Young Adult Medicine Research Articles

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic

ObjectivesThe Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions. MethodsWe conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children’s hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019–March 15, 2020) and during the COVID-19 pandemic (March 16, 2020–March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use. ResultsThere were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year. ConclusionsWidespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Telemedicine in an adolescent and young adult medicine clinic: a mixed methods study

BackgroundAdolescents and young adults are a diverse patient population with unique healthcare needs including sensitive and confidential services. Many clinics serving this population began offering telemedicine during the Covid-19 pandemic. Little is known regarding patient and parent experiences accessing these services via telemedicine.MethodsTo assess for trends and disparities in telemedicine utilization in the first year of the pandemic, we used the electronic health record to obtain patient demographic data from an adolescent and young adult medicine clinic in a large urban academic institution. Characteristics of patients who had accessed telemedicine were compared to those who were only seen in person. Mean age was compared using t-test, while other demographic variables were compared using chi-squared test or Fisher’s exact test. We performed qualitative semi-structured interviews with patients and parents of patients in order to characterize their experiences and preferences related to accessing adolescent medicine services via telemedicine compared to in-person care.ResultsPatients that identified as female, white race, Hispanic/Latinx ethnicity were more likely to have utilized telemedicine. Telemedicine use was also more prevalent among patients who were privately insured and who live farther from the clinic. Although interview participants acknowledged the convenience of telemedicine and its ability to improve access to care for people with geographic or transportation barriers, many expressed preferences for in-person visits. This was based on desire for face-to-face interactions with their providers, and perception of decreased patient and parent engagement in telemedicine visits compared to in-person visits. Participants also expressed concern that telemedicine does not afford as much confidentiality for patients.ConclusionsMore work is needed to address patient and parent preferences for telemedicine as an adjunct modality to in-person adolescent and young adult medicine services. Optimizing quality and access to telemedicine for this patient population can improve overall healthcare for this patient population.

The Revolutionary Étude Commentary on the Revolutionary Étude.

1A. Sinha is a clinical fellow, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California; email: [email protected]; Twitter: @anoushkaasinha.

2084. Importance of the Primary Care Physician in HIV PrEP Adherence During a Pandemic

Abstract Background In 2015 emtricitabine-tenofovir (PrEP) was approved for use as a pre-exposure prophylactic medication for preventing HIV infections. In 2017, WHO declared PrEP to be an essential medicine, gaining widespread acceptance for outpatient care. In 2020, the COVID-19 pandemic disrupted the healthcare system, with several studies showing lower rates of PrEP prescriptions during the pandemic particularly among Black and Latinx groups. Methods Medical records at Rutgers New Jersey Medical School (NJMS) were queried for PrEP prescriptions from 2017-2021. All duplicate entries, and all patients prescribed emtricitabine and tenofovir as part of HIV treatment were removed. Years 2017-2019 were defined as “pre-pandemic” and years 2020-2021 were defined as “pandemic.” Results Average annual prescriptions for PrEP at NJMS decreased by only 13% (157 to 137 p=0.53) for all ages and 25% (29 to 22 p=0.38) for adolescents and young adults (ages 16-24) (AYA) from pre-pandemic to pandemic years. The annual number of AYAs who had their PrEP prescribed by the Division of Adolescent and Young Adult Medicine practice (DAYAM) remained the same during the pandemic while the annual number of AYAs who had their PrEP prescribed by the Infectious Disease practice (IDP) decreased by over 50% (p = 0.07). PrEP prescriptions for trans-identifying individuals (over 90% prescribed by the IDP) increased by 15% (p = 0.58). PrEP Prescriptions for Adolescents and Young Adults All PrEP Prescriptions at Rutgers NJMS Conclusion Despite the national decline in PrEP prescriptions during the COVID-19 pandemic, NJMS experienced a non-statistically significant decrease in PrEP prescriptions despite serving a majority Black and Latinx population who have elsewhere suffered the most disruption in healthcare during the pandemic. At NJMS, the IDP provides primary care for trans-identifying individuals, and DAYAM provides primary care for AYAs. Average annual PrEP prescriptions for trans-identifying individuals increased and AYA PrEP prescriptions by the DAYAM remained the same throughout the pandemic emphasizing the key role primary care physicians have in PrEP access during the pandemic and may play a significant role in the strong continuation of PrEP program provided at NJMS throughout the pandemic. Disclosures All Authors: No reported disclosures.

