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Shakir RM, Doshi S, Blakeslee S, Jessee M. Seize the Opportunity: Increasing the HIV Screening Rate in Adolescents Presenting to a Community Pediatric Emergency Department. Pediatr Emerg Care 2023; 39:801-806. [PMID: 37665966 DOI: 10.1097/pec.0000000000003044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVES Our objective was to increase human immunodeficiency virus (HIV) screening in adolescents presenting to our community pediatric emergency department with symptoms suggestive of a sexually transmitted infection (STI) and who were being tested for gonorrhea and chlamydia. Specifically, we aimed to increase the monthly average proportion of adolescents concurrently screened for HIV in this target group from 11% to 50% in 6 months. METHODS We identified barriers to HIV screening, focusing on physician-related challenges and adolescents' concerns about confidentiality. We designed interventions targeting these barriers and implemented them in plan-do-study-act cycles beginning in February 2020. We educated physicians and nurses about screening recommendations, emphasized a physician-conducted private interview during which confidential contact information could be obtained, and assured confidentiality on after visit summaries by removing STI results. We also provided regular feedback to physicians on the screening rate. In addition, we implemented an electronic health record quick order set and a documentation tool. Using a statistical process control chart, we measured the average monthly proportion of adolescents in the target group who were offered HIV screening or tested for HIV before and after interventions. RESULTS A total of 140 adolescents in the target group presented to our pediatric emergency department from February 2020 through December 2021. After plan-do-study-act cycles, the average monthly screening rate increased to 80%. CONCLUSIONS Raising physician awareness of HIV screening recommendations and the importance of conducting a private interview improved screening rates. Assuring adolescent minors of confidentiality in a private interview, removing STI results from the after visit summary, and obtaining confidential contact information were important measures to overcome confidentiality barriers.
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Affiliation(s)
- Rashida M Shakir
- From the Children's Hospital of Philadelphia at Virtua Mount Holly Hospital, Mount Holly, NJ
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Tiffany-Appleton S, Mickievicz E, Ortiz Y, Migliori O, Randell KA, Rothman EF, Chaves-Gnecco D, Rosen D, Miller E, Ragavan MI. Adolescent Relationship Abuse Prevention in Pediatric Primary Care: Provider, Adolescent, and Parent Perspectives. Acad Pediatr 2023; 23:1151-1158. [PMID: 36584939 PMCID: PMC10293467 DOI: 10.1016/j.acap.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Adolescent relationship abuse (ARA) is associated with myriad negative health outcomes. Pediatric primary care presents an opportunity to engage adolescents and parents, who can be protective against ARA, in ARA prevention; however, no family-focused, health care-based ARA interventions exist. The purpose of this study is to explore the perspectives of adolescents, parents, and health care providers (HCPs) on incorporating ARA prevention into primary care, including 1) current discussions around ARA, 2) how to best include ARA prevention education, and 3) how to address implementation barriers. METHODS We conducted individual, semi-structured interviews with HCPs, adolescents ages 11 to 15, and parents recruited through convenience sampling. Transcripts were individually coded by 4 study team members (with every third transcript co-coded to assess discrepancies) and analyzed via thematic analysis. RESULTS Participants identified a need for pediatric HCPs to involve younger adolescents and parents in universal, inclusive ARA prevention and noted that HCPs require training, techniques, and resources around ARA. Participants acknowledged multilevel barriers to implementing primary care-based ARA prevention. They suggested that ARA education be intentionally integrated into HCP and clinic workflows and recommended strategies to garner adolescent and parent buy-in to facilitate ARA-focused conversations. CONCLUSIONS Pediatric primary care is a promising environment to involve parents and adolescents in universal ARA-prevention. Future research should contextualize these results with larger samples across multiple practice settings and integrate relevant partners in the development and evaluation of evidenced-based ARA prevention for pediatric primary care.
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Affiliation(s)
- Sarah Tiffany-Appleton
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa; University of Pittsburgh School of Social Work (S Tiffany-Appleton and D Rosen), Pittsburgh, Pa
| | - Erin Mickievicz
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa
| | - Yanet Ortiz
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa
| | - Olivia Migliori
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa
| | - Kimberly A Randell
- Children's Mercy (KA Randell), Kansas City, Mo; University of Missouri-Kansas City School of Medicine (KA Randell); University of Kansas School of Medicine (KA Randell), Kansas City, Kans
| | - Emily F Rothman
- Community Health Sciences, Boston University School of Public Health (EF Rothman), Boston, Mass; Department of Pediatrics, Boston University School of Medicine (EF Rothman), Boston, Mass
| | - Diego Chaves-Gnecco
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa
| | - Daniel Rosen
- University of Pittsburgh School of Social Work (S Tiffany-Appleton and D Rosen), Pittsburgh, Pa
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine (E Miller), Pittsburgh, Pa
| | - Maya I Ragavan
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine (S Tiffany-Appleton, E Mickievicz, Y Ortiz, O Migliori, D Chaves-Gnecco, and MI Ragavan), Pittsburgh, Pa.
