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Adolescence – A Challenging Time to Promote Prevention and Immunization . Juan Carlos Batlle, MD ‘04 University of Pennsylvania School of Medicine Thomas K. Zink, MD GlaxoSmithKline, Immunization Policy and Scientific Affairs. Adolescence: A Hidden Opportunity.

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Adolescence – A Challenging Time to Promote Prevention and Immunization


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    1. Adolescence – A Challenging Time to Promote Prevention and Immunization Juan Carlos Batlle, MD ‘04 University of Pennsylvania School of Medicine Thomas K. Zink, MD GlaxoSmithKline, Immunization Policy and Scientific Affairs

    2. Adolescence: A Hidden Opportunity

    3. Adolescence: A Hidden Opportunity • 41 million youths aged 10-19 • Age group a crucible for high-risk behavior • 45% of high school students have had sex • 10% have tried cocaine • Older adolescents not accessing health care • ~20% have foregone needed care in the past year • ~20% have no insurance or medical home • One study puts cost of preventable adolescent morbidities at $700 billion / year (Adolescent Medicine: StARs. 1999;10(1):131-151.)

    4. Adolescent Immunity (Or Lack Thereof) • Vaccination rates range from 20-90% • 35 mm youths 11-21 missing at least one vaccine • Late 80s/Early 90s: 47% of measles cases were among adolescents/young adults • Adolescents represent 70% of the 100-140K cases/year of hepatitis B and 29% of all pertussis cases Handal G. Adolescent immunization. Adolescent Medicine: State of the Art Reviews. 2000;11(2):439-452.; MMWR 2002; 51: 73-76.

    5. Challenges to an Adolescent Approach • Age group changeability - Adolescents are a moving target, aged somewhere between 6 and 21 • Physicians tough to target - Adolescents are not the exclusive province of any MD • Deficient data - Most health and immunization data focuses on children 0-3 • Lack of a medical targeting model - Few products prescribed primarily to teens

    6. Teens Engage In Risky Behaviors YRBS: CDC-conducted national school-based survey of 13,601 students in grades 9-12 during Feb-Dec 2001. • 46% had ever had sex (61% of blacks). 7% had sex before age 13 (16% of blacks). • 33% of students had sex within 3 mos. of survey. • 42% had not used a condom at last intercourse. • 870,000 pregnancies/year among 15-19 year olds. • 3mm STDs among 10-19 year olds. Youth risk behavior surveillance--United States, 2001. Morbidity & Mortality Weekly Report. Surveillance Summaries. 51(4):1-62, 2002 Jun 28.

    7. Health Care “Risk” Also Increases 1999 Add Health Study: 12,105 adolescents (grades 7-12), 1994-95 school year. • 18.7% had foregone care in the past year. • 13.0% of teens had no insurance and another 6.5% had interrupted insurance. • Uninsured teens were most likely to forego care (23.9%). • 33.0% of all teens had no physical exam in the past year. Ford CA. Bearman PS. Moody J. Foregone health care among adolescents. JAMA. 282(23):2227-2234, 1999 Dec 15.

    8. How Adolescents Are Addressed By Health Care

    9. No insurance 15% Alternative Site 10%* 25% Don’t Public insurance 20% 15% Don’t Private insurance 65% 17% Don’t Other 1° 20-25%** FP 20-25% Peds 20-25% E.R. 20-25% 80% Access Care 20% Don’t The Teen Health Care Universe 65-70 million visits / yr *Includes School Health Centers, Family Planning Clinics **Includes OB/GYN, Internal Medicine, Hospital Outpatient Source: JAMA 1999;282(23): 2227-34.; NAMCS

    10. Physician Change Fragments Care NAMCS Office Visit Data

    11. Health Care Guidance Slowly Rising • In 1995, ACIP recommended catch-up Hep B of all children 10-12 at “early adolescent visit” • In 1996, professional societies join (AMA, AAFP, AAP) with ACIP to promote prevention-oriented early adolescent visit • Guidelines appear (Bright Futures, GAPS) • 2004 Childhood Immunization Schedule includes a preadolescent visit

    12. Adolescent Vaccines On The Way

    13. Adolescent Vaccines On The Way NIAID: The Jordan Report 2002.

    14. Messaging Is Missing • For kids <15, 50% of visits for an acute issue; only 27% for non-illness care. • In 63% of visits, no therapeutic or preventive services were ordered or provided. • HIV/STD transmission discussed in 0.6% of visits. (Counseling most often on diet, 15.0% of visits). • Yet 86% of teens 15-17 rated sexual health a “big personal concern” and the highest rated concern overall. Source: NAMCS 2000 data. Advance No. 328.; Kaiser Family Foundation National Survey of Adolescents and Young Adults 2003.