9.1 Screening for Early Emerging Mental Experiences (SEE ME), a Model for Early Detection of Psychosis in US Primary Care

9.1 Screening for Early Emerging Mental Experiences (SEE ME), a Model for Early Detection of Psychosis in US Primary Care

72. Potential Barriers to Viral Load Suppression in Adolescents and Young Adults in a Pre-Pandemic World (18-30 y.o.)

Research suggests that education and poverty levels greatly influence viral load suppression in adults. However, very few of these studies look at these and other socioeconomic barriers in young adults.1,2 This study sought to assess if viral load suppression is related to various social determinants of health within the clientele aged 18-30 of the Division of Adolescent and Young Adult Medicine (DAYAM) in a Pre-Pandemic World.

984. HIV Pre-Exposure Prophylaxis (PrEP) Prescription Rates Among Adolescents and Young adults (AYAs) at an Urban Academic Medical Center in Newark, NJ from 2017-2019: A Quality Assessment of HIV Prevention for High Risk Youth within the Epicenter of the NJ HIV Epidemic

BackgroundIn 2017, 21% of new HIV diagnoses occurred in AYAs (ages 13-24), disproportionately among black and Hispanic men who have sex with men (MSM). However, only 0.1-1.5% and 9.5-15.4% of national PrEP prescriptions have been provided to AYAs under 18 and 24, respectively, with a white male majority. In 2018, PrEP was approved for use in adolescents weighing more than 35kg. However, limited studies on attitudes of AYA providers suggest lack of familiarity of PrEP and concerns about adherence, safety, confidentiality, and cost have led to a slow uptake among AYAs. Here we describe the AYA PrEP prescription rates at Rutgers New Jersey Medical School (NJMS) in two unique practices, the Infectious Disease Practice (IDP) and Division of Adolescent and Young Adult Medicine (DAYAM).MethodsMedical records were queried for patients prescribed Truvada for PrEP at NJMS from 2017-2019 to assess the specialty-specific prescription rates and demographics of AYAs on PrEP.ResultsOf the 273 patients who were prescribed PrEP from 2017-2019, 2.2% (n=6) and 20.5% (n=56) were under 18 and 24, respectively. IDP and DAYAM respectively prescribed PrEP to 62.5% (n=35) and 33.9% (n=19) of AYAs. Among all AYAs on PrEP, 71.4% were black, 21.4% Hispanic, 19.6% transgender women (TGW), and 85.7% MSM or TGW who have sex with men. Most (73.7%) AYAs at DAYAM received PrEP from their primary care providers (PCP) compared to only 5.7% at IDP.Table 1. Department-specific characteristics of (A) patients of all ages and (B) AYAs prescribed PrEP at NJMS between 2017-2019, n (%). Fig. 1-3. Annual percentage of (1) patients receiving PrEP at NJMS by age group and (2) AYAs receiving PrEP by department, and (3) percentage of AYAs prescribed PrEP by their PCP, 2017-2019. Fig. 4. Percentage of AYAs prescribed PrEP at NJMS between 2017-2019 by (A) race, (B) gender identity, and (C) HIV transmission risk factor, % (n). ConclusionAYA PrEP prescription rates at NJMS were higher than national estimates, primarily driven by IDP and DAYAM, in contrast to national data identifying emergency, family and internal medicine providers as common AYA PrEP prescribers. Compared to national data, our AYAs on PrEP better reflected the national PrEP indications by race and HIV risk factor (although intravenous drug use was not identified as a PrEP indication in our study presumably due to a lack of forthcomingness). IDP and DAYAM routinely identify high risk AYAs, screen for PrEP eligibility using detailed, nonjudgmental sexual histories, and prescribe PrEP to AYAs. It is thus important to integrate primary care into subspecialty clinics with an emphasis on including PrEP in routine sexual/reproductive health services. PCPs in other fields should expand AYA PrEP prescriptions to further engage high risk youth in HIV prevention.Disclosures All Authors: No reported disclosures

The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation

PurposeThis study describes the rapid implementation of telemedicine within an adolescent and young adult (AYA) medicine clinic in response to the Coronavirus Disease 2019 (COVID-19) pandemic. While there are no practice guidelines specific to AYA telemedicine, observations made during this implementation can highlight challenges encountered and suggest solutions to some of these challenges. MethodsOver the course of several weeks in March, 2020, the Adolescent and Young Adult Medicine Clinic at the University of California San Francisco rapidly replaced most in-person visits with telemedicine visits. This required logistical problem-solving, collaboration of all clinic staff members, and continuous reassessment of clinical practices. This article describes observations made during these processes. ResultsTelemedicine visits increased from zero to 97% of patient encounters in one month. The number of visits per month was comparable with that one year prior. While there were limitations to the clinic’s ability to carry out health supervision visits, many general health, mental health, reproductive health, eating disorders, and addiction treatment services were implemented via telemedicine. Providers identified creative solutions for challenges that arose to managing general confidentiality issues as well as specific challenges related to mental health, reproductive health, eating disorders, and addiction care. Opportunities to implement and expand high-quality AYA telemedicine were also identified. ConclusionsThe COVID-19 pandemic is leading to widespread telemedicine implementation. While telemedicine seems to be feasible and acceptable for our clinic patients, unanswered questions remain regarding confidentiality, quality of care, and health disparities. Clinical guidelines are also needed to guide best practices for telemedicine in this patient population.

