- Email: [email protected]
44: Risk assessment in adolescent primary care
Abstracts / 38 (2006) 112–136
Purpose: Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV is a multimedia interactive health communication tool designed to increase sexual risk assessment and risk reduction counseling provided in clinical settings. The purpose of this study was to explore patient and staff perceptions of CARE. The specific objectives were to evaluate CARE tool usability and perceived strengths and limitations. Methods: Study Design: Mixed method qualitative non-random design utilizing participant observation and in-depth interviews with patient users and focus groups with clinic staff. Setting: Data were collected from six clinics in three states (a Planned Parenthood, a teen clinic, two STD clinics, a mobile van clinic and an urgent care clinic). Participants: Patient users were selected by non-random, convenience sampling. Eligible for inclusion if ⬎18, able to understand spoken English (n⫽63 participants). Staff were selected for focus groups by purposive sampling to obtain cross section clinical roles (6 focus groups, n⫽48). Data were managed using Atlas.ti. Grounded theory guided analysis. Inter-rater reliability was 0.90. Results: Users were 58% nonwhite, with a mean age of 27 (53% of users were ⬍25). Patients were able to use CARE with minimal to no assistance, especially the under 25 population. Time for session completion averaged 30.6 minutes. CARE usefulness rated 8.2 on ascending utility scale of 0 to 10. Key usability issues related to tablet computer format, navigation controls, question format, and programming errors. Patient themes raised as strengths were perceptions of novelty, simplicity, confidentiality, personalization and plan development. Patients reported an increased willingness to be honest, and perceived a lack of judgment when using the computer format. Patients acknowledged a unique opportunity for self-evaluation. Staff themes raised as strengths were perceived opportunity for enhanced data collection, customization of handouts, standardization of education, behavioral priming, and expansion of services. Patient themes raised as limitations included perceived limited flexibility and response choices, lack of personal touch, accuracy and redundancy. Staff themes raised as limitations were selecting users, cost, conflict with patient-provider role, privacy, and time for use. Conclusion: This pilot study showed CARE to be wellreceived and easily usable by the majority of patients (especially 18-25 year olds). Specific usability issues were addressed by developers with modifications to the software. Patient and staff perceptions support the use of CARE as an adjunct to the usual practice in a clinical setting and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to lead to increased self-evaluation which may prove an important component in moving patients forward in the process of behavior change.
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Support: Small Business Innovations Research Phase II grant from CDC, STD Behavioral Interventions Research Branch; and NIH Center for AIDS Research New Investigator Award P30 AI27757. 44. RISK ASSESSMENT IN ADOLESCENT PRIMARY CARE: ARE WE ALL ASKING THE SAME QUESTIONS? Jane Chang, M.D.*, Linda Juszczak, DNSc, MPH, CPNP, Elizabeth M. Alderman, M.D. *Dept. of Pediatrics, New YorkPresbyterian Hospital/Weill Cornell Medical College, New York, NY, Dept. of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY.
Background: Adolescents’ health risks are primarily behavioral in nature and potentially preventable. Five nationally recognized guidelines all agree that providers should be screening adolescent patients for a variety of high risk behaviors. Several studies have shown that many pediatricians feel uncomfortable addressing adolescent issues and do not screen adolescents for risky situations or behaviors. Purpose: To determine if there is a difference in risk assessment among family medicine (FM), general pediatrics (PED), internal medicine (IM), and obstetrics/gynecology (OB) practitioners who care for adolescents in a primary care network at a large urban medical center that sees over 40,000 adolescents ages 13-21 each year. Methods: An anonymous, self-administered questionnaire was distributed to all providers at all of the multiple ambulatory care sites of an urban medical center. Providers self-identified as FM, PED, IM, or OB. Providers were asked if they routinely screen their adolescent patients for 10 listed emotional/behavioral risk factors. SPSS was used to determine frequencies and compare responses by medical specialty. Results: 156 of the 255 identified providers returned the questionnaire (61% response rate). Of the 156 who responded, 22% were FM, 35% PED, 36% IM, and 7% OB. 63% were female and 66% Caucasian. The mean age was 47 years (28-77), and the mean number of years post-training was 17 (1-43). There were no significant demographic differences among the 4 medical specialties. Nearly all of the providers in each