Improving adolescent preventive care in community health centers.

OBJECTIVE: To evaluate implementation of the Guidelines for Adolescent Preventive Services (GAPS) in Community and Migrant Health Centers (CMHCs). DESIGN: Before and after comparison of health center policy, clinician and adolescent self-report, and chart reviews in 5 CMHCs. PARTICIPANTS: Eighty-one preintervention and 80 one-year postintervention providers and 318 preintervention and 331 postintervention 14- to 19- year-old adolescent patients being seen for well visits at 5 CMHCs. INTERVENTION: Health center staff were trained to implement GAPS and were provided resource materials, patient questionnaires, and clinician manuals. MAIN OUTCOME MEASURES: Delivery of and receipt of preventive services and perceived access to care. RESULTS: CMHC systems changes were related to stronger leadership commitment to adolescent care. Providers reported high levels of preventive services delivery before and after guideline implementation. After guideline implementation, adolescents reported increases in having discussed prevention content with providers in 19 of 31 content areas, including increased discussion of physical or sexual abuse (10% before to 22% after), sexual orientation (13% to 27%), fighting (6% to 21%), peer relations (37% to 52%), suicide (7% to 22%), eating disorders (11% to 28%), weapons (5% to 22%), depression (16% to 34%), smokeless tobacco (10% to 29%), and immunizations (19% to 48%). Adolescents were also more likely to report knowing where to get reproductive or mental health services and were more likely to have received health education materials. Implementation also increased documentation of recommended screening and counseling in 51 of 79 specific content areas assessed in chart reviews. CONCLUSION: Implementing GAPS increased the receipt of preventive services at these health centers. Adolescents received more comprehensive screening and counseling, more health education materials, and had greater access to care after implementation. GAPS implementation may help improve the quality of care for adolescents.

Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients?

OBJECTIVE: To determine whether pediatricians in managed care settings adhere to national guidelines concerning the provision of clinical preventive services. DESIGN: Surveys were mailed between September 1996 and April 1997 to all pediatricians practicing in a California group-model health maintenance organization. The survey asked pediatricians about their screening and education practices on 34 recommended services and the actions taken with adolescent patients who have engaged in risk behavior. RESULTS: The response rate was 66.2% (N = 366). Pediatricians, on average, screened 92% of their adolescent patients for immunization status and blood pressure; 85% for school performance; 60% to 80% for obesity, sexual intercourse, cigarette use, alcohol use, drug use, and seat belt and helmet use; 30% to 47% for access to handguns, suicide, eating disorders, depression, and driving after drinking alcohol; fewer than 20% for use of smokeless tobacco, sexual orientation, sexual and physical abuse, and riding a bike or swimming after drinking alcohol; and 26% to 41% for close friends' engagement in risk behavior. Pediatricians' assessment and education with adolescent patients who screened positive for risk behavior was particularly low. Female physicians, physicians who saw a greater proportion of older adolescents, and recent medical school graduates were more likely to provide preventive services. CONCLUSIONS: Pediatricians in this health maintenance organization provide preventive services to adolescent patients at rates below recommendations but at rates greater than physicians in other practice settings. Improvement is especially needed in the areas that contribute most to adolescent mortality and for patients who screen positive for a risk behavior.

Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services.

OBJECTIVE: To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall. DATA SOURCES/SETTING: Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers. DESIGN: 537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard. RESULTS: Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use. CONCLUSION: Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred.

The U.S. Preventive Services Task Force Guide to Clinical Preventive Services, Second Edition. AMA Council on Scientific Affairs.

A resolution, introduced by the American College of Preventive Medicine at the 1996 American Medical Association (AMA) Annual Meeting, asked the AMA to recommend to physicians the use of the United States Preventive Services Task Force's Guide to Clinical Preventive Services, Second Edition. In response to that resolution, the AMA's Council on Scientific Affairs has reviewed and evaluated this publication. The recommendations of the Council on Scientific Affairs on the use of the Guide to Clinical Preventive Services, Second Edition, by clinicians and medical educators are included in this report. These recommendations were adopted as AMA Policy at the AMA Annual Meeting in June 1997.

Adolescent preventive services.

Today, there are significant risks to the health of teenagers. Drugs (tobacco, alcohol, steroids and others), sex (pregnancy, STDs, date rape), nutrition (obesity and eating disorders), and violence (abuse, fighting) are unfortunately a part of many teens' lives. These risks increase throughout the teen years. Since each risk has a strong behavioral component, we hope to modify the behavior and minimize the risk. Prevention and health promotion are an important part of health care for teens. Primary care providers, such as family physicians, are in an excellent position to provide teen preventative care that is comprehensive and specific to the needs of each teen.

Comparison of recommendations for adolescent clinical preventive services developed by national organizations.

