How often do physicians counsel teens about health behaviors?

Physicians infrequently discussed health promotion topics with adolescents during preventive health visits from 1997 to 2000. Diet and exercise were more frequently discussed at visits related to obesity issues.

Percentage of physician visits by adolescents ages 11–18 at which health promotion counseling was offered, 1997–2000

Why is this important?

• Adolescence is a time of rapid change when youth experiment with and establish behaviors that can have both immediate and lifelong consequences for their health (Carnegie 1995). For example, most smokers start by age 18 and one-quarter remain addicted as adults (DHHS 1994).
• Adolescent health experts recommend that physicians counsel teens on healthy behaviors to help prevent injuries, heart disease, and sexually transmitted diseases, among other topics (Elster and Kuznets 1994; Elster 1998).
• There is limited evidence suggesting that clinical counseling can influence some adolescent behaviors, although intensive counseling is more likely to be effective (Klein and Auerbach 2002; Moyer and Butler 2004). Some recommendations are extrapolated from evidence on counseling adults.

Findings

• From 1997 to 2000, physicians discussed six expert-recommended health promotion topics during only 6 percent to 28 percent of preventive health visits with adolescents.
• Physicians were much more likely to counsel adolescents about exercise and diet at acute care visits related to obesity (discussed at 52 percent and 72 percent of such visits, respectively). (Rand et al. 2005)

Implications

Although many adolescents say that they want to discuss health behaviors with a doctor or other health professional (Klein and Wilson 2002), health professionals miss many opportunities to do so. Population-based surveys report similar gaps. In a 2000 survey of adolescents, for example, only one-third of those who had visited a physician or dentist in the past year reported that they received physician advice about smoking (Shelley et al. 2005).

Improvement Ideas and Resources

Adolescent health experts advise that counseling by health professionals should be part of a coordinated preventive effort involving family, schools, and the community (Santelli et al. 1999). Interventions to improve physician counseling must address factors such as lack of professional knowledge, confidence, or skills to address teen issues (Park et al. 2001). Interventions that have increased clinical counseling of adolescents include:

• skills-based training for health professionals (Lustig et al. 2001; Ozer et al. 2001);
• structured risk assessments and supportive office systems (Boekeloo et al. 1999; Klein et al. 2001); and
• a combination of educational "priming" for patients and reminders for health professionals (Boekeloo et al. 2003).

Studies have found that adolescents who have confidential time with their clinician and who visit teen health clinics are more likely to receive counseling (Blum et al. 1996; Klein and Wilson 2002).

Measure:

The denominator includes well-child and relevant acute care outpatient visits by adolescents ages 11–18. Relevant acute care visits means counseling for diet or exercise at obesity visits, for HIV/STDs or family planning at sexual health visits, for tobacco use/exposure at asthma visits, and for injury prevention at injury visits. The numerator includes visits in the denominator at which physicians provided counseling on selected preventive topics recommended by the American Medical Association's Guidelines for Adolescent Preventive Health (Elster and Kuznets 1994), the American Academy of Pediatrics (AAP 1997), and the national Bright Futures initiative sponsored by the federal Maternal and Child Health Bureau (Green and Palfrey 2002).

Limitations:

The survey includes only selected counseling topics and does not assess the quality of the counseling provided. "Physicians may deliver more or less counseling than they are documenting in the survey. Previous studies show that physicians tend to overestimate counseling offered, thus the percentages of each topic discussed may actually be even lower than reported" (Rand et al. 2005). Given limited time and the need to tailor counseling to meet individual patient needs, however, rates of 100 percent would not be expected across all topics at every visit.

Source:

Patient encounter data collected by nationally representative samples of physician offices participating in the National Ambulatory Medical Care Survey and of emergency rooms and hospital outpatient clinics participating in the National Hospital Ambulatory Medical Care Survey. Results were compiled by researchers at the University of Rochester School of Medicine and Dentistry (Rand et al. 2005).

References:

* Indicates source of data used in the chart(s).AAP (American Academy of Pediatrics). 1997. Guidelines for Health Supervision III. Elk Grove, Ill.: American Academy of Pediatrics. Blum, R. W., T. Beuhring, M. Wunderlich et al. 1996. Don't Ask, They Won't Tell: The Quality of Adolescent Health Screening in Five Practice Settings. American Journal of Public Health 86 (12): 1767–72. Boekeloo, B. O., M. P. Bobbin, W. I. Lee et al. 2003. Effect of Patient Priming and Primary Care Provider Prompting on Adolescent-Provider Communication About Alcohol. Archives of Pediatric and Adolescent Medicine 157 (5): 433–9. Boekeloo, B. O., L. A. Schamus, S. J. Simmens et al. 1999. A STD/HIV Prevention Trial Among Adolescents in Managed Care. Pediatrics 103 (1): 107–15. Carnegie (Carnegie Council on Adolescent Development). 1995. Great Transitions: Preparing Adolescents for a New Century. New York: Carnegie Corporation. DHHS (Department of Health and Human Services). 1994. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga.: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Elster, A. B. 1998. Comparison of Recommendations for Adolescent Clinical Preventive Services Developed by National Organizations. Archives of Pediatric and Adolescent Medicine 152 (2): 193–8. Elster, A. B., and N. J. Kuznets. 1994. AMA Guidelines for Adolescent Preventive Services (GAPS). Baltimore: Williams & Wilkins. Green, M., and J. S. Palfrey, Eds. 2002. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health. Klein, J. D., M. J. Allan, A. B. Elster et al. 2001. Improving Adolescent Preventive Care in Community Health Centers. Pediatrics 107 (2): 318–27. Klein, J. D., and M. M. Auerbach. 2002. Improving Adolescent Health Outcomes. Minerva Pediatrica 54 (1): 25–39. Klein, J. D., and K. M. Wilson. 2002. Delivering Quality Care: Adolescents' Discussion of Health Risks with Their Providers. Journal of Adolescent Health 30 (3): 190–5. Lustig, J. L., E. M. Ozer, S. H. Adams et al. 2001. Improving the Delivery of Adolescent Clinical Preventive Services Through Skills-Based Training. Pediatrics 107 (5): 1100–7. Moyer, V. A., and M. Butler. 2004. Gaps in the Evidence for Well-Child Care: A Challenge to our Profession. Pediatrics 114 (6): 1511–21. Ozer, E. M., S. H. Adams, J. L. Lustig et al. 2001. Can It Be Done? Implementing Adolescent Clinical Preventive Services. Health Services Research 36 (6 Pt 2): 150–65. Park, M. J., T. M. Macdonald, E. M. Ozer et al. 2001. Investing in Clinical Preventive Health Services for Adolescents. San Francisco: University of California, San Francisco, Policy Information and Analysis Center for Middle Childhood and Adolescence. * Rand, C. M., P. Auinger, J. D. Klein et al. 2005. Preventive Counseling at Adolescent Ambulatory Visits. Journal of Adolescent Health 37 (2): 87–93. Santelli, J. S., R. J. DiClemente, K. S. Miller et al. 1999. Sexually Transmitted Diseases, Unintended Pregnancy, and Adolescent Health Promotion. Adolescent Medicine 10 (1): 87–108, vi. Shelley, D., J. Cantrell, D. Faulkner et al. 2005. Physician and Dentist Tobacco Use Counseling and Adolescent Smoking Behavior: Results from the 2000 National Youth Tobacco Survey. Pediatrics 115 (3): 719–25.