Adolescent utilization of eating disorder higher level of care: roles of family-based treatment adherence and demographic factors.

BACKGROUND: Outpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system. METHODS: This retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index. RESULTS: 2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites. CONCLUSIONS: Reported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.

Adolescents with restrictive eating treated by Family-Based Treatment (FBT) teams had better early weight gain but no differences in the use of intensive outpatient, residential, partial hospital programs or inpatient psychiatry care when compared to those treated by teams with a low adherence to the FBT approach. Factors such as sex, race, ethnicity, mood disorders, and suicidality were associated with the use of psychiatric services. These findings are consistent with previously documented systematic disparities in accessing psychiatric services across patient demographics and should be used to inform the development of proposed care models that are more inclusive and accessible to all patients.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative.

OBJECTIVE: To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative. METHODS: A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic. RESULTS: Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds. DISCUSSION: A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Incidence and Medical Hospitalization Rates of Patients With Pediatric Eating Disorders.

Objective Eating disorders typically onset in preadolescence and adolescence and cause negative mental and physical health sequelae over the life span. This study examined the incidence and medical hospitalization rates of pediatric eating disorders in an integrated health system in the United States. Methods This retrospective cohort study examined 4883 Kaiser Permanente Northern California members 8-18 years of age with an eating disorder diagnosis from January 2015 to June 2019. Medical hospitalizations include admissions at any of the 13 Kaiser Permanente Northern California hospitals with a primary or secondary eating disorder diagnosis. Results Incidence rates ranged between 177 and 205 per 100,000 adolescents per year. More than half the adolescents were non-White: 10.8% Asian, 4.3% Black, 26.7% Hispanic/Latinx, 8.4% multiracial, 0.3% Native American/Alaskan Native, and 0.5% Native Hawaiian/Pacific Islander. Thirteen percent had a body mass index (BMI) below the 5th percentile, 61.8% had a BMI between the 5th and the 84th percentiles, 19.7% had a BMI above the 85th percentile, and 5.6% had an unknown BMI. During the 12-month follow-up period, 5.4% of adolescents had medical hospitalizations. Conclusions This study adds to the evidence that eating disorders affect children/adolescents across all weight/BMI ranges and racial/ethnic backgrounds. Future studies call for exploration on treatment strategies that tailor to the diverse populations.

Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth.

PURPOSE: To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. METHODS: Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. RESULTS: BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. CONCLUSIONS: SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.

Screening for Gender Identity in Adolescent Well Visits: Is It Feasible and Acceptable?

PURPOSE: This study aimed to pilot systematic gender identity screening during adolescent well checks and examine perceptions of feasibility and acceptability of screening from adolescents, parents/guardians, and clinicians. METHODS: Adolescents aged 12-18 years with a well visit between July 1, 2018, and June 30, 2019 (n = 134,114; 817 pilot and 133,297 usual care) in Kaiser Permanente Northern California (KPNC) pediatric primary care clinics. "What is your gender?" was added to the previsit questionnaire in pilot clinics; all other KPNC clinics provided usual care. Additional anonymous surveys were administered to adolescents and parents/guardians in the pilot clinics and to all KPNC pediatric clinicians. Multivariable logistic regression examined associations between clinics and patients reporting as transgender and gender diverse (TGD). Descriptive statistics summarized patient, parent/guardian, and clinician perceptions of gender identity screening. RESULTS: Adjusting for age and race/ethnicity, adolescents had higher odds of reporting as TGD in pilot clinics than in usual care (odds ratio = 6.91, 95% confidence interval = 3.76-12.74). Two thirds of adolescents, 75.5% of parents/guardians, and 92.5% of clinicians felt it was important to screen for gender identity in primary care. Less than 2% of adolescents found the question confusing, offensive, or uncomfortable, and 2.8% of parents/guardians felt it was offensive. In addition, 36.4% of clinicians and 3.6% of parents/guardians were concerned it would affect visit workflow/time. CONCLUSIONS: Most adolescents, parents/guardians, and pediatric clinicians viewed systematic gender identity screening as both feasible and acceptable. Standardized gender identity screening during adolescent well checks could facilitate and increase identification of TGD adolescents and the delivery of gender-affirming care for adolescents and families in need.

Identification of Sexual Minority Youth in Pediatric Primary Care Settings Within a Large Integrated Healthcare System Using Electronic Health Records.

PURPOSE: The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire. METHODS: This study assessed SMY status in youth aged 12.5-18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as self-reported attraction to the same sex or both sexes. RESULTS: A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n = 5,329) of respondents (N = 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6-2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth. CONCLUSIONS: This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.

Improvement in preventive care of young adults after the affordable care act: the affordable care act is helping.

