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Latest Developments in Adolescent Health Care

Latest Developments in Adolescent Health Care. Mark G. Martens, M.D. Vice-President and Chief Medical Officer Planned Parenthood of Arkansas and Eastern Oklahoma Research Center Professor Department of Obstetrics & Gynecology The University of Oklahoma-Tulsa

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Latest Developments in Adolescent Health Care

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  1. Latest Developments in Adolescent Health Care Mark G. Martens, M.D. Vice-President and Chief Medical Officer Planned Parenthood of Arkansas and Eastern Oklahoma Research Center Professor Department of Obstetrics & Gynecology The University of Oklahoma-Tulsa President- International Infectious Disease Society for Obstetricians and Gynecologists

  2. BACKGROUND • Majority of adolescent morbidity/ mortality is preventable

  3. Leading Causes of Mortality in Adolescents Ages 10-19

  4. MORBIDITY/MORTALITY • Accidents and injuries leading cause of death for both males and females • Many of these accidents involve alcohol and other substances

  5. MORBIDITY/MORTALITY • Sexually transmitted diseases are common infectious diseases among adolescents • Among adolescents ages 15-19, pregnancy and childbirth are the leading causes of hospitalization

  6. BACKGROUND • Risky behaviors co-occur • Behaviors responsible for leading causes of morbidity/mortality during adulthood are initiated during second decade of life (e.g., smoking, substance use, physical inactivity, risky sexual behavior)

  7. PROMOTE ADOLESCENT HEALTH • Requires participation of • Adolescents • Families • Schools • Communities • Federal, state & community policies

  8. PROMOTE ADOLESCENT HEALTH • Health care system • Most adolescents see a primary care provider at least once a year

  9. ADOLESCENT CLINICAL GUIDELINES Recommend that primary care providers screen & counsel adolescent patients for risky health behaviors

  10. ADOLESCENT CLINICAL GUIDELINES • National Committee for Quality Assurance (NCQA) Guidelines (HEDIS) have Adolescent-Specific Measures: • Screening for alcohol use • Annual visit to provider • Immunization status • Screening sexually active females for Chlamydia trachomatis (Over 15 years old)

  11. ADOLESCENT CLINICAL GUIDELINES • Despite guidelines, current delivery of preventive services below recommended levels • Limited research on how to implement adolescent preventive services

  12. RISK AREAS • Risky behaviors associated with major morbidity and mortality in adolescence: • Tobacco • Alcohol • Drugs • Sexual Behavior • Seatbelt • Helmet

  13. SEXUAL BEHAVIOR • Increase condom use • Delay onset • SUBSTANCE USE • Decrease initiation • Decrease use • TOBACCO • Decrease initiation • Decrease smoking • SEATBELTS • Increase seatbelt use • HELMETS • Increase helmet use • SYSTEM IMPLEMENTATION OF PREVENTIVE SERVICES • Increased Screening • Increased Counseling INCREASE PREVENTIVE SERVICES TO ADOLESCENTS

  14. GOAL • Develop and evaluate a system intervention to increase the delivery of adolescent clinical preventive services

  15. SYSTEM INTERVENTION TO INCREASE DELIVERY OF CLINICAL PREVENTIVE SERVICES CURRENT DELIVERY OF PREVENTIVE SERVICES IMPROVED DELIVERY OF PREVENTIVE SERVICES Provider Training Tools Health Educator

  16. TRAINING • 8-Hour Training for Pediatric Primary Care Providers • Adolescent Health and Development • Effective Communication with Adolescents • Give Clinicians Targeted Specific Messages about Risk Behaviors

  17. TOOLS • Adolescent Health Screening Questionnaire • Provider Charting Form • Provides information from the Adolescent Health Screening Questionnaire to indicate health behavior of the patients • Provides prompts and cues for provider intervention

  18. GUIDELINES FOR PROVIDER INTERVENTION • Not Engaging in Risky Behavior • Reinforce positive behaviors

  19. GUIDELINES FOR PROVIDER INTERVENTION • Engaging in Risky Behavior • Confirm response • Express concern about risky behavior • Provide key messages

  20. KEY MESSAGESKey Messages for Sexual Behavior Message 1 Avoiding sex is the safest way to prevent pregnancy and sexually transmitted diseases or AIDS.