Developmentally appropriate patient education during transition: A study of healthcare providers’ and parents’ perspective

Introduction:Patient education is recommended to improve the transition from paediatric to adult care for young people with chronic conditions. But a consensus has not been reached regarding a particular model. This study aimed to understand how to prepare for the implementation of a Developmentally Appropriate Patient Education during Transition (DAPET), which would revolve around the young person’s psychosocial development.Method:Three focus groups were organised with healthcare providers and two focus groups took place with the parents of young people with chronic conditions. We used activity theory to explore practices and to identify obstacles to the implementation of DAPET, as well as to recognise which resources might be available to implement DAPET.Results:Healthcare providers agreed on the need to engage in an educational approach centred on the psychosocial development of young people during transition. However, study findings highlight the following obstacles to doing so: a lack of competencies in adolescent and young adult medicine and a lack of available resources to meet these goals. Furthermore, parents wanted to redefine their role in the transition process and to allow their children to develop self-management skills.Conclusion:Healthcare providers and parents considered the implementation of DAPET to be acceptable and even advisable. However, the programme’s feasibility was questioned due to perceived shortfalls in the hospital system as it currently stands and the ways in which an educational approach would be applied. An environment that facilitates healthcare providers’ educational initiatives and encourages the participation of parents is required.

A Developmentally Appropriate Patient Education during Transition

Abstract Introduction Patient education is recommended to improve transition from pediatric to adult care for young people living with chronic conditions. But a consensus has not been reached regarding a particular model. Our study aims to understand how to implement a Developmentally Appropriate Patient Education during Transition (DAPET), which would revolve around the young people’s psychosocial development. Methods Three focus groups were organized with healthcare providers and two focus groups took place with the parents of young people with chronic conditions. We relied on Activity Theory to explore practices and to identify obstacles, as well as recognize which resources were available to implement a DAPET. Results Six themes were identitified via the thematic analysis. In summary, healthcare providers agreed on the need to engage in an educational approach centered on the psychosocial development of young people during transition. They did, however, highlight a lack of competencies in adolescent and young adult medicine and a lack of available resources to meet these goals. The parents wanted to redefine their role with healthcare providers in order to apprehend transition to adult care and to allow their children to develop self-management skills. Conclusions Healthcare providers and parents considered the implementation of a DAPET to be acceptable and even advisable. However, this program’s feasibility was questioned due to the perceived shortfalls of the hospital system as it currently stands and the ways in which an educational approach would be applied. An enabling environment is therefore required to facilitate the educational initiatives of healthcare providers and to encourage the participation of parents. The means and modalities for achieving this are discussed. Key messages Patient Education during transition from pediatric to adult care need to be developmentally appropriate. Healthcare providers need en enabling environment to carry on a developmentally appropriate approach during transition.

Journeys With HIV

Journeys With HIV

Prevalence, Predictors, and the Financial Impact ofMissed Appointments in an Academic Adolescent Clinic.

Introduction Missed appointments have been shown to have significant economic consequences on clinics and health systems. Furthermore, adolescents have been shown to miss appointments more frequently than other pediatric patients. Information regarding predictive factors for which patients will miss appointments has been researched for adolescents, but scheduling-related risk factors and the financial impact of missed appointments in an adolescent clinic are lacking. Therefore, we sought to identify the financial impact and schedule-related risk factors of missed appointments in an academic adolescent clinic.Methods A retrospective chart review of financial and scheduling information of each missed appointment was conducted at the Adolescent and Young Adult Medicine Clinic at Helen DeVos Children’s Hospital (HDVCH) in Grand Rapids, Michigan between November 2016 and October 2017. Information obtained was the day of the week, time of appointment, lead days till appointment, level of provider, historical weather data, appointment type (new patient, established physical, established visit, or injection only) and insurance type for each patient.Results We report a 21.2% missed appointment rate. Monday had a significantly higher fraction of missed appointments than other days of the week (p < 0.001). An increase in nonattendance was also seen with an increase in the lead days until appointment (p = 0.026). Weather (p = 0.507), time of day (p = 0.665) and type of provider (p = 0.361) were not found to be significant. We estimated an annual billing and reimbursement loss from missed appointments of $170,100 and $51,289, respectively.ConclusionThese results highlight that revenue lost from missed appointments is significant and directly affects the ability to improve patient access and care. Future efforts to decrease missed appointments should target schedule-related risk factors in addition to patient reminder systems.

