HIV/Pre-Exposure Prophylaxis Knowledge and Acceptability of Rapid HIV Testing Among Transgender Adolescents in a Multidisciplinary Gender Clinic

Purpose

The objectives of this study were to assess the knowledge of HIV and pre-exposure prophylaxis (PrEP) in transgender adolescents and young adults (AYAs) and to test the acceptability of rapid HIV testing among transgender adolescents in a multidisciplinary gender clinic.

Methods

Participants enrolled on the same day as their mental health or medical appointment in a multidisciplinary gender clinic. They completed survey questions regarding HIV and PrEP knowledge and were also offered an optional same-day, rapid, fourth-generation HIV test. Participants who had an HIV test answered additional questions about their testing experience.

Results

We enrolled 61 participants; just over half (n=31) were assigned female at birth. Less than a third (n=20, 32.8%) scored 80% or above regarding HIV knowledge. Nearly half of the participants (n=29, 47.5%) were not interested in PrEP. Forty-one percent of participants chose to have a rapid HIV test; all were "satisfied" with the testing experience. There were no positive HIV results.

Conclusions

Transgender AYAs have gaps in their understanding of HIV acquisition and transmission. Rapid HIV testing in the setting of gender care is well received by those who desire testing and may be a way to increase knowledge of transgender AYA HIV status.

Factors Associated With HIV Testing in Adolescent and Young Adult Females With a History of STI

To determine the percentage of female adolescent patients (13-26 years old) who had HIV testing ordered within 90 days of incident sexually transmitted infection (STI) diagnosis during an outpatient clinic visit. This was a retrospective chart review study evaluating 830 visits among 589 female patients 13 to 26 years who had an incident STI diagnosed in outpatient Adolescent Medicine or Pediatric Practices in an urban, nonprofit, academic, free-standing children's hospital at the main campus and a community site in the Northeast United States. Odds of HIV screening was greater at the community-based adolescent medicine practice (odds ratio [OR] = 3.17; 95% confidence interval [CI]: [1.92, 5.24]) and when seen by an adolescent medicine provider (OR = 1.44; 95% CI: [1.02, 2.03]). Only 33.5% (n = 283) of 844 clinical encounters had HIV screening obtained within 90 days of incident STI diagnosis. Overall, HIV screening rates within 90 days of STI diagnosis was low, and there is much room for improvement.

Primary care provider perceptions of an asthma home visiting program

INTRODUCTION

Pediatric asthma home visiting programs have improved clinical outcomes, but little is known about how providers perceive these programs. The purpose of this study was to understand how primary care providers and their colleagues in a medical home perceive an asthma home visiting program that is available at no cost to their patients.

METHODS

After several years of running an asthma home visiting program using community health workers (CHW) in 10 pediatric primary care offices in the South Coast of Massachusetts, we surveyed the providers of patients who had enrolled in the program. An anonymous online survey was developed by the program leaders, the program analytics team, and the CHWs for quality improvement purposes. Survey domains included the perceived utility of various aspects of the program, impact on patients, and interaction with CHWs, as well as demographic information about the providers.

RESULTS

Of the 24 providers asked to complete the survey from eight primary care practices, 21 completed the survey (88%). Respondents perceived that the most beneficial aspects were environmental assessment (95%), asthma education (91%), and addressing environmental issues (86%). In addition to numerous positive free-text responses, suggestions for improvement were in the areas of referral completion, post-visit communication, and patient identification in the medical record. All respondents would continue to refer to the program.

CONCLUSIONS

Primary care providers and medical home staff perceived an asthma home visiting program to have high utility, particularly the environmental assessment, asthma education, and mitigation of environmental issues. Additional opportunities for improvement were identified.

Anal dysplasia in adolescent and young adult men who have sex with men: a single-center retrospective and descriptive study (2010-2020)

Objective

There are limited studies evaluating anal cytology results or the prevalence of anal human papiloma virus in adolescent and young adult (AYA) men who have sex with men (MSM). The purpose of this study was to review anal cytology screening results and determine whether abnormal findings resulted in completion of anoscopy in AYA MSM (13-26 years old).

Patients and Methods

This was a retrospective study evaluating 84 anal Papanicolaou screening results among 36 AYA MSM patients aged 13-26 years who had an anal Papanicolaou test completed at an outpatient Adolescent/Young Adult Medicine Practice at Boston Children's Hospital, an urban, nonprofit, academic, free-standing children's hospital, from January 1, 2010, to December 31, 2020.