The 1990s have witnessed a resurgence in clinical preventive medicine. With a finite amount of health care dollars available, prevention is an attractive alternative to rationing health services or to other means of controlling medical expenditures. Strategies to promote preventive services include the development of clinical practice guidelines that describe recommended screening and counseling services, the development of new and improved immunizations, and campaigns to enhance the delivery of both selected, categorical preventive interventions and comprehensive preventive services.

Integrating comprehensive adolescent preventive services into routine medicine care. Rationale and approaches.

Relying on therapeutic interventions to address health problems after they occur has proven costly and does not address the need to reduce the number of youth who develop these health problems. Primary care physicians have an important role to play in promoting adolescent health through a strategy of providing health guidance to adolescents and parents, screening, and promoting immunizations. Reducing the health risk behaviors of adolescents is a challenge that is best accomplished with the support of other preventive initiatives. Clinical preventive services should complement and reinforce preventive efforts in schools (i.e., comprehensive school health programs) and communities (i.e., mass media campaigns and health regulations). GAPS recommendations developed by the AMA and recommendations from other groups provide a model for organizing the content and delivery of comprehensive preventive services for adolescents. Physicians and other primary care health providers may use these recommendations to expand the quantity and quality of preventive services they offer to adolescents. Additional information about preventive services and GAPS, including a complete list of the recommendations, dates for future GAPS training, a description of the materials developed to help implement preventive services, other national efforts in adolescent preventive services, and current articles in scientific literature, can be reviewed on the AMA web site (http:/(/)www.AMA-Assn.Org/Adolhlth/Adolhlth+ ++.htm).

The cost of comprehensive preventive medical services for adolescents.

OBJECTIVES: To address the need for clinical preventive services for 11- to 21-year-old males and females and provide cost estimates for those services under a fee-for-service system. Preventive services include screening, health promotion, and immunizations. DESIGN: The prevalence of adolescent morbidities was derived from national surveys. Estimated costs of these morbidities were obtained from published data and adjusted for 1992 dollars using the Consumer Price Index. The estimated costs of preventive services for adolescents under a fee-for-service system were derived from a 1993 survey of nine Blue Cross and Blue Shield plans and four insurance companies. MAIN OUTCOME MEASURES: The cost of adolescent morbidities includes only direct medical costs for a single year and excludes long-term and indirect costs. The cost of clinical preventive services is calculated at 100% participation levels. RESULTS: Each year, an estimated $33.5 billion is spent on medical treatment for select adolescent morbidities, approximately $859 per adolescent per year; this is a conservative estimate. The average cost of clinical preventive services per adolescent per year would be approximately $130 in a fee-for-service system, although these are not entirely "new" costs because payers already incur screening costs for some conditions. CONCLUSION: The cost-effectiveness of clinical interventions for various health risk behaviors among adolescents is unknown. It appears that preventive interventions would have to eliminate 15% of adolescent morbidities overall to break even in economic terms.

Adolescents and access to health care.

The developmental characteristics and health behaviors of adolescents make the availability of certain services--including reproductive health services, diagnosis and treatment of sexually transmitted disease, mental health and substance abuse counseling and treatment--critically important. Furthermore, to serve adolescents appropriately, services must be available in a wide range of health care settings, including community-based adolescent health, family planning and public health clinics, school-based and school-linked health clinics, physicians' offices, HMOs, and hospitals. National, authoritative content standards (for example, the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS), a multispecialty, interdisciplinary guideline for a package of clinical preventive services for adolescents may increase the possibility that insurers will cover adolescent preventive services, and that these services will become part of health professionals' curricula and thus part of routine practice. However, additional and specific guidelines mandating specific services that must be available to adolescents in clinical settings (whether in schools or in communities) are also needed. Although local government, parents, providers, and schools must assume responsibility for ensuring that health services are available and accessible to adolescents, federal and state financing mandates are also needed to assist communities and providers in achieving these goals. The limitations in what even comprehensive programs currently are able to provide, and the dismally low rates of preventive service delivery to adolescents, suggests that adolescents require multiple points of access to comprehensive, coordinated services, and that preventive health interventions must be actively and increasingly integrated across health care, school, and community settings. Unless access issues are dealt with in a rational, coordinated fashion, America's adolescents will not have access to appropriate health services. Current efforts to minimize current health care expenditures through managed care programs inevitably conflict with efforts to deliver comprehensive preventive services to all adolescents. Use of multiple sites may not represent inadequate access to care. However, as managed care reimbursement continues to expand, school-based clinics and free-standing adolescent health programs increasingly report decreases in reimbursement without a change in demand for services. The Office of Technology Assessment study called for explicit funding and expansion of services for America's youth; since then, a federal Office of Adolescent Health has been authorized, and, by the time this reaches print, should have received appropriations and been staffed. Dryfoos has called for expansion to nearly 5000 comprehensive programs in the coming years. 76 Additionally, The Robert Wood Johnson Foundation has just announced a $23.2 million state-community partnership grant program to increase availability of school-based health services for children and youth with unmet health needs.77 As health care reform efforts move forward,both careful definition of the services adolescents need and adequate financing for these services are essential to ensure access to care for all adolescents.

