Adolescent gynecology in the office setting

Provider Attitudes and Practices toward Sexual and Reproductive Health Care for Young Women with Cystic Fibrosis

STUDY OBJECTIVE

To investigate the attitudes and practices of cystic fibrosis (CF) providers toward sexual and reproductive health (SRH) care in young women with CF.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Adult and pediatric US CF providers were sent an online survey exploring their attitudes toward SRH importance, SRH care practices, and barriers/facilitators to SRH care in adolescent and/or young adult women. Descriptive statistics and logistic regression were used to analyze results.

MAIN OUTCOME MEASURES

Attitudes toward the importance of SRH care in patients with CF and self-report of practice patterns of SRH discussion.

RESULTS

Respondents (n = 196) were 57% pediatric (111/196) and 24% adult physicians (48/196) and 19% nurse practitioners (NPs)/physician assistants (PAs) (37/196). Ninety-four percent of respondents believed SRH was important for female patients with CF (184/196). More than 75% believed SRH care should be standardized within the CF care model (147/196) and 41% believed the CF team should have the primary role in SRH discussion and care (80/196). For many CF-specific SRH topics, discrepancies emerged between how important respondents believed these were to address and how often they reported discussing these topics in practice. Significant differences in SRH attitudes and practices were present between adult and pediatric physicians. The most significant barriers to SRH care identified were lack of time (70%, 137/196) and the presence of family in clinic room (54%, 106/196). Potential facilitators included training materials for providers (68%, 133/196) and written (71%, 139/196) or online (76%, 149/196) educational resources for patients.

CONCLUSION

CF providers perceive SRH topics as important to discuss, but identify barriers to routine discussion in current practice. Providers endorsed provider training and patient educational resources as means to improve SRH delivery.

Availability of adolescent health services and confidentiality in primary care practices

BACKGROUND

Little is known about availability of services and confidential care for adolescents in primary care practices or how availability among pediatric practices compares to that among other primary care practices. The objective of this study was to assess self-reported availability of services for medically emancipated conditions and confidential care in primary care practices, to compare physician responses to those from office staff who answer appointment lines, and to compare availability in pediatric practices to other primary care practice types.

METHODS

We conducted a telephone survey of randomly selected practices from the Washington, DC, metropolitan area in pediatrics (Peds), internal medicine (IM), and family medicine (FM). We asked staff who answer appointment lines about availability of services for medically emancipated conditions and confidential appointments for adolescents. Physicians received the same questions via a mail survey. Responses from office staff and physicians in the same practice were linked for comparison.

RESULTS

Of 434 practices contacted by telephone, 372 (86%) responded. Of the 615 physicians surveyed from these 372 practices, 264 (43%) from 170 practices responded to the mail survey. Peds practices were less likely than FM and IM practices to offer services for medically emancipated conditions and were less likely than FM practices to offer confidential services to adolescents. Office staff and physicians from FM and IM had higher agreement compared with Peds about availability of services for medically emancipated conditions. Agreement between office staff and physicians about provision of confidential appointments to adolescents was low among all practice types. However, having a written office policy on adolescent confidentiality was significantly associated with agreement between office staff and physicians about availability of confidential services.

CONCLUSIONS

Care for medically emancipated conditions and confidential services for adolescents are limited among primary care practices, especially among pediatric practices. All primary care practice types had significant disagreement between office staff and physicians about availability of confidential services to adolescents. Adolescents who call appointment lines are likely to receive inaccurate information about confidentiality policies. Establishing written office policies on adolescent confidentiality may help to improve access to confidential care for adolescents.

Effective prenatal care for adolescent girls

Provision of prenatal care for adolescents requires an understanding of routine prenatal care as well as developmental and psychosocial issues unique to this population. In this article, management of adolescent pregnancy, including the prenatal history, physical examination, diagnostic testing, and follow-up care are presented. Collaboration with other disciplines, which optimizes care, is also discussed.

Testing for Chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers

OBJECTIVES

Little is known about the practice patterns of primary care providers as they relate to assessing risk of and screening for chlamydial infections, an important cause of preventable reproductive morbidity in young women in the United States. The present cross-sectional study was undertaken to assess levels of chlamydia testing, sexual history taking, and prevention practices by Colorado primary care physicians, nurse practitioners, and physician assistants who provide gynecologic care to adolescent females (13-19 years old).

METHODS

Between July 1998 and October 1998, an anonymous, self-administered questionnaire was mailed to a 25% random sample (n = 1265) of Colorado physicians (family practitioners, internal medicine specialists, obstetrician-gynecologists, and pediatricians), nurse practitioners, and physician assistants. Practitioners were identified through professional organization membership, state-licensing bodies, and listings in the yellow pages.

RESULTS

After estimating the eligibility rate among non-respondents, the adjusted response rate was 71.5%. Only 53.8% of providers reported regularly testing sexually active female adolescents for chlamydia; 71.8% of providers regularly took a sexual history. Female providers reported significantly higher levels of regularly taking a sexual history (87. 2% vs 60.6% of males), feeling comfortable discussing sex (94.4% vs 77.8%), discussing sexually transmitted disease (STD) prevention (81. 5% vs 71.3%), and testing for chlamydia (64.4% vs 38.6%). Among provider types, obstetrician-gynecologists, nurse practitioners, and pediatricians were most likely to report regularly taking a sexual history (90.1%, 88.6%, and 76.0%, respectively). Internal medicine specialists were the least likely to report taking a sexual history (43.9%). Pediatricians and nurse practitioners were the most likely to report testing sexually active adolescent females for chlamydia (74.1% and 70.1%, respectively), whereas physician assistants and internal medicine specialists were the least likely (46.0% and 38.5%, respectively). In multivariate analysis, variables independently associated with regularly taking a sexual history included female provider gender (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 2.9-10.9), obstetrics/gynecology specialty (OR: 4.0; 95% CI: 1.7-10. 3; referent group: family practitioners), and provider comfort level in discussing sex (OR: 4.9; 95% CI: 2.3-11.1). Variables independently associated with regularly testing adolescent females for chlamydia included female provider gender (OR: 2.8; 95% CI: 1. 6-4.8), regularly discussing STD prevention (OR: 2.1; 95% CI: 1.1-4. 1), and regularly discussing limiting the number of patients' sex partners (OR: 2.4; 95% CI: 1.4-4.1).

CONCLUSIONS

Only a little over one half of providers (54%) reported regularly performing chlamydia tests on adolescent females who are sexually active by history. Because this falls well short of the recommendations of the Centers for Disease Control and Prevention to test all sexually active female adolescents, efforts are needed to improve STD clinical practices of Colorado physician and nonphysician providers of primary care for adolescent females. Particular efforts are needed to close the provider gender gap.