Results

The findings of anal Papanicolaou screening included atypical squamous cells of undetermined significance (ASCUS) (37%), negative for squamous intraepithelial lesion (31%), inability to read (21.3%), and low-grade squamous intraepithelial lesion (10.8%). Most patients who had ASCUS results were referred for anoscopy (n = 28, 90.3%), and of those referred only 6.5% (n = 2) completed an anoscopy. Of those with low-grade squamous cell intraepithelial lesion results, 88.9% (n = 8) were referred for anoscopy, and among those who were referred, only 3.3% (n = 3) had completed an anoscopy.

Conclusion

This study showed that there were abnormalities in cytology when anal Papanicolaou test screening was performed in this population, and the completion rates for anoscopy were low.

COVID-19 related familial economic disruptions and eating disorder patients' mental health concerns and motivation to recover

BACKGROUND

Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED.

METHODS

AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis.

RESULTS

Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption.

CONCLUSIONS

Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume

IMPORTANCE

The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking.

OBJECTIVE

To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data.

EXPOSURES

Onset of the COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

Monthly number of patients seeking inpatient/outpatient ED-related care.

RESULTS

Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic.

CONCLUSIONS AND RELEVANCE

In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.

Improved 10-year cost savings for patients served by the Boston Children's Hospital Community Asthma Initiative

OBJECTIVE

To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group).

METHODS

CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI).

RESULTS

There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years.

CONCLUSIONS

The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care

PURPOSE

The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms in adolescents and young adults. In order to examine COVID-19-related trends in ED care-seeking at our institution.

METHODS

We used interrupted time series regression to examine pre- and postpandemic monthly summary data of the following: (1) ED-related inpatient admissions for medical stabilization; (2) ED-related hospital bed-days; (3) completed outpatient ED assessments; and (4) ED outpatient care-related inquiries at a children's hospital in Boston, MA.

RESULTS

Inpatient admissions, hospital bed-days, and outpatient care-related inquiries increased on average over time postpandemic compared to stable volume over time prepandemic (p < .01). Outpatient assessments decreased precipitously initially following COVID-19-related limitations, and rose quickly back to baseline.

CONCLUSION

These results indicate increased need for ED-related care during the pandemic. Bolstering resources to meet the needs of these vulnerable patients is critical as the effects of the pandemic continue to be felt.

COVID-19 and eating disorder and mental health concerns in patients with eating disorders

BACKGROUND

The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery.

METHODS

Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms.

RESULTS

The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment.

CONCLUSIONS

Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic

BACKGROUND

Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors.

METHODS

AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19-specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16).

RESULTS

In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07).

CONCLUSIONS

Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multi-disciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study

BACKGROUND

Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs.

METHODS

145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression.

RESULTS

Mean (SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically significant anxiety and/or depression. Degree of malnutrition was not significantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care (p = 0.038). Patients with pre-morbid BMIs ≥75th percentile had lower depression scores than those with pre-morbid BMIs <75th percentile (p = 0.014).

CONCLUSIONS

We find high degree of clinically relevant anxiety and depression symptoms in a population of AYAs with EDs. Our findings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

Common and Emergent Oral and Gastrointestinal Manifestations of Eating Disorders

Eating disorders (EDs) such as anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder are associated with restricted diets and abnormal compensatory behaviors, frequently leading to malnutrition and oral and gastrointestinal manifestations. Dental and oral complications are generally caused by malnutrition, micro-nutrient deficiency, and chronic acid exposure; hence, treatment of the ED and frequent dental examinations are essential to reduce morbidity. Gastrointestinal manifestations are multifactorial in origin, and may be caused by disordered behaviors, malnutrition, anxiety, and/or may be a function of the ED itself. This article reviews the most common oral and gastrointestinal manifestations of EDs and describes emergent complications such as acute gastric dilation and superior mesenteric artery syndrome. It is important for providers to recognize complications associated with EDs to provide the best treatment possible.

Community Health Workers in Home Visits and Asthma Outcomes

BACKGROUND

The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family.

METHODS

A total of 389 patients enrolled under the CMS grant at Boston Children's Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales.

RESULTS

Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49-6.59]), missed school days (1.91 [1.09-3.36]), and parent and/or guardian missed workdays (2.72 [1.15-6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01).

CONCLUSIONS

The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL.

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians

OBJECTIVE

Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians.

METHOD

We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type.

RESULTS

Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ² = 9.90, df = 2, p = .007, φ_c = 0.356) and theme three (χ² = 6.42, df = 2, p = .04, φ_c = 0.287) than patients and parents.

DISCUSSION

Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

A Parenting and Life Skills Intervention for Teen Mothers: A Randomized Controlled Trial

: media-1vid110.1542/5985300176001PEDS-VA_2018-2303Video Abstract BACKGROUND: Teen mothers often present with depression, social complexity, and inadequate parenting skills. Many have rapid repeat pregnancy, which increases risk for poor outcomes. We conducted a randomized controlled trial of a parenting and life skills intervention for teen mothers aimed at impacting parenting and reproductive outcomes.