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Khetarpal SK, Tiffany-Appleton S, Mickievicz EE, Barral RL, Randell KA, Temple JR, Miller E, Ragavan MI. Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review. J Adolesc Health 2023; 72:487-501. [PMID: 36623966 PMCID: PMC10033391 DOI: 10.1016/j.jadohealth.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/23/2022] [Accepted: 11/14/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH. METHODS We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible. RESULTS Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes. DISCUSSION This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.
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Affiliation(s)
- Susheel Kant Khetarpal
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York.
| | - Sarah Tiffany-Appleton
- Division of General Academic Pediatrics, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erin E Mickievicz
- Division of General Academic Pediatrics, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Romina L Barral
- Division of Adolescent and Young Adult Medicine, Children's Mercy Kansas City, Kansas City, Missouri
| | - Kimberly A Randell
- Division of Emergency Medicine, Children's Mercy Kansas City, Kansas City, Missouri
| | - Jeff R Temple
- Center for Violence Prevention, University of Texas Medical Branch, Galveston, Texas
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maya I Ragavan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of General Academic Pediatrics, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Lim AC, Venkatesh M, Lewald DL, Emmanuel PJ, Sanders L. Changes in the time of COVID-19: a quality improvement initiative to maintain services at a youth sexual health clinic. Sex Transm Infect 2021; 98:525-527. [PMID: 34887351 DOI: 10.1136/sextrans-2021-055265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/26/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Adolescents and young adults (AYAs) face difficulties accessing sexual and reproductive health services. These difficulties were exacerbated for a variety of reasons by the COVID-19 pandemic. We document strategies and outcomes implemented at an urban youth sexual health clinic in Florida that allowed uninterrupted provision of services while protecting against spread of COVID-19. METHODS The plan-do-study-act (PDSA) model was used to implement COVID-19 interventions designed to allow continued service delivery while protecting the health and safety of staff and patients. This method was applied to clinic operations, community referral systems and community outreach to assess and refine interventions within a quick-paced feedback loop. RESULTS During the COVID-19 pandemic, changes made via PDSA cycles to clinical/navigation services, health communications and youth outreach/engagement effectively responded to AYA needs. Although overall numbers of youth served decreased, all youth contacting the clinic for services were able to be accommodated. Case finding rates for chlamydia, gonorrhoea, syphilis and HIV were similar to pre-pandemic levels. CONCLUSIONS Quality improvement PDSA initiatives at AYA sexual health clinics, particularly those for underserved youth, can be used to adapt service delivery when normal operating models are disrupted. The ability for youth sexual health clinics to adapt to a changing healthcare landscape will be crucial in ensuring that under-resourced youth are able to receive needed services and ambitious Ending the HIV Epidemic goals are achieved.
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Affiliation(s)
- Andrew C Lim
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Meghana Venkatesh
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
| | | | - Patricia J Emmanuel
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Lisa Sanders
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
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Smith J, Broker P, Chakrabarty M, Santiago J, Farabaugh J, Piatt J, Samaddar K. Implementing Routine HIV Screening in an Urban Adolescent Population at a General Pediatric Clinic. J Adolesc Health 2021; 68:737-741. [PMID: 33129642 DOI: 10.1016/j.jadohealth.2020.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To increase the rate of routine HIV screening during preventative visits for adolescent patients aged 15 to 21 in a pediatric and adolescent clinic in accordance with national recommendations, which are poorly implemented nationwide. METHODS This was a quality improvement initiative. Four plan-do-study-act (PDSA) cycles were conducted from May 2016 to February 2020. Interventions included education of and reminders for the multidisciplinary team on guidelines and testing, creation of a standardized workflow, introduction of a rapid point-of-care HIV antibody test (POCT), and implementation of an opt-out, medical assistant/nursing-driven protocol for HIV rapid point-of-care testing. The primary outcome measure was the monthly percentage of adolescents screened for HIV during preventative visits. Data is presented in a p-control chart and means were adjusted for special cause variation according to the Institute for Healthcare Improvement guidelines. RESULTS Rates of routine HIV screening at preventative visits for youth ages 15 to 21 increased from the pre-intervention rate of 5.16% to a final rate of 41.5% over four PDSA cycles. Mean screening rates were adjusted after introducing the HIV POCT (+18.5%) and after implementing the medical assistant/nursing-driven protocol (+17.9%). CONCLUSIONS We successfully increased routine HIV screening rates at preventative visits for adolescents at an urban pediatric and adolescent clinic. This was in large part due to testing with a rapid HIV POCT and a clinic protocol allowing medical assistants and nurses to order the test under a physician's name as part of the intake process. Ours can be a model for other clinics.
