SAN DIEGO – Initiation of a process improvement initiative helped to increase health risk screening during adolescent visits, results from a single-center study showed.
It also revealed challenges inherent in teaching residents about adolescent primary care.
“Adolescence is a peak period for risk-taking behaviors and the development of chronic physical and mental health conditions, which is why many professional organizations recommend that teenagers and young adults receive an annual preventive visit to receive counseling and screening around some of these issues,” lead study author Dr. Maya Kumar said at the annual meeting of the Pediatric Academic Societies. “Unfortunately there’s a growing body of evidence to suggest that most adolescents and young adults are not receiving this recommended preventive care.”
Dr. Maya Kumar
With the introduction of the Affordable Care Act, she continued, “we anticipated that more and more low-income youth would be starting to come to us once they were eligible to sign up for insurance and start receiving primary care. That led us to start asking ourselves the question: Do we have an adequate, comprehensive screening process in place to protect these vulnerable youth?”
At the Children’s Hospital Los Angeles Teen Health Center, where Dr. Kumar served as a fellow in adolescent medicine until 2014, the researchers set out to improve annual documented screening rates within 9 months to 90% or greater for each of four process measures chosen based on the American Academy of Pediatrics’ Bright Futures guidelines: health risk behaviors, sexually transmitted infections/HIV laboratory screening, tuberculosis risk assessment, and vaccine review. The Teen Health Center operates three types of clinics: one staffed by attending physicians, one staffed by fellows, and one staffed by residents. The office staff for all clinics includes one registered nurse, two medical assistants, and four administrative support staff.
“We do have an EMR [electronic medical record] although it does have limitations,” said Dr. Kumar. “If we want to give screening questionnaires to our patients, we have to do it on paper, and then the provider has to manually review it separately from the EMR. There is no way to tell from the EMR the last time the patient came in for a preventive visit. The only way you as a provider can know [that] is to manually comb through every visit they’ve had and look to see what was done.
“We also don’t have an automated system to notify patients when it’s time for their next annual preventive visit, and many of our patients don’t have their parents involved, so they’re unlikely to remember on their own, and we don’t have a consistent way to contact them and remind them.”
The baseline period was July 1 through Aug. 31, 2013, while the intervention period was Sept. 1, 2013, through March 31, 2014. At baseline, “we had a lot of room for improvement,” said Dr. Kumar, who is now an attending physician in adolescent medicine at the University of California, San Diego. “We were underscreening our sexually active youth. We were not looking for TB risk factors, and while we were doing well screening for some risk behaviors such as tobacco exposure, we were not doing so well with other behaviors like whether they wore a bicycle helmet or a seat belt.”
During the 9-month intervention period, the researchers conducted three tests of change based on Deming’s Plan-Do-Study-Act (PDSA) cycles, in which the interventions were developed from discussions in weekly faculty fellow meetings, monthly office business meetings, and discussions with rotating trainees. After each of the PDSA cycles, at least 20 charts from the practice were reviewed to track progress in the 30 days following the intervention.
“We identified a number of factors we felt were contributing to inadequate baseline screening rates, [including] office staff workload,” Dr. Kumar said. “Having only one nurse and two medical assistants to staff multiple clinics running at the same time made it impossible for them to participate in the screening process at baseline; we didn’t have a way to schedule an annual well visit; we did not have a formal TB risk assessment tool; we were stuck using paper questionnaires; and we got feedback from residents who told us when they started the rotation that they were unfamiliar with what was involved in adolescent primary care, because so few of them had been exposed to adolescents during their pediatric residencies.”
The researchers approached the clinic’s IT department to ask if changes to the EMR could be made, including a recall system for annual physicals and provider alerts for the last time a patient had preventive screening. “We were told that was not possible at that time,” Dr. Kumar said. “So we had to focus on key drivers that were within our control.”