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Addressing Reproductive Health in Hospitalized Adolescents—A Missed Opportunity
Journal of Adolescent Health 64 (2019) 721e724
www.jahonline.org Original article
Addressing Reproductive Health in Hospitalized AdolescentsdA Missed Opportunity Vanessa McFadden, M.D., Ph.D. a, *, Anna Schmitz, M.D. b, Kelsey Porada, M.A. a, Sonia Mehta, M.D. c, Alyssa Stephany, M.D. a, and Michelle Pickett, M.D., M.S. b a
Department of Pediatrics, Section of Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin c Department of Pediatrics, Section of Medical Education, Pediatric Resident, Medical College of Wisconsin, Milwaukee, Wisconsin b
Article history: Received November 2, 2018; Accepted January 3, 2019 Keywords: Reproductive health; Sexually transmitted infections; Contraception; HPV immunization
See Related Editorial on p. 689 A B S T R A C T
Purpose: Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents’ reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting. Methods: Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception. Results: Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females). Conclusions: Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Vanessa McFadden, M.D., Ph.D., Section of Pediatric Hospital Medicine, Medical College of Wisconsin, PO Box 1997, Milwaukee, WI 53201-1997. Data from this study have been presented at Pediatric Academic Societies 2018 Meeting, Pediatric Hospital Medicine 2018 Meeting, and Medical College of Wisconsin 2018 Research Day. E-mail address: [email protected] (V. McFadden). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.01.005
IMPLICATIONS AND CONTRIBUTION
Adolescents are at high risk for sexually transmitted infections and pregnancy and often lack access to reproductive health services in the primary care setting. This retrospective study identified numerous critical missed opportunities to identify and meet adolescent reproductive health needs in the hospital setting.
Adolescent access to essential reproductive health services is critical to avoid adverse health outcomes including unplanned pregnancy and sexually transmitted infections (STIs), risk reduction, and treatment. Currently, adolescents represent half of all new STIs, and one in four adolescent females has had an STI [1,2]. In 2017, STIs reached an all-time high and are on the rise for the fourth consecutive year with 200,000 more cases than 2016 [3]. In the U.S., approximately 750,000 teenage females become
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pregnant per year, one of the highest rates among industrialized nations [4]. In 2017, 23% of teens reported no contraception use at last intercourse [5]. Ideally, adolescents would receive reproductive health services from their primary care provider (PCP); however, only 38% attend visits with a PCP [6e10]. Visits with a PCP are important to discuss all aspects of preventive health care, which encompasses services designed to mitigate preventable illnesses. Included in these services is reproductive care, which specifically addresses STIs and unintended pregnancy. Not only do adolescents have poor access to preventive care but they also frequently do not receive reproductive health services when they do attend visits with a PCP [6,11]. Only 40% of adolescents spend time alone with their doctor, despite recommendations from the American Academy of Pediatrics that physicians provide confidential time to discuss reproductive health during adolescents’ preventive care visits [6,12]. In a multisite observational study, the average time per visit spent discussing sexual health was 36 seconds [13]. Among a population of pregnant adolescents who had visited PCP within 12 months before becoming pregnant, 57% did not have documentation of sexual activity, and only 35% had contraception prescribed; of those, only one patient was prescribed a long-acting method [14]. Barriers to providing reproductive health services may include perceived time constraints, patient confidentiality concerns, and patient discomfort addressing sexuality in the presence of caretakers [15e17]. Efforts to improve access to reproductive care continue to be explored, but researchers have identified a need for interventions that use nontraditional settings to provide adolescents with reproductive health services [18,19]. Hospitalizations present an opportunity to address adolescents’ reproductive health, as they are captive audience, and providers have the ability to address unmet needs. Some researchers theorize that hospital visits have the advantage of “teachable moments” when counseling may be effective because hospitalized patients are likely concerned about their health during that time [20,21]. Furthermore, recent literature demonstrates hospitalized adolescents want to discuss sexual health and are interested in receiving pregnancy prevention information and services while inpatient [22]. However, studies suggest that the opportunity to meet adolescents’ reproductive health needs is frequently missed. A medical record review of adolescents admitted to a pediatric hospitalist service identified that sexual history taking is inconsistent [23]. A Pediatric Health Information System database study identified that adolescent patients were more likely to have STI testing while inpatient than in the emergency department, yet the overall rate of testing was only 10.9% [24]. However, both these studies focused on only one component of reproductive health. To our knowledge, no studies have explored provision of comprehensive reproductive health services to hospitalized adolescents. The purpose of this study was to assess the current practice of sexual history documentation and provision of reproductive health services including contraception initiation, STI and pregnancy testing, and human papillomavirus (HPV) immunization within the pediatric hospital setting.
