Adolescent Use of Preventive Services

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Presented by James D. Nordin, MD, MPH, HealthPartners Research Foundation, at the 2010 National Chlamydia Coalition meeting

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Adolescent Use of Preventive Services

  1. 1. Adolescent Use ofAdolescent Use of Preventive ServicesPreventive Services James D. Nordin, MD, MPH Leif I. Solberg, MD HealthPartners Research Foundation Minneapolis, MN
  2. 2. USPSTF RecommendationsUSPSTF 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
  3. 3. Summary of Evidence–basedSummary of Evidence–based RecommendationsRecommendations • 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; (inadequate evidence for men) • Tobacco use and brief interventions; depression screening and referral • BMI screening and referral • HPV, meningococcal, Tdap, and influenza immunizations; • For at risk patients – gonorrhea, syphilis, and HIV screening – pneumococcus and hepatitis A immunizations
  4. 4. Primary Care Visit PatternsPrimary Care Visit Patterns
  5. 5. Prevalence of Delivery ofPrevalence of Delivery of Preventive ServicesPreventive 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
  6. 6. Opportunities for PreventionOpportunities 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
  7. 7. Adolescent Primary Care VisitAdolescent Primary Care Visit PatternsPatterns • 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)
  8. 8. PopulationPopulation • 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
  9. 9. Cross Sectional AnalysisCross Sectional Analysis Preventive Visit Rate by Year of AgePreventive Visit Rate by Year of Age 0.26 0.26 0.42 0.45 0.15 0.20 0.24 0.28 0.25 0.24 0.16 0.26 0.20 0.22 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 Meannumberofpreventivevisits 11, p=0.08144 12, p=0.0011 13, p<0.0001 14, p<0.0001 15, p=0.1327 16, p<0.0001 17, p=0.0013 Age, years Chart 1. Mean number of preventive visits by year of age and insurance type (commerical or government) in a sample of adolescents between the ages of 11 and 18, HealthPartners, 1998- 2007. Commercial preventive visits, p for trend =0.2404 Government preventive visits, p for trend = 0.3282
  10. 10. Cross Sectional AnalysisCross Sectional Analysis Non Preventive Visit Rate by Year of AgeNon Preventive Visit Rate by Year of Age 1.08 0.95 1.07 0.98 1.11 0.99 1.16 1.11 1.26 1.31 1.36 1.47 1.45 1.61 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Meannumbernonpreventivevisits 11, p<0.0001 12, p=0.0002 13, p<0.0001 14, p=0.0463 15, p=0.0891 16, p=0.001 17, p=<0.0001 Age, years Chart 2. Mean number of non preventive visits by year of age and insurance type (commerical or government) in a sample of adolescents between the ages of 11 anfd 18, HealthPartners, 1998-2007. Commercial non preventive visits, p for trend = 0.0007 Government non-preventive visits, p for trend = 0.0005
  11. 11. Longitudinal AnalysisLongitudinal 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 requiring immunization update for 7th grade • 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
  12. 12. Longitudinal AnalysisLongitudinal Analysis Male/Female BreakdownMale/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
  13. 13. Longitudinal Patterns of Health Care Use AmongLongitudinal Patterns of Health Care Use Among Adolescents Over 4 or More YearsAdolescents 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
  14. 14. ConclusionsConclusions • 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 at rates similar to those found a decade ago in the National Ambulatory Medical Care Survey (NAMCS)
  15. 15. RecommendationsRecommendations • Develop better evidence for adolescent CPS – Especially those that address health conditions with a large impact – More funding or shifted funding will be needed • Take advantage of every adolescent medical encounter to deliver CPS – Young women should be giving us an appropriately collected urine sample at non- preventive visits • Focus on clinical systems (recall/reminder, etc) to improve rates of delivery – Much easier with EMR – Use standing orders to imploement

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