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Affiliation(s)
- Jaron Smith
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona.
| | - Paul Broker
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Melony Chakrabarty
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jason Santiago
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jennifer Farabaugh
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Janice Piatt
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kristen Samaddar
- Division of Primary Care, Complex-Care, and Adolescent Medicine, Phoenix Children's Hospital, Phoenix, Arizona
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Luu MN, Wada PY, Levine-Hall T, Hurley L, Ramalingam N, Tran HN, Slome SB. Using a report card to increase HIV screening in a large primary care group practice. BMJ Open Qual 2021; 10:bmjoq-2020-000988. [PMID: 33414253 PMCID: PMC7797258 DOI: 10.1136/bmjoq-2020-000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/08/2020] [Accepted: 12/29/2020] [Indexed: 11/15/2022] Open
Abstract
Background Despite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV. Objective To determine whether provider education and personalised HIV screening report cards can increase HIV screening rates within a large integrated healthcare system. Design This quality improvement study provided a cohort of primary care physicians (PCPs) a brief educational intervention and personalised HIV screening report cards with quarterly performance data. Participants Participants included a volunteer cohort of 20 PCPs in the department of adult and family medicine. Main measures Per cent of empaneled patients screened for HIV by cohort PCPs compared with PCPs at the Kaiser Permanente Oakland Medical Center (KPOAK) and the non-Oakland Medical Centers in Northern California region (Kaiser Permanente Northern California (KPNC)). Key results Of the 20 participating PCPs, 13 were female and 7 were male. Thirteen were internal medicine and seven family medicine physicians. The average age was 40 years and average practice experience was 9 years after residency. During the 12-month intervention, the estimated increase in HIV screening in the cohort PCP group was 2.6% as compared with 1.9% for KPOAK and 1.8% for KPNC. Conclusions These findings suggest that performance-related report cards are associated with modestly increased rates of HIV screening by PCPs.
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Affiliation(s)
- Mitchell N Luu
- Adult and Family Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Paul Y Wada
- Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Leo Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Nirmala Ramalingam
- Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - H Nicole Tran
- Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Sally B Slome
- Infectious Diseases, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
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Lazar N, Rozansky H, Ely B, Ford CA, Dowshen N. Using Chart-Stimulated Recall to Identify Barriers and Facilitators to Routine HIV Testing Among Pediatric Primary Care Providers. J Adolesc Health 2019; 65:410-416. [PMID: 31248806 PMCID: PMC6748324 DOI: 10.1016/j.jadohealth.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/26/2019] [Accepted: 04/11/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Adolescents account for one in five new HIV infections in the U.S. Yet, only 25% of sexually active adolescents report HIV testing, and testing rates have not improved over time. In this study, the primary aim was to identify barriers and facilitators to routine HIV testing in the pediatric primary care setting. METHODS Practices within a large pediatric network were stratified by higher and lower rates of HIV testing. Providers were purposively sampled across practices, and chart-stimulated recall was used to explore HIV testing knowledge and practices by having providers review actual adolescent well visit records. Interviews were audio-recorded and transcribed. Qualitative content analysis identified categories of barriers and facilitators to HIV testing among higher and lower performing sites. RESULTS Of participants (n = 31), 52% were from higher performing clinics, and 48% from lower performing clinics, and mean number of years in practice was 16.9 (standard deviation 10.8). Provider-identified barriers at lower-performing sites included lack of knowledge of testing guidelines, inadequate sexual risk assessment, concerns about damaging patient/caregiver relationships, and competing priorities, whereas both high- and low-performing cites reported concerns about confidentiality. Identified facilitators at higher performing sites included availability of on-site resources (Title X funding; laboratory). CONCLUSIONS Several distinct barriers and facilitators to routine HIV screening were identified at lower and higher performing sites. These findings can inform the development of multilevel interventions to improve HIV testing rates in pediatric primary care.
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Affiliation(s)
- Nellie Lazar
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Hallie Rozansky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Beth Ely
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carol A Ford
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadia Dowshen
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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