Is there an increased clinical severity of patients with eating disorders under managed care?

OBJECTIVES: We sought to examine possible differences in medical status at presentation in 1996, compared to 1991, of adolescents with eating disorders (EDs) at a hospital-based multidisciplinary care program to reflect the increasing market penetration of managed care. DESIGN: Charts were reviewed for all new patients scheduled in a hospital-based outpatient ED program in 1996 and 1991. The 92-item standardized data extraction form included information on demographics, indicators of illness severity at the first visit, and subsequent hospitalization. The need for primary care referral was verified using billing records. Data were analyzed with Student's t-test, Chi-square, Fisher's exact, and Mann-Whitney U tests using SPSS 7.5. RESULTS: Of the 153 total patients, 133 kept their intake appointment and 130 (98%) of these had charts available for review. The age, racial/ethnic characteristics, and average length of disordered eating behaviors were not significantly different over the 5-year period. Referral from a primary care clinician was more commonly required in 1996 than 1991 (59% vs. 11%; p < .0001). Eighteen percent of the patients seen in 1996 were admitted from the initial appointment for medical stabilization, compared to 1.5% in 1991 (p = .002). Comparing 1996 to 1991, a similar number of patients had symptoms consistent with anorexia nervosa, whereas fewer patients in 1996 gave a history of bingeing and purging (22% vs. 40%; p = .027). There were no significant differences in indicators of illness severity, treatment by primary care clinician prior to referral, or hospitalization rates for those patients with and without managed care. CONCLUSIONS: Patients in 1996 were more likely to require referrals, were less likely to have symptoms consistent with bulimia nervosa, and were more likely to be admitted for medical stabilization. There were no differences in patient presentation characteristics or initial hospitalization rates based on their managed care status. Further research is needed to investigate the changes in illness severity at presentation and to assess the role that managed care plays in the treatment of patients with eating disorders.

Chlamydia trachomatis screening in the adolescent population.

Advances in the development of highly sensitive tests for Chlamydia trachomatis offer new options for screening and testing in adolescents. The availability of nucleic acid amplification technologies may make noninvasive urine testing available for young men and for young women when a gynecologic examination is not otherwise required. Accurate detection of asymptomatic chlamydial disease in a timely, cost-effective, and noninvasive manner as well as development of effective partner treatment strategies remain important challenges. This review provides a clinical update on office-based testing for C. trachomatis, management, and treatment options for the adolescent and young adult population.

Intentions to use violence among young adolescents.

OBJECTIVE: Frequent violent behavior among adolescents has been found to be associated with previous exposure to violence, personal victimization, depression, hopelessness, and older age. Although young adolescents engage in less severe violent behavior than older adolescents, their perceived normative expectations to use violence to resolve conflicts may already be established by early adolescence. This study examined the influence of exposure to violence, depression, church attendance, multiple drug use, and demographic variables on young adolescents' intentions to use violence to resolve conflict. METHODS: Young adolescents (N = 225, males = 49.4%, black = 88.7%, mean age = 12.9 +/- 1 years) in two middle schools serving low-income and working-class communities were administered a previously tested anonymous questionnaire. They were also asked how they would resolve conflict in 15 different hypothetical situations. Each situation had 10 possible responses ranging from humor or avoidance to severe violence (eg, use of a gun). The Intentions to Use Violence in Hypothetical Situations Scale had a high internal reliability (alpha = .88) and was correlated (r = .46) at the expected level for this age group with a standardized use of violence and weapon-carrying scale. RESULTS: The Intentions to Use Violence in Hypothetical Situations Scale was significantly correlated with age (r = .17), school grade (r = .14), lower church attendance (r = -.23), frequency of smoking (r = .24), alcohol use (r = .37), marijuana use (r = .36), crack cocaine use (r = .14), smokeless tobacco use (r = .20), injecting drug use (r = .16), depression (r = .12), and exposure to violence (r = .48). Based on multiple regression analysis, exposure to violence, marijuana use, frequency of church attendance, alcohol use, cocaine use, and tobacco use accounted for 36.6% of the variation in the Intentions to Use Violence in Hypothetical Situations Scale. CONCLUSION: Although the intention to use violence was associated with previous exposure to violence and current drug use, adolescents who attended religious services more often were less likely to report that they would use violence to resolve interpersonal conflict.

Primary care experiences and preferences of urban youth.

There are few qualitative studies that assess the experiences and preferences of urban youth with regard to use of primary care. The purpose of this pilot survey was to identify positive and negative influences and underlying issues for adolescents leading to seeking and returning for primary health care. Four focus groups totaling 20 diverse adolescents ranging in age from 13 to 21 years were conducted between April 1994 and June 1994. Participants were recruited through existing peer leadership groups that meet regularly at community health centers or afterschool programs. Urban adolescents are most concerned with being respected and treated well by primary care providers. They want to be listened to, to have their problems taken seriously, and to be treated with dignity and respect. Participants expressed strong preferences regarding sex, sexual orientation, and language of providers, but not for race or ethnicity. Qualitative methods such as focus groups give a voice to youth to advocate for access to adolescent-specific health services. Further research is needed to corroborate the results of this study, to expand our understanding of existing problems, and to investigate the predictors of health care use by vulnerable youth.

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.

Contraceptive choices for adolescents.

PIP: Because unintended pregnancy rates are 50-85% lower in European countries than in the US, there is great need to provide contraceptive choices to adolescents. In this context, there is discussion of confidential and comprehensive service requirements, the recommended medical care of the sexually active adolescent, the most effective protection with hormonal agents, the importance of barrier methods for sexually transmitted disease (STD) protection, and other choices for special groups. It is concluded that providers must obtain a confidential sexual history and discuss birth control and STD protection with adolescent patients: 50% of the 15-19 year old population are sexually active. Emphasis should be on the safety of the preventive methods available and the benefit of reducing the morbidity and mortality associated with early pregnancy. Abstinence and delay in sexual activity as the only complete protection needs to be communicated. Families need to be reassured that contraceptive counseling does not increase sexual activity or the number of partners, but education and comprehensive services reduce the adolescent pregnancy rate. Sociodemographic inequalities need attention also, but service providers are not able to do whole life counseling. Continuation of chosen methods is linked to frequent follow up, involvement of both partners, reducing barriers to appointments and information seeking, and personalized anticipatory guidance. Pediatricians can identify high risk patients. Rapid screening tests are important in early identification of pregnancy and patients need to know nonjudgementally the options available. Oral pills provide the most effective contraception, and latex condoms are needed to reduce exposure to viral and bacterial infections. However, with pill use there is still a 6-12/100 women years pregnancy rate for adolescents. Low-dose combined pills have the least reported side effects and their use may help the discontinuation rate due to side effects. In the future, the female condom with a spermicide may provide the simplest and most effective contraception and STD protection. For those who have difficulty with compliance, progesterone implants may be helpful. The life-long repercussions of early pregnancy and STDs required the involvement of providers, teachers, peers, and families.^ieng

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.