Adolescent Preventive Services Presentation
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Adolescent Preventive Services Presentation



Presentation given by Susan Maloney, in collaboration with James Nordin and Leif Solberg, at the American College of Preventive Medicine (ACPM) annual meeting on February 17, 2010

Presentation given by Susan Maloney, in collaboration with James Nordin and Leif Solberg, at the American College of Preventive Medicine (ACPM) annual meeting on February 17, 2010



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Adolescent Preventive Services Presentation Adolescent Preventive Services Presentation Presentation Transcript

  • Adolescent Preventive Services James D. Nordin, MD, MPH Leif I. Solberg, MD HealthPartners Research Foundation Minneapolis, MN
  • Introduction
    • Topics
    • 1. Currently recommended clinical preventive services (CPS)
      • Based on Solberg, Nordin et al AJPM Nov 2009
      • Recommendations
      • Services with adequate evidence
      • (Things are bad)
    • 2. Adolescent primary care visit patterns
      • Based on Nordin, Solberg et al (submitted to Pediatrics )
      • Preventive visits
      • Other visits
      • (No, they are worse)
  • I. Clinical Preventive Services for Adolescents
  • Objectives of the CPS Review
    • The objectives of the review we completed
      • identify those CPS for adolescents that do have a strong evidence base
      • update the literature review
      • summarize evidence gaps where research is needed
      • summarize current delivery prevalence and opportunities
  • Current Recommendations
    • Key national groups issue comprehensive sets of prevention recommendations for adolescents
      • American Academy of Family Physicians
      • American College of Obstetricians and Gynecologists
      • American Academy of Pediatrics (AAP; Bright Futures)
      • Society for Adolescent Medicine
      • American Medical Association (AMA; Guidelines for Adolescent Preventive Services [GAPS])
      • U.S. Preventive Services Task Force (USPSTF)
    • Together they recommend 28 counseling services and 31 screening services for adolescents
    • Ten immunizations recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP)
      • 4 recommended routinely
      • 2 recommended for high risk groups
      • 4 recommended as catch up by the ACIP
  • Evidence
    • A review of the evidence behind the CPS recommendations for well child care (Moyer and Butler, 2004)
      • Recommended by at least two of the recommending organizations
      • Most had limited supporting evidence.
    • The USPSTF is clearly recognized as the body that does the best and most transparent job of basing recommendations on research evidence of effectiveness in a clinical setting.
    • The ACIP performs the same role for immunization policy.
  • Summary of USPSTF Recommendations
    • USPSTF had reviewed 24 clinical preventive services (CPS) for adolescents, 11 to 17 years of age
    • Only 10 received definite recommendations:
      • 7 are recommendations to deliver the service (i.e., A or B grade)
      • 3 are recommendations against delivering the service (i.e., D grade)
      • Remainder C or I grade
  • USPSTF Grading Scale
    • A. Recommends. High certainty of substantial net benefit.
    • B. Recommends. High certainty that net benefit is moderate or moderate certainty that benefit is moderate to substantial.
    • C. Recommends against routine provision, but may be appropriate for individuals. At least moderate certainty of small net benefit.
    • D. Recommends against. At least moderate certainty of no net benefit or that harms outweigh benefits.
    • I. Current evidence is insufficient to assess the balance of benefits and harms.
  • Review Methods
    • The literature was reviewed to provide a current update
      • for those CPS with an I or C grade
      • where the latest USPSTF review was conducted prior to June 2006
    • Immunization reviews were not updated
      • the ACIP keeps those reviews current
  • Review Methods II
    • Review the USPSTF recommendation statement to clarify the service for both screening and counseling
    • Review the USPSTF evidence synthesis
    • Develop a list of medical subject headings (MeSH) search terms.
    • Search PubMed through April 23, 2008:
      • using those MeSH terms from the last date reviewed for the USPSTF.