Hospital of Wisconsin (CHW) hospital medicine service from May 1, 2017, through July 31, 2017. CHW is a large academic pediatric tertiary care center with 5,000 general pediatrics hospitalizations in 2017 (83% of those hospitalizations were to hospital medicine). Patients with any documentation of developmental delay were excluded from this study. Developmentally delayed patients represent a population with unique and often unmet reproductive health needs. These needs were recognized, and future iterations of this project can be expanded to include all patients. Data collected from each medical record included the following: age (by year), gender, insurance status (public, private, or not insured), admission and discharge dates, admission service (hospital medicine or critical care), type of provider who wrote the admission note (senior resident, intern resident, advanced practice provider, or fellow), and diagnoses. Primary outcome measures were also extracted from each medical record and included documentation of sexual history, provision of contraception (oral contraceptive pill prescription, vaginal ring, birth control patch, or medroxyprogesterone injection), pregnancy and STI testing (gonorrhea, chlamydia, syphilis, human immunodeficiency virus, and trichomoniasis), and HPV immunization status and administration. Sexual history documentation was determined to be present if documented at any time during the hospital encounter including in the emergency department and by any provider including social worker. Pregnancy and STI testing were determined to be completed if done either during the hospital encounter or during the 2 weeks prior based on outside records available during current hospital encounter to incorporate ongoing outpatient work-up for presenting symptoms. Immunization status was determined based on the Wisconsin Immunization Registry (a complete and accurate computerized Internet database provided by the state of Wisconsin to record and track immunizations), linked to the medical record in the patient encounters [25]. If the same patient was hospitalized more than once during the study period, each hospital encounter was considered separately, given each encounter was a chance to address the patient’s reproductive health and given the importance of addressing sexual history at every encounter because sexual history can change quickly in adolescents. CHW Institutional Review Board reviewed this project and determined it exempt from full Institutional Review Board review.
Methods
There were 172 hospital encounters during the study period that met inclusion criteria; 22 were excluded because of a developmental delay; therefore, 150 encounters were included in the analysis. The patient characteristics are outlined in Table 1. Most encounters (94; 63%) were female patients. The mean patient age was 15.5 years (standard deviation 1.5) with an age
Study design This is a retrospective chart review of all hospitalized adolescents (aged 13 years and older) discharged from the Children’s
Data analysis Descriptive statistics were used to report rates of sexual history documentation, provision of contraception, pregnancy and STI testing, and HPV immunization. Chi-squared tests were used to compare rates for subgroup analysis with an alpha of .05 considered significant. Age was dichotomized based on mean age of study population. Results Patient characteristics
V. McFadden et al. / Journal of Adolescent Health 64 (2019) 721e724 Table 1 Patient characteristics (N ¼ 150)
Table 2 Characteristics associated with documentation of sexual history (N ¼ 83) n (%)
Gender Female Male Age (y) 13e15 16e19 Insurance Private Public Reason for hospitalization Ingestion Other Admission service Hospital medicine Critical care
723
94 (63) 56 (37) 65 (43) 85 (57) 74 (49) 75 (50) 49 (33) 101 (67) 136 (91) 14 (9)
range of 13e19 years. The most common reason for hospitalization was ingestion (49; 33%). Fourteen (9%) of the patient encounters were initially admitted to critical care. Four patients had multiple encounters with three patients having two encounters and one patient having seven encounters. Of the encounters in this study with their PCP linked to our electronic medical record, only 40% (44/110) followed up with their PCP within 1 month after their hospitalization. Documentation of sexual history Only 83 (55%) of patients had any documentation of sexual history with 39 (47%) of those patients endorsing ever having sex. Characteristics associated with documentation of sexual history are outlined in Table 2. Females compared with males were more likely to have sexual history documented (67% vs. 36%, p < .01). Patients hospitalized secondary to an ingestion were more likely to have a sexual history documented than the other diagnoses combined (71% vs. 48%, p < .01). Sexual history was more likely to be documented for patients admitted to hospital medicine compared with critical care (59% vs. 14%, p < .01) and encounters where the admission note was written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Age was not associated with documentation of sexual history, with 57% of patients aged 13e15 years compared with 54% of patients aged 16e19 years having sexual history documentation (p ¼ .73). Reproductive services provided Reproductive services provided are outlined in Table 3. Overall, 18 (12%) had any STI testing done, of which four (22%) were positive for chlamydia and two (11%) positive for gonorrhea. One patient was positive for both chlamydia and gonorrhea. Of the five people positive for an STI, discharge diagnoses included pelvic inflammatory disease (n ¼ 3), rhabdomyolysis (n ¼ 1), and Guillain Barre Syndrome (n ¼ 1). Only 60% of females had a pregnancy test performed, and all were negative. Contraception was provided in two encounters (2% of females), both received medroxyprogesterone. One patient was already on medroxyprogesterone and was overdue, and the other patient was initiated on medroxyprogesterone for menorrhagia that led to anemia. Of all patients, 69 (46%) patients were due for HPV
