Can a guideline-oriented intervention increase counseling on healthy behaviors for poor and uninsured adolescents?

Implementing adolescent preventive care guidelines as part of an intervention that included training, changes in scheduling policies, use of a risk-assessment tool, and enhanced education and referral services significantly increased the rates at which poor and uninsured adolescents reported discussing several health- and lifestyle-related topics with their clinician.

Why is this important?

Adolescents face many behavioral and lifestyle choices—such as whether to use tobacco, alcohol, or drugs, eat healthy foods, get regular exercise, engage in risky sexual behaviors, or take precautions to prevent injury—that can have both immediate and lasting consequences for their health and success in life (Klein and Auerbach 2002). Many adolescents say they would like to discuss these issues with a physician, yet most have not done so (Klein and Wilson 2002).Medical experts recommend that physicians provide guidance to adolescents to help encourage healthy lifestyles and screen for medical, behavioral, and emotional problems for which treatment, counseling, or referral to other services is indicated (Elster and Kuznets 1994). Putting clinical guidelines into practice often requires an intentional, systematic approach.

Interventions

Five urban and rural community and migrant health centers (CMHCs) received training and technical assistance to implement the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) among poor and uninsured adolescents ages 14 to 19 years (Klein et al. 2001). The CMHCs made improvements in preventive care delivery including:

• scheduling 30-minute well-child visits,
• encouraging confidential counseling time,
• using a patient questionnaire to screen for health risks, and
• enhancing patient education materials and referral networks when possible.

Findings

Adolescents visiting for well-child care nine to 15 months after GAPS implementation were significantly more likely than those who had visited before the intervention to report receiving educational materials and discussing preventive topics with their health professional in 19 of 31 content areas (only the 10 topics exhibiting the greatest increase are shown in the charts).

• Rates of counseling were 10 to 29 percentage points higher for these 19 topics after the intervention.
• Rates of counseling did not increase significantly for topics that had relatively higher rates before the intervention (Klein 2001).

Implications

Health centers and similar clinical practice settings can improve preventive care for adolescents when they adopt guidelines along with a program of supportive practice improvements. (Given limited time and the need to tailor screening and counseling to meet individual patient needs, rates of 100 percent would not be expected across all topics at every visit.) Effectively coordinating preventive care for adolescents requires commitment to recognize adolescents' unique developmental needs as well as the importance of providing adequate time and privacy for confidential screening and counseling (Klein et al. 2001).

Improvement Ideas and Resources

Implementation materials are available from the American Medical Association Web site.

Measure:

In this before-and-after study, five community and migrant health centers (CMHCs) were selected for study participation based on diversity of geography, patient population, and clinician types; adequacy of information infrastructure; and stability and commitment of leadership. Telephone interviews were conducted two to four weeks after clinic visits with two independent samples of adolescent patients (ages 14 to 19 years) at preintervention (N=260) and nine to 15 months post-intervention (N=274). Interviews assessed whether adolescents recalled receiving each of 31 counseling, screening, examination, or laboratory services recommended by the Guidelines for Adolescent Preventive Services (Elster and Kuznets 1994). Differences in rates of screening (before versus after the intervention) were significant for all topics shown in the chart (Klein et al. 2001).

Limitations:

The authors noted that the "study is limited in generalizability by our choice of health centers, because the CMHCs in this study were selected for their likelihood of success" (Klein et al. 2001). Not all health centers would be able to offer 30 minute patient visits, for example. Lack of a control group means that the results cannot be definitively attributed to the intervention, although the magnitude of changes and their correlation with improvements in physician-reported data (not shown) "add to the validity of [the] findings" (Klein et al. 2001).

Source:

Telephone interviews were conducted by research staff at the University of Rochester, New York. Results were analyzed and reported by researchers at the University of Rochester School of Medicine, the American Medical Association, and the Bureau of Primary Health Care (Klein et al. 2001).

References:

* Indicates source of data used in the chart(s).Elster, A. B., and N. J. Kuznets. 1994. AMA Guidelines for Adolescent Preventive Services (GAPS). Baltimore: Williams & Wilkins. * 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.