Volume 37, Issue 5, Pages 445-454 (November 2009)

11 of 17

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Clinical Preventive Services for Adolescents

Context

Most of the many clinical preventive services (CPS) recommended for adolescents by various national organizations lack good evidence of effectiveness. Improving adolescent preventive care will require focusing on those CPS for which there is such evidence and on developing better delivery strategies. The objective of the current study was to identify those CPS for adolescents that do have a strong evidence base, to update the literature review and summarize evidence gaps where research is needed, and to summarize current delivery prevalence and opportunities.

Evidence acquisition

A summary was conducted of the recommendations for adolescents of the U.S. Preventive Services Task Force (USPSTF) and the CDC's Advisory Committee on Immunization Practices (ACIP). An update is provided of the literature review for services with an inadequate evidence base to support a recommendation. A summary was prepared of the types of evidence still needed. A literature search was also conducted for current delivery prevalence of recommended services for those aged 11–17 years, and common gaps in the evidence were identified.

Evidence synthesis

Although 24 CPS for adolescents have been reviewed by the USPSTF, only ten received definite recommendations and only seven of these favored delivery of the service. In addition, the ACIP recommends four immunizations for all adolescents, and two additional ones for those at high risk. There are many gaps in the evidence supporting most of the other services as well as in the information about current delivery prevalence.

Conclusions

There are too many CPS recommended for adolescents with insufficient evidence of effectiveness, and there is low delivery prevalence for the few services with good evidence of effectiveness. Both more research and more attention to the practice changes that might improve delivery prevalence are needed.

Article Outline

• Abstract

• Introduction

• Methods

• Results

• Literature Updates

• Evidence Gaps and Unknowns

• Current Delivery Prevalence

• Opportunities for Prevention

• Discussion

• Recommendations

• Conclusion

• Acknowledgment

• References

• Copyright

Introduction

Prevention is receiving more national attention, both because the most common underlying causes of death are preventable and because of the growing costs of treating existing conditions.1, 2, 3, 4 Even though there are many important population-based prevention actions that can and should be taken in communities, there is also need for improvement in clinical preventive services (CPS)—those usually delivered in clinical care settings.

As CPS gain importance, the recommendations for them have grown in number and in complexity, especially those targeting children and adolescents. Some recommendations also conflict with each other, especially those from organizations that rely on expert opinion. Currently, 28 counseling services and 31 screening services are recommended for adolescents by at least one of the five national groups that issue comprehensive sets of prevention recommendations: American Academy of Family Physicians; American College of Obstetricians and Gynecologists; American Academy of Pediatrics (AAP; Bright Futures); American Medical Association (AMA; Guidelines for Adolescent Preventive Services [GAPS]); and the U.S. Preventive Services Task Force (USPSTF). These 59 CPS do not include the ten immunizations recommended by the CDC's Advisory Committee on Immunization Practices (ACIP). In a review5 of the evidence behind the CPS that are recommended by at least two of the five organizations for well-child care, it was found that most had limited supporting evidence. The authors pointed out that because poorly evidenced recommendations can cause harm (at least by displacing more effective activities during all-too-brief clinical encounters), “all recommendations should be based on the strongest possible evidence.”

The USPSTF is clearly recognized as the body that does the best and most transparent job of basing recommendations on research evidence of effectiveness in a clinical setting. Although the stringent requirements of the USPSTF have reduced the number of recommended CPS, it is still difficult to fit this more limited set of services into well-child visits. It has been calculated6 that in a typical primary care practice, delivery of only USPSTF-recommended CPS for adolescents would take about 40 minutes per year per adolescent. This time period is well beyond that available within the 0.2 preventive visits per year reported7 as being currently utilized by this age group on average.

For adults, this problem of the volume and complexity of CPS has been greatly helped by the efforts of the National Commission on Prevention Priorities to objectively and transparently prioritize those preventive services with evidence of effectiveness. The resulting priority ranking and its recent updating allows patients, clinicians, care systems, payers, and purchasers to know where their resources and time will have the greatest impact.8, 9

For adolescents, however, delivery of CPS is associated with a number of unique problems that make improvement difficult:

1.There are more services recommended for adolescents by various advocacy organizations than for adults/other age groups.