of the specialties routinely screen adolescents for sexual activity (97%), tobacco (98%), and drug/alcohol use (97%). Fewer screen for depression/ suicidal ideation (82%), family problems (75%), and school problems (74%). Even fewer screen for peer problems (64%), physical/sexual abuse (64%), violence (58%), and eating disorders (57%). Examining differences by specialty area, FM and PED were overall more likely to screen for the listed emotional and behavioral risk factors compared with IM and OB. In particular, PED was significantly more likely to screen for eating disorders (p⫽0.011), and FM was significantly more likely to screen for physical/sexual abuse and violence compared with the other specialties (p⫽0.002 and p⫽0.003, respectively). Both IM and OB were
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significantly less likely to screen for school problems, family problems, or peer problems (p⫽0.000 for all). Conclusions: Nearly all providers are routinely screening adolescent patients in the areas of sexual activity, tobacco, and drug/alcohol use. Fewer providers are screening for depression, eating disorders, school problems, physical/ sexual abuse, violence, and family or peer problems. Of the ones who do screen in these areas, disproportionate numbers are in FM or PED, as compared to IM or OB. To achieve the goals set forth by Healthy People 2010, more training and education may be needed among all disciplines who care for adolescents in the importance of performing a complete risk assessment during primary care visits. Support: NICHD Grant # 1 R13 HD049226-01. 45. ADOLESCENTS’ ACCESS TO HEALTH CARE Jonathan D. Klein, MD, MPH, Randall K. Thomas. Division of Adolescent Medicine, University of Rochester, and Harris Interactive, Rochester, NY.
Purpose: Access to health care for adolescents requires the identification, and use, of a usual source of care, as well as the availability and delivery of confidential services. Methods: We examined parents’ reports of the care received by their adolescent children, including reported usual sources of care, last routine health care (well) visit, unmet needs, and whether parents knew if their adolescents’ care included an opportunity for confidential, 1-on-1 interactions. We surveyed a stratified quota-based sample of 12,370 respondents from the Harris Poll Online in 2005. Data were weighted to be representative of the population of U.S. adults ⱖ18 years old, using demographics (sex, age, education, race and ethnicity) and several variables representing the propensity of an individual respondent to be online and to respond to a particular survey. Results: Of 12,370 adults surveyed, 2,007 (16.2%) reported having one or more adolescent children ages 13 to 18. Most parents reported their adolescents’ usual source of primary
care was in a doctor’s office or clinic, although the proportion reporting these sources declined with increasing age (86.4% for 13-14 year olds, 82.5% for 15-16 year olds, 80.8% for 17-18 year olds; p ⫽ 0.03). Parents of older adolescents were also more likely to report their adolescent used school based health clinics or family planning services; a decreasing proportion reported using school nurses. Many (77.8%) parents reported that their adolescents’ last routine health care visit was within the past 12 months, and an additional 10.8% reported having a well visit within 24 months. Older adolescents were also more likely to have received confidential care. Parents reported that 41.0% of 13-14 year olds, 44.7% of 15-16 year olds, and 60.7% of 17-18 year olds had a private, 1-on-1 talk with their clinician in the past year (p⬍0.001). The proportion whose parents reported they did not know whether a confidential discussion occurred was 12.5% for 13-14 year olds, 17.2% for 15-16 year olds, and 10.4% for 17-18 year olds (p⬍0.001). Overall, 10.7% of parents reported their teen had an unmet health care need, and only 5.0% reported not knowing if their adolescent had an unmet need. Parents of older adolescents were more likely to report their adolescent had unmet health care needs than were parents of younger children (7.6% for 13-14 year olds, 8.7% for 15-16 year olds, and 14.6% for 17-18 year olds, p⬍0.001). By parent report and controlled for age, adolescents who had an opportunity for private, 1-on-1 discussion were no more likely to report unmet health care needs than those who had not have private visits (12.0% versus 9.4%; F ⫽5.96, p⫽0.08). Conclusions: Adolescent’s usual care sources and care patterns change over time and receipt of confidential care increases with age. While parental reports may not reflect all of the services that an adolescent receives, most parents are aware of their teenagers’ care use patterns and know whether or not their adolescent has had an opportunity for one-on-one, private time with their clinician. Many opportunities exist for additional improvements in the quality of adolescent health care. Support: Supported in part by grant ATPM TS-1072 from the Centers for Disease Control and Prevention.
