Preventive Care Visits Research Articles

Understanding health-care access and utilization disparities among Latino children in the United States.

It is important to understand the source of health-care disparities between Latinos and other children in the United States. We examine parent-reported health-care access and utilization among Latino, White, and Black children (≤17 years old) in the United States in the 2006-2011 National Health Interview Survey. Using Blinder-Oaxaca decomposition, we portion health-care disparities into two parts (1) those attributable to differences in the levels of sociodemographic characteristics (e.g., income) and (2) those attributable to differences in group-specific regression coefficients that measure the health-care 'return' Latino, White, and Black children receive on these characteristics. In the United States, Latino children are less likely than Whites to have a usual source of care, receive at least one preventive care visit, and visit a doctor, and are more likely to have delayed care. The return on sociodemographic characteristics explains 20-30% of the disparity between Latino and White children in the usual source of care, delayed care, and doctor visits and 40-50% of the disparity between Latinos and Blacks in emergency department use and preventive care. Much of the health-care disadvantage experienced by Latino children would persist if Latinos had the sociodemographic characteristics as Whites and Blacks.

Sleep Society: Screen for Apnea at First Medicare Visit

MINNEAPOLIS – The American Academy of Sleep Medicine (AASM) is pushing to have a simple sleep apnea questionnaire included in the initial Welcome to Medicare preventive care visit. Including such a screening tool would help identify obstructive sleep apnea (OSA) when patients first join the Medicare program and thus improve the odds of diagnosing and treating the condition, said Timothy Morgenthaler, MD, president of the AASM. Getting a handle on OSA could also reduce the potential that the beneficiary will develop related chronic conditions, and that will help Medicare curb expenditures, he said. An estimated 20% of current Medicare beneficiaries have OSA. That number is expected to grow with rising obesity rates, he said. Untreated OSA can increase the risk of hypertension, heart disease, type 2 diabetes, and stroke, said Dr. Morgenthaler, who is professor of medicine at the Mayo Clinic in Rochester, MN. OSA is associated with several cognitive and functional deficits. Treatment with continuous positive airway pressure (CPAP) previously had been found to improve the condition of grey matter in the brain. Recently, results from a prospective clinical study reported online (Sleep 2014;37[9]:1465-75) found improved areas of white matter in the brain after treatment with CPAP. In 17 previously untreated patients with OSA who had impairments in most cognitive areas, mood and sleepiness associated with white matter abnormalities, who used a CPAP machine, white matter abnormalities associated with OSA almost completely resolved after 12 months. “Recovery of cognitive deficits after treatment is consistent with the presence of a reversible structural neural injury in OSA in patients who were compliant with treatment,” the researchers wrote. The AASM has been lobbying Congress to include a validated OSA screen in the initial Medicare visit and found sponsors in Rep. Michael Burgess (R-TX) and Rep. Bobby Rush (D-IL). Recently, the two congressmen introduced a bill (H.R. 4695) that would do just that. “This important legislation addresses the barriers that prevent new Medicare beneficiaries from receiving what we know to be required sleep apnea services,” Dr. Morgenthaler said at the annual meeting of the Associated Professional Sleep Societies. Rep. Erik Paulsen (R-MN), who recently signed on to the bill as a cosponsor, told AASM attendees that adding an OSA screen to the initial Medicare visit would help increase detection of disease, raise patient awareness, and “improve health care quality and reduce costs to the Medicare program,” over the long term. The bill would apply to initial preventive physical examinations performed on or after Jan. 1, 2016. The AASM is asking its members to back the legislation and educate local lawmakers and patients through the group's Seniors Sleep Campaign. The association also wants to make it easier for board-certified sleep medicine specialists to care for Medicare patients from start to finish. Currently, antikickback laws prevent sleep specialists and sleep centers from directly providing therapeutic durable medical equipment to Medicare patients, said Dr. Morgenthaler. The AASM has developed model language for an exception to that statute, which it hopes legislators or regulators will approve, he said. It would allow board-certified specialists to provide the continuum of care from start to finish, including durable medical equipment such as CPAP devices. Eliminating the current fragmented system of care would eliminate waste, simplify the work flow, and improve the quality of care and reduce costs, said Dr. Morgenthaler.

Adolescent anemia screening during ambulatory pediatric visits in the United States.

