, and environmental change offer potential for sustained population impact. The current initiative used an innovation framework to develop a novel systems-level approach to address adolescent access to health care. The Framework for Public Health Innovation provided an approach to develop a novel intervention. Confident Teen is a systems-level intervention that creates the opportunity, through organizational policy change, to increase adolescents' access to confidential sexual and reproductive health services through organizational policies. Gaps in adolescents' access to health care services allowed for a systems-level approach to be designed through an adolescent pregnancy prevention innovation initiative. Confidentiality is a right and critical component to their health care; therefore, a policy and conversation between provider and patient is a prioritized component of the novel intervention.

Patients' comfort with and receipt of health risk assessments during routine dental visits: Results from the South Atlantic region of the US National Dental Practice-Based Research Network

OBJECTIVES

To understand patients' comfort with health risk assessments (HRAs) and patient and dentist factors associated with the provision of HRAs.

METHODS

In this cross-sectional study, 857 patients seen by 30 dental practitioners in the United States National Dental Practice-Based Research Network reported their comfort receiving HRA for six risk factors (tobacco use, alcohol use, dietary sugar intake, human immunodeficiency virus risks, human papillomavirus risks and existing medical conditions) and whether they discussed any of the risk factors during their visits. Multi-level logistic models were used to examine the impacts of patient, practitioner, practice characteristics on the (1) number of risk factors patients were comfortable discussing and (2) number of risk factors assessed in the current dental visit.

RESULTS

Only a small percentage (4%) of patients reported being uncomfortable receiving any HRA during their dental visits. However, over half of the patients (53%) reported that they did not receive any HRAs during the current visit. In the regression analyses, patients who were older, male and from the suburban were more likely to be comfortable with more HRAs. Dentists were more likely to provide HRA if they were younger, not non-Hispanic white, less likely to feel that providing HRAs was beyond their scope of practice, yet more likely to feel occasional discomfort in providing HRA.

CONCLUSIONS

Interventions should focus on reducing dental practitioner perception that conducting HRAs is beyond their scope of practice and standardizing screening assessments for multiple risk factors.

Feasibility of using an app-based coaching intervention to improve provider communication about HPV vaccination

Provider communication training is effective for increasing HPV vaccination rates among U.S. adolescents. However, such trainings often rely on in-person meetings, which can be burdensome for providers and costly to implement. To evaluate the feasibility of Checkup Coach, an app-based coaching intervention, to improve provider communication about HPV vaccination. In 2021, we offered Checkup Coach to providers in 7 primary care clinics in a large integrated delivery system. Participating providers (n = 19) attended a 1-h interactive virtual workshop that taught 5 high-quality practices for recommending HPV vaccination. Providers then had 3 months of access to our mobile app, which offered ongoing communication assessments, tailored tips for addressing parents' concerns, and a dashboard of their clinic's HPV vaccination coverage. Online surveys assessed pre-/post-intervention changes in providers' perceptions and communication behaviors. Compared to baseline, more providers reported high-quality HPV vaccine recommendation practices at 3-month follow-up (47% vs. 74%, p < .05). Providers' knowledge, self-efficacy, and shared commitment to improving HPV vaccination also improved (all p < .05). Although we found improvements in several other cognitions after the workshop, these changes did not retain statistical significance at 3 months. About three-quarters (78%) of providers used the mobile app, logging 2.3 sessions on average. Most providers agreed the app was easy to use (mean = 4.7/5.0), a convenient way to get vaccination data (mean = 4.6/5.0), and a tool they would recommend (mean = 4.3/5.0). Our app-based coaching intervention demonstrated feasibility and warrants additional evaluation as a novel mode for training providers to improve their HPV vaccine communication.

Perceived Barriers and Use of Evidence-Based Practices for Adolescent HPV Vaccination among East Texas Providers

Adolescents living in rural areas are less likely to be up to date on the human papillomavirus (HPV) vaccine, which can prevent cervical cancer. We administered a telephone survey to 27 clinics in rural East Texas to assess perceived barriers to HPV vaccination and current use of evidence-based interventions to promote HPV vaccination. Perceived barriers were assessed using a 5-point Likert scale and clinical implementation of evidence-based practices was determined. Findings are reported using descriptive statistics. The most commonly reported barriers were missed vaccination opportunities due to the pandemic (66.7%), followed by vaccine hesitancy due to the pandemic (44.4%) and due to the HPV vaccine specifically (33.3%). Fewer than a third of clinics reported using the evidence-based strategies of use of a “refusal to vaccinate” form (29.6%), having an identified HPV vaccine champion (29.6%), and recommending the HPV vaccine at age 9 (22.2%). While many clinics surveyed currently implement evidence-based practices to promote HPV vaccination, there is a need and desire for additional HPV vaccination interventions in East Texas clinics.