  21. KEY MESSAGESKey Messages for Sexual Behavior Message 2 If you choose to have sex, be responsible. Use a condom every time you have sex. If you don’t have a condom, don’t have sex. To ensure you don’t get pregnant or get your partner pregnant, and as a backup to a condom, use another form of birth control

  22. INTERVENTION PROCEDURE • Adolescent Health Screening Questionnaire prior to well-visit • Provider well-visit • 20 to 30 minutes • Health Educator visit • 15 to 30 minutes

  23. Four in ten girls get pregnant at least once before age 20. Source: National Campaign to Prevent Teen Pregnancy analysis of Henshaw, S.K., U.S.. Teenage Pregnancy Statistics, New York: Alan Guttmacher Institute, May, 1996; and Forrest, J.D., Proportion of U.S. Women Ever Pregnant Before Age 20, New York: Alan Guttmacher Institute, 1986, unpublished.

  24. International Pregnancy and Birth Rates, Teens 15-19 The United States has much higher teen pregnancy and birth rates than other fully industrialized countries. U.S. teen pregnancy rates are twice as high as rates in Canada and eight times as high as rates in Japan. UNICEF. (2001). A league table of teenage births in rich nations. Innocenti Report Card, 3. Pregnancy rates were calculated by the National Campaign using birth and abortion data from this report and miscarriage data which were estimated using the formula the Alan Guttmacher Institute uses in generating U.S. teen pregnancy data, with miscarriages=20% of births + 10% of abortions. Just the Facts (September 2004) – Page PB-3

  25. The consequences of teen motherhood are many: • Less likely to complete high school • Dependence on welfare • Single parenthood • More likely to have more children sooner on a limited income • More likely to abuse or neglect the child National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

  26. Risks to children of teen mothers • growing up without a father • low birthweight and prematurity • school failure • mental retardation • insufficient health care • abuse and neglect • poverty and welfare dependence Source: Maynard, R.A., (ed.), Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing, New York: Robin Hood Foundation, 1996.

  27. Only 32 percent of teen mothers get their high school diploma • Teen mothers: Educational attainment by age 30 68% 32% National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

  28. The children of teen mothers are at greater risk of abuse and neglect 110 51 29 18 National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

  29. Taxpayers spend about $6.9 billion ($2,831 per teen parent) on teen childbearing Estimated annual costs to taxpayers of teen childbearing in billions $1.0 $1.4 $2.7 $1.7 $0.1 National Campaign to Prevent Teen Pregnancy. (1997). Whatever Happened to Childhood? The Problem of Teen Pregnancy in the United States. Washington, DC: Author.

  30. Teen birth rates, girls aged 15-19(number of births per 1,000 girls) The teen birth rate declined steadily from 1960 through the mid-1970s, stayed fairly constant for the next decade, then increased 24 percent between 1986 and 1991. Between 1991 and 1999, the teen birth rate decreased 20 percent to a record low. Note: data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14). Ventura, S.J., Mathews, T.J., & Curtin, S.C. (1998). Declines in teenage birth rates, 1991-97: National and state patterns. National Vital Statistics Reports 47(12).

  31. Nearly 1 million teen pregnancies. To put it another way, more than 100 U.S. teens become pregnant each hour. Forty percent of these pregnancies were to girls under age 18, and 60 percent were to girls aged 18-19. 100 teen girls get pregnant each hour Total: 905,000 542,640 337,530 24,830 The Alan Guttmacher Institute. (1999). Special report: U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: Author.

  32. Each year, half a million teens give birth Just over one-half of teen pregnancies to girls aged 15-19 ended in birth, about one-third ended in abortion, and 14 percent ended in miscarriage. 124,700 491,577 263,890 The Alan Guttmacher Institute. (1999). Special report: U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: Author.

  33. 55 teen girls give birth each hour Nearly one-half million teen births occurred. To put it another way, more than 55 U.S. teens give birth each hour. Thirty-six percent of these births were to girls under age 18, and 64 percent were to girls aged 18-19. Total: 484,794 312,186 9,049 163,559 * Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

  34. State teen pregnancy rates(pregnancies per 1,000 girls aged 15-19) 50-62 per 1,000 65-85 per 1,000 86-90 per 1,000 95-106 per 1,000 108-140 per 1,000 Teen pregnancy rates vary widely by state, ranging from 50 per 1,000 in North Dakota to 140 per 1,000 in Nevada. The Alan Guttmacher Institute. (1999). Teenage pregnancy: Overall trends and state-by-state information. New York: Author.

  35. Changes in teen pregnancy rates(pregnancies per 1,000 girls aged 15-19) 16.4-31.2% decline 12.2-15.5% decline 9.4-11.5% decline 3.4-9.2% decline No change Teen pregnancy rates declined in every state but New Jersey; declines ranged from 3.4 percent in Nevada to 31.2 percent in Alaska. The Alan Guttmacher Institute. (1999). Teenage pregnancy: Overall trends and state-by-state information. New York: Author.

