Angela Diaz

Contraception and Adolescents

Although adolescent pregnancy rates in the United States have decreased significantly over the past decade, births to adolescents remain both an individual and public health issue. As advocates for the health and well-being of all young people, the American Academy of Pediatrics strongly supports the recommendation that adolescents postpone consensual sexual activity until they are fully ready for the emotional, physical, and financial consequences of sex. The academy recognizes, however, that some young people will choose not to postpone sexual activity, and as health care providers, the responsibility of pediatricians includes helping teens reduce risks and negative health consequences associated with adolescent sexual behaviors, including unintended pregnancies and sexually transmitted infections. This policy statement provides the pediatrician with updated information on contraception methods and guidelines for counseling adolescents.

Achieving Quality Health Services for Adolescents

In recent years, there has been an increased national focus on assessing and improving the quality of health care. This statement provides recommendations and criteria for assessment of the quality of primary care delivered to adolescents in the United States. Consistent implementation of American Academy of Pediatrics recommendations (periodicity of visits and confidentiality issues), renewed attention to professional quality-improvement activities (access and immunizations) and public education, and modification of existing quality-measurement activities to ensure that quality is delivered are proposed as strategies that would lead to improved care for youth.

The teen driver

Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates.

Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative

Importance Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost. Objectives To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation’s health and fiscal integrity. Evidence Review Qualitative synthesis of 19 National Academy of Medicine–commissioned white papers, with supplemental review and analysis of publicly available data and published research findings. Findings The US health system faces major challenges. Health care costs remain high at

Expert survey for the management of adolescent depression in primary care

3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation’s health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities—pay for value, empower people, activate communities, and connect care—recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs—measure what matters most, modernize skills, accelerate real-world evidence, and advance science—were the most commonly cited foundational elements to ensure progress. Conclusions and Relevance The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

Cervical, Anal and Oral HPV in an Adolescent Inner-City Health Clinic Providing Free Vaccinations

OBJECTIVE. Primary care clinics have become the “de facto” mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS. Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS. Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, “active monitoring” was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS. Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Recommendations of the IOM clinical preventive services for women committee: implications for obstetricians and gynecologists.

Objectives Published human papillomavirus (HPV) vaccine trials indicate efficacy is strongest for those naive to the vaccine-types. However, few high-risk young women have been followed and cervical HPV has been the predominant outcome measure. Methods We collected cervical and anal swabs, as well as oral rinse specimens from 645 sexually active inner-city young females attending a large adolescent health-clinic in New York City that offers free care and HPV vaccination. Specimens were tested for HPV-DNA using a MY09/MY11-PCR system. Type-specific prevalence of HPV at each anatomic site was compared for individuals by vaccination dose using generalized estimating equation logistic regression models. Results The majority of subjects reported being of non-Caucasian (92%) and/or Hispanic ethnicity (61%). Median age was 18 years (range:14–20). All had practiced vaginal sex, a third (33%) practiced anal sex, and most (77%) had also engaged in oral sex. At enrollment, 21% had not received the vaccine and 51% had received three doses. Prevalent HPV infection at enrollment was detected in 54% of cervical, 42% of anal and 20% of oral specimens, with vaccine types present in 7%, 6% and 1% of specimens, respectively. Comparing prevalence for vaccine types, the detection of HPV in the cervix of vaccinated compared to unvaccinated adolescents was significantly reduced: HPV6/11 (odds ratio [OR] = 0.19, 95%CI:0.06–0.75), HPV16 (OR = 0.31, 95%CI:0.11–0.88) and HPV18 (OR = 0.14, 95%CI:0.03–0.75). For anal HPV, the risk of detecting vaccine types HPV6/11 (OR = 0.27, 95%CI:0.10–0.72) and HPV18(OR = 0.12, 95%CI:0.01–1.16) were significantly reduced for vaccinated adolescents however, the risk for HPV16 was not significantly decreased (OR = 0.63, 95%CI:0.18–2.20). Conclusion HPV Prevalence is extremely high in inner-city female adolescents. Administration of the HPV vaccine reduced the risk for cervical HPV; however continued follow-up is required to assess the protection for HPV at all sites in young women with high exposure.

Advancing Medical Education Training in Adolescent Health

PURPOSE OF REVIEW In July 2011, in response to language in the Affordable Care Act (ACA) the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to develop a report on the clinical preventive services necessary for women. The committee proposed eight new clinical preventive service recommendations aimed at closing significant gaps in preventive healthcare. This article reviews the process, findings, and the implications for obstetrician gynecologists and other primary care clinicians. Obstetricians and gynecologists play a major role in delivering primary care to women and many of the services recommended by the Committee are part of the core set of obstetrics and gynecology services. RECENT FINDINGS The womens health amendment to the ACA (Federal Register, 2010) requires that new private health plans cover - with no cost-sharing requirements - preventive healthcare services for women. Congress requested that a review be conducted to ascertain whether there were any additional needed preventive services specific to womens health that should be included. SUMMARY The IOM Committee on Preventive Services for Women recommended eight clinical measures specific to womens health that should be considered for coverage without co-payment. The US Department of HHS reviewed and adopted these recommendations, and, as a result, new health plans will need to include these services as part of insurance policies with plan years beginning on or after 1 August 2012. The authors discuss the implications of the IOM recommendations on practicing clinicians and on their potential impact on womens health and well being.