Effect of Outreach Messages on Adolescent Well-Child Visits and Coronavirus Disease 2019 Vaccine Rates: A Randomized, Controlled Trial

OBJECTIVE

To determine effectiveness of text/telephone outreach messages, with and without coronavirus disease 2019 (COVID-19) vaccine information.

STUDY DESIGN

We conducted an intent-to-treat, multiarm, randomized clinical trial with adolescents aged 12-17 years. Eligible patients did not have an adolescent well-care visit in the past year or scheduled in the next 45 days or an active electronic health record portal account. We randomized participants to the standard message, COVID-19 vaccine message, or no message (control) group and delivered 2 text messages or telephone calls (per family preference) to the message groups. The primary outcome was adolescent well-care visit completion within 8 weeks, and secondary outcomes were adolescent well-care visit scheduled within 2 weeks and receiving COVID-19 vaccine within 8 weeks.

RESULTS

We randomized 1235 adolescents (mean age, 14 ± 1.5 years; 51.6% male; 76.7% Black; 4.1% Hispanic/Latinx; 88.3% publicly insured). The standard message group had higher odds of scheduling an adolescent well-care visit compared with the control group (OR, 2.07; 95% CI, 1.21-3.52) and COVID-19 vaccine message group (OR, 1.66; 95% CI, 1.00-2.74). The odds of completing an adolescent well-care visit did not differ significantly (standard message group vs control group; OR, 1.35; 95% CI, 0.88-2.06; COVID-19 vaccine message group vs control group, OR, 1.33; 95% CI, 0.87-2.03). In per-protocol analyses, adolescents in the standard message group were twice as likely as the control group to receive the COVID-19 vaccine (OR, 2.48; 95% CI, 1.05-5.86).

CONCLUSIONS

Outreach messages were minimally effective. Efforts are needed to address widening disparities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT04904744.

After "The Talk": Adolescents' Perspectives Reveal Need for Improvement in Hospital Sexual Health Care Delivery

OBJECTIVES

To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents' perception of SRH conversations with hospital providers and the extent to which they were helpful.

METHODS

Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children's hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history.

RESULTS

Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14-16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms.

CONCLUSIONS

Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial

Introduction: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED). Methods: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors. Results: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02). Conclusion: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents’ perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

Adolescent Perceptions of Technology-Based Sexual and Reproductive Health Services: A Systematic Review

Technology-based services, including telehealth, text messaging, and the internet are increasingly popular methods for adolescents and young adults (AYA) to access sexual and reproductive health (SRH) information and healthcare. This systematic review examined AYA perceptions of privacy and confidentiality of technology-based SRH services. The PubMed, Scopus, and PsycINFO were systematically searched in May 2021 to capture relevant qualitative or quantitative articles from the past 10 years. Included studies had AYA (i.e., mean age, 13-26-years with <10% of the sample outside this range), technology-based services for SRH, and outcomes of perceived privacy or confidentiality. Twenty-eight articles were included (N = 8638 AYA). Most studies utilized the internet and mobile apps to address human immunodeficiency virus infection (HIV), sexually transmitted infections, and general SRH topics. Most AYA reported that these services were private and confidential, with minimal differences across SRH topic addressed. More interactive services had greater concerns (e.g., family or friends seeing notifications). Most AYA considered technology-based SRH to be confidential and private. As technology will likely remain an integrated part of healthcare delivery, improving the privacy and confidentiality of these services can facilitate AYA's independent and autonomous engagement in SRH care, and potentially improve their SRH outcomes.

Closing the Equity Gap: An Intervention to Improve Chlamydia and Gonorrhea Testing for Adolescents and Young Adults in Primary Care

BACKGROUND

Chlamydia trachomatis and Neisseria gonorrhea are the most reported sexually transmitted infections in the United States. Testing rates remain suboptimal and may be subject to implicit bias. We evaluated the effectiveness of an opt-out chlamydia and gonorrhea testing program for adolescents and young adults in improving testing rates and promoting equity.

METHODS

An opt-out testing program that standardized testing to once annually for 14 to 24-year-old patients was implemented across 28 federally qualified health centers spanning 4 specialties. A quasi-experimental design using interrupted time series analyses evaluated testing and infection rates between baseline, intervention, and pandemic-associated test shortage periods. Reduction in testing inequities based on sex, race, ethnicity, insurance, and language preference were also examined.