The Centers for Disease Control and Prevention recommends anemia screening for reproductive age women every 5-10 years and annually for those with risk factors. Due to the lower risk of anemia among males, screening for men is recommended only if risk factors exist. The study objective was to examine health care professionals' current anemia screening patterns for male and female adolescents. Data are from the 2001 -2004 National Ambulatory Medical Care Survey, a nationally representative sample of ambulatory visits to primary care practices. The frequency of anemia screening during preventive care visits by 12-21-year-olds was estimated by sex using a reported hemoglobin/hematocrit or complete blood count as an indicator of screening. Multivariable logistic regression identified patient, provider and practice-level factors associated with screening. During the study period, 1,263 preventive care visits occurred for 12-21 year-olds. In bivariate analysis, higher odds of anemia screening were observed for both younger females (OR 1.85; 95 % CI 1.09-3.14) and older males [1.83 (1.02-3.26)] compared to older females (≥ 16 years). In the multivariable model, odds of screening increased with non-white race [3.29 (1.84-5.88)], tobacco use [3.57 (1.94-6.58)], longer visit length [1.03 (1.01-1.06)], and practice site acceptance of managed care plans [2.08 (1.04-4.14)]. Patient sex and age were not statistically significant predictors of screening. Although anemia is more prevalent among older adolescent females, they were not more likely to be screened. This suggests providers are not targeting groups at highest risk of anemia for screening.

Clinical Conversations About Health: The Impact of Confidentiality in Preventive Adolescent Care

PurposeTo better understand how confidentiality impacts the delivery of preventive adolescent health care by examining adolescent and parent beliefs and the relationship between confidentiality and the number and subject matter of health topics discussed at the last visit. MethodsThis study represents a secondary analysis of nationally representative online survey data collected from adolescents aged 13–17 years (N = 504) and parents of adolescents aged 13–17 years (N = 500). Descriptive statistics were conducted on confidentiality variables of interest. Analysis of variance and Scheffe post hoc tests were computed to determine whether the mean number of topics discussed varied by level of confidential consultation provided. Associations between confidential consultation and health topics discussed at the last visit were examined using multivariate logistic regression. ResultsApproximately, half of both samples reported provision of confidential consultation. Eighty-nine percent of parents believed adolescents should be able to speak with providers alone, yet 61% preferred to be in examination room for the entire visit. Nearly half of all adolescents believed parental presence impacted conversation. Mean number of topics discussed was significantly higher when a visit was partially confidential (4.11 ± 3.05; p = 0) versus when a visit was not confidential (2.76 ± 2.68; p = 0). There were significant associations between confidential consultation and discussions about 8 of 11 health topics. ConclusionsConfidential consultation significantly impacts the number and subject matter of health topics discussed. A split-visit confidentiality model for adolescent preventive care visits may result in clinical conversations that address more topics. This arrangement may also appeal to parents who have mixed feelings about confidentiality.

Employee knowledge of value-based insurance design benefits.

Value-based insurance designs (VBD) incorporate evidence-based medicine into health benefit design. Consumer knowledge of new VBD benefits is important to assessing their impact on health care use. To assess knowledge of features of a VBD. The eligible study population was employees receiving healthcare benefits in an integrated care system in the U.S. Pacific Northwest. In 2010, participants completed a web-based survey 2 months after rollout of the plan, including three true/false questions about benefit design features including copays for preventive care visits and chronic disease medications and premium costs. Analysis was completed in 2012. Knowledgeable was defined as correct response to all three questions; self-reported knowledge was also assessed. A total of 3,463 people completed the survey (response rate=71.7%). The majority of respondents were female (80.1%) Caucasians (79.6%) aged 35-64 years (79.0%), reflecting the overall employee population. A total of 45.7% had at least a 4-year college education, and 69.1% were married. About three quarters of respondents correctly answered each individual question; half (52.1%) of respondents answered all three questions correctly. On multivariate analysis, knowledge was independently associated with female gender (OR=1.80, 95% CI=1.40, 2.31); Caucasian race (OR=1.72, 95% CI=1.28, 2.32); increasing household income (OR for ≥$100,000=1.86, 95% CI=1.29, 2.68); nonunion job status (OR compared to union status=1.63, 95% CI=1.17, 2.26); and high satisfaction with the health plan (OR compared to low satisfaction=1.26; 95% CI=1.00, 1.57). Incomplete knowledge of benefits is prevalent in an employee population soon after VBD rollout.

