Dillon J. Etter

Human papillomavirus vaccine in adolescent women: A 2012 update

Purpose of review Despite recommendations from the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescents with the human papillomavirus (HPV) vaccine, U.S. coverage among women remains less than 50%, with that of adolescent men below 2%. Recent findings Ongoing studies document the efficacy and safety of the HPV vaccine. Nevertheless, misconceptions and negative attitudes persist and serve as barriers to vaccine uptake. Additionally, other factors such as age, insurance status, poverty status, and racial or ethnic background have been associated with diminished vaccine uptake and poor completion rates. Internationally, HPV vaccination programs and school-based programs have achieved increased rates of uptake and series completion. HPV vaccination coverage may also be facilitated by improving communication between physicians, parents, and adolescents as well as by addressing common misconceptions about the vaccine. Summary This review highlights significant findings of recent literature on HPV vaccination of adolescent women with a special focus on uptake, series completion, communication, disparities in vaccine coverage, and other health outcomes associated with HPV vaccination.

The Complex Etiology and Lasting Consequences of Child Maltreatment

Child maltreatment is a global public health problem of epidemic proportions [1]. Internationally, the prevalence is striking, with reports suggesting that 25%e50% of children report being physically abused [1]. The annual estimates of child maltreatment in the developed world are highest in the United States: 3.4 million referrals of child abuse involved 6.2 million children in 2011 [2]. It is estimated that 1,570 of these children (or about four children every day) died as a result of child abuse and neglect [2]. Child sexual abuse has consistently been associated with adverse psychological outcomes in adulthood [3]. Norman et al. [4] focused on nonsexual child maltreatment and found a consistent association between nonsexual child maltreatment (e.g., physical abuse, emotional abuse, and neglect) and negative outcomes related to both mental and physical health. These outcomes include depression, alcohol abuse, anxiety, suicidal behavior, and increased risk of infection with human immune deficiency virus and herpes simplex virus type 2 [4e8]. Recent research suggests that developmental timing of exposure to maltreatment during childhood influences the risk of negative outcomes such as depression and suicide in young adulthood [9,10], although there is little agreement as to whether earlier or later exposure is associated with worse outcomes. In response to the burden of child maltreatment on individuals, families, and society, the Centers for Disease Control and Prevention (CDC) recently launched Essentials for Childhood [11], a component of the Public Health Leadership for Child Maltreatment Prevention Initiative toolkit. The Public Health Leadership Initiative is a resource sponsored by the Doris Duke Charitable Foundation and developed in partnership with the CDC Foundation and CDC’s Division of Violence Prevention, to help state departments enhance child maltreatment efforts and serve as a foundation for building a national public health prevention system that promotes safe, stable, nurturing relationships (SSNRs) in an effort to prevent child maltreatment [12]. This special issue showcases the latest research initiatives that examine the intergenerational transmission of child maltreatment and investigate the moderating effects of SSNRs on continuity of the intergenerational cycle of maltreatment. In most families, child maltreatment is not perpetuated from one generation to the next [13,14]. However, in cases where it is, children are at elevated risk for a variety of negative health

Characteristics Associated with Confidential Consultation for Adolescents in Primary Care

Objective To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training. Study design This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent‐reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ2 tests. Associations between adolescent characteristics, risk factors, and provider‐reported confidential consultation were examined using logistic regression analyses. Results The sample included 1233 English and Spanish‐speaking adolescents 12‐20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation. Conclusions Provider training is needed to reinforce the importance of confidential consultation for all adolescents.

Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents

PURPOSE The purpose of this study was to assess the feasibility of using an existing computer decision support system to screen adolescent patients for suicidality and provide follow-up guidance to clinicians in a primary care setting. Predictors of patient endorsement of suicidality and provider documentation of follow-up were examined. METHODS A prospective cohort study was conducted to examine the implementation of a CDSS that screened adolescent patients for suicidality and provided follow-up recommendations to providers. The intervention was implemented for patients aged 12-20 years in two primary care clinics in Indianapolis, Indiana. RESULTS The sample included 2,134 adolescent patients (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Just over 6% of patients screened positive for suicidality. A positive endorsement of suicidality was more common among patients who were female, depressed, and seen by an adolescent-medicine board-certified provider as opposed to general pediatric provider. Providers documented follow-up action for 83% of patients who screened positive for suicidality. Documentation of follow-up action was correlated with clinic site and Hispanic race. The majority of patients who endorsed suicidality (71%) were deemed not actively suicidal after assessment by their provider. CONCLUSIONS Incorporating adolescent suicide screening and provider follow-up guidance into an existing computer decision support system in primary care is feasible and well utilized by providers. Female gender and depressive symptoms are consistently associated with suicidality among adolescents, although not all suicidal adolescents are depressed. Universal use of a multi-item suicide screener that assesses recency might more effectively identify suicidal adolescents.

Physician Intervention to Positive Depression Screens Among Adolescents in Primary Care

PURPOSE The objective of this study was to determine the effectiveness of computer-based screening and physician feedback to guide adolescent depression management within primary care. METHODS We conducted a prospective cohort study within two clinics of the computer-based depression screening and physician feedback algorithm among youth aged 12-20 years between October 2014 and October 2015 in Marion County (Indianapolis), Indiana. RESULTS Our sample included 2,038 youth (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Over 20% of youth screened positive for depression on the Patient Health Questionnaire-2 and 303 youth (14.8%) screened positive on the Patient Health Questionnaire-9 (PHQ-9). The most common follow-up action by physicians was a referral to mental health services (34.2% mild, 46.8% moderate, and 72.2% severe range). Almost 11% of youth in the moderate range and 22.7% of youth in the severe range were already prescribed a selective serotonin reuptake inhibitor. When predicting mental health service referral, significant predictors in the multivariate analysis included clinic site (40.2% vs. 73.9%; p < .0001) and PHQ-9 score (severe range 77.8% vs. mild range 47.5%; p < .01). Similarly, when predicting initiation of selective serotonin reuptake inhibitors, only clinic site (28.6% vs. 6.9%; p < .01) and PHQ-9 score (severe range 46.7% vs. moderate range 10.6%; p < .001) were significant. CONCLUSIONS When a computer-based decision support system algorithm focused on adolescent depression was implemented in two primary care clinics, a majority of physicians utilized screening results to guide clinical care.