Ardis L. Olson, MDArdis L. Olson, MDCecelia Gaffney, MedCecelia Gaffney, MedZsolt Nagakaldi, PhD*Zsolt Nagakaldi, PhD*

Department of PediatricsDepartment of Pediatrics& Community and Family Medicine& Community and Family Medicine

Dartmouth Medical SchoolDartmouth Medical School*Oklahoma Health Sciences University*Oklahoma Health Sciences University

CECH primary care research NetworkCECH primary care research NetworkArdis.Olson@dartmouth.eduArdis.Olson@dartmouth.edu

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Are Adolescents healthy?Are Adolescents healthy?

Wide range of psychosocial and health risk behaviors exist in adolescence

Health and social choices adolescents make place them at risk and establish adult habits

Increased stress and mental health issues impact health

The health visit; The health visit; missed opportunitymissed opportunity

74% of teens had a health check up in the past 2 years

Wished to discuss an average of 6.7 topics1/3 had not discussed any of the topics they wanted to talk about

Only 12% discussed all their desired topics

Only 50% had counseling when risk factors present28% counseled if used alcohol 38% counseled if inadequate exercise 40% counseled if smoking

JD Klein et al., J Adol Health 25;120-130 & 30:190-195

Rethinking Adolescent Primary CareRethinking Adolescent Primary Care

Better ways to efficiently assess the wide range of current health behaviors and risks

More effective counseling Better ways to motivate teens to make changes to improve their health

ChallengesChallenges Wide range of health risks and key issues missed in clinical interviews or a few questions

Existing screening with GAPSAMA Guidelines for Adolescent Preventive Services

Screening surveys for younger/older teens and parents (70-80 questions). Initial and follow up forms

Assesses health risk and protective factorsComprehensive contentCumbersome to maintain paper survey system

Does not address key issues like anxiety, alcohol, strengths

““Healthy Teens” ProjectsHealthy Teens” Projects Robert Wood Johnson Foundation Prescription for Health National Program Funded in both Round One and Round Two

Develop new approaches to health counseling in the preventive health visit Only adolescent focused project

Utilize technology to optimize time available to clinician to discuss issues Comprehensive health history/screening adapted from GAPS Branching question path, if positive for risk behaviors Additional assessments such as CRAFFT, eating disorders, sports

risk screening Assessed motivation and self-efficacy for change for 5 health

behaviors Confidentiality and Health Messages included during screening

CECH: Clinicians Enhancing Child Health

Northern New England practice based research networkNH, VT and southern MaineCommunities range from 2,000 to 150,000

45 Pediatric and Family Medicine practitioners

Network research in primary care involves common child and family health issuesAdolescent health, parental depression, obesity prevention

John, 14 yr old for a health visitJohn, 14 yr old for a health visitHis doctor had cared for him for years He found him a shy kid with no problems who was hard to get talking.

What his PDA revealed:Sad thoughts, no recent fun, no friends or adults he felt he could talk with, guns in the home, didn’t feel his parents really listened to him, school performance worse than last year. Concerned about problems in his family. Binge drinking and CRAFFT positive. Otherwise screener topics negative.

What happened with his provider:The provider knew it was important to talk with John alone. With review of his PDA answers and John opened up and talked about personal and family problems. He acknowledged recent increased drinking at parties and drinking alone recently.

Issues covered with the PDA ScreenerIssues covered with the PDA Screener

Health Concerns, Social and Medical HistoryNutrition, Physical Exercise and Eating disorders

School, Home Environment and Safety IssuesTobacco, Alcohol and Drug UseSexuality and RelationshipsMental Health, Abuse, and conduct issues

66 Questions Up to 25 additional questions if have risks

Lessons learned using the Lessons learned using the PDA screenersPDA screeners

Used in over 4000 adolescent encounters by clinicians in NH

2 studies of adolescentsExit surveys of teens about how they see their visit using the PDA*

Follow up of teens for 6 months after their visit**

* Olson, AL, Gaffney, CA, Hedberg,VA, Gladstone, GR. Use of inexpensive technology to enhance adolescent health behavior and screening approach, Archives of Child and Adolescent Medicine, 163(2):172-177, 2009.

**Olson, AL, Gaffney, CA, Lee, PW, Starr P. Changing adolescent health behaviors; The Healthy Teens Counseling Approach, American Journal of Preventive Medicine, 35(5S):S359-S364, 2008

Does the Teen Health VisitDoes the Teen Health VisitChange with the PDA?Change with the PDA?