Identifying human papillomavirus vaccination practices among primary care providers of minority, low-income and immigrant patient populations

ObjectiveMinority populations in the United States are disproportionally affected by human papillomavirus (HPV) infection and HPV-related cancer. We sought to understand physician practices, knowledge and beliefs that affect utilization of the HPV vaccine in primary care settings serving large minority populations in areas with increased rates of HPV-related cancer. Study designCross-sectional survey of randomly selected primary care providers, including pediatricians, family practice physicians and internists, serving large minority populations in Brooklyn, N.Y. and in areas with higher than average cervical cancer rates. ResultsOf 156 physicians randomly selected, 121 eligible providers responded to the survey; 64% were pediatricians, 19% were internists and 17% were family practitioners. Thirty-four percent of respondents reported that they routinely offered HPV vaccine to their eligible patients. Seventy percent of physicians reported that the lack of preventive care visits for patients in the eligible age group limited their ability to recommend the HPV vaccine and 70% of those who reported this barrier do not routinely recommend HPV vaccine. The lack of time to educate parents about the HPV vaccine and cost of the vaccine to their patients were two commonly reported barriers that affected whether providers offered the vaccine. ConclusionsOur study found that the majority of providers serving the highest risk populations for HPV infection and HPV-related cancers are not routinely recommending the HPV vaccine to their patients. Reasons for providers’ failure to recommend the HPV vaccine routinely are identified and possible areas for targeted interventions to increase HPV vaccination rates are discussed.

Low Proportion of High School Senior Athletes Receiving Recommended Immunizations

Background: The preparticipation physical evaluation (PPE) often serves as the only preventive health care visit for athletes, but immunization status is not uniformly addressed in such visits. Thus, athletes may not be receiving recommended immunizations. Our aim was to determine the proportion of high school senior athletes who received all recommended immunizations. Hypothesis: Our hypothesis was that females would be less likely than males to receive all recommended immunizations given suboptimal human papillomavirus (HPV) vaccine uptake. Methods: We conducted a cross-sectional survey evaluation of the immunization status of high school senior athletes in Davidson County, TN. The primary composite outcome was receipt of recommended immunizations for tetanus, meningococcal, and seasonal influenza. For females, the primary outcome also included completion of the HPV series. Results: A total of 162 participants, 104 males and 58 females, were included. More males than females received all recommended immunizations (15.4% vs 3.5%; P = 0.02). When HPV immunization was excluded from the composite outcome, there was no difference in the proportion of males and females who received all recommended immunizations (15.4% vs 15.5%; P = 0.98). The odds of receiving all recommended immunizations was 0.14 (95% CI, 0.03–0.72) for females compared with males when adjusted for covariates. Athletes seen at retail-based clinics for their PPE were less likely to receive all recommended immunizations compared with athletes seen in primary care (OR, 0.13; 95% CI, 0.02–0.69). Conclusions: Only 1 in 6 high school senior athletes received the recommended tetanus, meningococcal, and influenza immunizations. A lower proportion of females, only 1 in 28, received all recommended immunizations due to the HPV series. Policy changes requiring a review of immunizations at the PPE would benefit many high school athletes.

AmeriCorps Members increase enrollment in Medicaid/CHIP and preventive care utilization at a community health center.

Uninsured children have less access than others to primary care; Latino children are more likely than non-Latino children to be uninsured. 1. Determine whether case management (CM) by AmeriCorps Members (ACM) increases enrollment of children in Medicaid/CHIP at a federally qualified community health center (FQHC); 2. Identify factors associated with non-enrollment; 3. Compare health care utilization by enrolled and non-enrolled children. Parents of uninsured children at two urban FQHCs serving primarily Latino families were offered CM assistance for enrollment in Medicaid/CHIP at one of the clinics. Application instructions alone were provided at the other clinic. Results. Of 107 children at the CM clinic, 74% were enrolled compared with 26% of the 96 from the non-CM clinic. Non-enrolled children completed fewer preventive care visits than enrolled children despite sliding fees at both FQHCs. Case management by ACM is a low-cost, effective approach to increasing access to care for Latino children.

What’s Your Policy? Same-Day Preventive and Other Medical Services

Staff and patient/caregiver education and careful documentation for situations where preventive care visits lead to services that may incur cost-sharing expenses

U.S. Preventive Services Task Force Recommendation and Pediatric Hypertension Screening: Dereliction of Duty or Call to Arms?