RESULTS

A total of 57 452 encounters during the baseline, 17 320 during the intervention, and 26 993 during the test supply shortage periods were included. Testing increased from 66.8% to 81.0% (14.2% absolute increase) between baseline and intervention periods. Pediatric clinics demonstrated the largest improvement compared to other settings (absolute increase 30.9%). We found significant reductions in testing inequities for language preference (P < .001), and un-insured and public insured individuals (P < .001). More cases of chlamydia and gonorrhea were detected in the intervention period (chlamydia-29.7; gonorrhea-7.4 per 1000 patients) than in the baseline period (chlamydia-20.7; gonorrhea-4.4 per 1000 patients; P < .001).

CONCLUSIONS

An opt-out approach increased testing, reduced inequities between some groups and detected more infections than a risk-based approach. Opt-out testing should be considered as an approach to increase detection of chlamydia and gonorrhea and promote equity.

Provider Use of Time Alone With Adolescents: Differences by Health Concern

PURPOSE

To examine associations between reports of sensitive health behaviors and the provision of time alone by a clinician during adolescent well visits.

METHODS

Data were collected from 547 adolescents who completed a well visit at one of eight clinics. Adjusted mixed logistic regression was used to examine whether reports of sexual behavior, substance use, disordered eating, mental health concerns, and demographic characteristics were associated with time alone.

RESULTS

Sexual behavior was found to be significantly associated with time alone, while substance use, disordered eating, a positive depression screen, and suicidal ideation were not. Older adolescents and males were more likely to report time alone, while race/ethnicity had no association with time alone.

DISCUSSION

Clinicians may be prioritizing time alone for behavioral concerns differently than for other sensitive behaviors.

Impact of risk-based sexually transmitted infection screening in the emergency department

OBJECTIVES

Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents.

METHODS

We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real-time into the electronic health record. Patients who tested positive received treatment according to our standard-of-care practices. All patients 15-21 years of age were asked to complete this on an opt-out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non-English speaking. Our primary outcome was to describe STI-testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it.

RESULTS

In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. non-participants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non-participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia.

CONCLUSIONS

Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations.

Mental Health Service Provision at School-Based Health Centers During the COVID-19 Pandemic: Qualitative Findings From a National Listening Session

INTRODUCTION

School-based health centers (SBHCs) provide health services to more than six million youth annually. When schools throughout the United States closed in spring 2020, many SBHCs were also forced to close physical operations..

METHOD

This study uses qualitative data collected from SBHC representatives nationwide to examine supports and challenges affecting mental health services provision during the COVID-19 pandemic, changes in the provision of these services, and priorities for assessing and supporting student mental health needs in the 2021-2022 school year.

RESULTS

Partnerships, community and stakeholder buy-in, and student access were key supports to continuous care throughout the pandemic, whereas lack of available staff and lack of in-person access to students were key challenges. Patients demonstrated increased acuity of presenting mental health problems, more immediate and complex mental health challenges, and greater co-morbidities.

DISCUSSION

SBHCs pivoted, even with limited resources, to meet students' increasing needs for mental health care.

Professionally Created Content Related to HPV Vaccination on TikTok

Despite the protective abilities of the HPV vaccine, roughly half of adolescents in the United States have not completed the recommended HPV vaccine series. Professionals have taken to using social media platforms to encourage health behaviors such as receipt of the HPV vaccine. As such, the purpose of this study was to identify content created by professionals related to HPV on TikTok. This descriptive, cross-sectional study was conducted in January 2022 using the hashtag #HPV Vaccine to examine the 100 English language videos created by people who claimed to be health professionals. In addition to capturing metadata, each videos' content and subsequent comments were coded. Overall, 75.0% of the videos mentioned HPV-related cancer but few discussed vaccination as a cancer preventive measure (40.0%). More than half (52.0%) of the comments were neutral in tone and most focused on cancer (54.0%), alternative medicine (58.0%), and general questions about vaccination (62.0%). Comments about videos with greater numbers of “likes” more often mentioned cancer (85.0% vs. 46.3%, p = 0.002), the age at which to get vaccinated (70.0% vs. 41.3%, p = 0.02) and more frequently posed questions about vaccination (80.0% vs. 41.3%, p = 0.002) and cost and insurance coverage of vaccination (35.0% vs. 11.3%, p = 0.02) compared to videos with fewer “likes.” The power of provider information is paramount with HPV vaccine uptake. As providers increasingly create health messages on platforms such as TikTok, it is important that they remain aware of the potential for opposing or non-factual discourse.

