Type 2 Diabetes in High-risk Youth: Improving Identification and Interventions in Community Health with a Decade of Quality Improvement Efforts.

INTRODUCTION: This manuscript describes quality improvement interventions with aims (1) to increase identification and follow-up testing of youth with prediabetes and type 2 diabetes (T2D) and (2) to improve outcomes for youth with prediabetes and low-range T2D (HbA1c 6.5-6.9%). METHODS: Interventions included (a) dissemination of evidence-based guidelines and (b) creation of in-house weight management (WM) programs and programs to increase prediabetes follow-up testing and T2D self-management. Data from the electronic health record are presented. RESULTS: Between 2009-2020, T2D screening for obese youth increased from 24% to 76%. Two WM programs served 2,726 unique youth for 11,110 billable visits. Youth with prediabetes seen in WM clinic had a lower risk of developing T2D if they attended three or more visits. Teaching self-monitoring blood glucose showed promise for improving HbA1c outcomes in youth with low-range T2D. CONCLUSIONS: Interventions have increased identification, access to preventive services, and treatment for youth with prediabetes and T2D.

Improving Blood Pressure Accuracy in the Outpatient Adolescent Setting.

INTRODUCTION: Hypertension (HTN) is increasing in the pediatric population, and hypertensive children become hypertensive adults. Blood pressure (BP) is often overlooked due to factors including distrust in readings, lack of time in visits, and discomfort prescribing antihypertensive medications. The objective of our multistage, clinically based quality improvement project was to improve BP measurement and HTN diagnosis and intervention in adolescents. METHODS: Study investigators performed interventions in an adolescent medicine clinic at Children's Hospital Colorado (ages 12-24 years), which included equipment inventory, mapping clinic processes, manual/automated BP training for staff, education of faculty/staff on guidelines, and creation/implementation of updated best practice alerts (BPAs) based on age-appropriate guidelines for stage 1, 2 HTN in patients younger/older 18years. RESULTS: With equipment updates, medical assistant manual BP certifications, educational sessions for faculty/staff, and creation of a BPA with instruction before the go-live date, confidence in using automated and manual BP measurements increased for faculty/staff. The number of unique patient visits presenting with elevated BPs decreased significantly in the postintervention period reflecting the education/training. Staff used the new order set minimally, but there was an increase in correct diagnoses of elevated BP and laboratory workup. CONCLUSIONS: Having appropriate equipment while introducing BP guideline education in the ambulatory setting with electronic health record reminders and utility of BPAs can decrease erroneous BP values saving providers and staff encounter time. Real-time alerts can aid in accurate diagnosis rates and improved intervention for youth with elevated BP readings. Providers still inconsistently interact with order sets despite such parameters.

Feasibility and Acceptability of Accelerometer Measurement of Physical Activity in Pregnant Adolescents.

During pregnancy, physical activity relates to better maternal and child mental and physical health. Accelerometry is thought to be effective for assessing free-living physical activity, but the feasibility/acceptability of accelerometer use in pregnant adolescents has not been reported. In this short communication, we conducted secondary analysis of a small pilot study to describe the feasibility/acceptability of accelerometry in pregnant adolescents and the preliminary results of physical activity characteristics. Participants were recruited from a multidisciplinary adolescent perinatal clinic. Physical activity was assessed with wrist-worn accelerometers. Feasibility was described as median days of valid wear (≥10 h of wear/day) for the total sample and the number/percentage of participants with ≥4 days of valid wear. Sensitivity analyses of wear time were performed. Acceptability ratings were collected by structured interview. Thirty-six pregnant (14.6 ± 2.1 gestational weeks) adolescents (17.9 ± 1.0 years) participated. Median days of valid wear were 4 days. Seventeen participants (51.5%) had ≥4 days of valid wear. There were no differences in characteristics of adolescents with vs. without ≥4 days of valid wear. Twenty participants (60.6%) had ≥3 days of valid wear, 24 (72.7%) ≥2 valid days, and 27 (81.8%) ≥1 valid wear day. Acceptability ratings were neutral. Assessing physical activity with accelerometry in pregnant adolescents was neither feasible nor acceptable with the current conditions. Future research should investigate additional incentives and the potential utility of a lower wear-time criterion in pregnant adolescents.

Missed Opportunities for Discussing Contraception in Adolescent Primary Care.

