David W. Kaplan

Use of health and mental health services by adolescents across multiple delivery sites

PURPOSEnTo assess the role that school-based health centers (SBHCs) play in facilitating access to care among low-income adolescents and the extent to which SBHCs and a community health center network (CHN) provide similar or complementary care.nnnMETHODSnA retrospective cohort design was used to compare health care service use among adolescents relying on SBHCs compared with adolescents relying on a CHN. The study sample consisted of 451 inner-city high school students who made 3469 visits between 1989 and 1993. Encounter data were abstracted from medical records. Frequency of use and reason for use are examined according to various sociodemographic and health insurance characteristics.nnnRESULTSnSBHC users averaged 5.3 visits per year. Minority youth who used the SBHC had the highest visit rates (Hispanic, 6.6 visits/year; African-American, 10.6 visits/year). Visits to SBHCs were primarily for medical (66%, p <.001) and mental health services (34%, p <.001). Visits at CHN sites were 97% medical (p <.001). Visits by adolescents were 1.6 times more likely to be initiated for health maintenance reasons (p =.002; confidence interval [CI], 1.17-2.06) and 21 times more likely to be initiated for mental health reasons (p = <.001; CI, 14.76-28.86) at SBHCs than at CHN facilities. Urgent and emergent care use in the CHN system was four times more likely for adolescents who never used a SBHC (p <.001; CI, 3.44-5.47).nnnCONCLUSIONSnThis study supports the view that SBHCs provide complementary services. It also shows their unique role in improving utilization of mental health services by hard-to-reach populations. The extent to which community health centers and other health care providers, including managed care organizations, can build on the unique contributions of SBHCS may positively influence access and quality of care for adolescents in the future.

Clinical Tracking of Severely Obese Children: A New Growth Chart

The 2000 Centers for Disease Control and Prevention growth charts are unable to accurately define and display BMI percentiles beyond the 97th percentile. At Children’s Hospital Colorado, we created new growth charts that allow clinicians to track and visualize BMI values in severely obese children. This growth chart defines a child’s BMI as a “percentage of the 95th percentile.” It has the potential to allow clinicians to define subgroups of severe obesity, monitor trends in obese children, and measure treatment success or failure.

Patient Health Questionnaire-9 as an Effective Tool for Screening of Depression Among Indian Adolescents

PURPOSEnDetection of depression among adolescents in the primary care setting is of paramount importance, especially in resource-constrained countries such as India. This article discusses the diagnostic accuracy, reliability, and validity of the Patient Health Questionnaire-9 (PHQ-9) when pediatricians use it among Indian adolescents.nnnMETHODSnPediatricians administered the PHQ-9 to 233 adolescent students aged 14-18 years, along with the Beck Depression Inventory. Our psychologist clinically diagnosed depression based on an International Classification of Diseases, 10th Revision, interview of participants. One month later, the PHQ-9 was readministered among students. We conducted appropriate analyses for validity and diagnostic accuracy.nnnRESULTSnA total of 31 students (13.3%) had a form of depression on psychiatric interview. A PHQ-9 score of ≥5 was ideal for screening (sensitivity, 87.1%; specificity, 79.7%). In addition to good content validity, PHQ-9 had good 1-month test-retest reliability (r = .875) and internal consistency (Cronbachs α = .835). There was high convergent validity with the Beck Depression Inventory (r = .76; p = .001). The concordance rate between the PHQ-9 threshold score of ≥10 and the International Classification of Diseases, 10th Revision based diagnosis was good (Cohens κ = .62). The area under the receiver operating characteristic curve for PHQ-9 was .939.nnnCONCLUSIONSnThe PHQ-9 is a psychometrically sound screening tool for use by pediatricians in a primary care setting in India. Because it is a short, simple, easy to administer questionnaire, the PHQ-9 has tremendous potential in helping to tackle the growing problem of depression among adolescents in developing countries.