n (%) Gender Female Male Age (y) 13e15 16e19 Reason for hospitalization Ingestion Other Admission service Hospital medicine Critical care Admission note written by Intern resident Senior resident Advanced practice provider Fellow
p value <.01
63 (67) 20 (36) .73 37 (57) 46 (54) <.01 35 (71) 48 (48) <.01 81 (60) 2 (14) <.01 59 14 4 1
(67) (44) (29) (13)
immunization, and of those, only 13 (19%) received it before discharge. Discussion This analysis identified substantial missed opportunities to assess, educate, and provide adolescent reproductive health services. Only 55% of adolescent patients had documentation of sexual activity, which is similar to the 62% of patients found by Riese et al. [23]. Providers were significantly less likely to document sexual activity for males, patients admitted directly to the critical care service, and patients hospitalized for complaints other than ingestion. Intern residents were more likely to document sexual activity than other providers. Interns may be more likely to address sexual activity for several reasons, including the recent completion of medical school training that currently stresses the importance of comprehensive social histories on all patients. Interns are also rotating through outpatient settings where the importance of addressing preventative health, especially reproductive health, is evident. Moreover, when a patient is seen by an intern that patient is also usually seen by a senior resident and an attending provider, thus more providers are involved in writing the admission note and therefore more potential for one of those providers to address reproductive health during that admission note. We identified numerous opportunities for targeted interventions to meet adolescent reproductive needs in the hospital setting. Potential interventions could focus on improving standardized sexual health assessment concentrating on the factors that were associated with statistically significant
Table 3 Reproductive services provided STI testing done Positive for chlamydiaa Positive for gonorrheaa Pregnancy testing (females only) Contraception provision (females only) Due for HPV vaccine HPV vaccine given
12% 22% 11% 60% 2% 46% 19%
HPV ¼ human papillomavirus; STI ¼ sexually transmitted disease. a One patient positive for both chlamydia and gonorrhea.
(18/150) (4/18) (2/18) (56/94) (2/94) (69/150) (13/69)
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decreased frequency of sexual history documentation. One example is to have a hospital acceptance note template, for patients being transferred from the ICU to the hospital medicine service, include a section for sexual activity documentation. Another example would be to educate providers on the importance of screening and providing reproductive services to all adolescents, not just females who may get pregnant or patients who have exhibited high-risk behaviors by presenting after an ingestion. Overall, reproductive health services were provided infrequently in hospitalized adolescents. Only 12% of patients had any STI testing, similar to the rates found by Masonbrink et al. [24]. Only 19% of those due for HPV immunization were given the HPV vaccine, and only 60% of females had a pregnancy test. Furthermore, only two patients were prescribed any contraception. One patient had initiation of contraception during the hospital encounter for her anemia, not for contraception necessarily, and one patient was already getting medroxyprogesterone as an outpatient and had a dose given while she was hospitalized. Despite support for reproductive health care in nontraditional settings from adolescents [22], adolescent health experts [19], and evidence-based guidelines [26], our findings show these services are infrequently provided. Interest among adolescents in obtaining reproductive health care from providers outside the primary care setting has been demonstrated previously, and prior literature has called for routine pregnancy risk assessment for adolescent women in the hospital setting [5,27]. A June 2018 article called for increased reproductive health advocacy among pediatricians, and a clinical report in August 2018 emphasized admission to the hospital provides an opportunity to review the general health of the child, who may not have access to PCP [28,29]. Implicit in reviewing general health includes addressing reproductive health care [27]. Finally, our finding of poor follow-up with PCPs after hospitalization in this study population reinforces the importance of addressing reproductive health needs in the hospital. Limitations of the present study included our assumption that sexual history was not discussed if not documented. In addition, this study relies on provider documentation, which may not accurately depict all aspects of services discussed, offered, or provided. Finally, the study population was from a single tertiary care site and thus may not be generalizable to adolescents hospitalized in other settings; however, results are similar to previous literature [23,24]. Our findings highlight numerous opportunities to improve access to reproductive care for adolescents in the hospital by increasing universal sexual history assessment and provision of reproductive health education and services. Funding Sources Support for this work was provided by the American Academy of Pediatrics Community Access to Child Health Grant awarded to V.M. References [1] Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40:187e93.