2.Only a small proportion of these recommended services have enough evidence to allow either assurance that they are effective or prioritization among them.5

3.More than for adults, clinician delivery of preventive services to adolescents tends to be driven by tradition, expert opinion, and the very limited needs of particular required preventive visits (e.g., school or sports physicals).

4.Existing data on the frequency of clinician visits by adolescents (especially preventive visits) are both limited and outdated.10, 11, 12, 13

5.Many clinicians feel that adolescents are less interested in their long-term health than adults, more likely to engage in risky behaviors, and less likely to heed clinician recommendations.14, 15, 16

6.The time scheduled for adolescent routine exams is usually quite short, and extending it is unlikely, given that the Centers for Medicare and Medicaid Services (CMS) has recently increased the relative value for nonpreventive visits, thereby effectively reducing reimbursement for preventive visits.

Despite these problems and the fact that most adolescents are healthy, more than 70% of adolescent morbidity and mortality is the result of risky behaviors, such as alcohol use, unsafe sex, and violence. In addition, behavioral patterns established in adolescence, such as poor nutrition, physical inactivity, and tobacco use, contribute to cardiovascular disease, diabetes, and cancer in adulthood.5 The clinical setting presents an opportunity to identify risky behaviors early and to steer adolescents in the right direction.

In order to clarify the situation for adolescent CPS, this paper has the following objectives:

1.to identify those CPS for adolescents that do have a strong evidence base (i.e., have been recommended by the USPSTF or the ACIP);

2.to update the literature review concerning those adolescent CPS with insufficient evidence for a clear recommendation and to summarize the evidence gaps where research is needed;

3.to summarize what is known about current delivery prevalence for these CPS, as well as opportunities to provide them during medical visits.

Finally, based on the results of these objectives, along with the relevant quality-improvement literature, actions that might lead to improvements were identified.

Methods

Because many CPS for adults begin at age 18 years, this review was limited to those CPS applicable to those aged 11–17 years. As of May 2009, only seven CPS have received positive recommendations from the USPSTF. In addition, the USPSTF relies on the ACIP for recommendations for immunizations. As of May 2009, the ACIP was recommending four immunizations for all adolescents aged 11–18 years, plus two others for certain high-risk groups.17 These 13 CPS are listed in Table 1.

Table 1.

Adolescent clinical preventive services recommended by the USPSTF or ACIP


Service	Grade	Release date	Targeted population
Cervical cancer (Pap)	A	January 2003	Sexually active women with a cervix
Chlamydia (girls)	A	June 2007	Sexually active women aged <25 years
Depression	B	April 2009	Adolescents
Tobacco	B	May 2008	Adolescents
Gonorrhea	B	May 2005	Sexually active women at increased risk
Syphilis	A	July 2004	People at any age at increased risk for any sexually transmitted infections
HIV	A	April 2007	People at any age at increased risk
Tdap, influenza, and meningococcal vaccines	N/A		Adolescents
HPV vaccine	N/A		Adolescent girls
For those at increased risk
Pneumococcal and hepatitis A vaccine	N/A		People at increased risk

ACIP, Advisory Committee on Immunization Practices; HPV, human papillomavirus; USPSTF, U.S. Preventive Services Task Force

The recommendations of the USPSTF are based on a set of letter grades reflecting its assessment of a combination of the strength of evidence and the balance between benefits and harms. The current definitions are as follows18:

A.Recommends. High certainty of substantial net benefit.

B.Recommends. High certainty that net benefit is moderate or moderate certainty that benefit is moderate to substantial.

C.Recommends against routine provision, but may be appropriate for individuals. At least moderate certainty of small net benefit.

D.Recommends against. At least moderate certainty of no net benefit or that harms outweigh benefits.

I.Current evidence is insufficient to assess the balance of benefits and harms.

The literature was reviewed to provide a current update for those CPS with an I or C grade where the latest USPSTF review was conducted prior to June 2006. Immunization reviews were not updated as the ACIP keeps those reviews current. The review update followed this sequence:

1.Review the USPSTF recommendation statement to clarify the service.