    15. Getting Vaccines Into Teens

    16. Immunization registries Physician education Improved insurance Improved access to care Middle school mandates Patient education Tracking/outreach Incentive programs Passive: Attempt to “catch” patients. Active: Influence patients to ask for immunization. “Passive-Teen” vs. “Active-Teen” Strategies

    17. Passive Strategy: Catch the Teens • School based health clinics - Proven entities with broad support; high enrollment of teens. • Job-related efforts - Employer incentives to build in paid time for minimum wage employees to seek health care. • Mobile clinic - Access under-served or fragmented areas. Concerts, malls, etc. • Mall kiosks - Low cost, confidential clinics to administer reproductive health services, immunizations, minor acute care.

    18. Active Strategy: Quid Pro Quo • School entry requirements - Proof of immunization at a certain grade level. • Sports participation / Camp participation requirements • Motor voter type effort - Require immunization for driver’s license or SAT exam. • Tattoo/body piercing - Policy requirement of proof of immunization.

    19. Thought Experiment: Churn Rate • 4 mm new 10 year olds each year – how do we catch them before they are 14? • Assume 30% are immunized annually • 1.2 mm immunized each year, then? No problem immunizing all 4mm by 14. • But, some kids never present to the system • Churn rate becomes important • Need to improve % of kids newly presenting to system, “churning” in the unimmunized

    20. Takeaways At 30% annual rate, entire cohort is easily caught if all teens presented to system. # of years of catch-up is fixed. Churn rate is crucial: Increasing teens new to system to 58.3% yields 0.7mm incremental catchup each year and no lost teens The Churn Factor New 10 yr olds 4mm Imm. rate (4mmx30%) -1.2mm Churn Rate 58.3% Incremental gain/yr -0.7mm (-4mmx58.3%x30%) Years of catch-up 4yrs Incremental Catchup (-0.7mmx4yrs) -2.8mm Lost 10 year olds 0 Getting Teens Into System Is Key

    21. Alternative Care Sites Simulate Churn • Clinics catch teens outside the traditional patient-doctor relationship • School-based health centers • Planned Parenthood / Teen clinics • HMO-based clinics • Immunization programs similarly catch teens • Motor/voter type drives • Canvassing campaigns • “Vaccinate Before You Graduate” • 70%+ of physicians agree that alternative care sites are acceptable for immunization.

    22. Other Tools Effective At Churn • CHIP Enrollment: CHIP children were 85.6% UTD on at 24 months compared to 54% of non-CHIP • Tracking/Outreach: Increased mean health visits by 0.44/child/yr; raised immunization rate 20 % points. • Information systems: AFIX, using CASA system, increased immunization rate by 10 % points in 1 year in Maine. • Immunization drives: Baton Rouge drive immunized 5000 teens in 5 years with little financial support; GET HEP B in Missouri. Pediatrics 2002;110: 940-945.,Pediatrics 1999;103:31-38., Pediatrics. 1999; 103:1218-1223., Ped Inf Disease Journal. 1998;17(7 Suppl):S43-6.

    23. The “Pre-Adolescent Visit”

    24. F I N I SH L I NE? Crowded schedule … until 24 months • 0-24 months = “shots” • 4-6 years = “boosters” • 10-12 years = “not my kid”

    25. Hep B virus isolated 1967 Hep B vax available 1981 ACIP reco universal 1991 Kid coverage hits 90% 2001 Hep B Vaccine As A Model • “High-risk”-oriented STD, not always reimbursed • ACIP recommendation initiates growth, but growth not uniform over time. • Boosting growth: reimbursement, mandates, public health initiatives, additional recos. • Lesson: progress has been slow...

    26. STOP FAST SLOW Hep B Immunization, Kids 19-35mos. ACIP Birth dose reco Oct 01 ACIP Reco Nov 91 CDC/NHIS Healthy People 2000 & 2010 Database; http://www.cdc.gov/nchs/about/otheract/hp2000/immunization/immunization.htm

    27. Expanding Physician Involvement Family Physicians • 33% to 50% of adolescent visits made to FP Emergency Physicians • 25% of adolescent visits to ER (13mm visits) OB/GYNs • Reach almost all women • Represent 40%-50% of all female teen visits Ramifications • Insurance coverage; new CPT codes • Patient / parent / provider attitudes

    28. Milestone Prevention Visits As A Tool • Pre-adolescent visit at age 10-12 • Recommended visits at age 5, 10, 15, 20?

    29. Questions? … Thank you!