Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit.

Introduction: Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic. Methods: We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims. Results: Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since. Conclusions: Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.

Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders.

STUDY OBJECTIVE: To evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs) DESIGN: Retrospective multicenter cohort study from February 2014 through February 2020 SETTING: Young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas PARTICIPANTS: Female patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placement INTERVENTIONS AND MAIN OUTCOME MEASURES: Rates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatment RESULTS: We identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently. CONCLUSIONS: In this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.

Emergency Department Evaluation of Abnormal Uterine Bleeding in US Children's Hospitals.

STUDY OBJECTIVE: To assess initial evaluation patterns of patients presenting to the Emergency Department (ED) with abnormal uterine bleeding (AUB) including differences by race DESIGN: Retrospective multicenter cohort study from October 2015 through September 2020 SETTING: Forty-seven children's hospitals submitting data to the Pediatric Health Information System PARTICIPANTS: Female patients aged 8-21 with an ED encounter with AUB as the primary diagnosis code INTERVENTIONS AND MAIN OUTCOME MEASURES: Proportion of visits with at least 1 laboratory assessment for the evaluation of anemia, iron deficiency, and/or hemostatic disorders RESULTS: We identified 17,759 unique patients with AUB seen in the ED who met inclusion criteria. Median age was 16.3 years (IQR, 14.1-17.8 years). Most encounters (n = 11,576, 65.2%) included evaluation for anemia, but only 6.8% (n = 1,215) included assessment for iron deficiency and 26.2% (n = 4,654) for hemostatic disorders. Black patients accounted for 34.7% (n = 6,155) of AUB encounters yet constituted only 25% of all ED encounters (n = 198,192). Black patients with AUB were less likely to undergo bleeding disorder evaluation (OR = 0.76; 95% CI, 0.69-0.83) but more likely to receive evaluation for sexually transmitted infections (OR = 1.63; 95% CI, 1.48-1.80) compared with White patients, despite controlling for age and concomitant pain. CONCLUSIONS: In a national cohort of adolescents presenting to the ED with AUB, evaluations for anemia and hemostatic disorders were infrequently performed, and racial differences existed regarding initial assessment. Further studies are needed to understand the factors underlying racial differences in hematologic testing and the impact of this disparity on health outcomes for females with AUB.

Impact of Early Stages of the COVID-19 Pandemic on Sexually Transmitted Infection Screening Claims Among Adolescent Females in a Pediatric Accountable Care Organization in Ohio, United States.

Background Testing for sexually transmitted infections (STIs) decreased during the early months of the coronavirus disease 2019 (COVID-19) pandemic. Less is known about the extent to which screening of asymptomatic adolescents for STIs was specifically affected. Our aim was to describe the impacts of early stages of the COVID-19 pandemic on asymptomatic STI screening and overall STI testing among adolescent females aged 13 to 19. We hypothesized that screening would decrease more than overall testing. Methods We evaluated claims data from a pediatric accountable care organization responsible for approximately 40,000 adolescent females. We assessed rates of asymptomatic screening and overall testing for chlamydia and gonorrhea in this population, comparing the early pandemic to pre-pandemic levels. Results Both STI screening and overall STI testing were found to be significantly decreased during the early period of the COVID-19 pandemic compared to pre-pandemic levels. The proportion of tests billed as screening was 70% of tests for April to August 2020 (early pandemic), compared to 67% for October 2019 to February 2020 and 64% for April to August 2019, contrary to our hypothesis. Conclusion Asymptomatic screening represented a similar proportion of STI testing among this population of adolescent females during the early COVID-19 pandemic compared to pre-pandemic testing. More work is needed to understand how asymptomatic screening was proportionally maintained despite COVID-19 pandemic restrictions.

Characterizing adolescents with heavy menstrual bleeding and generalized joint hypermobility.

Patients with generalized joint hypermobility (JHM) may experience excessive bruising/bleeding, with heavy menstrual bleeding (HMB) commonly reported. We performed a retrospective review of 30 adolescents seen in a Young Women's Hematology Clinic with both HMB and JHM. We found that (1) a significant delay (mean 36 months, range 5-72) occurred between menarche and referral to specialty care, (2) HMB had moderate to severe impact on school and physical activities in 60% of patients, and (3) most patients (68%) required escalation of their initial therapy. We suggest providers consider JHM as a risk factor for a more complex clinical course.

Hematologic Considerations and Management of Adolescent Girls with Heavy Menstrual Bleeding and Anemia in US Children's Hospitals.