2.Review the USPSTF evidence synthesis.

3.Develop a list of medical subject headings (MeSH) search terms.

4.Search PubMed through April 23, 2008, using those MeSH terms from the last date reviewed for the USPSTF. Other limits were abstracts, humans, English, and adolescents.

5.Search Cochrane Database of Systematic Reviews through 2007 (Cochrane Collaboration does not allow searches to limit dates to a specific month or day), using those MeSH terms from the past year reviewed for the USPSTF evidence review.

6.Review relevant articles cited in the bibliographies of articles from the above searches.

In order to identify research gaps and improvement actions, the USPSTF's systematic evidence reviews, evidence syntheses, and recommendation statements were first reviewed. During these reviews, barriers were identified that the USPSTF identified as preventing it from issuing a definite recommendation for each service, most of which were research gaps. Then information obtained from the update review process was added, and the main evidence gaps were summarized. Because most recommended CPS require face-to-face encounters in medical settings, a literature review was also conducted to clarify what is known about current opportunities to provide any CPS during medical visits, both those scheduled as well visits (e.g., school and sports physicals) and those generated for other reasons.

A review of current delivery prevalence was conducted by searching PubMed for adolescent clinical preventive services as well as the individual service topics. First, abstracts of relevant articles were reviewed to determine if information about delivery prevalence was included. If it was, the full article was reviewed, as well as any cited articles that were published through 2007. Little information is available about the prevalence of these services, so there was no need to apply selection criteria—anything found in multiple searches was included.

Results

The screening and counseling services recommended for adolescents aged 11–17 years by the USPSTF or the ACIP are summarized in Table 1. Table 2 contains the other services reviewed by the USPSTF but not recommended. The only other immunizations recommended by the ACIP for adolescents (hepatitis B, inactivated poliovirus, measles, mumps, rubella, and varicella) are identified for catch-up if not received previously. Twenty-four adolescent preventive services other than immunizations have been reviewed by the USPSTF, but only ten received definite recommendations (i.e., A, B, or D grades), and only seven services were given A or B grades, indicating that there is a high certainty of benefit. The other three were given D grades, indicating that they should not be performed. Most of the services receiving A or B grades involve sexually transmitted infections (STIs) or cervical cancer. Many of the services with insufficient evidence for adolescents had enough evidence to be recommended for adults by the USPSTF. Comparable adolescent services received an I grade because usually either the studies reviewed were limited to adults or findings for adolescents were not reported separately even though some adolescents may have been included in the study population. Among the ten immunizations recommended by the ACIP, three are recommended for all adolescents, namely conjugated meningococcal vaccine, Tdap, and influenza; one, human papillomavirus (HPV), is recommended for girls only. Four are “catch-up” recommendations for those who were not immunized at the recommended ages, and two are for high-risk groups only. Influenza had been recommended for high-risk groups only, but the June 2008 ACIP meeting recommended it for all adolescents.

Table 2.

Other adolescent clinical preventive services reviewed by the USPSTF


Service	Grade	Release date	Targeted population
Overweight	I	July 2005	Children and adolescents
Suicide risk	I	May 2004	General population
Alcohol misuse	I	April 2004	Adolescents
Chlamydia (boys)	I	June 2007	Boys/men
Gonorrhea (boys)	I	May 2005	Sexually active men aged <25 years
HIV (low-risk)	C	April 2007	People not at increased risk
Lipid disorders	I	July 2007	Children and young adults aged <21 years
Illicit drug use	I	January 2008	General population
Testicular cancer	D	February 2004	Asymptomatic adolescent and adult boys/men
Idiopathic scoliosis	D	June 2004	Adolescents
Syphilis (low-risk)	D	July 2004	Asymptomatic people not at increased risk
Physical activity	I	August 2002	General population
Healthy diet	I	January 2003	General population without risk factors for cardiovascular or diet-related disease
Skin cancer	I	October 2003	General population
HIV and STIs	C	1996*	Adolescents and adults
Auto restraints	I	August 2007	General population
Alcohol and autos	I	August 2007	General population