A Closer Look at the Psychosocial Realities of LGBTQ Youth.

* Abbreviation: LGBTQ — : lesbian, gay, bisexual, transgender, and questioning This month’s issue of Pediatrics features studies from Baams1 and Becerra-Culqui et al,2 in which they contribute to the ever-growing body of literature that characterizes psychosocial disparities faced by lesbian, gay, bisexual, transgender, questioning (LGBTQ), and gender nonconforming youth. Authors of several studies have previously described the psychosocial realities of these youth that include, but are not limited to, depression, anxiety, nonsuicidal self-injury, suicidality, homelessness, and substance use.3–5 However, in 2 studies in this issue, both with the strength of describing large population-based samples, authors confirm the dismal psychosocial disparities experienced by these youth and provide novel information that should embolden health care providers to better identify such youth in their practices, assess risk factors, and offer support options that may not only promote resilience but may also be lifesaving. There has been growing evidence in which stress associated with cumulative adverse childhood … Address correspondence to Stanley Ray Vance Jr, MD, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, 3333 California St, Suite 245, Box 0503, San Francisco, CA 94143. E-mail: stanley.vance{at}ucsf.edu

Implantable Peace of Mind: Etonogestrel Implant Use and Experience in Los Angeles Adolescents and Young Adults

This original research was conducted at the Division of Adolescent and Young Adult Medicine at Children's Hospital Los Angeles.

Adolescent Dating Violence and Nonmedical Prescription Drug Use.

* Abbreviations: DV — : dating violence NMUPD — : nonmedical use of prescription drugs In this issue of Pediatrics , Clayton et al1 report on the associations between adolescent dating violence (DV) victimization and the nonmedical use of prescription drugs (NMUPD) using the Youth Risk Behavior Surveillance System. Given our national focus on the opioid epidemic, studies on associations of NMUPD with other health risk exposures among adolescents, such as DV victimization, are timely. Because most researchers conducting studies on NMUPD among adolescents have relied on emergency department samples or limited geographic areas, researchers conducting a study using nationally representative data to estimate prevalence ratios add needed perspective. With a sample of 10 443 male- and female-identified US high school students who had dated in the past 12 months, Clayton et al1 provide sex-stratified analyses revealing that experiencing both physical and sexual DV victimization is associated with NMUPD for both sex categories. Stratifying by sex category identifies some subtle but important differences. Among boys, there is an association of lifetime NMUPD with sexual violence victimization, whereas among girls, lifetime NMUPD is associated with physical DV victimization. Among girls, NMUPD is associated with a higher frequency of sexual violence victimization … Address correspondence to Elizabeth Miller, MD, PhD, Division of Adolescent and Young Adult Medicine, Oakland Medical Building, 3420 Fifth Ave, Pittsburgh, PA 15213. E-mail: elizabeth.miller{at}chp.edu

Book Review: The 50 Healthiest Habits and Lifestyle Changes

The 50 Healthiest Habits and Lifestyle Changes is written by a physician with special training in adolescent and young adult medicine, and his wife. They agreed to write the book based on research that shows the importance of starting healthy habits at an early age. Topics covered in this book are topics that would be of interest to adolescents and young adults.

Reducing Provider Variation in the Diagnosis of Polycystic Ovarian Syndrome

Diagnosing polycystic ovarian syndrome (PCOS) in adolescents is often challenging. Existing diagnostic criteria are based on adults and features of PCOS, such as, irregular menses, are typical clinical findings during adolescence. Over-diagnosis may mislabel patients leading to undue anxiety and overtreatment while under-diagnosis could result in missed opportunities to address risks associated with poor health outcomes. Using recommendations for diagnosis of PCOS based on the international consensus on the diagnosis of PCOS in adolescents (Horm Red Ped 2015; 83:376), this quality improvement project aims to assess variations in provider practices and adherence to diagnostic criteria in order to reduce variation within the Division of Adolescent and Young Adult Medicine at the Children’s Hospital of Pittsburgh.