Improving Sexually Transmitted Infection Screening in Inpatient Pediatric Patients

BACKGROUND

Sexually transmitted infections (STIs) are a group of infectious diseases that cause acute illness and lifelong health effects. Half of the diagnosed cases occur in adolescents and young adults, ages 15 to 24. The American Academy of Pediatrics and the Centers for Disease Control and Prevention provide guidelines for STI screening for sexually active adolescents. Despite this, screening rates in adolescents admitted to our hospital are low. The purpose of this study is to use quality improvement methodology to improve the percent of adolescent patients who had documentation of sexual histories from 49% to 69% and STI testing from 29% to 49%.

METHODS

Eligible patients included adolescents ages 14 to 18 admitted to our hospital's academic general pediatric service. After baseline data collection, we introduced a series of 6 interventions; percentages of sexual history documentation and STI screening were recorded monthly. Interventions included resident education on STI screening, history, and physical form prompts for sexual history documentation, "badge buddy" sexual history templates, faculty development, and an electronic medical record template. Data were interpreted by using statistical process control to show process change.

RESULTS

Before the interventions, 48.7% of patients ages 14 to 18 had sexual histories documented; 29.1% of patients were tested for STIs. After interventions, there was a special cause variation resulting in new center lines of 67.1% and 49.1%, respectively.

CONCLUSIONS

Simple interventions to normalize and standardize adolescent sexual history discussions cumulatively led to a significant increase in sexual history documentation and STI screening in an inpatient adolescent population.

The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments

Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.

Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

Adolescents' health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs

PURPOSE

Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians.

METHODS

We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers.

RESULTS

SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs.

CONCLUSIONS

Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

Adolescent and Parent Perceptions of Telehealth Visits: A Mixed-Methods Study

PURPOSE

Telehealth presents unique benefits and challenges for adolescents and their parents. This study aimed to explore adolescent and parent perceptions of privacy, confidentiality, and therapeutic alliance during telehealth video visits.

METHODS

This was a cross-sectional convergent parallel mixed-methods study. English-speaking parents and 13- to 17-year-old adolescents who completed a video visit at eight academic-affiliated pediatric primary care practices in the Southeastern U.S. were recruited between September 2020 and January 2021. Online surveys were administered and analyzed using descriptive and bivariable analysis. Subsequent semi-structured qualitative interviews were conducted and analyzed using thematic analysis.

RESULTS

Forty-eight adolescents and 104 parents completed surveys. Fourteen adolescents and 20 parents were interviewed. Mean ages of adolescents and parents were 15 and 46 years, respectively, and most participants identified as female, non-Hispanic, and white. Seventy-seven percent of adolescents reported very private telehealth visits. Most privacy concerns were related to the location of the visit in the patient's home or family members overhearing. Adolescents reported that alone time with their provider increased comfort in discussing sensitive issues, although only 31% of adolescents reported having time alone with their provider during their telehealth visit. Neither adolescents nor parents reported concerns about confidentiality. Interviews suggested that adolescent autonomy and independence in accessing health care may explain the positive relationship observed between therapeutic alliance and privacy.

CONCLUSIONS

Adolescents and parents describe telehealth as convenient, useful, private, and confidential. Providers should strive to maximize privacy and the therapeutic alliance during video visits, including encouraging alone time and supporting adolescent autonomy and independence.

Measuring the quality of dental care among privately insured children in the United States

OBJECTIVE

To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns.

DATA SOURCE

Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019.

STUDY DESIGN

A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality.

DATA COLLECTION/EXTRACTION METHODS

Continuously enrolled US dental insurance beneficiaries younger than 21 years of age.

PRINCIPAL FINDINGS

Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score.

CONCLUSION

Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Electronic Screening, Feedback, and Clinician Training in Adolescent Primary Care: A Stepped-Wedge Cluster Randomized Trial

PURPOSE

The aim of this study is to test the effects of an electronic screening and feedback tool and training for primary care clinicians on care and adolescent health behaviors.

METHODS

We conducted a stepped-wedge cluster randomized trial with six clinics randomly assigned to sequential crossover from control to intervention periods with clinician training between periods. Adolescents (ages 13-18) with a well visit during the control periods (n = 135) received usual care, while adolescents during the intervention periods (n = 167) received the electronic screening and feedback tool prior to their well visit, with results sent to their clinicians. Adolescents completed surveys at baseline, 1 day, 3 months, 6 months, and 12 months. Linear mixed effects models were used to examine associations between outcomes and treatment, controlling for time as a fixed effect and clinic as a random effect. All analyses employed intent-to-treat analyses and utilized multiple imputations for missing data.