  36. Teen pregnancy rates, racial/ethnic subgroups(number of pregnancies per 1,000 girls aged 15-19) Teen pregnancy rates vary substantially among the three largest racial/ethnic subgroups. The rate for African-American teens declined 20 percent and the rate for non-Hispanic White teens declined 24 percent. The teen pregnancy rate for Hispanics increased between 1990 and 1994, but then declined 6 percent. Non-Hispanic Black Hispanic (any race) Non-Hispanic White Darroch, J.E., & Singh, S. (1999). Why is teenage pregnancy declining? The roles of abstinence, sexual activity and contraceptive use. Occasional Report 1. New York: The Alan Guttmacher Institute.

  37. Teen birth rates by race/ethnicity, girls aged 15-19(number of births per 1,000 girls) Teen birth rates vary substantially among the largest racial/ethnic subgroups. Between 1991 and 1999, the rate for African-American teens declined 30 percent, the rate for all White teens declined 16 percent and the rate for non-Hispanic White teens declined 21 percent, the rate for Hispanics decreased 13 percent, the rate for Native Americans declined 20 percent, and the rate for Asian/Pacific Islanders declined 17 percent. Hispanic (any race) African American Native American TOTAL White (total) Non-Hispanic White Asian/Pacific Islander Note: data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14). Ventura, S.J., Martin, J.A., Curtin, S.C., Mathews, T.J., & Park, M.M. (2000). Birth: Final data for 1998. National Vital Statistics Reports 48(3).

  38. Pregnancy Outcomes, Teens Aged 15-19(number of pregnancies per 1,000 girls aged 15-19) Hispanic teens are most likely, and non-Hispanic Black teens least likely, to have a pregnancy that ends in a birth. The Alan Guttmacher Institute. (2004). U.S. teenage pregnancy statistics: Overall trends, trends by race and ethnicity and state-by-state information. New York: Author Just the Facts (April 2004) – Page P-25

  39. Number of teen births Among teens aged 15-19, more births occur to non-Hispanic White teens than to any other racial/ethnic group. * Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

  40. Number of teen births by birth order(births to girls aged 15-19) Nearly four-fifths of all teen births are first births. Of the other 22 percent, 18 percent are births to teens who already have one child, 3 percent are births to teens who already have two children, less than one percent are fourth or higher-order births, and the final 1 percent of births do not have a birth order stated on the birth certificate. Total: 475,745 (85,455) (14,643) (370,749) (2,148) (2,750) * Data for 1999 are preliminary. Curtin, S.C., & Martin, J.A. (2000). Births: Preliminary data for 1999. National Vital Statistics Reports 48(14).

  41. Pregnancy Outcomes Pregnancies to girls aged 15 or younger are less likely to end in birth than pregnancies to other age groups. Henshaw, S.K. (2004). U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24. New York: The Alan Guttmacher Institute. Just the Facts (April 2004) – Page P-20

  42. Association of HPV with Cervical Cancer HPV is present in virtually all cervical cancers, estimated at 99.7% J MM Walboomers et al., Journal of Pathology 189:12-19,1999 1980s 1990s 2000s 1999

  43. 30 30 25 25 20 20 15 15 10 10 5 5 0 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 HPV Prevalence and Cervical Cancer - Incidence by Age 1,2 Cancer incidence per 100,000 HPV Prevalence (%) Age (Years) 1. Sellors et al. CMAJ. 2000;163:503. 2. Ries et al. Surveillance, Epidemiology and End Results (SEER) Cancer Stats NCI, 1973-1997. 2000.

  44. HPV Types Differ in Disease Associations Cutaneous Mucosal/Genital ~40 Types ~ 60 Types “High” Risk : HPV 16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 70, etc “Low” Risk: HPV 6, 11, 42, 43, 44, etc Low grade cervical disease Cervical cancer precursors Cervical cancer “Common” hand and foot warts Genital warts Low grade cervical disease Laryngeal papillomas HPV = Human papillomavirus Adapted from Unger ER. CDC. June 2005 ACIP meeting Burd EM. Clin Microbiol Rev 2003;16:1-17.

  45. GARDASILQuadrivalent Human Papillomavirus [HPV Types 6, 11, 16, 18] Recombinant Vaccine

  46. HPV Vaccine • News of Phase II HPV Vaccine Results released April, 2005 in Lancet • HPV 6,11,16,18 Vaccine • 552 Women ages 16-23 • After 2 ½ years, 100% prevention of HPV (36 patients vs 4 in HPV negative women) • 100% effective at preventing any cervical abnormalities /cancer* • 25,000 more women vaccinated now

  47. Prophylactic Efficacy: 100% Efficacious Against HPV 16- and 18-related CIN 2/3 or AIS

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