STIs, sexually transmitted infections; USPSTF, U.S. Preventive Services Task Force

Literature Updates

Five of the remaining 14 services with either insufficient evidence (I grade) or no recommendation (C grade) have been reviewed and updated by the USPSTF since June 2007, with no change in status. Updated literature searches of the nine other services produced the 19 articles listed in Table 3, Table 4.. Although the search strategies identified 20–1000 articles for each service, limiting these lists to those including adolescents, English language, an abstract, and the appropriate date range reduced these lists to two to 39 articles per service. Reviews of those abstracts further reduced potential articles to zero to six articles per service. Most abstracts were rejected because the studies did not include adolescents, did not address the evidence gaps, or addressed an intervention not feasible in the clinical practice setting. Five addressed delivery prevalence only and two were pilot studies. The meta-analyses, reviews, and clinical trials had mostly weak, mixed, or negative findings. In all cases, the additional studies found were not sufficient to warrant a definite recommendation.

Table 3.

Literature review updates for screening tests for adolescents


Service	Dates	Articles identified	Relevant articles	Sample (age in years)	Findings
Overweight	April 2005–April 2008	8	Taveras (2007)19	324(10–18)	Report infrequent specific doctor weight counseling
Overweight	April 2005–April 2008	8	Klein (2006)20	8,384(14–18)	One third at risk or overweight and report frequent doctor counseling
Suicide risk	October 2002–April 2008	39	Miranda (2008)21	191(teens)	In 4–6 years, 17% screened and made attempts
			Folse (2006)22	104(12–82)	Pilot study of four-item screen in emergency rooms
			Gould (2005)23	2,342(teens)	No evidence screening increases distress or suicidal thoughts
Alcohol misuse	February 2003–April 2008	11	Boekeloo (2004)24	409(12–17)	RCT of brief office intervention had no effect on use
Gonorrhea (boys)	July 2004–April 2008	16	Peterman (2006)25	1,183(15–39)	3-month check after STI clinic treatment: 15% new STI
Gonorrhea (boys)	July 2004–April 2008	16	Gaydos (2006)26	16,850(40%<19)	0%–1.5% of asymptomatic men tested in medical clinics had gonorrhea
HIV (low-risk)	June 2004–April 2008	18	0

STI, sexually transmitted infection

Table 4.

Literature review updates for counseling services for adolescents


Service	Dates	Articles	Relevant articles	Sample (age in years)	Findings
Physical activity	March 2002–April 2008	11	Ma (2005)11	NAMCS (13–18)	Only 22% report activity counseling during physicals
			Ortega (2004)27	392(12–21)	Those counseled at 0, 6, and 12 months increased activity
			Patrick (2006)28	878(11–15)	DOCTOR advice and 12 monthly mailings increased activity
Healthy diet	January 2000–April 2008	12	Ma (2005)11	NAMCS (13–18)	Only 26% reported diet counseling during physicals
Healthy diet	January 2000–April 2008	12	Patrick (2001)29	117(11–18)	PACE intervention is feasible
Skin cancer	August 2002–April 2008	2	Norman (2007)30	819(11–15)	RCT: DOCTOR counseling and periodic materials increased recorded behaviors
HIV and STIs	January 1994–April 2008	15	Sussman (2007)31	37 clinicians	Interviews identified problems for HPV counseling
			Roye (2007)32	400(teens)	RCT: video and counseling did not increase condom use at 1 year.
			Jemmott (2005)33	682(teens)	RCT: CBT or information was ineffective, skills-based both effective and ineffective
			Sales (2006)34	Systematic review	39 studies suggest there are effective interventions
			Boekeloo (1999)35	197(12–15)	RCT: at 9 months, no difference in behaviors but increased STIs

CBT, cognitive–behavioral therapy; NAMCS, National Ambulatory Medical Care Survey; PACE, Prescriptive Adherence Counseling and Education; STIs, sexually transmitted infections