Most pediatricians would assert that measurement of blood pressure (BP) should be incorporated into the care of all children and adolescents. They know that the American Academy of Pediatrics has recommended that routine measurement of BP should be done at well toddler, children, and teen visits. Pediatric nephrologists have been more vocal in their advocacy for routine measurement of BP at all encounters because hypertension can be a sign of significant underlying disease and is often asymptomatic. 2 There is no doubt that BP measurement per se is a safe, readily accessible, and low-cost procedure. One might ask whether a practice guideline is needed at all. The U.S. Preventive Services Task Force (USPSTF) has stepped into this seemingly trivial and self-evident area of care and has concluded that “current evidence is insufficient to assess the balance of benefits and harms” of screening for high BP in asymptomatic children to prevent heart disease. They assert, based on the literature, that childhood readings do not predict hypertension in later life, and that there is no proven benefit of treatments designed to lower BP in the pediatric years. 3 The clear implication is that BP should not be measured routinely in otherwise healthy children and adolescents. As might be expected, this recommendation has been met with strong opposition among pediatric nephrologists. The American Society of Pediatric Nephrology issued a press release that expressed concern that the USPSTF position will discourage pediatricians from measuring BP and undermine efforts to identify hypertension, especially in those children with disease who are asymptomatic. We are three pediatric nephrologists who think the USPSTF may have done our subspecialty a great service and here is why. The USPSTF report was anticipated in a review by Chiolero and colleagues published earlier this year. 4 Despite the good intentions of most pediatricians and family practitioners, the majority of children do not have their BP checked at routine ambulatory visits and only 80% of obese adolescents attending preventive care visits have their BP measured. 5 Even in pediatric hypertension clinics, the majority of patients have no identifiable underlying secondary disease. 6 Even if there is an underlying cause of hypertension, there is usually no immediate threat to health in otherwise well children. When elevated BP is a medical emergency, there are usually concomitant symptoms indicating the presence of a systemic cause for the hypertension. Malignant hypertension with the risk of sudden deterioration in cardiac or renal function is distinctly uncommon in children. 7 This suggests that there is little risk of a policy that advocates deferring routine measurement of BP in asymptomatic children.

Proactive Parents Are Assets to the Health and Well-Being of Teens

To analyze parents who self-identified themselves as being proactive parents (PPs) compared with non-PPs who were queried about their teen's health to understand common adolescent health concerns, parenting practices/behaviors around health, and whether their adolescent had received a preventive care visit in the last year Secondary analyses of parents (n = 504) from a nationally representative online panel were surveyed to assess health beliefs/attitudes, perceived adolescent health concerns, frequency of health discussions, topics that pediatricians should discuss, and their teen's last annual visit. Demographics, parental beliefs, frequency of health conversations, and topics that physicians should discuss were compared. Logistic regression determined the likelihood of PPs compared with non-PPs reporting a teen annual health visit within the last year. Greater education and having a single-child household were slightly more common among PPs. PPs expressed greater concern about their teens getting good grades, getting sick, and their teen's future (P < .001). PPs indicated a greater severity of worry (P < .02) across all health topics and rated issues of sexual health, vaccines, and stress/mental health as very important for pediatricians to discuss (P < .01). Controlling for demographics, PPs were 3.4 (95% CI 2.06-5.56) times more likely to report an annual visit of their teen in the last year. PPs are an asset to the health promotion and the well-being of their teens. PPs were more likely to have their teen receive an annual visit, report more frequent discussions about health, and place a high value on physician discussions about health.

Improving preventive care in high risk children with asthma: lessons learned

Objectives: Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). Methods: Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. Results: Children were primarily male, young (3–5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. Conclusions: A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.

Trends in preventive care among insured adolescents

The goal of the report published in this issue of The Journal by Tsai et al from the Centers for Disease Control and Prevention was to investigate patterns of preventive care visits among commercially-insured adolescents before and after the recommendation of the Advisory Committee on Immunization Practices (ACIP) of three vaccines targeted toward adolescents. The data were derived from the Market Scan database. Eleven to 21-year-olds who were continuously enrolled in the same insurance plan during 2003-2010 were included in the study. The proportion of individuals making at least one preventive visit increased from 25% to 41% between 2003 and 2010, and the rate of vaccination-related visits increased from 13% to 26%. The increases were greater during the years in which ACIP issued recommendations. Rates of preventive and vaccination-related visits were considerably higher among females, early adolescents, and those in managed-care plans. Without this stimulus for attendance, only 2.4% of 11- to 21-year-olds had annual preventive visits during the 8 years. The data from this study show that yearly improvements in preventive care visits were substantial and that the recommendations of the ACIP may have stimulated this improvement. However, rates of immunizations are still relatively low and rates of attendance for preventive care are low in this age group, so there is still important work to be done. Article page 625▶ Trends and Characteristics of Preventive Care Visits among Commercially Insured Adolescents, 2003-2010The Journal of PediatricsVol. 164Issue 3PreviewTo examine preventive care visit patterns among commercially insured adolescents during 2003-2010. In 2005-2007, the Advisory Committee on Immunization Practices (ACIP) recommended 3 vaccines targeted at adolescents. We also investigate the relationship between preventive care visits and immunization. Full-Text PDF

