- Email: [email protected]
A qualitative study of outpatient environments and experiences from the adolescent perspective
February 2003
and to use trigger/screening questionnaires during adolescent well visits, and 3) forming partnerships with community corporate leaders to promote awareness and encourage parents to advocate for high quality adolescent preventive services through corporate health promotion newsletters. Interventions were evaluated by comparing 2000 and 2001 QARR quality measures, comparing pre- and post-intervention rates of documented tobacco use, substance use, and HIV prevention screening and counseling. Results: Two hundred eighty-five providers attended one or more CME sessions (62% of the 459 pediatric and family medicine practitioners in our 6 county area), and 94 offices received on-site detailing visits during NYSDOH HEDIS/QARR chart reviews. Consistent improvements in the delivery of adolescent preventive health services were noted in both commercial and Medicaid populations. Comparing 2001 results with those from 2000: Tobacco use screening increased from 42.5% to 45.5% for the commercial population and from 32.0% to 43.5% for the Medicaid population, and substance use screening increased from 42.5% to 44.0% for the commercial population and from 32.0% to 43.5% for the Medicaid population. The rate of HIV counseling increased from 26.5% to 35.5% for the commercial population, and from 28.0% to 40.0% for the Medicaid population (all Medicaid and HIV differences significant at p ⬍ .05). Conclusions: Preliminary data suggest that these activities have been successful in improving adolescent preventive services for the Medicaid population in New York. Academic detailing of guideline-based clinical content and effective system change strategies can assist health plans in promoting preventive care improvements by primary care clinicians. Further quality measurement is needed to assess the impact of these strategies on commercially insured populations. A QUALITATIVE STUDY OF OUTPATIENT ENVIRONMENTS AND EXPERIENCES FROM THE ADOLESCENT PERSPECTIVE Tanya Tivorsk, B.A., Maria Britto, M.D., M.P.H., Brenda Klostermann, Ph.D., Dawn Nebrig, M.S.W., and Gail Slap, M.D., M.S. Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH., Illinois Education Research Council, Southern Illinois University Edwardsville, Edwardsville, IL. Purpose: To describe adolescent attitudes and preferences regarding the physical environments of health care sites and the waiting experiences within those environments. Methods: The study sample consisted of 56 adolescents aged 11–19 yrs with and without chronic illness who agreed to participate in two-hour discussion groups divided by age and gender about experiences such as physical environment, waiting, scheduling in health care sites. Subjects with chronic illness were recruited from four subspecialty programs of an urban children’s hospital and comprised 7 focus groups. Those with chronic illness were recruited from 2 community sites near the hospital and comprised 5 groups. Each group discussion was moderated by a professional facilitator, audiotaped, transcribed, and coded independently by four investigators according to a standard schematic for the organization of qualitative data. When the team reached consensus about the themes of discussion, the transcripts and thematic coding scheme were imported into N5 NUD*IST威. The data were re-sorted by utterance and re-coded by 2 investigators.