METHODS

Teen mothers were recruited from a teen-tot clinic with integrated medical care and social services. Participants were randomly assigned 1:1 to receive (1) teen-tot services plus 5 interactive parenting and life skills modules adapted from the Nurturing and Ansell-Casey Life Skills curricula, delivered by a nurse and social worker over the infant's first 15 months or (2) teen-tot services alone. A computerized questionnaire was self-administered at intake, 12, 24, and 36 months. Outcomes included maternal self-esteem, parenting attitudes associated with child maltreatment risk, maternal depression, life skills, and repeat pregnancy over a 36-month follow-up. We used generalized linear mixed modeling and logistic regression to examine intervention effects.

RESULTS

Of 152 invited, 140 (92%) participated (intervention = 72; control = 68). At 36 months, maternal self-esteem was higher in the intervention group compared with controls (P = .011), with higher scores on preparedness for mothering role (P = .011), acceptance of infant (P = .008), and expected relationship with infant (P = .029). Repeat pregnancy by 36 months was significantly lower for intervention versus control participants.

CONCLUSIONS

A brief parenting and/or life skills intervention paired with medical care for teens and their children has positive effects on maternal self-esteem and repeat pregnancy over 36 months.

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

Parent experiences with a nurse-supervised community health worker asthma home-visiting program

Objective: This study seeks to identify helpful components of a nurse-supervised Community Health Worker (CHW) asthma home-visiting program, obtain feedback from parents and families about their experiences, and receive suggestions for new services that the program could provide. Methods: Likert scale ratings and semi-structured qualitative interviews were conducted with parents who were selected from a representative sample and previously participated in the program. Five-point Likert scale ratings from 1 (not helpful) to 5 (very helpful) were obtained for 11 program components. Interviews were analyzed using a grounded theory participatory approach. Data were analyzed and themes were identified by two different coders using Dedoose software. Results: A total of 22 participants were enrolled and 20 participants completed Likert scale ratings and qualitative interviews. Likert scale ratings (mean standard deviation [SD]) show that program strengths include asthma education (4.75 [0.55]), supplies (4.65 [0.99]), help with housing conditions (3.94 [1.56], pest management (3.79 [1.69]) and greater access to community resources (3.70 [1.30]). The ratings suggest that families need more help with other social determinants of health, such as school, lack of enough money or food, and mental health and behavioral concerns (3.05 [1.78]). Interviews echoed these ratings and revealed several themes about family and parental stress, children's activity limitations, desire for outreach after the 12-month intervention, a need for help with other social determinants and more emotional support. Conclusions: This study shows that the program was well received and reveals the importance of addressing social determinants of health and behavioral health concerns.

Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts

OBJECTIVES

To test the applicability of the Environmental Scoring System, a quick and simple approach for quantitatively measuring environmental triggers collected during home visits, and to evaluate its contribution to improving asthma outcomes among various child asthma programs.

METHODS

We pooled and analyzed data from multiple child asthma programs in the Greater Boston Area, Massachusetts, collected in 2011 to 2016, to examine the association of environmental scores (ES) with measures of asthma outcomes and compare the results across programs.

RESULTS

Our analysis showed that demographics were important contributors to variability in asthma outcomes and total ES, and largely explained the differences among programs at baseline. Among all programs in general, we found that asthma outcomes were significantly improved and total ES significantly reduced over visits, with the total Asthma Control Test score negatively associated with total ES.

CONCLUSIONS

Our study demonstrated that the Environmental Scoring System is a useful tool for measuring home asthma triggers and can be applied regardless of program and survey designs, and that demographics of the target population may influence the improvement in asthma outcomes.

Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders

PURPOSE

Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up.

METHODS

Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available.

RESULTS

For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI.

CONCLUSION

In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa

PURPOSE

Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder.

METHODS

Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN.

RESULTS

Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight.

CONCLUSIONS

Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.

Boston children's hospital community asthma initiative: Five-year cost analyses of a home visiting program

OBJECTIVE

To evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) through reduction of Emergency Department (ED) visits and hospitalizations for the full pilot-phase program participants.

METHODS

A cost-benefit analyses was conducted using hospital administrative data to determine an adjusted Return on Investment (ROI): on all 268 patients enrolled in the CAI program during the 33-month pilot program phase of CAI intervention between October 1, 2005 and June 30, 2008 using a comparison group of 818 patients from a similar cohort in neighboring ZIP codes without CAI intervention. Cost data through June 30, 2013 were used to examine cost changes and calculate an adjusted ROI over a 5-year post-intervention period.