Electronic health record use and preventive counseling for US children and adolescents

The objective was to assess whether rates of preventive counseling delivered at well child visits (WCVs) differ for practices with basic, fully functional, or no electronic health record (EHR). Cross-sectional analyses of WCVs included in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Electronic Medical Records Supplement, 2007-2010 were performed. Practices with fully functional EHRs documented delivery of 34% more counseling topics than those without an EHR. WCVs with a fully functional EHR lasted 3.5 more minutes than those with a basic EHR. Overall, for each additional 10 min, 12% more topics were covered, regardless of EHR functionality. Further studies should assess the impact of such systems on the quality of patient care during preventive care visits and on health outcomes.

An Argument for Comprehensiveness as the "Special Sauce" in a Recipe for the Patient-Centered Medical Home

How can we study and quantify potential value that may be added by having primary care specialists (PCSs) from both family medicine and internal medicine provide preventive care services for women? Does seeing one's personal physician (PCP) make a difference? Early answers come from the study by Cohen and Coco in this issue: "Do physicians address other medical problems during preventive gynecologic visits?" Their assessment of a nationally representative sample of preventive gynecological visits uses self-reported data from the physicians to tell us "yes" and to quantify to what extent by specialty, region, and PCP status. This sampling of the content of women's preventive health visits allows us to get a flavor for how the majority of PCSs provide comprehensive care for concomitant acute and chronic issues in the context of individual preventive care visits. Patients are unlikely to parse their presenting concerns into the acute or chronic or preventive categories. The practice of addressing multiple issues during one visit improves the efficiency of addressing patient concerns. This may be a key to the special flavor of a true patient-centered medical home.

US Provider-Reported Diet and Physical Activity Counseling to Pregnant and Non-pregnant Women of Childbearing Age During Preventive Care Visits

Healthy diet, physical activity and appropriate weight gain during pregnancy contribute to healthy birth outcomes. The Institute of Medicine recommends that women receive counseling about diet and exercise during preconception, pregnancy and postpartum periods. We sought to determine how often healthcare providers report counseling women of childbearing age about diet or exercise and if such rates vary by pregnancy, overweight/obesity status or physician specialty. We combined the 2005-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to obtain nationally representative estimates of outpatient preventive care visits for women of child-bearing age (15-44years). Accounting for survey design, we compared proportions of preventive visits that included diet/exercise counseling for pregnant women versus non-pregnant women and performed multivariable logistic regression models to estimate odds ratios. Providers reported counseling pregnant women about diet/exercise during 17.9% of preventive care visits compared to 22.6% of visits for non-pregnant women (P<0.01, adj. OR 0.8, 95% CI 0.7, 1.0). Overweight/obese pregnant (vs. non-pregnant) women were significantly less likely to receive diet/exercise counseling (adj. OR 0.7, CI 0.5, 0.9) as were women seen by OB/GYNs versus non-OB/GYNs (adj. OR 0.4, CI 0.3, 0.5). Our findings suggest that provider-reported diet/exercise counseling rates during preventive care visits for women of childbearing age vary by overweight/obesity and pregnancy statuses, as well as by provider specialty. Our data suggest that there may be missed opportunities to provide diet/exercise counseling and that increasing rates of counseling could result in improved maternal and infant health outcomes.

Trends and Characteristics of Preventive Care Visits among Commercially Insured Adolescents, 2003-2010

To examine preventive care visit patterns among commercially insured adolescents during 2003-2010. In 2005-2007, the Advisory Committee on Immunization Practices (ACIP) recommended 3 vaccines targeted at adolescents. We also investigate the relationship between preventive care visits and immunization. Data were drawn from the MarketScan database. Adolescents aged 11-21 continuously enrolled in the same insurance plan during the calendar year were included. We calculated the annual proportion of adolescents with at least 1 preventive and 1 vaccination-related visit. Longitudinal analyses were conducted by following the 1992 birth cohort for 8 consecutive years. The proportion of adolescents making at least 1 preventive visit increased from 24.6%-41.1% during 2003-2010. The rate of vaccination-related visits increased from 12.9%-26.3%. The magnitude of the increase in preventive and vaccination-related visits was greater during the years in which ACIP issued recommendations. The rates of preventive and vaccination-related visits were considerably higher among female and early adolescents and adolescents in managed care plans. Longitudinal analyses indicated that only 2.4% of adolescents had an annual preventive visit during the 8 years. Yearly improvements in preventive care visits by adolescents were substantial. ACIP recommendations may be associated with this improvement. However, ongoing efforts are needed to improve the use and delivery of preventive care services.