Tobacco cessation counseling has recently moved from insufficient evidence (i.e., an I grade) to a B recommendation for adolescents on the strength of additional studies as reviewed by the U.S. Public Health Services guideline group (which the USPSTF defers to), which released its updated recommendations in May 2008.36 After conducting a meta-analysis of seven trials involving adolescents, it concluded that: “Counseling has been shown to be effective in treatment of adolescent smokers. Therefore, adolescent smokers should be provided with counseling interventions to aid them in quitting smoking.” However, only two of the seven trials in their meta-analysis addressed typical adolescents in medical settings, and those two were in emergency departments. Thus, one could still question whether the intervention benefit would apply in primary care. Nevertheless, in a well-designed RCT of 2526 teens making primary care visits that was not selected for that meta-analysis, it was demonstrated37 in 2005 that brief physician advice followed by two phone calls could increase prolonged cessation.

Similarly, depression screening for adolescents moved from an I to a B rating, based on a USPSTF update review. However, in its recommendation statement, the USPSTF said, “The USPSTF recommends screening of adolescents (aged 12–18 years) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive–behavioral or interpersonal), and follow-up.”38 Thus, the recommendation currently will apply to only those few clinics that have such systems in place.

Evidence Gaps and Unknowns

Summarizing the evidence gaps identified by the USPSTF that prevented I- and C-grade services from receiving an A- or B-grade recommendation demonstrated that a relatively common set of gaps was present. For both counseling and screening services, the main problem was inadequate evidence about the effect of delivering the service to adolescents in primary care settings on either short-term (patient behaviors) or long-term outcomes (morbidity and mortality). There was also little evidence about the acceptability or harms of tests, interventions, or subsequent treatments. Although there may be evidence to allow a balancing of benefits versus harms for adults, that evidence was generally lacking for adolescents. In nearly all cases, the problem was less a lack of clarity among existing trials than an absence of any good scientific studies about realistic clinical interventions in adolescents.

Current Delivery Prevalence

The estimates of current delivery prevalence for all the services relevant for adolescents from the literature search conducted for the current study are summarized in Table 5. The three services given D recommendations (screening for scoliosis, testicular cancer, and those at low risk for syphilis) are omitted, in part because no data were found about their frequency of delivery. Identifying prevalence specific to adolescents that might be representative of national averages was especially difficult. For many of the services, only survey-based self-reports of physicians were available. The population or sample represented by the data in this sample varied from one study to another, so it was impossible to directly compare the prevalence of different services unless they came from the same study. With the possible exception of Paps, delivery prevalence for all services is low, especially considering that self-reported prevalences from physician surveys are probably considerably higher than they are in reality.

Table 5.

Current frequency of preventive services in adolescents


Service	Delivery frequency	Source
Screening
Cervical cancer (Pap)	HEDIS population=81% commercial and 66% Medicaid	HEDIS (2007)39
Chlamydia (girls)	HEDIS for ages 16–20 years=36% commercial and 50% for Medicaid	HEDIS (2007)39
Gonorrhea (girls)	30% of primary care doctors report screening	St. Lawrence (2002)40
Syphilis (high-risk)	20% of primary care doctors report screening	St. Lawrence (2002)40
HIV (high-risk)	26% of primary care doctors report screening	St. Lawrence (2002)40
Overweight	55% of doctors report screening	Halpern-Felsher (2000)41
Depression	36% of those aged 13–17 years report being screened	Ozer (2007)42
Depression	17% of doctors report screening	Halpern-Felsher (2000)41
Suicide risk	15% of doctors report screening	Halpern-Felsher (2000)41
Alcohol misuse	Doctors report screening 84% of those aged 15–18 years in preventive exam	Ellen (1998)43
Alcohol misuse	28% of users report discussing it with clinician	Klein (2002)44
Chlamydia (boys)	12.8% of primary care doctors report screening	St. Lawrence (2002)40
Gonorrhea (boys)	13.4% of primary care doctors report screening	St. Lawrence (2002)40
HIV (low-risk)	No data
Lipid disorders	No data
Illicit drug use	Doctors report screening 82% of those aged 15–18 years in preventive exam	Ellen (1998)43
Illicit drug use	37% of recent drug users reported having discussed drugs with their clinician	Klein (2002)44
Counseling
Physical activity	42%–48% of those aged 13–17 years report a clinic conversation	Bethel (2001)45
	83% of those aged 14–18 years report clinician discussion during a just-completed well visit	Klein (2006)20
	22.3% have NAMCS visit documentation	Ma (2005)11
	34% of sedentary report discussing with clinician	Klein (2002)44
Healthy diet	26%–32% of those aged 13–17 years report a clinic conversation	Bethel (2001)45
Healthy diet	25.8% have NAMCS visit documentation	Ma (2005)11
Skin cancer	3.2% have NAMCS visit documentation	Ma (2005)11
HIV and STIs	36.4% of those aged 14–18 years report a clinic conversation	Bethel (2001)46
HIV and STIs	5.1% have NAMCS visit documentation	Ma (2005)11
Tobacco use	23% of those aged 13–17 years report a clinic conversation	Bethel (2001)45
	11.4% have NAMCS visit documentation	Ma (2005)11
	40% of users report discussing it with clinician	Klein (2002)44
Vehicle restraints	14.9% have NAMCS visit documentation of “injury prevention”	Ma (2005)11
Any health counseling	39% of those aged 13–18 years have NAMCS counseling documented during general medical exam visits	Ma (2005)11