Outcomes Assessed with post health visit exit surveys 65 teens pre- PDA screening/counseling 98 teens during PDA screening/counseling

Assessed Visit satisfaction, perceived confidentiality

and whether clinician listened to them carefully Topics discussed by clinician during the visit How valuable teens found the clinician

discussion

Analysis Chi square comparison of proportions pre vs post No significant differences by practice site in

outcomes

Outcomes: Interaction with teenOutcomes: Interaction with teen

More teens felt their discussion was confidential 84% with PDA vs. 61% prior to PDA*

More teens felt their provider listened very carefully to them during the visit

88% during PDA use vs. 63% before PDA* rated their provider as listening very carefully to them (1 on a 7 point likkert scale)

More teens were very satisfied overall with the visit 88% during PDA use vs. 64% before PDA* rated visit

satisfaction as 1 on a 7 point scale

*p <.01*p <.01

Topics DiscussedTopics Discussed

Comparison of the topics teens reported discussed prior to PDA use and after showed

An increase in the proportion who discussed:Prior PDA use

Fruit/vegetable intake 42% 61% p <.05

Tobacco Use 40% 57% p .07Alcohol Use 38% 54% p <.05

No significant change in proportion who discussed ;Television viewing 32% 37%Exercise 64% 67%Milk product intake 45% 52%Drug use 38% 50%Mood issues 40% 42%

60 teens with usual care prior to PDAs vs. 91 teens with PPA use

Teen View of Helpfulness of Discussion Teen View of Helpfulness of Discussion when Topics Discussed*when Topics Discussed*

Prior PDA use

Fruit/vegetable intake (n=80) 32% 58% p <.05

Milk product intake ( n=74) 44% 70% p <.05

Exercise (n=99) 40% 57% p .08

No significant change;

Tobacco Use (n=74) 63% 70%

Alcohol Use (n=73) 60% 61%

Mood issues (n=62) 38% 53%

Drug use (n=59) 61% 67% TV viewing (n=53) 32% 37%

*Among teens with topic discussed the proportion who responded discussion was

very helpful vs somewhat/ not helpful

Changes in Teen BehaviorsChanges in Teen BehaviorsAfter 6 months adolescents* who had a Healthy Teens visit using the PDA were significantly increased the number of days of exercise/week

After the visit were more likely to list multiple nutrition/exercise changes they were planning

*92 teens with usual care vs.136 teens with PPA use

Beyond GAPS;Beyond GAPS; what is included on the PDA what is included on the PDA

Branching question path, if positive for risk behaviors

Additional assessments such as CRAFFT, eating disorders, sports risk screening, strengths

Assessed motivation and self-efficacy for change for 5 health behaviors

Confidentiality Message

Concerns /medical problems

Calculation of BMI and BMI % for age; optional feature

Questions or worried about- Weight/height; Weight/height; Future plans/job; Future plans/job; Stomach ache/vomiting Stomach ache/vomiting Diarrhea/constipationDiarrhea/constipation Masturbation Masturbation Trouble peeingTrouble peeing Discharge from Discharge from

penis/vaginapenis/vagina Wetting the bed Wetting the bed Sexual organs/genitals Sexual organs/genitals Wet dreamsWet dreams

Trouble sleepingTrouble sleeping Feeling tired a lotFeeling tired a lot Being stressed outBeing stressed out Violence, bullying or your Violence, bullying or your

safetysafety Anger/temperAnger/temper OtherOther

Have any of the following problems

Allergies or hay feverAllergies or hay feverAsthma/trouble breathingAsthma/trouble breathingSeizuresSeizuresHeart problem/chest pain Heart problem/chest pain Headaches/migrainesHeadaches/migraines

I had none of the aboveI had none of the above

Sports Cardiovascular risk screeningSports Cardiovascular risk screening

During exercise have you ever been dizzy or passed During exercise have you ever been dizzy or passed out? out?

Have you ever been unconscious or had a concussion?Have you ever been unconscious or had a concussion?

Have any of your family members or relatives died Have any of your family members or relatives died of a heartof a heart

problem or sudden death before age 50?problem or sudden death before age 50?

Eating Disorders Are you satisfied with your eating habits? Are you satisfied with your eating habits?

If No, then asked- If No, then asked-

Do you ever eat in secret? Do you ever eat in secret?

Are you satisfied with the size or shape of your Are you satisfied with the size or shape of your body? If No, then asked- body? If No, then asked-

Do you spend a lot of time thinking about ways to Do you spend a lot of time thinking about ways to be thinner?be thinner?

