By Elyse O. Kharbanda, MD, MPH, HealthPartners Institute for Education and Research
Although adolescence has long been recognized as a vulnerable period, preventive health care for this age group is a relatively recent phenomenon. Today a wide range of adolescent clinical preventive health services are recommended
In 1998, Dr. Arthur Elster, author of the American Medical Association’s (AMA) Guidelines for Adolescent Preventive Services (GAPS), wrote “As the ‘final common pathway’ for synthesizing and applying scientific information . . . primary care physicians are likely to experience a preventive services information overload.”
Sixteen years later, this quote remains true.
Guidelines Exist from a Variety of Sources
Some of the earliest preventive health recommendations came from the United States Preventive Services Task Force (USPSTF). Only a few adolescent preventive services are recommended by the USPSTF, including depression, obesity, and tobacco screening, along with routine immunizations. For sexually active female adolescents, USPSTF recommends routine chlamydia and gonorrhea screening. On the other hand, counseling adolescents to abstain from using alcohol or drugs has received an “I” grade, signifying insufficient evidence of efficacy.
In 1992 the AMA introduced a set of 24 clinical preventive services for adolescents, known as GAPS. In 1994 the American Academy of Family Physicians (AAFP) released its own recommendations.
Today, Bright Futures provides the most comprehensive and widely used guide for health supervision of infants, children, and adolescents. First introduced in 1994, Bright Futures, 3rd edition, published in 2008, was led by the AAP, in collaboration with MCH and AMA. Bright Futures recommends annual preventive health visits for adolescents and young adults, ages 11 to 21 years. Areas to address during visits include social and emotional development, physical development and health habits, relationships and sexuality, family functioning, and school performance.
The Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Center for Quality Assurance, rates insurance plans. As such, clinicians may be under pressure to comply with HEDIS measures. Currently, adolescent-specific HEDIS measures include immunizations (notably HPV vaccine for girls), nutrition and physical activity counseling, and chlamydia screening.
An additional source for adolescent preventive health recommendations is the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. Clinicians caring for publicly insured children are required to comply with EPSDT recommended services. EPSDT recommends adolescents receive comprehensive assessments and physical exams at a minimum, every 2 years.
Many Adolescents Missing Recommended Services
Although recommendations vary, it is clear that health screening and counseling, performed on a routine basis, is beneficial for adolescents. Unfortunately, many adolescents do not receive these services. For the period 1997-2008, Dr. Jim Nordin and colleagues found that from age 13 to 17, one-third of adolescents with HealthPartners insurance had no preventive health visits, and an additional 40 percent had only one preventive health visit. Others have found that when adolescents present for preventive or acute visits, they rarely receive all recommended screening and counseling.
Along with not having routine well visits, lack of time is a major barrier to delivering preventive health services to adolescents. It has been estimated to simply focus on USPSTF recommended services would take providers 40 minutes. In an AAP survey of pediatricians, the average adolescent visit lasted only 19 minutes.
As an additional barrier, many recommended services require confidentiality. In a national survey, only 40 percent of adolescents reported time alone with their provider during a routine preventive health visit. Finally, although comprehensive care is important, there is a concern that providers cannot do it “all” and that the most effective and beneficial services (such as vaccinations and depression and chlamydia screening) may be crowded out by others where the benefits are less clear.
In most primary care practices, adolescents do receive many recommended services, including immunizations, screening for physical and behavioral risks, and age-appropriate health guidance. Improved documentation of these services can help improve care and ensure appropriate physician reimbursement for time spent. Practices can encourage visits by maintaining an adolescent-friendly office. For example, keep one part of the waiting area specific to adolescents, with age-appropriate reading materials. Similarly, encourage office staff to greet adolescents, and not just their parents. Finally, establish systems to allow parents to consent for their teen to receive care in the future when unaccompanied by their parent or guardian.
Offices should ensure that all staff are familiar with services adolescents can access without parental notification and/or consent and should consider implementing systems for confidential appointment-making, confirmation and billing. In Minnesota, a minor’s right to access confidential health care is guaranteed by Minnesota Statute 144.341-347. Services covered under this statute include medical services related to pregnancy, sexually transmitted infections, alcohol and other drug abuse. Parental notification, but not parental consent, is required for a minor in Minnesota to obtain an abortion.
Offices can facilitate discussions with teens regarding sensitive topics with the use of pre-visit surveys. Surveys should be completed in a private area, away from parents, significant others, and other patients. Although not meant to replace face time with a clinician, these questionnaires can help identify those adolescents who may need additional counseling, examination, or testing.
Finally, there is a growing movement toward strength-based screening of adolescents. In this model, providers assess for protective factors and assets (making healthy choices, identifying individuals and community sources of support, etc.) rather than simply screening for risky behaviors. This approach allows providers to develop rapport and connection around positive factors in adolescents’ lives and facilitates motivational interviewing.