HEDIS, Healthcare Effectiveness Data and Information Set; NAMCS, National Ambulatory Medical Care Survey; STIs, sexually transmitted infections

Opportunities for Prevention

Identifying published information about the frequency with which adolescents have medical encounters, either for routine exams or for illness, is an easier task than finding current delivery prevalence. A review11 of 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, less than any other age group except those aged 19–24 years (e.g., those aged 25–64 years averaged 3.1 and those aged ≥65 years averaged 6.1). That average of 1.9 visits for the adolescents varied substantially among subgroups. For example, it was 1.7 for boys, 2.2 for girls, 2.4 for whites, 1.5 for blacks, 1.2 for Hispanics and Asians, and only 0.3 for Native Americans. General medical exams accounted for 7.5% of adolescent visits, but boys had another 3.7% for physical exams for extracurricular activities. A review47 of NAMCS data for 1994–2003 found that 9% of adolescent visits were for preventive care, but the rate declined after age 14 years for girls and 13 years for boys. They found that “more than three times as many preventive visits were made by early adolescents as by late adolescents.”

An analysis48 of data from the 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, only 43% of girls and 26% of boys reported having discussed STIs, HIV, or pregnancy prevention at those visits. Thus, even those who report having preventive visits are missing opportunities to receive effective preventive services.

Another national survey, the national health interview survey, found that 90% of insured adolescents in 1995 had at least one physician contact in the past year (M=2.8).12 However, only 75% of uninsured adolescents (representing 14% of all adolescents) had been seen by a physician during the same period (M=1.5 contacts). In a survey10 of 6748 adolescents in 1997, 85% said they had had a well visit in the past year, 9% said 1–2 years ago, and 6% said more than 2 years ago. However, for those with no insurance, the rates were 76%, 12%, and 12%, respectively.

In a prepaid HMO system (Kaiser Portland) where insurance is not a limiting factor, 69% of those aged 14–17 years had a primary care visit during a 1-year period and 83% during a 2-year period (85% for girls and 81% for boys).13 Primary care visits accounted for 90% of all visits. Those who made primary care visits averaged 2.5 such visits per year.

Discussion

Although the USPSTF has reviewed 24 CPS for adolescents, only seven have sufficient evidence to recommend their routine use, and five of these relate to sexual health. In addition, the ACIP has found good evidence for six immunizations relevant to this age group. The evidence-based services with the broadest application among adolescents are as follows:

1.cervical cancer screening at least every 3 years for all sexually active women;

2.chlamydia screening for all sexually active women under the age of 25;

3.tobacco use and depression screening and brief interventions;

4.HPV, meningococcal, Tdap, and influenza immunizations;

5.In addition, gonorrhea, syphilis, and HIV screening plus pneumococcus and hepatitis A immunizations are needed for groups at increased risk.