[2] Forhan SE, Gottlieb SL, Sternber MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009;124:1505e12. [3] Centers for Disease Control and Prevention. New CDC analysis shows steep and sustained increases in STDs in recent years. CDC Press Release; August 28, 2018. Available at: https://www.cdc.gov/nchhstp/newsroom/2018/pressrelease-2018-std-prevention-conference.html. [4] Ralph LJ, Brindis CD. Access to reproductive healthcare for adolescents: Establishing healthy behaviors at a critical juncture in the lifecourse. Curr Opin Obstet Gynecol 2010;22:369e74. [5] Miller MK, Randell KA, Barral R, et al. Factors associated with interest in same-day contraception initiation among females in the pediatric emergency department. J Adolesc Health 2016;58:154e9. [6] Irwin CE, Adams SH, Park J, Newacheck PW. Preventive care for adolescents: Few get visits and fewer get services. Pediatrics 2009;123:e565e72. [7] Brindis CD, Ott M. Adolescents, health policy, and the American political process. J Adolesc Health 2002;30:9e16. [8] Mulye TP, Park MJ, Nelson CD, et al. Trends in adolescent and young adult health in the United States. J Adolesc Health 2009;45:8e24. [9] Lim SW, Chhabra R, Rosen A, et al. Adolescents’ views on barriers to health care: A pilot study. J Prim Care Community Health 2011;3:99e103. [10] Chariatte V, Berchtold A, Akre C, et al. Missed appointments in an outpatient clinic for adolescents, an approach to predict the risk of missing. J Adolesc Health 2008;43:38e45. [11] Burstein GR, Lowry R, Klein JD, Santelli JS. Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics 2003;111:996e1001. [12] Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; 2008. [13] Alexander SC, Fortenberry JD, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2014;168:163e9. [14] Kharbanda E, Stuck L, Molitor B, et al. Missed opportunities for pregnancy prevention among insured adolescents. JAMA Pediatr 2014;128:e142809. [15] Adams SH, Park MJ, Tweitmeyer L, et al. Association between adolescent preventive care and the role of the affordable care act. JAMA Pediatr 2018; 172:43e8. [16] Tylee A, Haller DM, Graham T, et al. Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet 2007;369: 1565e73. [17] Schaeuble K, Haglund K, Vukovich M. Adolescents’ preferences for primary care provider interactions. J Spec Pediatr Nurs 2010;15:202e10. [18] Chernick LS, Westhoff C, Ray M, et al. Enhancing referral of sexually active adolescent females from the emergency department to family planning. J Womens Health 2015;24:324e8. [19] Miller MK, Mollen CJ. Critical access to care: Bringing contraception to adolescents in nontraditional settings. J Adolesc Health 2017;61:667e8. [20] Rand CM, Auinger P, Klein JD, Weitzman M. Preventive counseling at adolescent ambulatory visits. J Adolesc Health 2005;37:87e93. [21] Fonarow GC. In-hospital initiation of statins: Taking advantage of the ‘teachable moment’. Cleve Clin J Med 2003;70:502e6. [22] Guss CE, Wunsch CA, McCullon R, et al. Using the hospital as a venue for reproductive health interventions: A survey of hospitalized adolescents. Hosp Pediatr 2015;5:67e73. [23] Riese A, Tarr EE, Baird J, Alverson B. Documentation of sexual history in hospitalized adolescents on the general pediatrics service. Hosp Pediatr 2018;8:179e86. [24] Masonbrink AR, Richardson T, McCulloh RJ, et al. Sexually transmitted infection testing in adolescents: Current practices in the hospital setting. J Adolesc Health 2018;63:342e7. [25] Koepke R, Petit AB, Eickhoff JC, et al. Completeness and accuracy of the Wisconsin immunization registry: An evaluation coinciding with the beginning of meaningful use. J Public Health Manag Prac 2015;21:273e81. [26] Centers for Disease Control and Prevention, Division of Reproductive Health. Contraceptive and reproductive health services for teens: Evidence-based clinical best practices. Available at: https://www.cdc.gov/ teenpregnancy/pdf/about/Fact-Sheet-Contraceptive-Reproductive-HealthServices-Teens_TAGGED-508.pdf. Accessed December 21, 2018. [27] Coles MS, Lau M, Akers AY. If you do not ask, they will not tell: Evaluating pregnancy risk in young women in pediatric hospitals. J Adolesc Health 2016;58:251e2. [28] Wilkinson TA, Carroll AE. The role of pediatricians in reproductive health advocacy. JAMA Pediatr 2018;172:509e10. [29] Rauch D, Committee on Hospital Care, Section on Hospital Medicine. Physician’s role in coordinating care of hospitalized children. Pediatrics 2018;142:e20181503.
