This document discusses adolescent use of preventive services based on USPSTF recommendations and an analysis of claims data from a large health plan. The analysis found that the rate of preventive care visits was low, averaging less than 0.3 visits per year. Adolescents had more frequent non-preventive visits, averaging 1.5 visits per year. Longitudinal data on over 40,000 continuously enrolled adolescents showed that guidelines for annual preventive visits were met less than 2% of the time. The document recommends developing better evidence for adolescent clinical preventive services, taking advantage of every medical encounter to provide preventive care, and using clinical systems to improve delivery rates.

1. Adolescent Use of
Preventive Services
James D. Nordin, MD, MPH
Leif I. Solberg, MD
HealthPartners Research
Foundation
Minneapolis, MN

2. USPSTF Recommendations
• A and B Recommendations for Screening and Counseling
– Cervical cancer (Pap) Sexually active women
– Chlamydia (girls) Sexually active women
– Depression All adolescents
– Tobacco All adolescents
– Gonorrhea Sexually active women
– Syphilis Increased risk for STDs
– HIV Increased risk for STDs
• Immunizations
– Tdap, influenza All adolescents
– meningococcal vaccines All adolescents
– HPV Adolescent girls
– Pneumococcal, hepatitis A At risk adolescents

3. Summary of Evidence–based
Recommendations
• Cervical cancer screening at least every 3 years for all
sexually active women;
• Chlamydia screening for all sexually active women under
the age of 25; (inadequate evidence for men)
• Tobacco use and brief interventions; depression
screening and referral
• BMI screening and referral
• HPV, meningococcal, Tdap, and influenza
immunizations;
• For at risk patients
– gonorrhea, syphilis, and HIV screening
– pneumococcus and hepatitis A immunizations

4. Primary Care Visit Patterns

5. Prevalence of Delivery of
Preventive Services
• A review of current delivery prevalence was conducted
– Searched PubMed for adolescent clinical preventive
services and the individual service topics.
• HEDIS reports
– 70% of females (of all reproductive ages) get a Pap
smear at least every 3 years
– 40+% of females are screened for chlamydia
• Surveys of doctors
– Range from 20% to 50% who state they perform the
other preventive services
– Measure intention more than performance

6. Opportunities for Prevention
• National Ambulatory Medical Care Survey (NAMCS)
medical visit data for 1993–2000 found that adolescents
aged 13–18 years
– averaged 1.9 total medical visits per year
– 9% were for preventive care
• National 1999 youth risk behavior surveillance survey of
high school students found that of those reporting a
preventive care visit in the preceding 12 months few
reported having discussed STIs, HIV, or pregnancy
prevention at those visits
– 43% of girls
– 26% of boys

7. Adolescent Primary Care Visit
Patterns
• A retrospective descriptive analysis based on claims
data from a large health plan with 700,000 members in
Minnesota
• Data from 1998 through 2007
• Analysis
– Cross sectional analysis
– Longitudinal analysis of teens having at least 4 years
of continuous enrollment
• Not a representative sample
• As good as it gets (stable population)

8. Population
• 300,866 eligible adolescents
– 93% commercial insurance
– 7% government insurance
• Minnesota at the time (for comparison)
– 72% commercial
– 21% government insurance
– 7% no insurance
• For longitudinal analysis
– 40,043 met the 4 year enrollment requirement

9. Cross Sectional Analysis
Preventive Visit Rate by Year of Age
0.26 0.26
0.42
0.45
0.15
0.20
0.24
0.28
0.25
0.24
0.16
0.26
0.20
0.22
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Mean
number
of
preventive
visits
11, p=0.08144 12, p=0.0011 13, p<0.0001 14, p<0.0001 15, p=0.1327 16, p<0.0001 17, p=0.0013
Age, years
Chart 1. Mean number of preventive visits by year of age and insurance type (commerical or
government) in a sample of adolescents between the ages of 11 and 18, HealthPartners, 1998-
2007.
Commercial preventive visits, p for trend
=0.2404
Government preventive visits, p for trend =
0.3282

10. Cross Sectional Analysis
Non Preventive Visit Rate by Year of Age
1.08
0.95
1.07
0.98
1.11
0.99
1.16
1.11
1.26
1.31
1.36
1.47 1.45
1.61
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
Mean
number
non
preventive
visits
11, p<0.0001 12, p=0.0002 13, p<0.0001 14, p=0.0463 15, p=0.0891 16, p=0.001 17, p=<0.0001
Age, years
Chart 2. Mean number of non preventive visits by year of age and insurance type
(commerical or government) in a sample of adolescents between the ages of 11 anfd 18,
HealthPartners, 1998-2007.
Commercial non preventive visits, p for trend =
0.0007
Government non-preventive visits, p for trend =
0.0005

11. Longitudinal Analysis
• Subjects with continuous enrollment for 4 or 5 years
• Age 13 through 18
– Eliminated 12 year olds due to anomaly caused by
state law requiring immunization update for 7th grade
• Total population 40,043
– Uniquely stable population
– Insured by the same company for 4 or 5 years
– These people should have the easiest and most
frequent access to medical care

12. Longitudinal Analysis
Male/Female Breakdown
mean # of visits Female Male p-value
preventive visits 1.2 1 <0.0001
non-preventive visits 7.7 5.9 <0.0001
mean visit rate per year
preventive visits 0.3 0.2 <0.0001
non-preventive visits 1.7 1.3 <0.0001

13. Longitudinal Patterns of Health Care Use Among
Adolescents Over 4 or More Years
Number of
visits
Non preventive
Com
Non preventive
Gvt P-value
Preventive
Com
Preventive
Gvt P-value
0 8% 15% 30% 30%
1 9% 13% 41% 36%
2 10% 10% 22% 21%
3 9% 9% 5% 9%
4 9% 8% 1% 2%
5 to 10 34% 25% 0% 0%
>10 20% 20% 0% 0%
Overall
mean
total
visits 6.83 6.41 0.0277 1.07 1.18 <0.0001
mean per
year 1.5 1.47 0.5702 0.23 0.27 <0.0001

14. Conclusions
• AMA and AAP guidelines calling for one
preventive care visit annually for
adolescents are being met less than 2% of
the time in this select longitudinal cohort
• Adolescents are visiting their primary care
source for other reasons at rates similar to
those found a decade ago in the National
Ambulatory Medical Care Survey
(NAMCS)

15. Recommendations
• Develop better evidence for adolescent CPS
– Especially those that address health
conditions with a large impact
– More funding or shifted funding will be needed
• Take advantage of every adolescent medical
encounter to deliver CPS
– Young women should be giving us an
appropriately collected urine sample at non-
preventive visits
• Focus on clinical systems (recall/reminder, etc)
to improve rates of delivery
– Much easier with EMR
– Use standing orders to imploement