Despite the obvious need for more evidence for the services that received I or C grades from the USPSTF for this age group, few relevant studies were found in the current update of the literature, and none of the services gained any strength from subsequent studies, except for depression screening and tobacco counseling.

Summaries of the unknowns and evidence gaps for both screening and counseling services with an I grade for insufficient evidence demonstrated a lack of support for making the critical decision as to whether the magnitude of benefits clearly outweighs harms. In most cases, there is little definitive information about either benefits or harms. Without a surge of new, strong evidence, there will continue to be little evidentiary basis for providing adolescents with many CPS beyond immunizations and STIs.

Deficiencies in supportive evidence are also apparent in the limited and generally poor-quality data on current prevalence of delivering any of these services. Even among the recommended services, only Pap screening for cervical cancer is performed at a high prevalence, and that service is primarily aimed at older adolescents and women <65 years, with no data specifically for adolescents. For many of the other services, either there are no national data or the data are based on unreliable or incomplete sources, as in the following cases:

1.Clinician self-report studies continue to be conducted and published, although results may reflect intention to provide the service more than actual delivery of the service.49, 50

2.Patient reports of receiving advice during medical encounters are fairly useful, especially if collected very soon after the service, but they can be unreliable.51 Moreover, when reported at a general level (e.g., X% reported a conversation about physical activity), it is impossible to differentiate passing comments from a serious effort to affect behavior.

3.NAMCS data are relatively reliable for procedures and tests, but they are much worse for counseling services because of patient recall problems.52

4.Clinician documentation of counseling services in medical records seriously underestimates performance.53

Even considering the difficulties of under- and over-estimation, the delivery prevalences illustrated in Table 5 are insufficient. Thus, there are currently many adolescent CPS—most of which lack evidence supporting their effectiveness—being delivered at low prevalences with no relationship between prevalence and effectiveness.

Finally, there is literature about the frequency with which adolescents are seen in medical settings, but the average visit rates per year are low (1–2/year), and only a small proportion (10%) of these visits are for preventive services. Thus, the continued emphasis among national guidelines for frequent prevention visits appears to have been relatively ineffective, and restricting preventive services to these visits is unlikely to improve the low–delivery prevalence problem.

Recommendations

1.Develop the evidence for adolescent CPS, especially those that address health conditions with a large impact. From a public policy perspective, it should be a national priority to develop the evidence needed for adolescent CPS, at least for those services that address conditions with a large health impact. Such an effort would require both additional resources for such research and a shift in funding priorities for the federal and private agencies that fund prevention research. Unfortunately, the CPS without an evidence base are typically those that address the greatest risks and problems for adolescents and their future health.

2.Prioritize CPS improvement efforts for those adolescent CPS with good evidence of effectiveness. While the policy, funding, and research communities are expanding the evidence base for these I- and C-graded services, the health plans, payers, care systems, and clinicians can do several things to improve delivery of services that have good evidence of effectiveness. First, the large number of CPS recommended for adolescents by professional associations without adequate evidence has led most care systems and clinicians to dilute their limited prevention time and energy to the point where no core set of services gets serious attention. One strategy for improvement would be to focus special attention on delivering those services with A or B evidence grades. During every prevention visit, staff can review whether these services are needed and remind the clinician about those needing further attention. Care systems and payers might foster such a focus on evidence-based services by providing incentives for the evidence-based services. An even more drastic approach would be to not reimburse services without evidence of effectiveness. This might stimulate the advocates for evidence-lacking CPS to encourage the additional research needed for these services.

3.Take advantage of every medical encounter with adolescents to address CPS needs.