www.jahonline.org Original article
Addressing Reproductive Health in Hospitalized AdolescentsdA Missed Opportunity Vanessa McFadden, M.D., Ph.D. a, *, Anna Schmitz, M.D. b, Kelsey Porada, M.A. a, Sonia Mehta, M.D. c, Alyssa Stephany, M.D. a, and Michelle Pickett, M.D., M.S. b a
Department of Pediatrics, Section of Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin c Department of Pediatrics, Section of Medical Education, Pediatric Resident, Medical College of Wisconsin, Milwaukee, Wisconsin b
Article history: Received November 2, 2018; Accepted January 3, 2019 Keywords: Reproductive health; Sexually transmitted infections; Contraception; HPV immunization
See Related Editorial on p. 689 A B S T R A C T
Purpose: Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents’ reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting. Methods: Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception. Results: Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females). Conclusions: Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Vanessa McFadden, M.D., Ph.D., Section of Pediatric Hospital Medicine, Medical College of Wisconsin, PO Box 1997, Milwaukee, WI 53201-1997. Data from this study have been presented at Pediatric Academic Societies 2018 Meeting, Pediatric Hospital Medicine 2018 Meeting, and Medical College of Wisconsin 2018 Research Day. E-mail address: [email protected] (V. McFadden). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.01.005
IMPLICATIONS AND CONTRIBUTION
Adolescents are at high risk for sexually transmitted infections and pregnancy and often lack access to reproductive health services in the primary care setting. This retrospective study identified numerous critical missed opportunities to identify and meet adolescent reproductive health needs in the hospital setting.
Adolescent access to essential reproductive health services is critical to avoid adverse health outcomes including unplanned pregnancy and sexually transmitted infections (STIs), risk reduction, and treatment. Currently, adolescents represent half of all new STIs, and one in four adolescent females has had an STI [1,2]. In 2017, STIs reached an all-time high and are on the rise for the fourth consecutive year with 200,000 more cases than 2016 [3]. In the U.S., approximately 750,000 teenage females become
722
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pregnant per year, one of the highest rates among industrialized nations [4]. In 2017, 23% of teens reported no contraception use at last intercourse [5]. Ideally, adolescents would receive reproductive health services from their primary care provider (PCP); however, only 38% attend visits with a PCP [6e10]. Visits with a PCP are important to discuss all aspects of preventive health care, which encompasses services designed to mitigate preventable illnesses. Included in these services is reproductive care, which specifically addresses STIs and unintended pregnancy. Not only do adolescents have poor access to preventive care but they also frequently do not receive reproductive health services when they do attend visits with a PCP [6,11]. Only 40% of adolescents spend time alone with their doctor, despite recommendations from the American Academy of Pediatrics that physicians provide confidential time to discuss reproductive health during adolescents’ preventive care visits [6,12]. In a multisite observational study, the average time per visit spent discussing sexual health was 36 seconds [13]. Among a population of pregnant adolescents who had visited PCP within 12 months before becoming pregnant, 57% did not have documentation of sexual activity, and only 35% had contraception prescribed; of those, only one patient was prescribed a long-acting method [14]. Barriers to providing reproductive health services may include perceived time constraints, patient confidentiality concerns, and patient discomfort addressing sexuality in the presence of caretakers [15e17]. Efforts to improve access to reproductive care continue to be explored, but researchers have identified a need for interventions that use nontraditional settings to provide adolescents with reproductive health services [18,19]. Hospitalizations present an opportunity to address adolescents’ reproductive health, as they are captive audience, and providers have the ability to address unmet needs. Some researchers theorize that hospital visits have the advantage of “teachable moments” when counseling may be effective because hospitalized patients are likely concerned about their health during that time [20,21]. Furthermore, recent literature demonstrates hospitalized adolescents want to discuss sexual health and are interested in receiving pregnancy prevention information and services while inpatient [22]. However, studies suggest that the opportunity to meet adolescents’ reproductive health needs is frequently missed. A medical record review of adolescents admitted to a pediatric hospitalist service identified that sexual history taking is inconsistent [23]. A Pediatric Health Information System database study identified that adolescent patients were more likely to have STI testing while inpatient than in the emergency department, yet the overall rate of testing was only 10.9% [24]. However, both these studies focused on only one component of reproductive health. To our knowledge, no studies have explored provision of comprehensive reproductive health services to hospitalized adolescents. The purpose of this study was to assess the current practice of sexual history documentation and provision of reproductive health services including contraception initiation, STI and pregnancy testing, and human papillomavirus (HPV) immunization within the pediatric hospital setting.