Purpose: Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV is a multimedia interactive health communication tool designed to increase sexual risk assessment and risk reduction counseling provided in clinical settings. The purpose of this study was to explore patient and staff perceptions of CARE. The specific objectives were to evaluate CARE tool usability and perceived strengths and limitations. Methods: Study Design: Mixed method qualitative non-random design utilizing participant observation and in-depth interviews with patient users and focus groups with clinic staff. Setting: Data were collected from six clinics in three states (a Planned Parenthood, a teen clinic, two STD clinics, a mobile van clinic and an urgent care clinic). Participants: Patient users were selected by non-random, convenience sampling. Eligible for inclusion if ⬎18, able to understand spoken English (n⫽63 participants). Staff were selected for focus groups by purposive sampling to obtain cross section clinical roles (6 focus groups, n⫽48). Data were managed using Atlas.ti. Grounded theory guided analysis. Inter-rater reliability was 0.90. Results: Users were 58% nonwhite, with a mean age of 27 (53% of users were ⬍25). Patients were able to use CARE with minimal to no assistance, especially the under 25 population. Time for session completion averaged 30.6 minutes. CARE usefulness rated 8.2 on ascending utility scale of 0 to 10. Key usability issues related to tablet computer format, navigation controls, question format, and programming errors. Patient themes raised as strengths were perceptions of novelty, simplicity, confidentiality, personalization and plan development. Patients reported an increased willingness to be honest, and perceived a lack of judgment when using the computer format. Patients acknowledged a unique opportunity for self-evaluation. Staff themes raised as strengths were perceived opportunity for enhanced data collection, customization of handouts, standardization of education, behavioral priming, and expansion of services. Patient themes raised as limitations included perceived limited flexibility and response choices, lack of personal touch, accuracy and redundancy. Staff themes raised as limitations were selecting users, cost, conflict with patient-provider role, privacy, and time for use. Conclusion: This pilot study showed CARE to be wellreceived and easily usable by the majority of patients (especially 18-25 year olds). Specific usability issues were addressed by developers with modifications to the software. Patient and staff perceptions support the use of CARE as an adjunct to the usual practice in a clinical setting and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to lead to increased self-evaluation which may prove an important component in moving patients forward in the process of behavior change.
135
Support: Small Business Innovations Research Phase II grant from CDC, STD Behavioral Interventions Research Branch; and NIH Center for AIDS Research New Investigator Award P30 AI27757. 44. RISK ASSESSMENT IN ADOLESCENT PRIMARY CARE: ARE WE ALL ASKING THE SAME QUESTIONS? Jane Chang, M.D.*, Linda Juszczak, DNSc, MPH, CPNP, Elizabeth M. Alderman, M.D. *Dept. of Pediatrics, New YorkPresbyterian Hospital/Weill Cornell Medical College, New York, NY, Dept. of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY.
Background: Adolescents’ health risks are primarily behavioral in nature and potentially preventable. Five nationally recognized guidelines all agree that providers should be screening adolescent patients for a variety of high risk behaviors. Several studies have shown that many pediatricians feel uncomfortable addressing adolescent issues and do not screen adolescents for risky situations or behaviors. Purpose: To determine if there is a difference in risk assessment among family medicine (FM), general pediatrics (PED), internal medicine (IM), and obstetrics/gynecology (OB) practitioners who care for adolescents in a primary care network at a large urban medical center that sees over 40,000 adolescents ages 13-21 each year. Methods: An anonymous, self-administered questionnaire was distributed to all providers at all of the multiple ambulatory care sites of an urban medical center. Providers self-identified as FM, PED, IM, or OB. Providers were asked if they routinely screen their adolescent patients for 10 listed emotional/behavioral risk factors. SPSS was used to determine frequencies and compare responses by medical specialty. Results: 156 of the 255 identified providers returned the questionnaire (61% response rate). Of the 156 who responded, 22% were FM, 35% PED, 36% IM, and 7% OB. 63% were female and 66% Caucasian. The mean age was 47 years (28-77), and the mean number of years post-training was 17 (1-43). There were no significant demographic differences among the 4 medical specialties. Nearly all of the providers in each of the specialties routinely screen adolescents for sexual activity (97%), tobacco (98%), and drug/alcohol use (97%). Fewer screen for depression/ suicidal ideation (82%), family problems (75%), and school problems (74%). Even fewer screen for peer problems (64%), physical/sexual abuse (64%), violence (58%), and eating disorders (57%). Examining differences by specialty area, FM and PED were overall more likely to screen for the listed emotional and behavioral risk factors compared with IM and OB. In particular, PED was significantly more likely to screen for eating disorders (p⫽0.011), and FM was significantly more likely to screen for physical/sexual abuse and violence compared with the other specialties (p⫽0.002 and p⫽0.003, respectively). Both IM and OB were