BACKGROUND: Over half of adolescents are sexually active by age 18 years and represent half of sexually transmitted infections (STI). These individuals often do not obtain routine medical care, so discussing contraception at each visit becomes imperative. Our study objectives were to determine the frequency of visits before contraception was discussed/initiated, and to assess factors affecting primary care contraception provision. METHODS: A retrospective chart review (January 2009-June 2019) was conducted for preventive, follow-up, and sick visits; Title X confidential visits were excluded. Questions were asked about method at start and end of the visit. Nonparametric median tests for continuous variables and chi-squared tests for categorical variables assessed for differences for patient age, race, gender, insurance type, visit type, and provider gender. The institutional review board approved the study as exempt. RESULTS: Patients (n = 12,619; median = 15 years; 58% female) were seen in primary care clinic. Providers asked about contraception for 82% of visits, and averaged 3 visits before contraception was discussed. For patients asked about contraception, 60% were using a contraceptive method, 15% left the visit on a new method (24.9% long-acting reversible contraception [LARC]). For patients not using contraception, 39.9% left the visit on a method. Patients asked about contraception were female, older, Hispanic, had public insurance, and were seen by female providers (P < .001). Follow-up/sick visits represented <20% of patients asked about contraception. CONCLUSIONS: Multiple visits occur before contraception is discussed in adolescent primary care, and factors including age, race, and gender affect these discussions. Strategies to increase contraception discussions at all visits is essential, as adolescents do not always present for yearly visits.

Protocol for a pilot randomized controlled feasibility study of brief interpersonal psychotherapy for addressing social-emotional needs and preventing excess gestational weight gain in adolescents.

BACKGROUND: Excess gestational weight gain (GWG) in pregnant adolescents is a major public health concern. Excess GWG increases risk of pregnancy complications as well as postpartum and offspring obesity and cardiometabolic disease. Prevention interventions for pregnant adults that target lifestyle modification (i.e., healthy eating/physical activity) show insufficient effectiveness. Pregnant adolescents have distinct social-emotional needs, which may contribute to excess GWG. From an interpersonal theoretical framework, conflict and low social support increase negative emotions, which in turn promote excess GWG through mechanisms such as overeating and physical inactivity. METHODS: The current manuscript describes the design of a pilot randomized controlled feasibility trial of adolescent interpersonal psychotherapy (IPT) to address social-emotional needs and prevent excess GWG. Up to 50 pregnant, healthy adolescents 13-19y, 12-18 weeks gestation are recruited from an interdisciplinary adolescent maternity hospital clinic and randomized to IPT + usual care or usual care alone. IPT involves 6 individual 60-minute sessions delivered by a trained behavioral health clinician during 12-30 weeks gestation. Sessions include relationship psychoeducation, emotion identification and expression, and teaching/role-playing communication skills. Between sessions, adolescents are instructed to complete a daily journal and to have conversations to work on relationship goals. Outcomes are assessed at baseline, mid-program, post-program, and 3-months postpartum. Primary outcomes are feasibility and acceptability based upon rate of recruitment, session attendance, program acceptability ratings, and follow-up retention. Secondary outcomes are perinatal social functioning, stress, depression, and eating behaviors assessed with validated surveys and interviews; perinatal physical activity and sleep measured via accelerometer; GWG from measured weights; and at 3-months postpartum only, maternal adiposity by dual energy x-ray absorptiometry, maternal insulin sensitivity derived from 2-hour oral glucose tolerance testing, and infant adiposity by air displacement plethysmography. DISCUSSION: This pilot trial will address a key gap in extant understanding of excess GWG prevention for a high-risk population of adolescents. If feasible and acceptable, brief psychotherapy to address social-emotional needs should be tested for its effectiveness to address excess GWG and postpartum maternal/infant health. If effective, such an approach has potential to interrupt an adverse, intergenerational cycle of social-emotional distress, obesity, and cardiometabolic disease among young mothers and their offspring. TRIAL REGISTRATION: ClinicalTrials.gov NCT03086161, retrospectively registered.

Longitudinal follow up of dysglycemia in overweight and obese pediatric patients.