Initiation of Oral Contraceptives—Start Now!

P COMPREHENSIVE CARE to adolescents is a multifaceted undertaking, requiring not only routine medical services but also health education, risk reduction, mental health, behavioral health, and sexual health services. Yet, this vital spectrum of care is unavailable to most adolescents. Not only is there a paucity of adolescent medical specialists, but many pediatricians—the providers increasingly likely to care for adolescents—report that they lack training and confidence in diagnosing and managing adolescents’ psychosocial and reproductive problems. Although this issue has not been the subject of much research, 1 national survey of pediatricians in 1998 found that 57% cited lack of training in gynecological care and 40% reported lack of training in mental health as significant barriers to providing needed services to adolescents.1 Incenter Strategies’ recent national surveys of adolescent medicine fellowship program directors, pediatric residency program directors, and adolescent medicine faculty in pediatric residency programs show a high degree of support for new options to enhance clinical training in adolescent medicine. The response rates, ranging from 75% to 88%, underscore the salience of this issue for academicians. Currently, pediatric residency programs, like other primary care residency programs, are not structured to give in-depth attention to adolescent medicine. The required rotation for adolescent medicine is just 1 month, with that time allotment exceeded by only 5% of residency programs. During the rotation, residents receive at least some training on a wide variety of adolescent health issues. Yet, in our survey, a third or more of adolescent medicine faculty responsible for the one-month rotation report that, in terms of clinical practice and application, exposure to key adolescent medicine topics is limited. Faculty report that areas such as anticipatory guidance, health promotion, disease prevention, chronic illness, mental health and behavioral health are only somewhat covered or not covered at all. Residents generally train in a small proportion of the settings in which adolescents typically receive care, according to surveyed faculty. Moreover, time spent in each site is often limited to a few days. In the predominant clinical site where residents are trained, adolescent medicine faculty report that mental health, behavioral health, and sexual health services are not consistently available. Neither are needed specialists; in fact, a psychiatrist or obstetrician/gynecologist is regularly on staff at only 10% of these clinics. Although clinical training in adolescent medicine should be integrated throughout residency training, most residents’ exposure to adolescents is currently focused heavily on inpatient and subspecialty care in which the medical concerns of the general adolescent population are not the focus of training. Continuity clinics might be expected to provide balance by offering opportunities for wide-ranging clinical experience in adolescent medicine. Yet, pediatric residency program directors, in more than a third of programs report that adolescents comprise 10% or less of the pediatric patient population in continuity clinics. Moreover, in well over three-quarters of programs, residents rarely see the same adolescent patient more than once in continuity clinic settings. Given these findings, it seems that the time has come to consider the need for major reforms in adolescent medicine training. At least 4 reform options should be examined: 1) extending the length of the mandatory adolescent medicine rotation, 2) introducing more flexibility in residency programs to allow for formalized optional training tracks in adolescent medicine 3) creating a combined pediatrics/adolescent medicine residency, and 4) increasing the availability of one-year adolescent medicine clinical training programs after completion of categorical training in general pediatrics. Each option has distinct strengths and weaknesses. Requiring a longer adolescent medicine rotation offers the advantages of encounters with more adolescents and a broader array of problems, more time spent at community sites, and increased exposure to faculty with expertise in adolescent medicine. Extending the length of the rotation, however, would not necessarily address the need for more experience developing longitudinal therapeutic relationships with adolescents, arguably a

Institute of Medicine Report: New Directions in Child Abuse and Neglect Research

PURPOSE Conventional practice for initiating oral contraceptive (OC) pills involves waiting to start the pills with the next menstrual period. We investigated whether immediate initiation of OCs would lead to improved continuation rates and therefore decreased pregnancy rates in adolescents aged 12-17 years. METHODS Study subjects were recruited from adolescent women presenting to 2 inner city clinics requesting OCs. A total of 539 adolescents between 12 and 17 years old were randomized to conventional initiation of the OC pill (Conventional Start [CS]) versus immediate, directly observed OC pill ingestion in the clinic (Quick Start [QS]). At 3 and 6 months the participants completed interviews that questioned them about their OC continuation and pregnancies. RESULTS In all, 86% of our adolescents completed follow-up interviews at 3 months, and 77% at 6 months. There were 45 pregnancies during the study period. QS was associated with continuing OCs to a second pack (adjusted OR 1.8, 95% CI 1.1-3.3). There was no difference in OC continuation rates at 3 or 6 months. Only 26% of adolescents continued OCs at 6 months and we identified 45 pregnancies during follow-up. CONCLUSION We conclude that directly observed, immediate initiation of oral contraceptives (QS) with adolescents briefly improves continuation although overall continuation rates are discouraging low. Health care providers could use this simple strategy to start adolescents on OCs at the initial visit. The low 6-month OC continuation rates highlight the need to seek novel ways to provide adolescents with the necessary tools to be successful at contraception.