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  1. Adolescent Healthcare Utilization in the U.S. Cynthia Rand, MD, MPH University of Rochester School of Medicine and Dentistry

  2. Outline Adolescent healthcare utilization • Visit-based data (NAMCS) • Population-based data (MEPS) • Additional visit burden for universal HPV vaccine delivery (MEPS)

  3. 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)

  4. Overall Visits for Adolescents Females

  5. Overall Visits for Adolescents Females

  6. Overall Visits for Adolescents Females

  7. Overall Visits for Adolescents Females

  8. Overall Visits for Adolescents Females

  9. Overall Visits for Adolescents Females Males

  10. Preventive Visits for Adolescents Females Males

  11. Proportion of Visits for Preventive Care Females Males

  12. 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

  13. Ambulatory and Primary Care Within 1 Year: Females • 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 C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006

  14. Ambulatory and Primary Care Within 1 Year • 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 C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006

  15. Female Adolescents With No Ambulatory Care in 12 months

  16. Female Adolescents With Visits to Emergency Department (ED) Only

  17. Female Adolescents With Visits to Specialty Only

  18. Female Adolescents With Visits to School-based Clinic Only

  19. Female Adolescents With Visits to Ob/gyn Only

  20. Female Adolescents With Visits to Ob/gyn and Any Other Site(except 1° care)

  21. Female Adolescents With Any Primary Care Visit

  22. Overall Healthcare Utilization by Female Adolescents

  23. Overall Healthcare Utilization by Female Adolescents within a 1-Year Period

  24. 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

  25. 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

  26. Additional Visits Needed for Females, 1st Vaccine at Well Visit Window to vaccinate

  27. Additional Visits Needed for Females, 1st Vaccine at Well Visit Window to vaccinate

  28. Additional Visits Needed for Females, 1st Vaccine at Well Visit Window to vaccinate

  29. Additional Visits Needed for Females, 1st Vaccine at Well Visit Window to vaccinate

  30. Additional Visits Needed for Females, 1st Vaccine at Well Visit Window to vaccinate

  31. Additional Visits Needed for Females, 1st Vaccine at Well Visit Type of visit 1st vaccine

  32. Additional Visits Needed for Females, 1st Vaccine at Well Visit vs. Any Visit Type of visit 1st vaccine

  33. Additional Visits Needed for Males, 1st Vaccine at Well Visit vs. Any Visit Type of visit 1st vaccine

  34. 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

  35. 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)

  36. 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

  37. 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

  38. 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)

  39. Acknowledgements • Rochester Center for Adolescent Immunization Research • Peter Szilagyi, MD, MPH • Christina Albertin, MD, MPH • Peggy Auinger, MS • Jonathan Klein, MD, MPH

  40. Additional Visits Needed by Age for Females, 1st Vaccine at Any Visit (24 mo window) Age

  41. Additional Visits Needed by Age for Males, 1st Vaccine at Any Visit (24 mo window) Age

  42. Preventive Visits in 2 Years

  43. Literature Review