AJPM article calls for increased effectiveness research on clinical preventive services for adolescents

Oct 27 2009

Too little attention is paid to improving the delivery of clinical preventive services to adolescents by addressing problems unique to that population, says a new study commissioned by Partnership for Prevention.

Most of the clinical preventive services that are recommended for adolescents also don't have good evidence to support their effectiveness, say authors of the study, which appears in the current online edition and the November print edition of the American Journal of Preventive Medicine.

The review article, "Clinical Preventive Services for Adolescents," is freely available to the public electronically at www.ajpm-online.net/article/S0749-3797(09)00490-5/abstract. It sheds light on the lack of attention that's been given to preventive health and wellness recommendations for adolescents between the ages of 11 and 17.

"We need to encourage both more clinical effectiveness research on clinical preventive services for adolescents and changes in the ways medical practices serving adolescents approach improving delivery rates," said Leif I. Solberg, MD, the study's chief author who is Associate Medical Director for Care Improvement Research, HealthPartners Medical Group.

"It's important that healthcare providers use every medical encounter, not just 'well-child visits,' which not all adolescents receive regularly, to address their clinical preventive services needs," Solberg said.

The study reviewed 28 counseling services and 31 screening services recommended by at least one of five national groups that issue comprehensive preventive care recommendations for teens. Only seven non-immunization services were given A or B recommendations from the U.S. Preventive Services Task Force (USPSTF), which uses a rigorous approach to assess the effectiveness of both the service itself and the benefits of delivering the service in a clinical setting. Those seven included cervical cancer (Pap test), Chlamydia (girls), depression, tobacco, and for persons at increased risk of gonorrhea, syphilis, and HIV.

Of the seven effective recommended services, five involve sexual health, including STIs (sexually transmitted infections) and cervical cancer (Pap test). Of this limited set of services, only Chlamydia screening and Pap tests are recommended for all sexually active young women and also have been judged to also be high value, according to the National Commission on Prevention Priorities.

However, even among STI screening services for which there is good evidence, too little attention is paid to improving delivery of these services by addressing problems unique to adolescents. Those problems include:

• The time typically allocated for routine adolescent exams is quite short and is unlikely to be extended, given Medicaid's recent reductions in preventive visit reimbursements relative to other services.
• Many clinicians feel that adolescents are less likely to heed their recommendations because they believe adolescents are less interested in their long-term health than adults and more likely to engage in risk behaviors.
• Delivery of clinical services to adolescents tends to be driven by tradition, expert opinion, and the very limited needs of particular required preventive visits (e.g., school or sports physicals)

"Despite these problems and the fact that most adolescents are healthy, more than 70% of adolescent morbidity and mortality is the result of risk behaviors, such as alcohol use, unsafe sex and violence," the authors wrote. "The clinical setting presents an opportunity to identify risky behaviors early and to steer adolescents in the right direction."