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.

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.

Long-term consequences of adolescent health behaviors: implications for adolescent health services.

The authors discuss the evidence supporting the effectiveness of adolescent preventive services to influence health outcomes, the magnitude of the long-term consequences of adolescent health-compromising behaviors, and their implications for health policies. Particular attention is given to the contribution that behaviors participated in or begun during adolescence have on long-term health, including cancer and heart disease. They postulate the health benefits that might accrue from the widespread implementation of comprehensive adolescent preventive services, assuming a conservative estimate of effectiveness, could be significant.

Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent preventive services.

OBJECTIVE: To evaluate a low-cost strategy for providing preventive health services to adolescents using computerized health assessments with individualized educational videos, trained health counselors, and nurses. DESIGN: Feasibility study, cost analysis, and comparative evaluation of health problems identified, guidance delivered, and patient satisfaction. SETTING: Eleven sessions at nontraditional sites including schools, universities, shopping malls, and after-hours clinics on Oahu, Hawaii. PARTICIPANTS AND INTERVENTION: Adolescents (N=258, mean age 17 years) completed confidential computerized health assessments, received individualized feedback, and viewed automatically selected educational videos on a laptop computer. The computer additionally printed a prioritized problems list for the graduate student-level health counselor to review with the adolescent. The counselor subsequently reviewed each encounter with a nurse-educator who performed further counseling and physical examinations when indicated. RESULTS: Visit length averaged 44 minutes. Subjects spent an average of 21 minutes completing the automated health assessment and viewing interactive multimedia and 15 minutes with the health counselor. One third of subjects required further evaluation and counseling by the nurse (average, 8 minutes). A team of 2 counselors and 1 nurse provided comprehensive screening, health counseling, and physical examinations to 1 patient every 10 minutes at a salary cost of $7.46 per visit. This model identified risk behaviors at levels consistent with local behavioral data, and addressed and documented them significantly more often than do physicians in traditional settings. Subjects (71%) preferred the computer-assisted visits to standard office visits, and 92% felt the amount of time spent was acceptable. CONCLUSIONS: Computer-assisted delivery of adolescent preventive services using nonphysician health counselors is a feasible, economical, and acceptable alternative to traditional clinical practice for screening young people for health-compromising behaviors and providing individualized health education and routine physical examinations. This model would likely increase adolescents' access to needed preventive services at a very modest cost.

Health counseling in adolescent preventive visits: effectiveness, current practices, and quality measurement.

Most morbidity and mortality among adolescents results from their participation in health-compromising behaviors. Recent guidelines for clinical adolescent preventive services recommend that primary care clinicians routinely screen for and counsel adolescents about these behaviors, identify and address related social, psychological, and biologic factors. Office-based counseling can influence adult health behaviors, but little is known about the effectiveness of office-based counseling for adolescents. In this review we: (a) evaluate available information about the effectiveness of office-based health counseling to improve outcomes; (b) report what is known about the health counseling adolescents receive from primary care clinicians; and (c) critically review different approaches that have been, or might be, used to measure the content and quality of health counseling provided during adolescent medical visits. With the emphasis on accountability in the current health care environment, evidence supporting the effectiveness of counseling is needed to justify investment in this aspect of clinical adolescent preventive services. Challenges to studying the effectiveness of health counseling include the lack of well-defined theory-based models for adolescent office-based counseling, the complexity of measuring counseling quality, and the many factors that influence adolescent outcomes. Reliable and valid measures of counseling quality are needed both to study and to ensure the quality of counseling received by adolescents. No single measure can be expected to fully capture counseling quality, although patient self-report deserves further development.

The role of community health centers in providing preventive care to adolescents.

OBJECTIVES: To (1) compare preventive health visits by poor and nonpoor adolescents, (2) describe adolescent users of community health centers (CHCs), (3) investigate adolescent preventive visits to CHCs, and (4) determine factors independently associated with timely preventive visits. DESIGN: Analysis of the nationally representative sample of 6635 adolescents aged 11 to 17 years in the Child Health Supplement to the 1988 National Health Interview Survey. RESULTS: Overall, 4% of US adolescents used CHCs for routine health care, and the percentage was higher for poor compared with nonpoor adolescents (11% vs 3%, P < .01). Although CHC users were more likely to be poor (41% vs 10%, P < .001), uninsured (23% vs 10%, P < .001), and to have behavior (16% vs 9%, P = .02) and school problems (56% vs 43%, P < .001), they were as likely to have had timely preventive visits (83% vs 81%, P = .61) as adolescents who used private practices. Using logistic regression, timely adolescent preventive visits were independently associated with having a source for routine care (odds ratio, 4.1; 95% confidence interval, 3.3-5.2), a chronic health condition (odds ratio, 1.2; 95% confidence interval, 1.0-1.5), and the use of seat belts all or most of the time (odds ratio, 1.4; 95% confidence interval, 1.2-1.6), but no independent association was observed between poverty status and timely preventive visits. CONCLUSIONS: Community health centers are an important source of preventive care for impoverished adolescents. Although those who use CHCs have greater psychosocial problems, they seek preventive care as regularly as those using private practices. Thus, periodic comprehensive visits may be an effective strategy for CHCs to provide preventive services to adolescents.

Preventive health care for teenagers and young adults.

Risk-taking behaviors are the major source of morbidity among adolescents. The authors discuss risk reduction through preventive activities. An approach is offered to structure preventive visits for this age group given the time and financial constraints of providers.

Thrombocytopenia with absent radii. A review of 100 cases.

The syndrome of thrombocytopenia with absent radii (TAR) is a rare congenital syndrome in which the characteristic hematological findings are hypomegakaryocytic thrombocytopenia, periodic leukemoid reactions, and eosinophilia. The thrombocytopenia usually presents at birth or during the neonatal period and may be profound, accounting for significant morbidity. However, resolution of the thrombocytopenia usually occurs after the first year. In this review of 100 cases, the clinical manifestations, pathophysiology, genetics, and treatment are discussed in detail. With the increased understanding of the natural history and pathophysiology of the hypomegakaryocytic thrombocytopenia in the TAR syndrome, in conjunction with the advances in supportive therapy discussed, the outlook for patients with this syndrome has become quite good.