STUDY OBJECTIVE: To assess the frequency, severity, and inpatient management of girls admitted with heavy menstrual bleeding and iron deficiency anemia at US children's hospitals, with a focus on hematologic considerations. DESIGN: Retrospective multicenter cohort study from October 2012 through September 2015. SETTING: Children's hospitals submitting data to the Pediatric Health Information System. PARTICIPANTS: Female patients, age 8-18 years, admitted with heavy menstrual bleeding and anemia as either a primary or secondary diagnosis. Patients with cancer, immune thrombocytopenic purpura, aplastic anemia, and pregnancy were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES: Hemostatic evaluation; provision of iron therapy. RESULTS: We identified 1183 admissions (1134 unique patients). Patients' median (interquartile range) age was 14 (11-17) years. Forty-one percent were Caucasian (n = 480), 31% African American (n = 371), and 26% Hispanic ethnicity (n = 310). Intensive care use occurred in 5% of admissions (n = 56). Hemostatic assessment was inconsistent; 15% (n = 182) had no such evaluation. Two-thirds (n = 797; 67%) involved transfusions, 37% (n = 433) received no inpatient iron therapy, and 17% (n = 197) received no hormonal or antifibrinolytic therapy. Hemostatic evaluation was associated with intensive care use: odds ratio (OR), 4.80 (95% confidence interval [CI], 1.16-19.86; P = .03); emergency department visit: OR, 2.60 (95% CI, 1.86-3.65; P < .01); private insurance: OR, 1.62 (95% CI, 1.12-2.35; P = .01); and younger age: OR, 0.84 (95% CI, 0.77-0.92; P < .01). CONCLUSION: Hundreds of girls with heavy menstrual bleeding and anemia are hospitalized at US children's hospitals each year with variable inpatient hematologic evaluation and management. Future guidelines should emphasize early identification of at-risk patients and promote effective implementation strategies to reduce the burden of this preventable complication.

Mobile Application vs Paper Pictorial Blood Assessment Chart to Track Menses in Young Women: A Randomized Cross-over Design.

STUDY OBJECTIVE: Heavy menstrual bleeding is a common symptom reported by approximately 30% of women. The Pictorial Blood Assessment Chart (PBAC) score is often used to quantify severity of menstrual bleeding. However, the traditional PBAC paper diary might be subject to recall bias and compliance issues, especially in adolescents. We developed a mobile application (app) version of the PBAC score and evaluated patient satisfaction and compliance with app reporting vs paper reporting. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study was a randomized cross-over study of 25 postmenarchal female adolescents and young women ages 13-21 years. Participants agreed to track bleeding in 2 consecutive menstrual cycles and were randomized to use the PBAC paper diary or mobile app format first. At the end of each cycle, a satisfaction survey and system usability scale (app only) was used to assess the acceptability of the format used. RESULTS: Twenty-five participants had a median age of 15 years. Cross-over analysis showed that satisfaction level was significantly higher for the app (P < .001). Twenty of 25 (80%) participants preferred the app over the paper diary. For the app, 20 of 25 participants (80%) had high compliance for reporting bleeding, with a mean of 2 app entries per day. Participants' PBAC scores did not vary significantly between the paper diary (median, 95) and mobile app (median, 114). All paper diaries met definition for high compliance. There was no significant period or carryover effect. CONCLUSION: This study showed that a PBAC app compared with the paper diary was the preferred method of recording menstrual bleeding in adolescents and showed feasibility as a research data collection tool.

Heavy Menstrual Bleeding in Adolescents.

Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.

Heavy Menstrual Bleeding as a Common Presenting Symptom of Rare Platelet Disorders: Illustrative Case Examples.

Heavy menstrual bleeding (HMB) is a common symptom in patients who present to the obstetrician-gynecologist or adolescent medicine specialist and might result from an underlying inherited bleeding disorder. Whereas relatively common bleeding disorders such as von Willebrand disease are often included in standard laboratory assessments, rarer platelet function disorders can be challenging to diagnose. Additionally, HMB can be a particularly difficult symptom to manage in adolescents with platelet function disorders, and it is associated with decreased quality of life. We review the diagnostic and management issues of patients with platelet function disorders through the presentation of 2 patient case reports, with a focus on a diagnosis of Glanzmann thrombasthenia, an inherited qualitative disorder that affects platelet function. Whereas the first patient presented to the emergency department before the diagnosis of a bleeding disorder and required a hematologic referral and extensive laboratory assessments, the second patient had been diagnosed with Glanzmann thrombasthenia as a child but experienced severe management challenges at the onset of menarche. In both patients, collaboration between the obstetrician-gynecologist or adolescent medicine specialist and the hematologist was critical for achieving acute management of the bleeding symptoms and for ensuring optimal long-term disease management. Together, these cases highlight the importance of properly identifying females with HMB who might have an undiagnosed bleeding disorder and of consulting with a hematologist to determine an appropriate management plan throughout all life stages.

Overview of sexually transmitted infections in adolescents.

STIs are very common among adolescents, thus routine screening is warranted. Recognition of common clinical syndromes can aid in timely diagnosis and treatment. Preventive measures, including vaccines, may significantly impact the disease burden in this vulnerable population.