Hospital of Wisconsin (CHW) hospital medicine service from May 1, 2017, through July 31, 2017. CHW is a large academic pediatric tertiary care center with 5,000 general pediatrics hospitalizations in 2017 (83% of those hospitalizations were to hospital medicine). Patients with any documentation of developmental delay were excluded from this study. Developmentally delayed patients represent a population with unique and often unmet reproductive health needs. These needs were recognized, and future iterations of this project can be expanded to include all patients. Data collected from each medical record included the following: age (by year), gender, insurance status (public, private, or not insured), admission and discharge dates, admission service (hospital medicine or critical care), type of provider who wrote the admission note (senior resident, intern resident, advanced practice provider, or fellow), and diagnoses. Primary outcome measures were also extracted from each medical record and included documentation of sexual history, provision of contraception (oral contraceptive pill prescription, vaginal ring, birth control patch, or medroxyprogesterone injection), pregnancy and STI testing (gonorrhea, chlamydia, syphilis, human immunodeficiency virus, and trichomoniasis), and HPV immunization status and administration. Sexual history documentation was determined to be present if documented at any time during the hospital encounter including in the emergency department and by any provider including social worker. Pregnancy and STI testing were determined to be completed if done either during the hospital encounter or during the 2 weeks prior based on outside records available during current hospital encounter to incorporate ongoing outpatient work-up for presenting symptoms. Immunization status was determined based on the Wisconsin Immunization Registry (a complete and accurate computerized Internet database provided by the state of Wisconsin to record and track immunizations), linked to the medical record in the patient encounters [25]. If the same patient was hospitalized more than once during the study period, each hospital encounter was considered separately, given each encounter was a chance to address the patient’s reproductive health and given the importance of addressing sexual history at every encounter because sexual history can change quickly in adolescents. CHW Institutional Review Board reviewed this project and determined it exempt from full Institutional Review Board review.
Methods
There were 172 hospital encounters during the study period that met inclusion criteria; 22 were excluded because of a developmental delay; therefore, 150 encounters were included in the analysis. The patient characteristics are outlined in Table 1. Most encounters (94; 63%) were female patients. The mean patient age was 15.5 years (standard deviation 1.5) with an age
Study design This is a retrospective chart review of all hospitalized adolescents (aged 13 years and older) discharged from the Children’s
Data analysis Descriptive statistics were used to report rates of sexual history documentation, provision of contraception, pregnancy and STI testing, and HPV immunization. Chi-squared tests were used to compare rates for subgroup analysis with an alpha of .05 considered significant. Age was dichotomized based on mean age of study population. Results Patient characteristics
V. McFadden et al. / Journal of Adolescent Health 64 (2019) 721e724 Table 1 Patient characteristics (N ¼ 150)
Table 2 Characteristics associated with documentation of sexual history (N ¼ 83) n (%)
Gender Female Male Age (y) 13e15 16e19 Insurance Private Public Reason for hospitalization Ingestion Other Admission service Hospital medicine Critical care
723
94 (63) 56 (37) 65 (43) 85 (57) 74 (49) 75 (50) 49 (33) 101 (67) 136 (91) 14 (9)
range of 13e19 years. The most common reason for hospitalization was ingestion (49; 33%). Fourteen (9%) of the patient encounters were initially admitted to critical care. Four patients had multiple encounters with three patients having two encounters and one patient having seven encounters. Of the encounters in this study with their PCP linked to our electronic medical record, only 40% (44/110) followed up with their PCP within 1 month after their hospitalization. Documentation of sexual history Only 83 (55%) of patients had any documentation of sexual history with 39 (47%) of those patients endorsing ever having sex. Characteristics associated with documentation of sexual history are outlined in Table 2. Females compared with males were more likely to have sexual history documented (67% vs. 36%, p < .01). Patients hospitalized secondary to an ingestion were more likely to have a sexual history documented than the other diagnoses combined (71% vs. 48%, p < .01). Sexual history was more likely to be documented for patients admitted to hospital medicine compared with critical care (59% vs. 14%, p < .01) and encounters where the admission note was written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Age was not associated with documentation of sexual history, with 57% of patients aged 13e15 years compared with 54% of patients aged 16e19 years having sexual history documentation (p ¼ .73). Reproductive services provided Reproductive services provided are outlined in Table 3. Overall, 18 (12%) had any STI testing done, of which four (22%) were positive for chlamydia and two (11%) positive for gonorrhea. One patient was positive for both chlamydia and gonorrhea. Of the five people positive for an STI, discharge diagnoses included pelvic inflammatory disease (n ¼ 3), rhabdomyolysis (n ¼ 1), and Guillain Barre Syndrome (n ¼ 1). Only 60% of females had a pregnancy test performed, and all were negative. Contraception was provided in two encounters (2% of females), both received medroxyprogesterone. One patient was already on medroxyprogesterone and was overdue, and the other patient was initiated on medroxyprogesterone for menorrhagia that led to anemia. Of all patients, 69 (46%) patients were due for HPV