      • Other limits were abstracts, humans, English, and adolescents.
    • Search Cochrane Database of Systematic Reviews through 2007 using those MeSH terms from the past year reviewed for the USPSTF evidence review
    • Review relevant articles cited in the bibliographies of articles from the above searches
  • Literature Updates
    • 14 services in USPSTF list
      • with I (inadequate data) or C (no recommendation)
      • 5 reviewed since 2006 by the USPSTF
        • No change in recommendations
      • We reviewed literature on the other 9
        • None provide adequate evidence for change of recommendation
  • USPSTF Recommendations
    • A and B Recommendations for Screening and Counseling
      • Cervical cancer (Pap) Sexually active women
      • Chlamydia (girls) Sexually active women
      • Depression All adolescents
      • Tobacco All adolescents
      • Gonorrhea Sexually active women
      • Syphilis Increased risk for STDs
      • HIV Increased risk for STDs
    • Immunizations
      • Tdap, influenza All adolescents
      • meningococcal vaccines All adolescents
      • HPV Adolescent girls
      • Pneumococcal, hepatitis A At risk adolescents
  • USPSTF Recommendations
    • D Recommendations Against
      • Testicular Cancer Screening (asymptomatic males)
      • Idiopathic Scoliosis Screening
      • Syphilis Screening (low risk persons)
    • C Recommendations, deliver per individual risks
      • HIV Screening (low risk persons)
      • HIV & STD Counseling—update underway
  • USPSTF Recommendations
    • I Recommendations
      • Overweight screening (NEW)
      • Physical activity counseling
      • Healthy diet counseling
      • Lipid disorder screening
      • Suicide risk
      • Suicide risk screening
      • Alcohol misuse screening
      • Illicit drug use screening
      • Chlamydia screening (males)
      • Gonorrhea screening (males)
      • Sun safety counseling
      • Auto restraints counseling
      • Alcohol and autos counseling
  • Summary of I, C, D and release dates
    • Service Grade Release date Targeted population
    • Overweight I July 2005 Children and adolescents
    • Suicide risk I May 2004 General population
    • Alcohol misuse I April 2004 Adolescents
    • Chlamydia (boys) I June 2007 Boys/men
    • Gonorrhea (boys) I May 2005 Sexually active men aged < 25 years
    • HIV (low-risk) C April 2007 People not at increased risk
    • Lipid disorders I July 2007 Children and young adults aged < 21 years
    • Illicit drug use I January 2008 General population
    • Testicular cancer D February 2004 Asymptomatic adolescent and adult boys/men
    • Idiopathic scoliosis D June 2004 Adolescents
    • Syphilis (low-risk) D July 2004 Asymptomatic people not at increased risk
    • Physical activity I August 2002 General population
    • Healthy diet I January 2003 General population without risk factors for
    • Skin cancer I October 2003 General population
    • HIV and STIs C 1996 Adolescents and adults
    • Auto restraints I August 2007 General population
    • Alcohol and autos I August 2007 General population
  • Evidence Gaps and Unknowns
    • Common pattern for both screening and counseling services
    • Inadequate evidence about effect of delivering the service to adolescents in a clinical setting
      • Short term patient behavior change
      • Long term outcomes
    • Little evidence of acceptability or harms of interventions
    • Many have been adequately studied in adults but not in adolescents
  • Prevalence of Delivery of Services
    • A review of current delivery prevalence was conducted
      • Searched PubMed for adolescent clinical preventive services and the individual service topics.
