# Presentation: 309751

## Adolescent Healthcare Utilization in the U.S.

- Cynthia Rand, MD, MPH
- University of Rochester School of Medicine and Dentistry

## Outline

- Adolescent healthcare utilization
- Visit-based data (NAMCS)
- Population-based data (MEPS)
- Additional visit burden for universal HPV vaccine delivery (MEPS)

**Notes:**
Good morning

I’ll be speaking about up-to-date analyses of adolescent healthcare utilizations
First from a visit based perspective using the National Ambulatory Medical Care Survey dataset
Then from population based data using the Medical Expenditure Panel Survey

And then I’ll talk about the additional number of visits that adolescents would need for universal HPV vaccine delivery

## National Healthcare Visit Patterns of Adolescents

- 1994-2003 NAMCS (office-based) and NHAMCS (hospital-based) combined
- Visit-based database
- Visit patterns by age and gender
- Overall visits
- Preventive visits (V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9)

**Notes:**
We examined a decade of data from 1994-2003, using the NAMCS, an office based survey and the NHAMCS, a hospital based survey of outpatient visits
(so these would be visits to a hospital based clinic, not inpatient services)

These are visit-based databases, and we examined visit patterns by age and gender, 
First looking at overall visits, and then preventive visits defined by these ICD-9 codes

## Overall Visits for Adolescents

- Females

**Notes:**
We’ll be looking at overall visits for adolescents, with visits in millions on the y-axis, and age on the x-axis.  

There are roughly the same number of adolescents at each age, so a higher number means a greater percentage at each age are having visits

This graph is for visits by females and shows the provider type at each age, with the bottom representing family practice, next internal medicine, then pediatricians in dark purple and ob/gyn in light purple, then hospital based general practitioners and subspecialists at the top

## Overall Visits for Adolescents

- Females

**Notes:**
And here’s just a quick reminder of who adolescents are:
Early (11-14): rapid physical changes with puberty onset, self-absorbed, begin evolution from concrete thinking to abstract, middle school age
Middle (15-17): peer values more important, more comfortable with their body, high school age
Late (18-21): increasing independence, college-age, public insurance ends at 19

## Overall Visits for Adolescents

- Females

## Overall Visits for Adolescents

- Females

## Overall Visits for Adolescents

- Females

**Notes:**
Notice that visits for females actually increase with increasing age overall, and that’s in large part due to an increase in visits to ob/gyns, highlighted here in light purple.
Note that visits to pediatricians decline substantially after age 17, and family practitioners remain constant throughout as providers for adolescent females

## Overall Visits for Adolescents

- Females

- Males

**Notes:**
When we look at males, note that overall visits decline as males age, but not substantially until after age 16

Pediatricians and family physicians provide the majority of visits until that age, in addition to subspecialists (with the greatest number of those visits to orthopedics or dermatology)

## Preventive Visits for Adolescents

- Females

- Males

**Notes:**
Now looking at preventive services for adolescents, note that for both genders they decline dramatically after age 17, early adolescents have the most, and middle adolescents continue to have some, but fewer.

Pediatricians and family physicians provide most of these visits

## Proportion of Visits for Preventive Care

- Females

- Males

**Notes:**
Combining these previous graphs, we can see that the proportion of visits that are for preventive care declines after age 17 and that it makes up a small proportion of overall care for adolescents

## Population Based Analysis:Adolescent Healthcare Utilization

- MEPS 2002-2003
- Adolescents ages 11-21
- Parent or self-report of ambulatory care
- Primary care in past year (Peds, IM, FP, GP in office based practice or clinic)
- Includes all adolescents, even if not receiving care

**Notes:**
Now we looked at population based data for adolescents 11-21, given by parent or self-report

We looked at receipt of primary care in the past year

Note that this dataset includes all adolescents, even if they are not receiving care

## Ambulatory and Primary Care Within 1 Year: Females

- C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006

- Ambulatory care: Visit to a physician, nurse/nurse practitioner, physician assistant or midwife
- **Primary care: Had a visit to a pediatrician, family physician, internist or GP in an office-based practice or clinic

**Notes:**
So first looking at females, the darker pink shows receipt of primary care (not including ob/gyn), with the lighter pink showing receipt of any care.

Note that over 50% of adolescents receive some type of primary care in 12 months until age 19

## Ambulatory and Primary Care Within 1 Year

- C. Albertin, et al., presented at Pediatric Academic Societies’ Meeting, May 2006

- Ambulatory care: Visit to a physician, nurse/nurse practitioner, physician assistant or midwife
- **Primary care: Had a visit to a pediatrician, family physician, internist or GP in an office-based practice or clinic

**Notes:**
Adding males to this graph, you can see that 50% of males through age 16 are receiving some kind of primary care, but visits to primary care and overall start to decline after age  15.

