Validity of adolescent and young adult self-report of Papanicolaou smear results.

OBJECTIVE: To assess the validity of adolescent and young adult report of Papanicolaou smear results and to determine sociodemographic, cognitive, and behavioral factors associated with incorrect reporting. METHODS: We conducted a cross-sectional study of 477 female subjects aged 12 to 24 years who attended an adolescent clinic and had a previous Papanicolaou smear. Subjects completed a self-administered survey assessing self-report of Papanicolaou smear results, knowledge about Papanicolaou smears and human papillomavirus (HPV), attitudes about Papanicolaou screening and follow-up, and risk behaviors. The sensitivity, specificity, positive predictive value, and negative predictive value of self-reported results were calculated using the cytology report as the standard. Variables significantly associated with incorrect reporting were entered into logistic regression models controlling for age and race to determine independent predictors for incorrect reporting. RESULTS: Of the 477 participants, 128 (27%) had abnormal cytology reports and 66 (14%) had incorrect self-reports. Sensitivity of self-report was 0.79, specificity 0.89, positive predictive value 0.72, negative predictive value 0.92, and kappa (kappa) 0.66. The adjusted odds ratios (OR) and 95% confidence intervals (CI) of the variables comprising a logistic regression model predicting incorrect reporting were an HPV knowledge source of zero (OR 2.4, CI 1.0, 5.8), low perceived communication with the provider (OR 2.1, CI 1.1, 4.0), and no contraception at last intercourse (OR 5.5, CI 2.7, 11.0). CONCLUSION: The validity of adolescent and young adult self-reported Papanicolaou smear result is high, except among those who lack knowledge of HPV, perceive poor communication with the provider, and use contraception inconsistently.

Performance of Massachusetts HMOs in providing Pap smear and sexually transmitted disease screening to adolescent females.

PURPOSE: To describe the extent to which health maintenance organizations (HMOs) provide preventive health services to female adolescent enrollees. METHODS: All Massachusetts HMOs were asked to provide 1992 Papanicolaou (Pap) smear, gonorrhea, chlamydia, syphilis, and human immunodeficiency virus test rates for adolescents from medical records and claims data. The rates were compared with criterion standards and national utilization data from the National Survey of Family Growth. Seven of 14 Massachusetts HMOs agreed to provide data for female members aged 15-21 years on the Pap smear rate (n = 34,415) and sexually transmitted disease (STD) test rate (n = 33,701). RESULTS: Papanicolaou smear rates for females in the HMOs ranged from 5% of 15-year-olds to 45% of 21-year-olds during 1992. Test rates for chlamydia and gonorrhea ranged from 2% and 3%, respectively, for 15-year-olds to 9% and 10% for 21-year-olds. Among 15-19-year-old females, only 18% received a Pap smear, and only 11% received an STD test through their HMO during 1992, despite professional guidelines recommending that all of the estimated 53% of sexually active females age 15-19 years should receive both Pap smears and STD tests. Among 18-21-year-old females, only 37% had had a Pap smear through their HMO during 1992, despite professional guidelines recommending Pap smears for all women age 18 years and over. CONCLUSIONS: Efforts are needed within HMOs to ensure that STD screening, Pap smears, and other health screening services are provided for sexually active adolescent enrollees.

A clinical pathway for pelvic inflammatory disease for use on an inpatient service.

OBJECTIVE: (1) To create a guideline to improve care of adolescent patients diagnosed with pelvic inflammatory disease (PID); (2) to promote cost-effective, consistent care while minimizing delays and ensuring timely and appropriate use of laboratory tests and other interventions; and (3) to describe the process of the development and the implementation of a clinical pathway for PID. METHODS: The study involved the creation and piloting of a multidisciplinary, collaborative clinical pathway for uncomplicated PID on an inpatient service, and the development of a standardized form for analysis of demographics and variances from the pathway. The setting was an inpatient adolescent service at a children's hospital in an urban setting. All patients admitted with a clinical diagnosis of PID from April 1, 1993, to November 30, 1993, were followed up by means of the clinical pathway. All patients discharged with a diagnosis of uncomplicated PID in fiscal year 1992 (FY92: October 1, 1991, to September 30, 1992) were used as a comparison population. The main outcome measures included length of stay, charges per patient, timing of antibiotic administration, use of laboratory tests at admission and at 48 to 72 hours, and documentation of pathway variances. RESULTS: A clinical pathway was created by consensus during a period of several months. During implementation, 28 of 34 (82%) patients admitted by use of the pathway had a final diagnosis of PID; 23 of the 28 (82%) had uncomplicated PID. Variances from the pathway included missed rapid plasma reagins (RPRs) and laboratory tests that were not indicated. For uncomplicated PID, length of stay was reduced (p=.08) from a median of 4 days in FY92 (mean, 5.0 1 3.1 days; range, 2-15 days) to a median of 3 days in the study group (mean, 3.5 + 1.0 days; range, 2-4 days), with differences not reaching the level of significance. There were significantly more patients staying 5 days or longer in FY92 than in the study group (p<.03). Average charges per patient also decreased by 10% (median, $5,275 in FY92 to $4,919), although these results were not statistically significant. CONCLUSION: A clinical pathway for uncomplicated PID can be developed and implemented through a multidisciplinary, collaborative process, with ongoing use as a means of quality improvement and continuing education. Variances from the pathway highlight the need for ongoing education for health care providers. Downward trends in charges per patient and length of stay, although not significant, are encouraging; but they require longitudinal follow up with larger numbers of patients and analysis of outcomes.

