adolescent healthcare utilization in the u.s. cynthia rand, md, mph university of rochester school...
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Adolescent Healthcare Utilization in the U.S.
Cynthia Rand, MD, MPH
University of Rochester School of Medicine and Dentistry
Outline
Adolescent healthcare utilization
• Visit-based data (NAMCS)
• Population-based data (MEPS)
• Additional visit burden for universal HPV vaccine delivery (MEPS)
National Healthcare Visit Patterns of Adolescents
• 1994-2003 NAMCS (office-based) and NHAMCS (hospital-based) combined
• Visit-based database
• Visit patterns by age and gender
– Overall visits
– Preventive visits (V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9)
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Females
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Females
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Females
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Females
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Females
Overall Visits for Adolescents
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Ob/gyn
Pediatrician
IM office^
FP office*
Males
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Subspecialist
FP/IM hospital~
Pediatrician
IM office^
FP office*
Females Males
Preventive Visits for Adolescents
Females
0
100
200
300
400
500
600
11 12 13 14 15 16 17 18 19 20 21
Age
Num
ber o
f visi
ts (th
ousa
nds) Ob/gyn
Pediatrician
FP/IM*
Males
0
100
200
300
400
500
600
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f visi
ts (th
ousa
nds) Pediatrician
FP/IM*
Females Males
Proportion of Visits for Preventive Care
Females
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Preventive visit (ICD-9 code) Other visit type
Males
0
1
2
3
4
5
6
11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f vis
its (m
illio
ns)
Preventive visit (ICD-9 code) Other visit type
Females Males
Population Based Analysis:Adolescent Healthcare Utilization
• MEPS 2002-2003
• Adolescents ages 11-21
• Parent or self-report of ambulatory care
• Primary care in past year (Peds, IM, FP, GP in office based practice or clinic)
• Includes all adolescents, even if not receiving care
Ambulatory and Primary Care Within 1 Year: Females
C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006
•Ambulatory care: Visit to a physician, nurse/nurse practitioner, physician assistant or midwife
**Primary care: Had a visit to a pediatrician, family physician, internist or GP in an office-based practice or clinic
Ambulatory and Primary Care Within 1 Year
C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006
•Ambulatory care: Visit to a physician, nurse/nurse practitioner, physician assistant or midwife
**Primary care: Had a visit to a pediatrician, family physician, internist or GP in an office-based practice or clinic
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
No Care
Female Adolescents With No Ambulatory Care in 12 months
Female Adolescents With Visits to Emergency Department (ED) Only
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
ED Only
No Care
Female Adolescents With Visits to Specialty Only
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent Specialty Only
ED Only
No Care
Female Adolescents With Visits to School-based Clinic Only
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent Schools Only
Specialty Only
ED Only
No Care
Female Adolescents With Visits to Ob/gyn Only
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
Ob/gyn Only
Schools Only
Specialty Only
ED Only
No Care
Female Adolescents With Visits to Ob/gyn and Any Other Site
(except 1° care)
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
Ob/gyn+Other
Ob/gyn Only
Schools Only
Specialty Only
ED Only
No Care
Female Adolescents With Any Primary Care Visit
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
Any 1° Care
Ob/gyn+Other
Ob/gyn Only
Schools Only
Specialty Only
ED Only
No Care
Overall Healthcare Utilization by Female Adolescents
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Per
cent
of
Fem
ales All other
Any 1° Care
Ob/gyn+Other
Ob/gyn Only
Schools Only
Specialty Only
ED Only
No Care
Overall Healthcare Utilization by Female Adolescents within a 1-Year Period
0102030405060708090
100
11 12 13 14 15 16 17 18 19 20 21
Age in Years
Pe
rce
nt o
f F
em
ale
s
All otherAny 1° Care Ob/gyn+OtherOb/gyn OnlySchools OnlySpecialty OnlyED OnlyNo Care
Adolescent Factors Associated With No Ambulatory Care
• Age– Older age (17-21 yrs old) for male
adolescents
• Race/Ethnicity– Other than white
• Income– All income levels less than 400% FPL
Potential Healthcare Visit Needs for Universal HPV Vaccine Delivery
• Primary care visits in 2002-2003 MEPS
• Determined whether 0, 1, 2 or 3 more visits needed
• Varied window of time to vaccinate
• Two scenarios:
– 1st vaccine given at a well visit
– 1st vaccine given at any visit
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
6 months
Window to vaccinate
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
6 months
12 months
Window to vaccinate
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
6 months
12 months
18 months
Window to vaccinate
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
6 months
12 months
18 months
24 months
Window to vaccinate
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
6 months
12 months
18 months
24 months
Window to vaccinate
Additional Visits Needed for Females, 1st Vaccine at Well Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
Well visit
Type of visit 1st vaccine
Additional Visits Needed for Females, 1st Vaccine at Well Visit vs. Any Visit
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
Well visit
Any visit
Type of visit 1st vaccine
Additional Visits Needed for Males, 1st Vaccine at Well Visit vs. Any Visit
0102030405060708090
100
% of male adolescents
0 1 2 3
# of additional visits needed
Well visit
Any visit
Type of visit 1st vaccine
Independent Predictors of Needing More Visits (2-3 vs. 0-1) in 24 months
• Adolescents more likely to need more visits:– Older age– Male– Black– Uninsured– Near-poor
Limitations
• NAMCS/NHAMCS well visit defined by ICD-9 code documented
• MEPS well visit defined by parent report if <17
• Alternative sites not well identified (teen clinics, family planning clinics, etc)
Conclusions
• 30% of adolescents receive no care in 12 months
• >50% have primary care visits, declines with age• Peds/FP major care providers to age 16• Females continue to receive care, more from
ob/gyn with older age• Male adolescents drop off from care after age 16• Few adolescents have sufficient visits for 3
vaccines
Implications
• Immunize preferentially in early/mid adolescence
• Ob/gyns should reach older adolescent females with vaccines if missed earlier
• Avoid missed opportunities for vaccination
• Consider delivering series at wider intervals
Future Questions
• How to encourage annual visits for adolescents?
• How to access those not getting care in the medical home?
• Do vaccine delivery strategies that work for younger children work for adolescents?
• Can a vaccine series be given annually? (HPV)
Acknowledgements
• Rochester Center for Adolescent Immunization Research– Peter Szilagyi, MD, MPH– Christina Albertin, MD, MPH
• Peggy Auinger, MS
• Jonathan Klein, MD, MPH
Additional Visits Needed by Age for Females, 1st Vaccine at Any Visit
(24 mo window)
0102030405060708090
100
% of female adolescents
0 1 2 3
# of additional visits needed
11-14
15-17
18-21
Age
Additional Visits Needed by Age for Males, 1st Vaccine at Any Visit
(24 mo window)
0102030405060708090
100
% of male adolescents
0 1 2 3
# of additional visits needed
11-14
15-17
18-21
Age
Preventive Visits in 2 Years
0102030405060708090
100%
of
ad
ole
sc
en
ts
11 13 15 17 19 21
Age
Female
Male
Literature ReviewAuthor Source Age Well visit Any medical
exam
Klein, 1999 1997 Commonwealth fund survey (self)
11-18 85% overall
89% 11-14
82% 15-18
CDC, 2005 2003 NHIS (parent)
12-17 86%
Burstein, 2003 1999 YRBS (self) 15-18 58-63% females
49-61% males
Ford, 1999 1995 Add Health (self)
12-18 68% <15
66% >15
Yu, 2001 1995 Add Health (self)
11-21 70% 11-14
67% 15-17
66% 18-21
McInerny, 2005 NCQA, HEDIS (insurer)
12-21 34% overall