Several national organizations continue to emphasize increasing preventive or well-child visits. However, because most adolescents do not have well-child visits at recommended intervals, especially after age 12 years, it would be better to take advantage of every medical encounter for evaluating prevention needs and providing services.13, 47 This approach is largely responsible for the improvements seen for childhood immunization prevalence, and it becomes more feasible with a limited number of priority services. There has been a clear movement in this direction for adult CPS, but it does not appear to be part of current practice for children and adolescents. As many as 80% of adolescents' encounters with healthcare providers do not include CPS interventions.54 GAPS (AMA), Bright Futures (AAP), and the Society for Adolescent Medicine appear to focus entirely on these well-child visits for delivering preventive services.16, 55 Because the literature suggests that only about 5%–10% of adolescent visits are for routine exams, discussing even one preventive service during most of the other 90% of visits could dramatically improve delivery prevalences.56, 57 Unlike most well-child visits in the first 10 years of life, many adolescent well visits are performed to satisfy school or sports requirements, so it is tempting to focus on completing the required forms rather than on the most important general preventive services.

Delivery of services for STIs to adolescents is complicated even more by the social milieu in which it happens. Legally, older adolescents are caught between childhood and adulthood. Although all states allow adolescents to consent to STI testing, age of consent and confidentiality laws involving STI-related medical visits and contraception vary considerably among states. In addition, commercial health plans are mandated by insurance laws to provide “explanation of benefits” (EOB) statements to the policy holder, generally a parent or guardian, that document payment for services received. Although EOB statements do not list diagnoses, they do indicate that the adolescent had a medical visit and provide some detail about services ordered (e.g., lab tests). Because of these two factors, many adolescents either seek sexual or reproductive health services at freestanding STI or family-planning clinics rather than their routine source of medical care or they do not seek such services at all. Moreover, because STI clinics are not oriented toward providing comprehensive preventive care, adolescent care tends to become even more fragmented. This makes it even more important for primary care medical clinics to take advantage of every visit for prevention.

4.Focus on implementing practice systems for CPS. Most importantly, for the above strategies to be successful, all of the stakeholders in improving CPS delivery for adolescents need to emphasize the critical role of practice systems.58 Such systems delegate as much as possible to support staff, specifying in their job description and standing orders the need to systematically assess the need for CPS during all encounters. Staff can then either remind the clinician or perform/schedule any needed services themselves. If the service (e.g., immunizations, screening tests) can be performed by staff on standing orders without reminding the clinician, it is much more likely to be performed.

The evidence for the importance of such systems has been strong for at least 15 years.59, 60, 61, 62, 63, 64, 65, 66, 67 Despite that, practice systems remain largely missing from most practices, and much of the research literature on guideline implementation has largely ignored systems.68, 69, 70, 71, 72, 73, 74 It is now abundantly clear that exhortation, education and training, and guideline dissemination alone will not produce much change in delivery prevalence.59, 75, 76, 77 Many studies that are entitled educational interventions usually focus that education on building practice systems, usually without making that point clearly.78, 79 Payment changes, incentives, and feedback of comparative performance measures may increase the desire of individual clinicians and group practices to improve, but to succeed, they will need effective practicewide systems.80, 81, 82, 83, 84, 85, 86, 87, 88, 89 These systems must both remind clinicians of their key roles (especially in counseling services) and greatly expand delegation and team approaches.81 It also appears that the Chronic Care Model provides a reasonable framework for conceptualizing the systems needed for CPS as well as chronic conditions.90 It has been demonstrated that external interventions can facilitate system implementation and care change, but it is less clear who would pay for such interventions outside the research environment.90, 91, 92, 93

Conclusion

Too many CPS are recommended for adolescents with insufficient evidence of effectiveness, low delivery prevalence for even those services with good evidence, and too little attention to the practice changes that might improve those delivery prevalences. Adolescent CPS represent a neglected domain in many ways—it is time to change that.

This research was supported by Partnership for Prevention, Washington DC.

No financial disclosures were reported by the authors of this paper.

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a HealthPartners Research Foundation, Minneapolis, Minnesota

b Partnership for Prevention, Washington, District of Columbia

Address correspondence and reprint requests to: Leif I. Solberg, MD, HealthPartners Research Foundation, P.O. Box 1524, MS #21111R, Minneapolis MN 55440-1524

The full text of this article is available via AJPM Online at www.ajpm-online.net.

PII: S0749-3797(09)00490-5

doi:10.1016/j.amepre.2009.06.017

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