RESULTS

CAI patients had a cost reduction greater than the comparison group of $1,216 in Year 1 (P = 0.001), $1,320 in Year 2 (P < 0.001), $1,132 (P = 0.002) in Year 3, $1,123 (P = 0.004) in Year 4, and $997 (P = 0.022) in Year 5. Adjusting for the cost savings for the comparison group, the cost savings from the intervention resulted in an adjusted ROI of 1.91 over 5 years.

CONCLUSIONS

Community-based, multidisciplinary, coordinated disease management programs can decrease the incidence of costly hospitalizations and ED visits from asthma. An ROI of greater than one, as found in this cost analysis, supports the business case for the provision of community-based asthma services as part of patient-centered medical homes and Accountable Care Organizations.

Improving Social Determinants of Health: Effectiveness of a Web-Based Intervention

INTRODUCTION

Although patients who experience health-related social problems such as food insecurity are at increased risk for negative health outcomes, there are few systems for screening and intervention. The study aimed to determine whether a web-based intervention can (1) connect youth to services to address these problems and (2) increase their resolution.

DESIGN

Prospective intervention study.

SETTING/PARTICIPANTS

A total of 401 youth, aged 15-25 years, from an urban adolescent/young adult clinic were recruited.

INTERVENTION

A self-administered, web-based tool was developed to screen participants for problems in nine health-related social domains, identify and provide feedback about potential problems, and facilitate a patient-centered selection process of recommended local health and human service agencies to assist in addressing selected problems (conducted in 2008-2010). Follow-up phone calls 1-2 months later determined if patients had contacted recommended agencies and resolved their top-priority problem.

MAIN OUTCOME MEASURES

Outcome measures included prevalence of identified problems, selected problems, and priority problem selected by domain. We also examined frequencies of referral agencies contacted and resolution of priority problem at time of follow-up analysis conducted in 2011-2013.

RESULTS

Seventy-eight percent (313/401) of youth selected at least one problem to address. The most frequent domains selected as priority were income security (21%); nutrition/fitness (15%); and healthcare access (15%). Eighty-three percent (259/313) were reached at follow-up; overall, 40% contacted a selected agency and 47% reported "completely" or "mostly" resolving their priority problem.

CONCLUSIONS

When provided with services to address health-related social problems, the majority of youth choose to receive help, with nearly half successfully addressing their priority concern. Further research to understand the barriers to contacting and utilizing services is needed. A technology-based patient-centered feedback and referral system for social determinants of health can facilitate screening and connect patients with resources to address these problems.

Total Direct Medical Expenses and Characteristics of Privately Insured Adolescents Who Incur High Costs

IMPORTANCE

Accountable care payment models aim to reduce total direct medical expenses for high-cost patients through improved quality of care and preventive health services. Little is known about health care expenditures of privately insured adolescents, especially those who incur high costs.

OBJECTIVES

To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis was conducted of data from January 1 to December 31, 2012, of 13,103 privately insured adolescents aged 13 to 21 years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1, 2015.

MAIN OUTCOMES AND MEASURES

We compared demographic (age, sex, median income by zip code) and clinical (obesity, behavioral health problem, complex chronic condition) characteristics between high-cost (top 1%) and non-high-cost adolescents. We assigned high-cost adolescents to clinical categories using software from the Agency for Healthcare Research and Quality to describe clinically relevant patterns of spending.

RESULTS

Total direct medical expenses were $41.2 million for the entire cohort and a median $1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of expenses of the cohort, with a median $52,577 per patient. Mental health disorders were the most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1 behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated with being a high-cost patient included having 1 complex chronic condition (relative risk [RR], 6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI, 14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity (RR, 2.0; 95% CI, 1.3-3.0).

CONCLUSIONS AND RELEVANCE

Total direct medical expenses for privately insured high-cost adolescents are associated with medical complexity, mental health conditions, and obesity. Cost reduction strategies in similar populations should be tailored to these cost drivers.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Randomized controlled trial of an immunization recall intervention for adolescents

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PROBLEM

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

PURPOSE

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

KEY POINTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Malnutrition and hemodynamic status in adolescents hospitalized for anorexia nervosa

OBJECTIVE

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

DESIGN

Longitudinal observational study.

SETTING

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

Chart review.

SETTING

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

PARTICIPANTS

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

INTERVENTION

Provision of HIV PEP.

MAIN OUTCOME MEASURE

Documented completion of a 28-day course of PEP.

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parental acceptance of the human papillomavirus vaccine

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Youth preferences for prenatal and parenting teen services

STUDY OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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