OBJECTIVE: To examine factors related to progression of dysglycemia in overweight and obese youth in a large primary care setting. RESEARCH DESIGN AND METHODS: 10- to 18-year-old youth with body mass index (BMI) > 85 percentile and first-time A1c 5.7%-7.9% (39-63 mmol/mol) were identified retrospectively through electronic medical records (EMR). Levels of dysglycemia were defined as low-range prediabetes (LRPD; A1c 5.7%-5.9% [39-41 mmol/mol]), high-range prediabetes (HRPD; A1c 6.0%-6.4% [42-46 mmol/mol]), or diabetes-range (A1c 6.5%-7.9% [48 mmol/mol]). Follow-up A1c and BMI were extracted from the EMR. Follow up was truncated at the time of initiation of diabetes medication. RESULTS: Of 11 000 youth, 547 were identified with baseline dysglycemia (mean age 14.5 ± 2.2 years, 70% Hispanic, 23% non-Hispanic Black, 7% other). Of these, 206 had LRPD, 282 HRPD, and 59 diabetes. Follow-up A1c was available in 420 (77%), with median follow up of 12-22 months depending on A1c category. At follow-up testing, the percent with diabetes-range A1c was 4% in youth with baseline LRPD, 8% in youth with baseline HRPD, and 33% in youth with baseline diabetes-range A1c. There was a linear association between BMI increase and worsening A1c for LRPD (P < .001) and HRPD (P = .003). CONCLUSIONS: Most adolescents with an initial prediabetes or diabetes-range A1c did not have a diabetes-range A1c on follow up. Moreover, prediabetes-range A1c values do not all convey equal risk for the development of diabetes, with lower rates of progression for youth with initial A1c <6%. In youth with prediabetes-range A1c, BMI stabilization was associated with improvement of glycemia.

Which Pregnant Adolescents Would be Interested in Group-Based Care, and Why?

STUDY OBJECTIVE: To determine if pregnant adolescents interested in group-based prenatal care have different demographic and psychosocial characteristics than those interested in individual prenatal care. Factors that influence the preferred model of prenatal care patients were assessed. DESIGN, SETTING, AND PARTICIPANTS: Prospective comparison of demographic and psychosocial characteristics of 153 pregnant adolescents enrolled in an adolescent-oriented prenatal and pediatric program at Children's Hospital Colorado. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pregnant study participants were queried and their preferred mode of prenatal care and reasons for that preference were examined. RESULTS: Younger (16 years and younger) and primiparous adolescents were more likely to be interested in group care. Those not interested in group-based care were more likely to smoke and wanted to be pregnant. Most participants were interested in group-based prenatal care to belong to a peer group, receive additional education and support, and to have fun. Reasons participants were not interested in group-based care included concerns about belonging to a group, preferring individual care, and experiencing logistical concerns such as scheduling conflicts, limited transportation, and childcare resources. CONCLUSIONS: Identifying which patients are interested in group prenatal care influences development of the program model and recruiting procedures, maximizing the effectiveness of the program by offering services based on patient needs. Identifying factors that influence patients' prenatal care choices enables providers to offer support to reduce barriers to participation and structure care that is best suited to patients willing to commit to and engage in the program.

Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion.

OBJECTIVE: Induction of fetal demise via transabdominal injection has been used to facilitate second-trimester abortion but requires a second procedure and has associated risks. The method of amniotomy, cord transection and documentation of fetal asystole immediately prior to dilation and evacuation (D&E) is an alternative approach; however, characteristics of this method have not been described. STUDY DESIGN: This descriptive report from a single center involves a large case series of D&Es ranging from 16 to 23 weeks of gestation. Umbilical cord transection (UCT) was attempted immediately prior to D&E in 407 cases, which were reviewed to determine success, time to fetal asystole and complications. RESULTS: Both UCT and asystole were achieved in 100% of cases. Mean time from UCT to asystole was 3.35±2.11 min. When compared to cases performed at less than 20 weeks of gestation, mean time to asystole was slightly longer in the ≥20-week group (3.7±2.4 min vs. 3.1±1.9 min; p=.008). Few patients had minor (4.6%) or major (0.3%) complications; time to asystole was not associated with complications. CONCLUSIONS: Umbilical cord transection immediately prior to D&E is a feasible, efficacious and safe way to induce fetal demise without performing additional procedures. IMPLICATION STATEMENT: This study demonstrates the feasibility, effectiveness and safety of utilizing umbilical cord transection to induce fetal demise in a large cohort. This method is an alternative to other feticidal procedures.

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE: The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion. STUDY DESIGN: Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined. RESULTS: Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03). CONCLUSION: IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.