RESULTS

Adolescents who received the intervention had a higher rate of counseling for their endorsed risk behaviors during the well visit (45% vs. 33%, Wald's T = 2.29, p = .02). There were no significant intervention effects on adolescent satisfaction with the clinician or perception of patient centeredness. The intervention was associated with a small but statistically significant reduction in overall risk score relative to control at 3 months (-.63, 95% confidence interval [-1.07, -.19], Cohen's d = .21), but not at 6 or 12 months.

CONCLUSIONS

The results suggest that electronic screening and feedback may be associated with small reductions in risk behaviors at 3 months but that changes do not persist at longer term follow-up.

Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care

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.

State-Level Managed Care Penetration in Medicaid and Rates of Preventive Care Visits for Children

OBJECTIVE

To examine time trends in receipt of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services in serial cohorts of Medicaid beneficiaries <21 years, as Medicaid managed care (MMC) was adopted by states.

METHODS

Using annual state-level data from the Centers for Medicare & Medicaid Services, we performed national analyses of Medicaid beneficiaries <21 years from 2000 to 2017. We used generalized linear models to assess the relationship between MMC enrollment and EPSDT encounters, accounting for repeated measures, first at the national level overall and then specifying random effects at the state level.

RESULTS

From 2000 to 2017, there was an increase at the national level in Medicaid beneficiaries <21 years enrolled in MMC, from 65% to 94%. At the national level, for every additional 100 enrollees in MMC there was an associated increase of 36 beneficiaries with an EPSDT visit (95% confidence interval: 19-53; P < .001). When accounting for state-level variation, for every additional 100 enrollees in MMC, there was an increase of 6 beneficiaries with an EPSDT visit (95% confidence interval: 2-10; P = .003). Examining the association between MMC penetration and EPSDT participation within each state, including the 50 states and Washington DC, there were 17 states with a significant positive association between MMC ratio and EPSDT participation, and 6 states with a significant negative association.

CONCLUSIONS

As managed care has become the predominant form of Medicaid coverage, there has been a modest increase in preventive visits as indicated by EPSDT participation, with marked variation across states.

Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment.

OBJECTIVE

To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools.

INTERVENTIONS

In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9.

MAIN OUTCOMES AND MEASURES

The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year.

RESULTS

A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03716869.

An Intervention to Improve Chlamydia and Gonorrhea Testing Among Adolescents in Primary Care

BACKGROUND AND OBJECTIVES

Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system.

METHODS

A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment.

RESULTS

In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic.

CONCLUSIONS

Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .

Sexual Health Behaviors and Pregnancy Risk Among Hospitalized Female Adolescents

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.

Incomplete Records as a Leading Cause of Missed Opportunity for Human Papillomavirus Vaccine Initiation in a Safety Net Health System

OBJECTIVE

The goal of this study was to categorize reasons behind missed opportunities for human papillomavirus (HPV) vaccine initiation in an under-resourced population and to identify associated patient and clinic characteristics.

METHODS

Manual chart review was performed for patients aged 11 to 18 years who visited a primary care clinic in a health system in Texas, USA between 06/01/18 and 08/31/18 and were due for an initial HPV vaccine dose but did not receive it. Reasons for HPV vaccine noninitiation were categorized as follows: incomplete immunization record, no documentation of discussion (no documentation that the HPV vaccine was offered or ordered), refusal, staff/provider error, and medical. Multinomial logistic regression was used to examine factors associated with each category.

RESULTS

Of 4467 adolescents seen in the study period, 575 (12.9%) were due for the first dose of HPV vaccine but did not receive it. The most common reason for noninitiation was incomplete immunization record (37%), followed by no documentation of discussion (24%), refusal (20%), staff/provider error (15%), and medical (4%). The highest odds of incomplete immunization were among older adolescents. The highest odds of no documentation of discussion were during sick visits. The highest odds of staff/provider error were among patients with commercial insurance. The lowest odds of refusal were in patients with county/indigent insurance.

CONCLUSIONS

The most common reason for missed opportunity visits for HPV vaccine initiation was lack of adequate immunization records. Our study highlights the importance of immunization record access and bidirectional reporting as important targets for future interventions.

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.

Social-Ecological Barriers to Access to Healthcare for Adolescents: A Scoping Review

Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.

Adolescent Risk Behavior Screening and Interventions in Hospital Settings: A Scoping Review

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.

In Their Own Words: Resources Needed by School Nurses to Facilitate Student Immunization Compliance

BACKGROUND

All 50 states have school-entry immunization requirements, and many also allow exemptions based on medical and non-medical reasons. School nurses are responsible for managing student immunization compliance based on state policies, but lack standardized resources and guidance.