Do you do things to lose or control your weight Do you do things to lose or control your weight (skip meals, try not to eat, vomit, take pills, (skip meals, try not to eat, vomit, take pills, etc)etc)

Screening for alcohol & Screening for alcohol & substance abusesubstance abuse

CRAFFT: adolescent alcohol/substance abuseC. Have you ever been in a car where the driver (including yourself) has been using

drugs or alcohol?R. Do you ever use alcohol/drugs to relax, feel better about yourself or fit in?A. Do you ever use alcohol/drugs while you are by yourself, alone?F. Do your family or friends ever tell you that you should cut down on your drinking or

drug use?F. Do you ever forget things you did while using alcohol or drugsT. Have you gotten into trouble while you were using alcohol or drugs?

Scoring: 2 or more positive responses is a positive screen Indicates need for further discussion/counseling 15% of 12-18 yr olds screen positive*

Depression/Anxiety Screening Depression/Anxiety Screening with the PHQ-2with the PHQ-2Over the past 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing thingsFeeling down, depressed or hopeless

Feeling nervous, anxious or on edgeNot being able to stop or control worrying

Responses: 0= not at all, 1= several days, 2= More than half the days, 3= Nearly every day

Scoring: 2 answers summed. screen positive = 3 or more Total score given. * added if screen positive

SuicidalitySuicidality

Have you ever seriously thought about killing yourself, made a plan, or tried to kill yourself?

If answer yes, then asked: Have you had any thoughts about hurting yourself or suicide in the past couple of weeks?

Strengths or Assets Strengths or Assets Do you volunteer at your school, church or community?

Do you feel that you have a strong attachment or belonging to a group such as your family, friends, teammates, or others?

Are you allowed to be more independent or make more of your decisions as you get older?

Do you feel that you are particularly good at doing a certain thing like math, or soccer, or theater, or cooking, or hunting, or anything else?

Do you have at least one friend you can really talk with?

Do you think your parent(s) or guardian(s) usually listen to you and take you seriously?

Interest in making a changeInterest in making a change

If a dietary risk, inadequate exercise, current use of tobacco, alcohol or drugs teens then asked:Are you interested in eating a healthier diet at this time?

How important is it to you to eat healthier? (1-100

How confident are you that you could eat healthier? (1-10)

Getting more exercise, changing your tobacco use, changing youralcohol use, changing your drug use

Risk Groups Requiring Clinician Risk Groups Requiring Clinician InterventionIntervention

Diet: < 5 Fruits/Vegs or < 3 Dairy ProductsExercise : < 3x/wk moderate for 30 minutesTV >2 hr and computer >1 hrEmotional: Sad/Depressed or history of suicide or violent when angry

Use of seat belts and helmets if neededTobacco use past monthAlcohol problems or drunkDrugs (Marijuana or OTC)Unprotected sexSports cardiac risks

Teen risk profilesTeen risk profiles

No risks 16% 8%

1-2 risks 61% 55%

3-5 risks 22% 32%

6-10 risks 2% 5%

Ages: 11- 14 yrs 15-19 yrs N= 1066 N= 921

Incorporating the PDA into Daily Incorporating the PDA into Daily PracticePractice

Roles of nursing and administrative staff Teen completes the screener Maintaining the PDA

Accessing the results Summary format on PDA that lists number of risk by topic and allows

one to jump to specific questions Printed summary after synch to website

Changes in Clinician counseling approach Brief motivational techniques to more effectively counsel

Office FlowOffice Flow PDA given to patient either in the waiting room or when put into

the exam room. Teen completes in 9-10 minutes Easy for nursing/rooming staff

Clinician reviews patient responses Summary format on PDA that lists number of risk by topic and allows

one to jump to specific questions Printed summary after synch to website

Clinician reviews results with teen Uses motivational techniques to discuss importance and confidence for

making behavioral changes Follows up as appropriate

Clinician ExperiencesClinician Experiences

Able to set priorities because informed before visit Joint agenda setting with teen Address issues teens interested in changing differently

than when not interested

Important mental health issues Cluster of fatigue, stress, parents don’t listen,

substance use and depression screen positive

Know all the issues have been asked Frees up time to explore key issues in more depth and

counsel vs only drag out the information. Difficult for clinicians to consistently assess all

topics

A pediatrician in practice for over 30 A pediatrician in practice for over 30 years said, years said,

““I thought I knew my kids, but I I thought I knew my kids, but I reallyreally

didn’t. I learned”didn’t. I learned”

Also available at our network websiteIndividual practice data online with capacity to query and download data on individual or group of patients

Brief PDA screener for 4 to 10 year old well child visit for parentsCovers concerns, development, safety, expanded questions re obesity risk behaviors

Software and information available at http://www.cancer.dartmouth.edu/cech/Palm PDAs can be purchased online from secondary vendors

Next year will have web based version available for use on netbooks, I touch and other platforms