- Female Adolescents With _**No**_ Ambulatory Care in 12 months

**Notes:**
So looking more closely at visits by females,
The red represents no ambulatory care in 12 months, and about 30% of all female adolescents across the ages receive no care

##  Female Adolescents With Visits to Emergency Department (ED) Only

**Notes:**
Yellow here represents the percent of female adolescents receiving care exclusively in the ED, averaging 3%.  

## Female Adolescents With Visits to Specialty Only

**Notes:**
Green represents receipt of specialty care only, (not including ob/gyn)

## Female Adolescents With Visits to School-based Clinic Only

**Notes:**
Light blue represents care in schools only, such as school based clinics– this is a very small percentage overall

## Female Adolescents With Visits to Ob/gyn Only

**Notes:**
Pink represents exclusive use of ob/gyn care, which increases with age to nearly 8% of 21 year olds. 

## Female Adolescents With Visits to Ob/gyn and Any Other Site (except 1° care)   

**Notes:**
From now on, we are looking at adolescents receiving care from ONE OR MORE settings.

The lighter pink segments represent the percentage of females with a visit for OB/GYN CARE AND ANOTHER SITE, OTHER THAN PRIMARY CARE. 

## Female Adolescents With Any Primary Care Visit 

**Notes:**
Blue represents the percent of females with ANY PRIMARY CARE VISIT.  This ranges from a high of 59% at age 16 to 32% at age 21.  

## Overall Healthcare Utilization by Female Adolescents 

**Notes:**
Finally, we’ve added all other combinations of care (for example, ED and subspecialty care). 

## Overall Healthcare Utilization by Female Adolescents within a 1-Year Period

**Notes:**
Now we’ll focus on the individuals who don’t receive any care within 12 months

## Adolescent Factors Associated With No Ambulatory Care

- Age
- Older age (17-21 yrs old) for male adolescents
- Race/Ethnicity
- Other than white
- Income
- All income levels less than 400% FPL

**Notes:**
Factors that are associated with no care include:
Older age for males
Race other than white
And lower income levels

## Potential Healthcare Visit Needs for Universal HPV Vaccine Delivery

- Primary care visits in 2002-2003 MEPS
- Determined whether 0, 1, 2 or 3 more visits needed
- Varied window of time to vaccinate
- Two scenarios:
- 1st vaccine given at a _well_ visit
- 1st vaccine given at _any_ visit

**Notes:**
Now we’ll look at the additional number of visits needed for universal HPV vaccine delivery

We examined primary care visits in the 2002 and 2003 Medical Expenditure Panel Surveys

We determined whether 0, 1, 2 or 3 more visits (beyond current utilization patterns) were needed for adolescents to be completely vaccinated for HPV, applying a likely interval for dosing (1 mo 1st to 2nd, 2 mo 2nd to 3rd, 4 mo 1st to 3rd)

We applied varying windows of time to vaccinate (over 6, 12, 18, or 24 months)
With 2 scenarios:

That the 1st vaccine would be given at a well visit
And that the 1st vaccine would be given at any healthcare visit

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Window to vaccinate**

**Notes:**
The following graphs show the number of additional visits needed for female adolescents if the 1st vaccine is given at a well visit, when a physician might have more time to explain the vaccine

The % of adolescents is along the y-axis, and the additional number of visits needed along the x axis

So given a 6 month window, which is the period studied in vaccine trials for efficacy, 86% of adolescent females had no well visit, and so would need 3 more visits for vaccination

Only 0.6% of adolescent females would need no additional visits

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Window to vaccinate**

**Notes:**
Within 12 months, 72% of adolescent females would need 3 additional visits

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Window to vaccinate**

**Notes:**
And within 18 months, 64% would need 3 additional visits

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Window to vaccinate**

**Notes:**
Within 24 months, 56% of adolescent females would need 3 additional visits, and 15% would need no additional visits if the 1st vaccine is given at a well visit

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Window to vaccinate**

**Notes:**
Now we will focus on the yellow bar which shows visits for a  24 month window to vaccinate

## Additional Visits Needed for Females, 1st Vaccine at Well Visit

**Type of visit 1****st**** vaccine**

**Notes:**
In 24 months, assuming the 1st vaccine is given at a well visit, 15% of adolescent females would need no visits, and another 13% would need 1 more visit

## Additional Visits Needed for Females, 1st Vaccine at Well Visit vs. Any Visit

**Type of visit 1****st**** vaccine**

**Notes:**
But if we then give the 1st vaccine at any type of visit, 33% of teens would need no additional visits, and another 20% would need only 1 more visit

## Additional Visits Needed for Males, 1st Vaccine at Well Visit vs. Any Visit

**Type of visit 1****st**** vaccine**

**Notes:**
Looking at the same graph for males, in 24 months, 10% would have sufficient visits if the 1st vaccine is delivered at a well visit, and 20% if it is delivered at any visit.