POSTER PRESENTATIONS
153
Adjustments were made in the thematic classification, and the final results were confirmed by the full team. Results: Two major themes emerged about the health care environment: (1) making the interior design sites less childish, more teen-oriented, and more home-like; (2) decreasing waiting time and enhancing waiting experience by providing teen diversions (e.g., magazines, tv, games). Younger subjects preferred teen-only waiting areas, while older subjects expressed more neutrality about separation by age. All preferred that artwork portray realistic than cartoon images, that medical paraphernalia be hidden, and that colors tend to neutral. There were minimal differences in preference by gender or health status. Conclusion: Adolescents seen in a children’s hospital experience the setting as child-oriented and inattentive to the interests of older patients. Modifying interior decor, constructing smaller sub-waiting areas, and incorporating diversions that are teenoriented may help promote positive health care experiences and utilization by adolescents EMERGENCY DEPARTMENT USE BY PREGNANT ADOLESCENTS Beth Barnet, M.D., Carmen Arroyo, Ph.D., and Margo DeVoe, M.S. University of Maryland School of Medicine, Baltimore, MD. Purpose: Problems with access to care have been associated with increased Emergency Department (ED) use by adolescents. This study describes ED use by pregnant adolescents and examines associated factors including the role of school-based health centers (SBHCs). Methods: Using school rosters and hospital clinic databases, we identified a group of 779 pregnant adolescents ⱕ18 years old who resided in a large urban city, delivered a baby between 7/1/95– 8/30/97, and who received prenatal care in a school-based health center or in non-school-based settings. Retrospective data from linked medical records, school records, birth certificates, and Medicaid claims were collected. We examined demographics, median household income, parity, school status, pregnancy risk including chronic medical problems, prenatal care setting (schoolbased vs. non-school-based), number of ED visits, ICD-9 codes for each visit, and timing of ED visit(s) in relation to delivery. Using logistic regression we computed models predicting the odds of an ED visit during pregnancy adjusted for variables significantly associated with ED use at the bivariate level. Results: Of the 779 pregnant teens identified, 683 (88%) were covered by Medicaid insurance and claims data were available for them. There were no significant differences in age, race, SES, parity, school status, and medical and pregnancy risk between teens with and without Medicaid insurance. The mean age of our sample was 15.9 years, 93% were African-American, 84% were in school, 13% had a prior birth, and 9% were classified as having a high risk pregnancy. One hundred eight (16%) received prenatal care in a SBHC. Overall, 130 teens (19%) made ⱖ1 ED visit (202 visits total) during the 12 months prior to delivery. Almost half of these visits occurred in the three months prior to conception and trauma was the most common diagnosis (20% of visits). For those ED visits that occurred during pregnancy (29% 1st trimester, 21% 2nd trimester, 13% 3rd trimester), the most common diagnoses were related to factors associated with pregnancy (39%) followed by trauma (17%), non-specified pain (16%), non-STI infections (15%), and STIs (6%). ED use during pregnancy was negatively associated with SES, but positively associated with parity and medical and pregnancy risk. ED use was not associated with age,
and to use trigger/screening questionnaires during adolescent well visits, and 3) forming partnerships with community corporate leaders to promote awareness and encourage parents to advocate for high quality adolescent preventive services through corporate health promotion newsletters. Interventions were evaluated by comparing 2000 and 2001 QARR quality measures, comparing pre- and post-intervention rates of documented tobacco use, substance use, and HIV prevention screening and counseling. Results: Two hundred eighty-five providers attended one or more CME sessions (62% of the 459 pediatric and family medicine practitioners in our 6 county area), and 94 offices received on-site detailing visits during NYSDOH HEDIS/QARR chart reviews. Consistent improvements in the delivery of adolescent preventive health services were noted in both commercial and Medicaid populations. Comparing 2001 results with those from 2000: Tobacco use screening increased from 42.5% to 45.5% for the commercial population and from 32.0% to 43.5% for the Medicaid population, and substance use screening increased from 42.5% to 44.0% for the commercial population and from 32.0% to 43.5% for the Medicaid population. The rate of HIV counseling increased from 26.5% to 35.5% for the commercial population, and from 28.0% to 40.0% for the Medicaid population (all Medicaid and HIV differences significant at p ⬍ .05). Conclusions: Preliminary data suggest that these activities have been successful in improving adolescent preventive services for the Medicaid population in New York. Academic detailing of guideline-based clinical content and effective system change strategies can assist health plans in promoting preventive care improvements by primary care clinicians. Further quality measurement is needed to assess the impact of these strategies on commercially insured populations. A QUALITATIVE STUDY OF OUTPATIENT ENVIRONMENTS AND EXPERIENCES FROM THE ADOLESCENT PERSPECTIVE Tanya Tivorsk, B.A., Maria Britto, M.D., M.P.H., Brenda Klostermann, Ph.D., Dawn Nebrig, M.S.W., and Gail Slap, M.D., M.S. Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH., Illinois Education Research Council, Southern Illinois University Edwardsville, Edwardsville, IL. Purpose: To describe adolescent attitudes and preferences regarding the physical environments of health care sites and the waiting experiences within those environments. Methods: The study sample consisted of 56 adolescents aged 11–19 yrs with and without chronic illness who agreed to participate in two-hour discussion groups divided by age and gender about experiences such as physical environment, waiting, scheduling in health care sites. Subjects with chronic illness were recruited from four subspecialty programs of an urban children’s hospital and comprised 7 focus groups. Those with chronic illness were recruited from 2 community sites near the hospital and comprised 5 groups. Each group discussion was moderated by a professional facilitator, audiotaped, transcribed, and coded independently by four investigators according to a standard schematic for the organization of qualitative data. When the team reached consensus about the themes of discussion, the transcripts and thematic coding scheme were imported into N5 NUD*IST威. The data were re-sorted by utterance and re-coded by 2 investigators.