Association between parenthood and problem behavior in a national sample of adolescents.

The association between problem behaviors and parental status was studied in a national sample of urban (n = 1263) and rural (n = 388) young women 15 to 17 years of age. When assessed according to age at childbearing, there was a clear association between problem behavior and the birth of a first child prior to age 19 years. The three parental status groups studied appeared ordered in risk, with school-aged mothers having engaged in the most problem behaviors, and followed, in turn, by young adult mothers (ie, those who had a child between 19 and 21 years of age), and then by women who had not had a child by age 21 years. Young urban women who engaged in three or more problem behaviors were more likely than women who claimed no involvement in problem behaviors to subsequently have a child prior to age 19 years. In addition, black adolescents reported fewer problem behaviors than did white adolescents. When individual behaviors were analyzed, school-aged mothers were more likely than either young adult mothers or nonmothers to have reported school suspension, truancy, runaway, smoking marijuana, and fighting. Although similar results were found in both samples, the effects appeared more consistent for young urban women. In future studies, researchers must determine whether adolescent mothers are at risk for parenting difficulties because of their previous involvement in problem behaviors.

Association between behavioral and school problems and fatherhood in a national sample of adolescent youths.

The relation between fatherhood and behavioral and school problems was studied in a nationally representative sample of adolescent youths. Data were obtained from the National Longitudinal Survey of Work Experience of Youth (NLSY). Of the 6400 youths interviewed in 1980, 367 (5.7%) reported that they had fathered a child before the age of 19 years. This group was compared with 1000 non-fathers selected at random from the same data set. The groups differed by race and family socioeconomic characteristics. Academic, drug, and conduct problems were significantly more common among adolescent fathers than among non-fathers. Race and family income, and fatherhood status were independently related to various problem behaviors. These results confirm previous findings demonstrating a relation between delinquency and adolescent fatherhood.

The medical and psychosocial impact of comprehensive care on adolescent pregnancy and parenthood.

To assess the medical and psychosocial effects of services provided by a comprehensive adolescent pregnancy and parenthood program, 125 adolescents who received care from a comprehensive program were compared with 135 adolescents who received care from community health providers. Few differences were found in pregnancy outcome measures. At 12 and 26 months after delivery, however, the intervention group scored significantly better on composite measures encompassing medical, psychosocial, and parenting events than did the comparison group, even after accounting for possible confounding factors. This suggests that comprehensive care has little effect on pregnancy outcomes for those adolescents who are already receiving prenatal and nutritional services, but does have a significant effect on events occurring during the first and second postpartum years.

Judicial involvement and conduct problems of fathers of infants born to adolescent mothers.

Data were obtained from retrospective review of 191 patient records to determine the extent and types of conduct problems among fathers of infants born to adolescent mothers. Ninety-eight fathers (51%) reported having committed a legal offense prior to the pregnancy. This rate appears substantially greater than rates of arrests of adolescents in the general population. When paired data for couples were analyzed, there was great similarity for severity of offense. Fathers, however, had committed more severe crimes than their partners. Male offenders came from families of lower socioeconomic status backgrounds and more single-parent families and were less frequently employed or in school (or graduated) than nonoffenders. They also had been more involved with various other problem behaviors, such as a previous pregnancy, drinking behavior, and behavior problems at school. There was a clustering of problem behaviors among offenders suggesting psychosocial maladjustment prior to the pregnancy. Our results suggest an association between fatherhood and delinquency among partners of adolescent mothers. It appears that these fathers form a heterogeneous group. Although some young fathers may be well adjusted, others have significant psychologic problems.

Characteristics of married and unmarried adolescent mothers and their partners.

PIP: In a middle class, urban clinic sample of 275 mostly Caucasian, adolescent mothers and their partners living in Utah, 3 groups were identified and their psychosocial characteristics were compared. Couples married at the time of conception (N=22) enjoyed more positive responses from prospective grandparents and earned more than couples not married at the time of conception. On the other hand, these initially married youths were much more likely to be high school dropouts, which suggests limits in their lifetime earning capacities, and they were not more likely to identify one another as sources of emotional support. Couples who married between conception and delivery (N=110) reported that prospective grandparents responded less favorably to news of the pregnancy than did relatives of the initially married couples, but while their current salaries were lower, they were much more likely to be continuing with their education. Those who married after conception also had fewer antisocial and conduct disorders than young men and women who chose to continue in a dating relationship (N=29). Overall, the couples who married after conception appeared to face less severe problems than either the initially married couples or the steady daters.^ieng