IMPORTANCE: The 2010 Affordable Care Act (ACA) included expansion of insurance coverage for young adults and improved access to preventive care. OBJECTIVE: To examine the ACA's initial effects on young adults' receipt of preventive care. DESIGN, SETTING, AND PARTICIPANTS: Secondary data analysis using a pre-post design that compared health care use by young adults (aged 18 to 25 years) from 2009 and 2011 Medical Expenditure Panel Surveys. Data were collected through computer-assisted personal interviews of a nationally representative sample of the noninstitutionalized US population. MAIN OUTCOMES AND MEASURES: Differences by year in rates of receiving a routine examination in the past year, blood pressure screening, cholesterol screening, influenza vaccination, and annual dental visit. Three logistic regression models were developed to (1) compare pre-ACA (2009) and post-ACA (2011) rates of receiving preventive care and (2) determine if post-ACA increases in insurance coverage accounted for changes in preventive care rates. Model 1 was a bivariate model to determine differences in preventive care rates by year; model 2, a multivariable model adding insurance status (full-year private, full-year public, partial-year uninsured, and full-year uninsured) to determine whether insurance accounted for survey year differences; and model 3, a multivariable model adding covariates (usual source of care and sociodemographic variables) to determine whether they further accounted for differences by survey year or insurance status. RESULTS: After ACA, young adults had significantly higher rates of receiving a routine examination (47.8% vs. 44.1%; P < .05), blood pressure screening (68.3% vs. 65.2%; P < .05), cholesterol screening (29.1% vs. 24.3%; P < .001), and annual dental visit (60.9% vs. 55.2%; P < .001) but not an influenza vaccination (22.1% vs. 21.5%; P = .70). Full-year private insurance coverage increased (50.1% vs. 43.4%; P < .001), and rates of lacking insurance decreased (partial-year uninsured, 18.4% vs. 20.7%; P = .03; and full-year uninsured, 22.2% vs. 27.1%; P < .001). Full-year public insurance rates remained stable (9.4% vs. 8.8%; P = .53). Insurance status fully accounted for the pre- and post-ACA differences in routine examination and blood pressure screening and partially accounted for year differences for cholesterol screening and annual dental visits. Covariate adjustment did not affect year differences. CONCLUSIONS AND RELEVANCE: The ACA provisions appear to increase insurance coverage and receipt of preventive services among young adults. Further studies are needed to replicate these findings as other ACA provisions are implemented.

Young adults' health care utilization and expenditures prior to the Affordable Care Act.

PURPOSE: To examine young adults' health care utilization and expenditures prior to the Affordable Care Act. METHODS: We used 2009 Medical Expenditure Panel Survey to (1) compare young adults' health care utilization and expenditures of a full-spectrum of health services to children and adolescents and (2) identify disparities in young adults' utilization and expenditures, based on access (insurance and usual source of care) and other sociodemographic factors, including race/ethnicity and income. RESULTS: Young adults had (1) significantly lower rates of overall utilization (72%) than other age groups (83%-88%, p < .001), (2) the lowest rate of office-based utilization (55% vs. 67%-77%, p < .001) and (3) higher rate of emergency room visits compared with adolescents (15% vs. 12%, p < .01). Uninsured young adults had high out-of-pocket expenses. Compared with the young adults with private insurance, the uninsured spent less than half on health care ($1,040 vs. $2,150/person, p < .001) but essentially the same out-of-pocket expenses ($403 vs. $380/person, p = .57). Among young adults, we identified significant disparities in utilization and expenditures based on the presence/absence of a usual source of care, race/ethnicity, home language, and sex. CONCLUSIONS: Young adults may not be utilizing the health care system optimally by having low rates of office-based visits and high rates of emergency room visits. The Affordable Care Act provision of insurance for those previously uninsured or under-insured will likely increase their utilization and expenditures and lower their out-of-pocket expenses. Further effort is needed to address noninsurance barriers and ensure equal access to health services.

Receipt of preventive health services in young adults.

PURPOSE: To examine self-reported rates and disparities in delivery of preventive services to young adults. METHODS: A population-based cross-sectional analysis, of 3,670 and 3,621 young adults aged 18-26 years who responded to California Health Interview Survey (CHIS) in 2005 and CHIS 2007, respectively. The main outcome measures were self-reported receipt of flu vaccination, sexually transmitted disease (STD) screening, cholesterol screening, diet counseling, exercise counseling, and emotional health screening. Multivariate logistic regression was used to examine how age, gender, race/ethnicity, income, insurance, and usual source of care influence the receipt of preventive services. RESULTS: Delivery rates ranged from 16.7% (flu vaccine) to 50.6% (cholesterol screening). Being female and having a usual source of care significantly increased receipt of services, with female participants more likely to receive STD screening (p < .001), cholesterol screening (p < .01), emotional health screening (p < .001), diet counseling (p < .01), and exercise counseling (p < .05) than male participants after controlling for age, race/ethnicity, income, insurance, and usual source of care. Young adults with a usual source of care were more likely to receive a flu vaccine (p < .05), STD screening (p < .01), cholesterol screening (p < .001), diet counseling (p < .05), and exercise counseling (p < .05) than those without a usual source of care after adjusting for age, race/ethnicity, income, and insurance. CONCLUSIONS: Rates of preventive services delivery are generally low. Greater efforts are needed to develop guidelines for young adults to increase the delivery of preventive care to this age-group, and to address the gender and ethnic/racial disparities in preventive services delivery.