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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

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

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  • 1. Adolescent Use of Preventive Services James D. Nordin, MD, MPH Leif I. Solberg, MD HealthPartners Research Foundation Minneapolis, MN
  • 2. 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
  • 3. 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; (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. Primary Care Visit Patterns
  • 5. Prevalence of Delivery of Preventive 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. 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
  • 7. 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)
  • 8. 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
  • 9. Cross Sectional Analysis Preventive Visit Rate by Year of Age
  • 10. Cross Sectional Analysis Non Preventive Visit Rate by Year of Age
  • 11. 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 requiring immunization update for 7 th 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. 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
  • 13. 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
  • 14. 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 at rates similar to those found a decade ago in the National Ambulatory Medical Care Survey (NAMCS)
  • 15. 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
    • 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