Contraceptive compliance with a levonorgestrel triphasic and a norethindrone monophasic oral contraceptive in adolescent patients.

OBJECTIVE: This study was undertaken to assess the impact of two low-dose oral contraceptive pills on compliance and side effects in adolescent patients. STUDY DESIGN: The use of a levonorgestrel-containing triphasic pill (N = 114) was compared with that of a monophasic (1 + 35) norethindrone-containing pill (N = 110) at two different sociodemographic sites. RESULTS: No significant difference in compliance or pill satisfaction was observed between the pills. Socioeconomic factors were the overriding predictors of compliance. At 3 and 12 months of follow-up, there were significantly fewer complaints of overall side effects (p less than 0.001 and p = 0.004, respectively), breakthrough bleeding (p = 0.017 and p = 0.018), and pill amenorrhea (p = 0.002 and p less than 0.001) among users of the triphasic pill. Mean weight change at 12 months was +1.1 kg for the monophasic pill and -0.1 kg for the triphasic pill. All known pregnancies occurred among noncompliant city clinic patients. CONCLUSIONS: Adolescents experienced fewer side effects with the triphasic pill than with the monophasic one, but compliance was the same.

PIP: This study was undertaken to assess the impact of 2 low-dose oral contraceptives (OCs) on compliance and side effects on adolescent patients. The use of a levonorgestrel-containing triphasic (n=114) was compared with that of a monophasic (1+35) norethindrone-containing pill (n=110) at 2 different sociodemographic sites. No significant difference in compliance or pill satisfaction was seen between the groups. Socioeconomic factors were the overriding predictors of compliance. At 3 and 12 months of followup, there were far fewer complaints of overall side effects (p0.001 and p=0.004, respectively), breakthrough bleeding (p=0.017 and p=0.018), and pill amenorrhea (p=0.002 and p0.001) among users of the triphasic pill. Mean weight change at 12 months was +1.1 kg for the monophasic pill group and -0.1 kg for the triphasic pill group. All known pregnancies occurred among noncompliant city clinic patients. Adolescents experienced fewer side effects with the triphasic pill than with the monophasic one, but compliance was the same.

Adolescents' compliance with the use of oral contraceptives.

To elucidate the factors that might influence compliance with oral contraceptive use among sexually active adolescents, we undertook a study of 209 unmarried adolescents initiating use of oral contraceptives in three different settings: an inner-city adolescent clinic, a birth control clinic in a midsized industrial city, and a suburban private practice. At the three-month follow-up visit, factors associated with compliance included older age, suburban residence, white race, health care in the suburban private practice, payment status, prior use of contraception, mother's unawareness of oral contraceptives, married parents, older boyfriend, lack of worry about being pregnant, and satisfaction with pill use. Compliance at long-term follow-up (13.5 +/- 3.7 months) was additionally associated with educational goals, father's education level, and absence of side effects. Ten pregnancies occurred during the study period among noncompliant site I patients. Inner-city clinic patients were at high risk of noncompliance and unplanned pregnancy.

Asymptomatic bacteriuria in adolescent girls: II. Screening methods.

Of 500 asymptomatic adolescent girls who were screened for bacteriuria by three methods-dipslide (Uricult), dipstrip (Microstix-3 reagent strips), and home nitrite test (Microstix-Nitrite reagent strips)-eight cases (1.6%) were detected: 6/8 by dipslide and dipstrip; 5/8 by nitrite testing. The false-positive-rate (greater than 10(4) colonies/ml) of the dipslide test was 6.4%, and the dipstrip test, 2.8%. A history of vaginal discharge was not associated with "contaminated" specimens. False-positive nitrite tests were reported by 0.6% of the patients who returned the postcards. Overall, 70.4% of the patients returned the postcards for the home nitrite test. The patients were divided by method of payment (Medicaid vs non-Medicaid) in order to provide an approximation of socioeconomic status; non-Medicaid patients were significantly more likely to return postcards than Medicaid patients (75.8% vs 63.7%). Of the group reporting previous urinary tract infection, 79% of both Medicaid and non-Medicaid patients returned postcards, suggesting that a prior experience with the diagnosis increased compliance with a home test.