Predictors of three dose on-time compliance with HPV4 vaccination in a disadvantaged, underserved, safety net population in the US Midwest.

BackgroundHPV4 is approved as a series of three timed doses expected to result in efficacy against specific HPV infections. Completion rates in the US are quite low at the same time the structure of health care delivery is changing. The aim of this study was to determine how the patient-, clinic- and systems-level characteristics facilitate or hinder the timely completion of three HPV4 doses in both adolescent and adult female populations in a high-risk safety net population.MethodsThis is a retrospective study in which patient-, clinic- and systems-level data are abstracted from the electronic medical record (EMR) for all females 10–26 years of age receiving at least one dose of HPV4 between July 1, 2006 and October 1, 2009.ResultsAdults were more likely to complete the three dose series if they had at least one health care visit in addition to their HPV4 visit, (aOR = 1.54 (95% CI:1.10, 2.15). Adults were less likely to complete the three dose series if they received their second HPV4 dose at an acute health care, preventive care or postpartum visits compared to an HPV4-only visit (aOR = 0.31 (95% CI: 0.13, 0.72), 0.12 (0.04, 0.35), 0.30 (0.14, 0.62), respectively). Hispanic adults were less likely than whites to complete the series (aOR = 0.24 (95% CI:0.10, 0.59). 39% of adolescents who completed two doses completed the series.ConclusionsHPV4 is more likely to be effectively administered to adults in a safety net population if multiple health care needs can be met within the health care system.

Missed Opportunities for Adolescent Vaccination, 2006–2011

To describe missed opportunities for meningococcal (MCV); tetanus, diphtheria, acellular pertussis (Tdap); and human papillomavirus (HPV) vaccination among adolescents. Retrospective electronic health record data review of adolescents aged 11-18 years at the time of their visit to a university-based pediatric practice in Seattle from 2006 to 2011. The primary outcome was missed vaccination opportunities, defined as the proportion of visits where a patient eligible for MCV, Tdap, and/or HPV remained unvaccinated. HPV vaccine analysis was limited to females. Bivariate and multivariate logistic regression assessed variables associated with missed vaccination opportunities. During the study period, 1,628 adolescents made 9,180 visits. The percentage of visits that were missed opportunities was 82% for MCV, 85% for Tdap, and 82% for the first HPV dose (HPV1), 63% for the second, and 71% for the third. Adolescents with at least one preventive care visit were significantly less likely to have missed opportunities for MCV, Tdap, or HPV1. Nonpreventive visits were associated with more missed opportunities for MCV (OR= 19.2, 95% CI 15.3-24.0), Tdap (OR= 25.8, 95% CI 19.3-34.6), and HPV1 (OR= 12.1, 95% CI 9.0-16.1) than preventive visits. Adolescent females were more likely to have a missed opportunity for HPV1 than Tdap (p < .001) or MCV (p= .03). Missed opportunities for adolescent vaccination against MCV, Tdap and HPV are common. Adolescents who utilize preventive care are less likely to have missed vaccination opportunities. Further research is needed to explore why missed vaccination opportunities occur and to develop evidence-based strategies to reduce missed opportunities and improve adolescent vaccination coverage.

Committee Opinion No. 568

: Elder abuse, a violation of human rights, is defined as a single or repeated act, or lack of appropriate actions, which causes harm, risk of harm, or distress to an individual 60 years or older. As many as 1 in 10 older adults have been victims of elder abuse. Most cases of abuse occur in women. The U.S. Census predicts that by 2030, the segment of the population that is older than 65 years will reach an estimated 72 million. Categories of elder abuse include physical, psychological, emotional, or sexual abuse; neglect; abandonment; and financial exploitation. Screening, education, and policy change are the best interventions for the prevention of elder abuse. Early identification and prompt referral should be part of the preventive health care visit for women aged 60 years and older.