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significantly less likely to screen for school problems, family problems, or peer problems (p⫽0.000 for all). Conclusions: Nearly all providers are routinely screening adolescent patients in the areas of sexual activity, tobacco, and drug/alcohol use. Fewer providers are screening for depression, eating disorders, school problems, physical/ sexual abuse, violence, and family or peer problems. Of the ones who do screen in these areas, disproportionate numbers are in FM or PED, as compared to IM or OB. To achieve the goals set forth by Healthy People 2010, more training and education may be needed among all disciplines who care for adolescents in the importance of performing a complete risk assessment during primary care visits. Support: NICHD Grant # 1 R13 HD049226-01. 45. ADOLESCENTS’ ACCESS TO HEALTH CARE Jonathan D. Klein, MD, MPH, Randall K. Thomas. Division of Adolescent Medicine, University of Rochester, and Harris Interactive, Rochester, NY.
Purpose: Access to health care for adolescents requires the identification, and use, of a usual source of care, as well as the availability and delivery of confidential services. Methods: We examined parents’ reports of the care received by their adolescent children, including reported usual sources of care, last routine health care (well) visit, unmet needs, and whether parents knew if their adolescents’ care included an opportunity for confidential, 1-on-1 interactions. We surveyed a stratified quota-based sample of 12,370 respondents from the Harris Poll Online in 2005. Data were weighted to be representative of the population of U.S. adults ⱖ18 years old, using demographics (sex, age, education, race and ethnicity) and several variables representing the propensity of an individual respondent to be online and to respond to a particular survey. Results: Of 12,370 adults surveyed, 2,007 (16.2%) reported having one or more adolescent children ages 13 to 18. Most parents reported their adolescents’ usual source of primary
care was in a doctor’s office or clinic, although the proportion reporting these sources declined with increasing age (86.4% for 13-14 year olds, 82.5% for 15-16 year olds, 80.8% for 17-18 year olds; p ⫽ 0.03). Parents of older adolescents were also more likely to report their adolescent used school based health clinics or family planning services; a decreasing proportion reported using school nurses. Many (77.8%) parents reported that their adolescents’ last routine health care visit was within the past 12 months, and an additional 10.8% reported having a well visit within 24 months. Older adolescents were also more likely to have received confidential care. Parents reported that 41.0% of 13-14 year olds, 44.7% of 15-16 year olds, and 60.7% of 17-18 year olds had a private, 1-on-1 talk with their clinician in the past year (p⬍0.001). The proportion whose parents reported they did not know whether a confidential discussion occurred was 12.5% for 13-14 year olds, 17.2% for 15-16 year olds, and 10.4% for 17-18 year olds (p⬍0.001). Overall, 10.7% of parents reported their teen had an unmet health care need, and only 5.0% reported not knowing if their adolescent had an unmet need. Parents of older adolescents were more likely to report their adolescent had unmet health care needs than were parents of younger children (7.6% for 13-14 year olds, 8.7% for 15-16 year olds, and 14.6% for 17-18 year olds, p⬍0.001). By parent report and controlled for age, adolescents who had an opportunity for private, 1-on-1 discussion were no more likely to report unmet health care needs than those who had not have private visits (12.0% versus 9.4%; F ⫽5.96, p⫽0.08). Conclusions: Adolescent’s usual care sources and care patterns change over time and receipt of confidential care increases with age. While parental reports may not reflect all of the services that an adolescent receives, most parents are aware of their teenagers’ care use patterns and know whether or not their adolescent has had an opportunity for one-on-one, private time with their clinician. Many opportunities exist for additional improvements in the quality of adolescent health care. Support: Supported in part by grant ATPM TS-1072 from the Centers for Disease Control and Prevention.