n (%) Gender Female Male Age (y) 13e15 16e19 Reason for hospitalization Ingestion Other Admission service Hospital medicine Critical care Admission note written by Intern resident Senior resident Advanced practice provider Fellow
p value <.01
63 (67) 20 (36) .73 37 (57) 46 (54) <.01 35 (71) 48 (48) <.01 81 (60) 2 (14) <.01 59 14 4 1
(67) (44) (29) (13)
immunization, and of those, only 13 (19%) received it before discharge. Discussion This analysis identified substantial missed opportunities to assess, educate, and provide adolescent reproductive health services. Only 55% of adolescent patients had documentation of sexual activity, which is similar to the 62% of patients found by Riese et al. [23]. Providers were significantly less likely to document sexual activity for males, patients admitted directly to the critical care service, and patients hospitalized for complaints other than ingestion. Intern residents were more likely to document sexual activity than other providers. Interns may be more likely to address sexual activity for several reasons, including the recent completion of medical school training that currently stresses the importance of comprehensive social histories on all patients. Interns are also rotating through outpatient settings where the importance of addressing preventative health, especially reproductive health, is evident. Moreover, when a patient is seen by an intern that patient is also usually seen by a senior resident and an attending provider, thus more providers are involved in writing the admission note and therefore more potential for one of those providers to address reproductive health during that admission note. We identified numerous opportunities for targeted interventions to meet adolescent reproductive needs in the hospital setting. Potential interventions could focus on improving standardized sexual health assessment concentrating on the factors that were associated with statistically significant
Table 3 Reproductive services provided STI testing done Positive for chlamydiaa Positive for gonorrheaa Pregnancy testing (females only) Contraception provision (females only) Due for HPV vaccine HPV vaccine given
12% 22% 11% 60% 2% 46% 19%
HPV ¼ human papillomavirus; STI ¼ sexually transmitted disease. a One patient positive for both chlamydia and gonorrhea.
(18/150) (4/18) (2/18) (56/94) (2/94) (69/150) (13/69)
724
V. McFadden et al. / Journal of Adolescent Health 64 (2019) 721e724
decreased frequency of sexual history documentation. One example is to have a hospital acceptance note template, for patients being transferred from the ICU to the hospital medicine service, include a section for sexual activity documentation. Another example would be to educate providers on the importance of screening and providing reproductive services to all adolescents, not just females who may get pregnant or patients who have exhibited high-risk behaviors by presenting after an ingestion. Overall, reproductive health services were provided infrequently in hospitalized adolescents. Only 12% of patients had any STI testing, similar to the rates found by Masonbrink et al. [24]. Only 19% of those due for HPV immunization were given the HPV vaccine, and only 60% of females had a pregnancy test. Furthermore, only two patients were prescribed any contraception. One patient had initiation of contraception during the hospital encounter for her anemia, not for contraception necessarily, and one patient was already getting medroxyprogesterone as an outpatient and had a dose given while she was hospitalized. Despite support for reproductive health care in nontraditional settings from adolescents [22], adolescent health experts [19], and evidence-based guidelines [26], our findings show these services are infrequently provided. Interest among adolescents in obtaining reproductive health care from providers outside the primary care setting has been demonstrated previously, and prior literature has called for routine pregnancy risk assessment for adolescent women in the hospital setting [5,27]. A June 2018 article called for increased reproductive health advocacy among pediatricians, and a clinical report in August 2018 emphasized admission to the hospital provides an opportunity to review the general health of the child, who may not have access to PCP [28,29]. Implicit in reviewing general health includes addressing reproductive health care [27]. Finally, our finding of poor follow-up with PCPs after hospitalization in this study population reinforces the importance of addressing reproductive health needs in the hospital. Limitations of the present study included our assumption that sexual history was not discussed if not documented. In addition, this study relies on provider documentation, which may not accurately depict all aspects of services discussed, offered, or provided. Finally, the study population was from a single tertiary care site and thus may not be generalizable to adolescents hospitalized in other settings; however, results are similar to previous literature [23,24]. Our findings highlight numerous opportunities to improve access to reproductive care for adolescents in the hospital by increasing universal sexual history assessment and provision of reproductive health education and services. Funding Sources Support for this work was provided by the American Academy of Pediatrics Community Access to Child Health Grant awarded to V.M. References [1] Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40:187e93.