    • HEDIS reports
      • 70% of females (of all reproductive ages) get a Pap smear at least every 3 years
      • 40+% of females are screened for chlamydia
    • Surveys of doctors
      • Range from 20% to 50% who state they perform the other preventive services
      • Measure intention more than performance
  • Opportunities for Prevention
    • National Ambulatory Medical Care Survey (NAMCS) medical visit data for 1993–2000 found that adolescents aged 13–18 years
      • averaged 1.9 total medical visits per year
      • 9% were for preventive care
    • National 1999 youth risk behavior surveillance survey of high school students found that of those reporting a preventive care visit in the preceding 12 months few reported having discussed STIs, HIV, or pregnancy prevention at those visits
      • 43% of girls
      • 26% of boys
  • Summary of Evidence–based Recommendations
    • Cervical cancer screening at least every 3 years for all sexually active women;
    • Chlamydia screening for all sexually active women under the age of 25;
    • Tobacco use and brief interventions; depression screening and referral
    • NEW- BMI screening and referral
    • HPV, meningococcal, Tdap, and influenza immunizations;
    • For at risk patients
      • gonorrhea, syphilis, and HIV screening
      • pneumococcus and hepatitis A immunizations
  • Conclusions
    • There are too many CPS recommended for adolescents with insufficient evidence of effectiveness
    • There is low delivery prevalence for the few services with good evidence of effectiveness
    • Both more research and more attention to the practice system changes that might improve delivery prevalence are needed
  • 2. Primary Care Visit Patterns
  • Adolescent Primary Care Visit Patterns
    • A retrospective descriptive analysis based on claims data from a large health plan with 700,000 members in Minnesota
    • Data from 1998 through 2007
    • Analysis
      • Cross sectional analysis
      • Longitudinal analysis of teens having at least 4 years of continuous enrollment
        • Not a representative sample
        • As good as it gets (stable population)
  • Population
    • 300,866 eligible adolescents
      • 93% commercial insurance
      • 7% government insurance
    • Minnesota at the time (for comparison)
      • 72% commercial
      • 21% government insurance
      • 7% no insurance
    • For longitudinal analysis
      • 40,043 met the 4 year enrollment requirement
  • Cross Sectional Analysis Preventive Visit Rate by Year of Age
  • Cross Sectional Analysis Non Preventive Visit Rate by Year of Age
  • Longitudinal Analysis
    • Subjects with continuous enrollment for 4 or 5 years
    • Age 13 through 18
      • Eliminated 12 year olds due to anomaly caused by state law described earlier
    • Total population 40,043
      • Uniquely stable population
      • Insured by the same company for 4 or 5 years
      • These people should have the easiest and most frequent access to medical care
  • Longitudinal Analysis Male/Female Breakdown mean # of visits Female Male p-value preventive visits 1.2 1 <0.0001 non-preventive visits 7.7 5.9 <0.0001 mean visit rate per year preventive visits 0.3 0.2 <0.0001 non-preventive visits 1.7 1.3 <0.0001
  • Longitudinal Patterns of Health Care Use Among Adolescents Over 4 or More Years Number of visits Non preventive Com Non preventive Gvt P-value Preventive Com Preventive Gvt P-value 0 8% 15%   30% 30%   1 9% 13%   41% 36%   2 10% 10%   22% 21%   3 9% 9%   5% 9%   4 9% 8%   1% 2%   5 to 10 34% 25%   0% 0%   >10 20% 20%   0% 0%   Overall             mean total visits 6.83 6.41 0.0277 1.07 1.18 <0.0001 mean per year 1.5 1.47 0.5702 0.23 0.27 <0.0001
  • Conclusions
    • AMA and AAP guidelines calling for one preventive care visit annually for adolescents are being met less than 2% of the time in this select longitudinal cohort
    • Adolescents are visiting their primary care source for other reasons
  • Recommendations
    • Develop better evidence for adolescent CPS
      • Especially those that address health conditions with a large impact
      • More funding or shifted funding will be needed
    • Prioritize delivery of services with good evidence of effectiveness
    • Take advantage of every adolescent medical encounter to deliver CPS services
    • Focus on clinical systems (recall/reminder, etc) to improve rates of delivery
    • Susan K. Maloney
    • Partnership for Prevention
    • 1015 18 th Street, NW
    • Washington, DC 20036