Reproductive health in school-based health centers: findings from the 1998–99 census of school-based health centers

PURPOSEnTo describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United StatesnnnMETHODSnWe examined questionnaire data on provision of reproductive health services from the 1998-99 Census of School-Based Health Centers (response rate 70%). We examined 551 SBHCs in schools with high or middle school grades. We used logistic regression to define factors independently associated with services and policies.nnnRESULTSnMost SBHCs (76%) were open full-time; over one-half (51%) of centers had opened in the past 4 years. Services provided, either on-site or by referral, included gynecological examinations (95%), pregnancy testing (96%), sexually transmitted disease (STD) diagnosis and treatment (95%), Human Immunodeficiency Virus (HIV) counseling (94%), HIV testing (93%), oral contraceptive pills (89%), condoms (88%), Depo-Provera (88%), Norplant (78%), and emergency contraception (77%). Counseling, screening, pregnancy testing, and STD/HIV services were often provided on-site (range 55%-82%); contraception was often provided only by referral (on-site availability = 3%-28%). SBHCs with more provider staffing were more likely to provide services on-site; rural SBHCs and those serving younger grades were less likely to provide these services on-site. Over three-quarters (76%) of SBHCs reported prohibitions about providing contraceptive services on-site; the sources of these prohibitions included school district policy (74%), school policy (30%), state law (13%), and health center policy (12%). While SBHCs generally required parental permission for general health services, many allowed adolescents to access care independently for certain services including STD care (48%) and family planning (40%). Older SBHCs were more likely to allow independent access.nnnCONCLUSIONSnSBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care.

Reproductive health risk behavior survey of Colombian high school students.

PURPOSEnTo establish rates of potentially risky sexual behaviors among Colombian adolescent students.nnnMETHODSnA total of 230 9th and 11th graders at a Colombian high school (69% of enrolled students) were anonymously surveyed about selected reproductive health behaviors using the Centers for Disease Control and Preventions self-administered Youth Risk Behavior Survey.nnnRESULTSnThe response rate was >90%. The group was demographically representative of students. Twenty-nine percent of the group had engaged in intercourse (13% of 9th and 43% of 11th graders). Male gender [beta = 0.7873; odds ratio (OR) = 2.09; 95% confidence interval (CI) = 1.57-3.08] and increasing age (beta = 0.3413; OR = 1.41; 95% CI = 1.02-1.93) were each significantly correlated with prior sexual activity. Compared with females, males initiated intercourse at a significantly earlier age (beta = 0.284; p < .001) but did not report significantly more partners (means 2.1 vs. 1.4; chi2 = 1.25; p = .262). Forty-eight percent of respondents used contraception during their last encounter. Sixty-three percent used oral contraceptives or condoms, while the remainder used less effective methods. Contraceptive use did not correlate with gender or age. Age was significantly and positively correlated with use of alcohol prior to sexual activity (B = 1.28; OR = 3.6; 95% CI = 1.49-8.44).nnnCONCLUSIONSnCompared with U.S. populations of similar ages, the Colombian group surveyed had fewer sexually active members, reported fewer partners, and used contraception with lower frequency.

A Quality Improvement Study to Improve Inpatient Problem List Use

BACKGROUNDnThe problem list is a meaningful use incentivized criterion, and >80% of patients should have 1 problem entered as structured data.nnnOBJECTIVEnThe aim of the present study was to use a series of interventions to increase the use of the problem list for inpatients to >80% as measured by at least 1 hospital problem at discharge.nnnMETHODSnThis study was a quasi-experimental time series quality improvement trial. The primary outcome was 80% of medical and psychiatric inpatients with a problem added to the problem list before discharge. Control charts of percentage (p charts) of medical and psychiatric patients with an inpatient problem list at discharge were constructed with three-σ control limits. Control limits were revised after evidence of improvement. The charts were annotated with interventions, including increasing awareness, focused education, and timely feedback in the form of performance graphs e-mailed to providers.nnnRESULTSnFor medical inpatients, use rose from 31% to 97% at its peak in April 2011 and continues to maintain above the goal of 80%. In psychiatry, problem list use rose from 2% initially to an average of 72% after the interventions.nnnCONCLUSIONSnSignificant gains were made with inpatient problem list usage by the medical and psychiatric teams. Our goal ascribed by meaningful use for >80% of inpatients to have a problem at discharge was met after initiation of our series of interventions.

Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Introduction: Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients. Methods: We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests. Results: Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time. Conclusions: Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.