[2] Forhan SE, Gottlieb SL, Sternber MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009;124:1505e12. [3] Centers for Disease Control and Prevention. New CDC analysis shows steep and sustained increases in STDs in recent years. CDC Press Release; August 28, 2018. Available at: https://www.cdc.gov/nchhstp/newsroom/2018/pressrelease-2018-std-prevention-conference.html. [4] Ralph LJ, Brindis CD. Access to reproductive healthcare for adolescents: Establishing healthy behaviors at a critical juncture in the lifecourse. Curr Opin Obstet Gynecol 2010;22:369e74. [5] Miller MK, Randell KA, Barral R, et al. Factors associated with interest in same-day contraception initiation among females in the pediatric emergency department. J Adolesc Health 2016;58:154e9. [6] Irwin CE, Adams SH, Park J, Newacheck PW. Preventive care for adolescents: Few get visits and fewer get services. Pediatrics 2009;123:e565e72. [7] Brindis CD, Ott M. Adolescents, health policy, and the American political process. J Adolesc Health 2002;30:9e16. [8] Mulye TP, Park MJ, Nelson CD, et al. Trends in adolescent and young adult health in the United States. J Adolesc Health 2009;45:8e24. [9] Lim SW, Chhabra R, Rosen A, et al. Adolescents’ views on barriers to health care: A pilot study. J Prim Care Community Health 2011;3:99e103. [10] Chariatte V, Berchtold A, Akre C, et al. Missed appointments in an outpatient clinic for adolescents, an approach to predict the risk of missing. J Adolesc Health 2008;43:38e45. [11] Burstein GR, Lowry R, Klein JD, Santelli JS. Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics 2003;111:996e1001. [12] Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; 2008. [13] Alexander SC, Fortenberry JD, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2014;168:163e9. [14] Kharbanda E, Stuck L, Molitor B, et al. Missed opportunities for pregnancy prevention among insured adolescents. JAMA Pediatr 2014;128:e142809. [15] Adams SH, Park MJ, Tweitmeyer L, et al. Association between adolescent preventive care and the role of the affordable care act. JAMA Pediatr 2018; 172:43e8. [16] Tylee A, Haller DM, Graham T, et al. Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet 2007;369: 1565e73. [17] Schaeuble K, Haglund K, Vukovich M. Adolescents’ preferences for primary care provider interactions. J Spec Pediatr Nurs 2010;15:202e10. [18] Chernick LS, Westhoff C, Ray M, et al. Enhancing referral of sexually active adolescent females from the emergency department to family planning. J Womens Health 2015;24:324e8. [19] Miller MK, Mollen CJ. Critical access to care: Bringing contraception to adolescents in nontraditional settings. J Adolesc Health 2017;61:667e8. [20] Rand CM, Auinger P, Klein JD, Weitzman M. Preventive counseling at adolescent ambulatory visits. J Adolesc Health 2005;37:87e93. [21] Fonarow GC. In-hospital initiation of statins: Taking advantage of the ‘teachable moment’. Cleve Clin J Med 2003;70:502e6. [22] Guss CE, Wunsch CA, McCullon R, et al. Using the hospital as a venue for reproductive health interventions: A survey of hospitalized adolescents. Hosp Pediatr 2015;5:67e73. [23] Riese A, Tarr EE, Baird J, Alverson B. Documentation of sexual history in hospitalized adolescents on the general pediatrics service. Hosp Pediatr 2018;8:179e86. [24] Masonbrink AR, Richardson T, McCulloh RJ, et al. Sexually transmitted infection testing in adolescents: Current practices in the hospital setting. J Adolesc Health 2018;63:342e7. [25] Koepke R, Petit AB, Eickhoff JC, et al. Completeness and accuracy of the Wisconsin immunization registry: An evaluation coinciding with the beginning of meaningful use. J Public Health Manag Prac 2015;21:273e81. [26] Centers for Disease Control and Prevention, Division of Reproductive Health. Contraceptive and reproductive health services for teens: Evidence-based clinical best practices. Available at: https://www.cdc.gov/ teenpregnancy/pdf/about/Fact-Sheet-Contraceptive-Reproductive-HealthServices-Teens_TAGGED-508.pdf. Accessed December 21, 2018. [27] Coles MS, Lau M, Akers AY. If you do not ask, they will not tell: Evaluating pregnancy risk in young women in pediatric hospitals. J Adolesc Health 2016;58:251e2. [28] Wilkinson TA, Carroll AE. The role of pediatricians in reproductive health advocacy. JAMA Pediatr 2018;172:509e10. [29] Rauch D, Committee on Hospital Care, Section on Hospital Medicine. Physician’s role in coordinating care of hospitalized children. Pediatrics 2018;142:e20181503.