POSTER PRESENTATIONS
153
Adjustments were made in the thematic classification, and the final results were confirmed by the full team. Results: Two major themes emerged about the health care environment: (1) making the interior design sites less childish, more teen-oriented, and more home-like; (2) decreasing waiting time and enhancing waiting experience by providing teen diversions (e.g., magazines, tv, games). Younger subjects preferred teen-only waiting areas, while older subjects expressed more neutrality about separation by age. All preferred that artwork portray realistic than cartoon images, that medical paraphernalia be hidden, and that colors tend to neutral. There were minimal differences in preference by gender or health status. Conclusion: Adolescents seen in a children’s hospital experience the setting as child-oriented and inattentive to the interests of older patients. Modifying interior decor, constructing smaller sub-waiting areas, and incorporating diversions that are teenoriented may help promote positive health care experiences and utilization by adolescents EMERGENCY DEPARTMENT USE BY PREGNANT ADOLESCENTS Beth Barnet, M.D., Carmen Arroyo, Ph.D., and Margo DeVoe, M.S. University of Maryland School of Medicine, Baltimore, MD. Purpose: Problems with access to care have been associated with increased Emergency Department (ED) use by adolescents. This study describes ED use by pregnant adolescents and examines associated factors including the role of school-based health centers (SBHCs). Methods: Using school rosters and hospital clinic databases, we identified a group of 779 pregnant adolescents ⱕ18 years old who resided in a large urban city, delivered a baby between 7/1/95– 8/30/97, and who received prenatal care in a school-based health center or in non-school-based settings. Retrospective data from linked medical records, school records, birth certificates, and Medicaid claims were collected. We examined demographics, median household income, parity, school status, pregnancy risk including chronic medical problems, prenatal care setting (schoolbased vs. non-school-based), number of ED visits, ICD-9 codes for each visit, and timing of ED visit(s) in relation to delivery. Using logistic regression we computed models predicting the odds of an ED visit during pregnancy adjusted for variables significantly associated with ED use at the bivariate level. Results: Of the 779 pregnant teens identified, 683 (88%) were covered by Medicaid insurance and claims data were available for them. There were no significant differences in age, race, SES, parity, school status, and medical and pregnancy risk between teens with and without Medicaid insurance. The mean age of our sample was 15.9 years, 93% were African-American, 84% were in school, 13% had a prior birth, and 9% were classified as having a high risk pregnancy. One hundred eight (16%) received prenatal care in a SBHC. Overall, 130 teens (19%) made ⱖ1 ED visit (202 visits total) during the 12 months prior to delivery. Almost half of these visits occurred in the three months prior to conception and trauma was the most common diagnosis (20% of visits). For those ED visits that occurred during pregnancy (29% 1st trimester, 21% 2nd trimester, 13% 3rd trimester), the most common diagnoses were related to factors associated with pregnancy (39%) followed by trauma (17%), non-specified pain (16%), non-STI infections (15%), and STIs (6%). ED use during pregnancy was negatively associated with SES, but positively associated with parity and medical and pregnancy risk. ED use was not associated with age,