METHODS

Pennsylvania school nurses (N = 21) participated in semi-structured interviews regarding their strategies for communication and management of student immunization information, along with resources needed for practice improvement. Data were analyzed using descriptive content analysis.

RESULTS

Nurses reported similarities in timelines used for communication of immunization requirements, but differences in mechanisms used to secure and manage immunization records. Nurses reported a need for clarity regarding exclusions and exemption policy implementation and requested standardized resources and guidance for navigating immunization compliance.

CONCLUSIONS

A need exists for standardized processes that support immunization compliance. Furthermore, nurses highlighted a need for additional training and enhanced networks to develop creative strategies for promoting immunization uptake among families.

Perspectives of Urban Adolescent Black Males and Their Parents on Well Care

OBJECTIVE

Adolescents have fewer well-care visits than all other age groups. Males and ethnic minorities are seen least often. We elicited from Black adolescent males and their parents key drivers of teen well-care seeking.

METHODS

We conducted separate semistructured interviews with Black adolescent males and their parents. We recruited parent-teen dyads from West Philadelphia. Eligible teens were age 13 to 18, with no complex chronic health conditions. We purposively sampled teens who had not received preventive care in at least 2 years, some of whom had since returned to care and some not. Interviews were recorded, transcribed, and coded by 2 coders using the constant comparative method, resolving discrepancies by consensus. Interviews continued until thematic saturation.

RESULTS

We interviewed 23 Black adolescent males (mean age 15) and 22 parents (20 mothers). Participants understood that teens should routinely receive preventive care. Four themes emerged: receiving preventive care is important to knowing teens are mentally and physically well; remembering to schedule/attend visits is challenging - participants find appointment reminders helpful; mothers noted that males of all ages are generally disengaged from health care; teens and parents felt that a "good" parent ensures teens receive preventive care.

CONCLUSIONS

Black adolescent males and their parents value regular preventive care as an opportunity to ensure the teen is physically and mentally well, but competing priorities interfere with care receipt. Results support testing the impact of reminders on receipt of care in this population. These reminders may be most effective if directed at mothers and focused on "good parenting."

High-risk Behavior Screening and Interventions in Hospitalized Adolescents

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.

Did You Get My Snap? Snapchat as a Health Education Tool for Hospitalized Adolescents

PURPOSE

Given the popularity of Snapchat with teens, we used this tool to disseminate reproductive health information to adolescent patients.

METHODS

We developed a unique Snapcode linked to educational materials located on a cloud service and accessible via the Snapchat app. The Snapcode was printed on a business card and distributed to hospitalized adolescents. We tracked card distribution and how often the materials were accessed through our cloud service and through Snapchat.

RESULTS

A total of 236 cards were distributed to teens with 117 unique scans and 122 views of the PDF. Of the teens who received the card (N = 236), 49.5% of teens used the Snapcode to access reproductive health education.

CONCLUSIONS

Snapchat is a promising way to distribute educational materials to adolescents in a discrete manner on a platform many teens use. This mechanism demonstrates a way for providers to use Snapchat as a tool to provide education to hospitalized adolescents.

Monitoring Adolescents' Receipt of Time Alone From Two National Surveys

PURPOSE

Despite professional endorsement and research supporting time alone with a clinician for adolescents, low rates and disparities persist. The purpose of the present analysis was to provide detailed monitoring of time alone estimates in two national surveys that assess time alone for adolescents aged 12-17 years: the National Survey of Children's Health (NSCH) and the Medical Expenditure Panel Survey (MEPS).

METHODS

Time alone assessments in the NSCH and the MEPS have different definitions. The NSCH assessed time alone within the most recent preventive visit, and the MEPS assessed it within the most recent health care visit. We analyzed these within the subsample of 12- to 17-year-olds who had any past-year preventive visit: MEPS 2016-2017, n = 2,689; and NSCH 2016-2017, n = 24,085. We developed time alone estimates for full and subgroup samples and conducted multivariable logistic regressions to determine differences by age, sex, race/ethnicity, income, insurance, and region.

RESULTS

Overall time alone receipt was 49% (NSCH) and 29% (MEPS). Overall rates are not comparable because their definitions differ. Some subgroup differences were similar across datasets: younger adolescents (p < .01) and females (p < .05) had lower rates.

CONCLUSIONS

Among adolescents with a past-year preventive visit, time alone rates are low. Lower rates for females versus males and younger versus older adolescents persist. Detailed monitoring results can help to shape promising strategies including clinic-based interventions, such as provider training and educating parents, in efforts to improve the provision of time alone in clinical practice.

Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department

PURPOSE

Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings.

METHODS

This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED.

RESULTS

Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01).

CONCLUSIONS

A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.

Results of a National Text Message Poll of Youth: Perspectives on Primary Care

PURPOSE

There is a significant interest in improving adolescent access to primary care, yet limited attempts to incorporate youth feedback within these efforts. The purpose of this study was to describe the experiences related to primary care among a large national sample of adolescents to improve patient-centered care.

METHODS

Youth were sent open-ended text message prompts via an ongoing study of 14- to 24-year-olds in the U.S. Text responses were analyzed using qualitative thematic analysis, including descriptive coding, consensus building, and theme development. Secondary quantitative analyses were conducted to determine differences by demographics.

RESULTS

Of 1,123 eligible participants, 789 (70.2%) responded to at least one prompt. Four themes were developed: (1) youth recognized the importance of primary care, but barriers exist that limited their utilization; (2) youth felt that improving convenience would increase the use of primary care; (3) youth were unsure how to transition between primary care settings; and (4) feeling respected was essential to youth having positive experiences in a primary care health care setting. Older youth and those identifying as female, nonbinary, or transgender were more likely to report previous bad experiences with primary care.

CONCLUSIONS

Our findings describe barriers and possible solutions to primary care among youth. Because attitudes toward health and health care are established during adolescence, a transformation is needed to create more patient-centered care that aligns with young people's values and experiences. Thus, primary care providers have the opportunity to positively impact the health of young people today and the adults of the future.

Missed Opportunities for Discussing Contraception in Adolescent Primary Care

BACKGROUND

Over half of adolescents are sexually active by age 18 years and represent half of sexually transmitted infections (STI). These individuals often do not obtain routine medical care, so discussing contraception at each visit becomes imperative. Our study objectives were to determine the frequency of visits before contraception was discussed/initiated, and to assess factors affecting primary care contraception provision.

METHODS

A retrospective chart review (January 2009-June 2019) was conducted for preventive, follow-up, and sick visits; Title X confidential visits were excluded. Questions were asked about method at start and end of the visit. Nonparametric median tests for continuous variables and chi-squared tests for categorical variables assessed for differences for patient age, race, gender, insurance type, visit type, and provider gender. The institutional review board approved the study as exempt.

RESULTS

Patients (n = 12,619; median = 15 years; 58% female) were seen in primary care clinic. Providers asked about contraception for 82% of visits, and averaged 3 visits before contraception was discussed. For patients asked about contraception, 60% were using a contraceptive method, 15% left the visit on a new method (24.9% long-acting reversible contraception [LARC]). For patients not using contraception, 39.9% left the visit on a method. Patients asked about contraception were female, older, Hispanic, had public insurance, and were seen by female providers (P < .001). Follow-up/sick visits represented <20% of patients asked about contraception.

CONCLUSIONS

Multiple visits occur before contraception is discussed in adolescent primary care, and factors including age, race, and gender affect these discussions. Strategies to increase contraception discussions at all visits is essential, as adolescents do not always present for yearly visits.

Pediatric Nurse Practitioners' Perspectives on Engaging Adolescents to Shift from Pediatric to Adolescent-Focused Health Care Services

INTRODUCTION

This study examined the perspectives of pediatric nurse practitioners (PNPs) on the shift from pediatric to adolescent-focused health care services (HCS). This movement coincides with the early stages of the health care transition process.

METHOD

Conference attendees (N = 170) participated in a discussion on the shift from pediatric to adolescent-focused HCS. A secondary analysis was conducted. Data were analyzed for themes using content analysis.

RESULTS

Confidentiality was found to be a foundational aspect of adolescent-focused HCS. Two additional themes described adolescent-focused HCS characteristics and the role of the PNP in providing education and empowerment for adolescents and parents throughout this process.

DISCUSSION

PNPs provide critical leadership in facilitating the shift to adolescent-focused care by providing HCS designed to support confidentiality, respond to the needs of adolescents, and offer education to empower adolescents and parents on the importance of adolescent-focused care and engagement in the overall health care transition process.

Reducing Missed Opportunities for Human Papillomavirus Vaccination in School-Based Health Centers: Impact of an Intervention

OBJECTIVE

Human papillomavirus (HPV) immunization rates among US adolescents are low. Missed opportunities (MOs) for HPV vaccination are common. School-based health centers (SBHCs) have potential to boost HPV vaccination, but their role in addressing MOs has not been examined.