## Independent Predictors of Needing More Visits (2-3 vs. 0-1) in 24 months

- Adolescents more likely to need more visits:
- Older age
- Male
- Black
- Uninsured
- Near-poor

**Notes:**
In regression analyses, adolescents who were more likely to need more visits were 
Older age
Male
Black
Uninsured, and
Near-poor

## Limitations

- NAMCS/NHAMCS well visit defined by ICD-9 code documented
- MEPS well visit defined by parent report if <17
- Alternative sites not well identified (teen clinics, family planning clinics, etc)

**Notes:**
Limitations of these studies are:
NAMCS well visits are defined by the ICD-9 code documented, which can be restrictive

MEPS well visits are defined by parent report for individuals under age 17

And visits to alternative sites are not well defined in these analyses

## Conclusions

- 30% of adolescents receive no care in 12 months
- >50% have primary care visits, declines with age
- Peds/FP major care providers to age 16
- Females continue to receive care, more from ob/gyn with older age
- Male adolescents drop off from care after age 16
- Few adolescents have sufficient visits for 3 vaccines

**Notes:**
In conclusion,
30% of adolescents receive no care in 12 months
But over 50% have primary care visits, which decline with age
Pediatricians and family practitioners are the major care providers through age 16
And with older age, females continue to receive care, but more from ob/gyns
Whereas males drop off from care after age 16
And few adolescents have sufficient visits for 3 vaccines

## Implications

- Immunize preferentially in early/mid adolescence
- Ob/gyns should reach older adolescent females with vaccines if missed earlier
- Avoid missed opportunities for vaccination
- Consider delivering series at wider intervals

**Notes:**
Implications include:
Immunize preferentially in early or mid adolescence
Ob/gyns should be trained to reach older adolescent females if missed earlier for vaccination
Providers should all avoid missed opportunities for vaccination
And we should consider delivering a series at wider intervals, such as annually

## Future Questions

- How to encourage annual visits for adolescents?
- How to access those not getting care in the medical home?
- Do vaccine delivery strategies that work for younger children work for adolescents?
- Can a vaccine series be given annually? (HPV)

**Notes:**
Future questions are:
How to encourage annual visits for adolescents?
How to access those not getting care in the medical home?
Do vaccine delivery strategies that work for younger children work for adolescents?
Can a vaccine series be given annually? (HPV)

## Acknowledgements

- Rochester Center for Adolescent Immunization Research
- Peter Szilagyi, MD, MPH
- Christina Albertin, MD, MPH
- Peggy Auinger, MS
- Jonathan Klein, MD, MPH

## Additional Visits Needed by Age for Females, 1st Vaccine at Any Visit (24 mo window)

**Age**

**Notes:**
But if we then give the 1st vaccine at any type of visit, 33% of teens would need no additional visits, and another 20% would need only 1 more visit

## Additional Visits Needed by Age for Males, 1st Vaccine at Any Visit (24 mo window)

**Age**

**Notes:**
But if we then give the 1st vaccine at any type of visit, 33% of teens would need no additional visits, and another 20% would need only 1 more visit

## Preventive Visits in 2 Years

## Literature Review

| Author | Source | Age | Well visit | Any medical exam |
| --- | --- | --- | --- | --- |
| Klein, 1999 | 1997 Commonwealth fund survey (self) | 11-18 | 85% overall
89% 11-14
82% 15-18 |  |
| CDC, 2005 | 2003 NHIS (parent) | 12-17 |  | 86% |
| Burstein, 2003 | 1999 YRBS (self) | 15-18 | 58-63% females
49-61% males |  |
| Ford, 1999 | 1995 Add Health (self) | 12-18 |  | 68% <15
66% >15 |
| Yu, 2001 | 1995 Add Health (self) | 11-21 |  | 70% 11-14
67% 15-17
66% 18-21 |
| McInerny, 2005 | NCQA, HEDIS (insurer) | 12-21 | 34% overall |  |