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Confidential, parent-free discussion should occur by age 13

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Change the office culture to ensure confidential dialogue with teens

Passage of the Affordable Care Act “provides a rich opportunity to improve the delivery of adolescent preventive services,” by lowering the financial barriers that had impeded preventive care, Jeanne Van Cleave, MD, wrote in an editorial published with the study. The findings in Santelli et al. “provide important direction for efforts to improve the delivery of adolescent preventive care.”

Specifically, changing office culture to ensure consistent screening, private time with providers, and policies that ensure discussion of confidentiality, can be accomplished by incorporating new roles for office staff, establishing team-based care, and requiring performance measurement. “By involving the whole practice, the burden of ensuring the elements of adolescent preventive care that facilitate discussion of potentially sensitive topics is lifted from individual providers,” advised Dr. Van Cleave.

Essential to the success of such a revised model of care is the practice-wide implementation and understanding of confidentiality. Dr. Van Cleave envisions a partnership between front-desk staff, medical assistants, and providers for administering screening tools and explaining to families the role of private time as well as confidentiality policies. Also essential is routine measurement of performance; the success of such a system would depend upon identifying where the gaps in care exist and what the options are for improving those gaps, she explained.

The use of alternative providers, such as nurses, social workers, or even properly trained parents, is a concept that has been tested previously. They afford greater flexibility, both during and outside of regular office hours, and they have been shown to raise the level of comfort among some youth who might otherwise be reluctant to discuss sensitive topics with their regular providers. These providers can be contacted by families outside of office visits when there are questions, giving advice and counseling by phone and electronic communication.

Dr. Van Cleave points out that while adolescents have many resources at their disposal for researching sensitive topics, including parents, social media, and even school health programs, such sources have been known to provide less accurate or incomplete information, compared with the specific, individually-tailored advice that only the primary care provider can give.

The important take-away message from the Santelli et al. report is that regular discussion of potentially sensitive topics in pediatric primary care leads to “positive patterns for seeking help later in adulthood,” Dr. Van Cleave observed. Their research offers important evidence concerning what needs to change in the practice care environment to facilitate these improvements.

What comes next, namely development and testing of appropriate interventions, will determine whether we can effectively change the role health care has to play in mitigating health risks for this population, she concluded.

Dr. Van Cleave is affiliated with Children’s Hospital Colorado and adult and child consortium for health outcomes research and delivery science, University of Colorado, Aurora. These comments are excerpted from an editorial by Dr. Van Cleave on the study by Santelli et al. (Pediatrics. 2019. doi: 10.1542/peds.2018-3618). She had no relevant financial disclosures and received no external funding.



Discussing confidentiality is essential to the appropriate health care of adolescents, especially prior to discussing sensitive subjects, reported John S. Santelli, MD, MPH, of Mailman School of Public Health, Columbia University, New York, N.Y., and his associates.

Doctor talking with teen girl. Rawpixel/Thinkstock

“Previous research has shown that when adolescents and young adults (AYAs) are not assured of confidentiality, they are less willing to discuss sensitive topics with their providers,” they wrote. The report is in Pediatrics.

According to national guidelines, although discussions concerning confidentiality can begin with parents in early adolescence, over time, the goal should be to allow fully for alone time for the AYA with you without parents present in the room.

You have a unique opportunity to help parents understand confidentiality and aid them in transitioning over time, with full respect and support for the developing adolescent-provider relationship, so that it can be fully realized by the time the adolescent reaches 13 years of age.

Using a nationally representative age-, race/ethnicity-, and income-matched sample of AYAs, the authors surveyed youth aged 13-26 years concerning preventive services received and discussions held with health care providers. Of the 1,918 individuals who completed the survey, the authors’ analysis was limited to the 1,509 (79%) youth who had seen their providers in the past 2 years.

The study focused on 11 youth-provider discussion topics. For 10 of the 11 topics, less than half of the young people said they had a discussion on the topic with a health care provider on their last visit. The most commonly discussed topics overall included mental health/emotional issues (55%), drug or alcohol use (46%), tobacco use (44%), and school performance (43%); the least common were gun safety (14%), sexual orientation (20%), and sexual or physical abuse (21%). There were more discussions concerning birth control among young women (from 26% at ages 13-14 to 54% by ages 23-26) compared with young men (13% at ages 13-14 to 12% by ages 23-26).

On average, young women reported discussing just 3.7 of the 11 topics during their last preventive care visit; young men similarly reported an average of 3.6 topics. Overall, the mean number of youth-provider discussions declined over time from 4.1 at ages 13-14 and 4.4 at ages 15-18 to 2.6 by ages 23-26.

Compared with white youth, who reported 3.3 topics at their last visit, Hispanic and African American youth reported discussing 4.2 topics. Similar differences were seen when comparing rural (2.7 topics) and urban or suburban youth (3.8 topics) or incomes greater than $75,000 (3.6 topics) compared with incomes of $25,000 or less (4.2 topics).

Youth who previously discussed confidentiality also reported discussing more topics (4.4), compared with those who had not talked about confidentiality (2.9).

Before the implementation of the Patient Protection and Affordable Care Act (ACA), which requires the provision of prevention services without cost sharing, less than half of adolescents visited a medical provider for annual preventive care visits, other studies have shown.

Although professional guidelines for adolescent preventive care recommend youth access to confidential services, “young people report that health care encounters often do not include an explanation of confidentiality by their health care provider.” Without the assurance of confidentiality, adolescents are more likely to not seek care or to opt not to disclose risky behaviors.

Current systems tend to rely on parent reporting regarding uses of services, and there is no mechanism in place for collection of data on discussion of sensitive health topics. The authors also noted a lack of time available for dialogue during visits as well as an absence of screening questionnaires prior to visits that might invite opportunities to disclose information on sensitive topics.

“Young people who reported ever having talked about confidentiality with their regular provider were more likely to engage in health discussions with providers,” emphasized Dr. Santelli and his associates. “The use of a health checklist and/or questionnaire and having spent more time with their provider during the visit were consistently associated with more of these discussions.”

You can build rapport with AYAs during preventive care visits that include screening and counseling. Immunizations, screening, and treatment of sexually transmitted infections, and dispensing of reproductive and sexual health services, including contraception, offer good opportunities for these discussions. Other sensitive topics are tobacco, alcohol, and drug use; depression and mental health; and obesity and physical activity.

Dr. Santelli and his associates consider the results of their research to serve as a “valuable addition to the literature.” They did, however, note several limitations. Because the data are cross-sectional, they cannot demonstrate causality. The use of self-report data may have contributed to underreporting of risk behaviors because adolescents were interviewed directly following parents on the same computer. Survey questions did account for the existence of youth-provider discussions, but the researchers were not able to measure the impact or quality of the resulting conversations.

It is important to note that because providers were not interviewed, the time pressures and other expected barriers were not fully accounted for in this research, Dr. Santelli and his colleagues cautioned. “Future research should ask specifically about provider-level barriers to providing preventive care to better understand their impact,” they advised.

Ultimately, the clinicians who are providing care to youth and their families will need support in implementing such changes, especially where education in the importance of discussion confidentiality and private time are concerned, they added.

The authors had no relevant financial disclosures. The study was funded by an unrestricted research grant from the Merck Foundation.

SOURCE: Santelli J et. al. Pediatrics. 2019. doi: 10.1542/peds.2018-1403.

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