Enhancing Pediatric Trainees' and Students' Knowledge in Providing Care to Transgender Youth

PurposeTo enhance pediatric trainees' and students' knowledge of the psychosocial and medical issues facing transgender youth through a comprehensive curriculum. MethodsDuring the 2015–2016 academic year, we administered a transgender youth curriculum to fourth-year medical students, pediatric interns, psychiatry interns, and nurse practitioner students on their 1-month adolescent and young adult medicine rotation. The curriculum included six interactive, online modules and an observational experience in a multidisciplinary pediatric gender clinic. The online modules had a primary care focus with topics of general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, and medical plan. At the completion of the curriculum, learners completed an evaluation that assessed change in perceived awareness and knowledge of transgender-related issues and learner satisfaction with the curriculum. ResultsTwenty learners participated in the curriculum with 100% completing the curriculum evaluations, 100% reporting completing all six online modules, and 90% attending the gender clinic. Learners demonstrated a statistically significant improvement in all pre-post knowledge/awareness measures. On a Likert scale where 5 indicated very satisfied, learners' mean rating of the quality of the curriculum was 4.5 ± .7; quality of the modules was 4.4 ± .7; and satisfaction with the observational experience was 4.5 ± .8. ConclusionsA comprehensive curriculum comprised interactive online modules and an observational experience in a pediatric gender clinic was effective at improving pediatric learners' perceived knowledge of the medical and psychosocial issues facing transgender youth. Learners also highly valued the curriculum.

Unplanned readmissions in younger and older adult patients: the role of healthcare-related adverse events.

BackgroundReadmissions are a burden for patients and increase healthcare costs. In Europe, factors associated with readmissions have not yet been extensively investigated. This study aimed to discover factors associated with readmissions in both young and older adult internal medicine patients. Furthermore, we explored the role of healthcare-related adverse events (AEs) in readmissions.MethodsAll patients admitted through the emergency department to the internal medicine department in the last 2 weeks of each month (2011) were included. Information on index admissions and readmissions, defined as an unplanned admission within 30 days after discharge, was obtained from the electronic patient record system. Demographic, clinical, and organizational factors were evaluated for their association with readmissions.ResultsOf all patients (n = 940), 17.3 % were readmitted; 16.9 % of the younger (<65 years, n = 485), and 17.8 % of the older patients (≥65 years, n = 455). Dependency in activities of daily living (ADL) was the only factor associated with readmissions in both all ages (OR 2.43) and in older patients (OR 3.19), while age was associated with readmissions in younger patients (OR 1.03 per year). AEs leading to 35.4 % of all index admissions were not associated with readmissions.ConclusionsReadmissions are common in medical patients, and, thus, remain a reason for concern in terms of patient safety and quality of care. AEs, responsible for to the index admission, were not associated with readmissions. ADL dependency was the only factor associated with readmission in patients of all ages and older patients, indicating that determining which patients are at risk for readmissions is not easy.Electronic supplementary materialThe online version of this article (doi:10.1186/s40001-016-0230-0) contains supplementary material, which is available to authorized users.

Eating Disorders in Adolescent and Young Adult Males: Presenting Characteristics

PurposeData on the clinical characteristics of adolescent males with eating disorders are limited. The purpose of this study was to describe the demographic characteristics, presenting vital signs, laboratory results, and relevant risk factors for eating disorders among males presenting to an outpatient adolescent and young adult medicine practice. MethodsRetrospective chart review of male eating disorder patients aged of 11–25 years presenting to the University of California, San Francisco Adolescent and Young Adult Eating Disorder Program between June 1, 2011, and November 1, 2014. Charts were reviewed for demographic and clinical characteristics and risk factors for eating disorders. ResultsThirty-three patients were included; mean age was 16 years. Patients presented with mean heart rate was 58.7 bpm, and orthostatic heart rate change was 22 bpm, with 51.5% meeting Society for Adolescent Health and Medicine hospital admission criteria. Mean percent of median body mass index was 88%. Of patients with available laboratory data, 33.3% were anemic, 23.8% leukopenic, 19.0% thrombocytopenic, and 10.0% neutropenic. Half had a history of a psychiatric disorder; 41.5% had a history of overweight or obesity, and 12.1% had a family history of an eating disorder. The DSM-IV-TR and DSM-5 diagnostic criteria were retrospectively applied to patients, with an increase in diagnosis of anorexia nervosa from 36.4% to 48.5%. Diagnoses of Eating Disorder Not Otherwise Specified, now Other Specified Feeding or Eating Disorder in DSM-5, decreased from 62.6% to 45.5%. ConclusionsMale patients with eating disorders presented with significant abnormalities; patients were bradycardic and orthostatic; and more than half met Society for Adolescent Health and Medicine admission criteria. Patients with available laboratory data demonstrated significant abnormalities consistent with malnutrition. Given that eating disorders are less likely to be detected in males, it is important to recognize early signs of malnutrition, particularly in those who present within the normal body mass index range for age.