METHODS

We implemented a multicomponent intervention, consisting of 3 immunization process workflow modifications combined with provider performance feedback, in 2 Los Angeles area SBHCs and conducted a pre/post evaluation of MOs. Our primary outcome was SBHC-based MOs for HPV vaccination during all visits, including visits for confidential reproductive health care (ie, confidential visits). Secondary outcomes were MOs for meningococcal (MenACWY) and influenza vaccination during visits for nonconfidential care.

RESULTS

MOs for HPV vaccination decreased during all visit types from the baseline to the intervention period (82.3% to 46.1%; adjusted risk ratio [RR] = 0.558, P < .0001). The rate decrease appeared to be greater during physical examination visits than confidential visits (83.4% to 31.6% vs 98.7% to 70.4%, respectively). MOs for MenACWY (74.5% to 35.0%; adjusted RR = 0.47, P < .0001) and influenza (86.7% to 69.3%; adjusted RR = 0.792, P < .0001) vaccination also decreased during nonconfidential visits. Vaccine refusal was the most frequently documented reason for HPV vaccine MOs during both physical examination and confidential visits.

CONCLUSIONS

A pragmatic, multicomponent SBHC intervention reduced MOs for HPV vaccination during all visit types. MOs for MenACWY and influenza vaccination also decreased during nonconfidential visits. Findings suggest that practice-level improvements in SBHCs can improve delivery of HPV and other adolescent vaccines.

Primary Care Use and Assessment of Adolescents' Sexual Health During Hospitalization

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.

Prevalence of and Factors Associated With Receiving a Pelvic Examination or Pap Testing Under the Age of 21 Years

PURPOSE

Current guidelines recommend that individuals receive their first Pap test at age 21 years and only receive a pelvic examination before age 21 years for clinical indications. We sought to determine the prevalence and associated covariates of receiving a pelvic examination or Pap test before 21 years of age.

METHODS

We analyzed the 2013-2015 National Survey of Family Growth. We conducted bivariate analyses comparing individuals who had and had not had a pelvic examination or Pap test and multivariable logistic regression to identify factors associated with having a pelvic examination or Pap test under 21 years.

RESULTS

This study included 1,170 individuals. Of respondents, 30.8% received a pelvic examination and 25.1% received a Pap test before 21 years of age. Receiving a pelvic examination was associated with being sexually active (adjusted odds ratio [aOR]: 6.6, 95% confidence interval [CI]: 3.8-11.7), having ever taken contraceptive pills (aOR: 2.6, 95% CI: 1.6-4.1) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 12.6, 95% CI: 7.3-21.8). Receiving a Pap test was also associated being sexually active (aOR: 7.2, 95% CI: 3.7-14.0), having ever taken contraceptive pills (aOR: 3.0, 95% CI: 1.9-4.7) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 8.94, 95% CI: 5.12-15.61).

CONCLUSIONS

Contrary to contemporary guidelines, a notable proportion of individuals under the age of 21 years continues to receive pelvic examinations and Pap testing.

Adolescent Attitudes Toward Sexually Transmitted Infection Screening in the Emergency Department

OBJECTIVES

Adolescents who seek care in emergency departments (EDs) are often at high risk for sexually transmitted infections (STIs). The objective of this study was to assess adolescent attitudes toward ED-based STI screening.

METHODS

We conducted a secondary analysis of a cross-sectional study that evaluated STI screening acceptability and prevalence when STI testing was universally offered to asymptomatic adolescents presenting to the ED for care. Adolescents 14 to 21 years old completed a computerized survey and answered questions regarding attitudes toward ED-based STI screening and sexual behavior. We performed multivariable logistic regression to compare differences in attitudes toward ED-based STI screening among patients who agreed versus declined STI testing.

RESULTS

Of 553 adolescents, 326 (59.0%) agreed to be tested for STIs. Most (72.1%) believed the ED was an appropriate place for STI screening. Patients who agreed to be tested for STIs were more likely to positively endorse ED-based STI screening than those who declined STI testing [77.0% vs 64.8%; adjusted odds ratios, 1.6; 95% confidence interval (CI), 1.1-2.4]. Most (82.6%) patients stated they would feel comfortable getting tested for STIs in the ED. There was no difference in the comfort level of ED-based STI testing between those who agreed and declined STI testing (83.5% vs 81.4%; adjusted odds ratios, 1.1; 95% CI, 0.7-1.8).

CONCLUSION

Our results suggest that adolescents view the ED as an acceptable location for STI screening. Therefore, the ED may serve a role in increasing the accessibility of STI detection and prevention resources for adolescents.