Abstract
OBJECTIVES: Adolescents are at high-risk for sexually transmitted infections and pregnancy, yet many do not receive regular preventive care. Hospitalization represents an opportunity for providing sexual and contraception counseling for this high-risk population. Our aim in this study was to assess the frequency of sexual and contraception history documentation in hospitalized adolescents and identify subgroups that may benefit from more vigilant screening.
METHODS: A retrospective chart review of adolescent patients 11 years of age and older who were discharged from the pediatric hospitalist service at an urban, academic children’s hospital from July 2017 to June 2018 was conducted. Patient and admission characteristics were analyzed for presence of sexual and contraception history documentation. Technology-dependent patients were analyzed separately. In addition, technology-dependent patients were assessed by chart review for developmental appropriateness for screening.
RESULTS: Twenty-five percent of patients (41 of 165) had a sexual history documented, and 8.5% (14 of 165) had a contraception history documented. Among patients with any technology dependence, 0 had a sexual history documented and only 1 had a contraception history documented, whereas 31.5% (12 of 38) were deemed developmentally appropriate for screening. Female and older patients were more likely to have sexual and contraceptive histories documented than male and younger patients. Patients transferred from the PICU had lower rates of sexual history documentation compared with direct admissions.
CONCLUSIONS: Hospitalized adolescents, especially those with technology dependence, did not have adequate sexual and contraception histories documented. Improving documentation of these discussions is an important step in providing adolescents with preventive medicine services while hospitalized.
Adolescence is a critical period of physical, cognitive, and sexual development when children undergo puberty and explore their independence.1 The American Academy of Pediatrics (AAP), US Preventive Services Task Force, and Centers for Disease Control and Prevention emphasize taking comprehensive sexual histories of adolescents at health maintenance visits to identify those at risk for sexually transmitted infections (STIs) and pregnancy while helping guide education, screening, and treatment interventions.2–6
Despite this, sexual health maintenance often remains inadequately screened and discussed at primary care provider appointments.7–9 Less than one-third of adolescents asked in a national survey have talked to their health care provider about sexual planning, STIs, or condoms or other methods of birth control.9 Another national survey of >8000 participants ages 10 to 17 revealed that only 38% of adolescents received a preventive visit in the past 12 months. One-third had no preventive care visits from the age of 13 to 17, and an additional 40% had only 1 visit during that time.10
Because the majority of teenagers do not have regular preventive care visits, hospitalization has been recognized as an opportune time to provide health maintenance services to adolescents, many of whom may require a prolonged length of stay.11 Indeed, some hospitals are already placing an increased emphasis on health care maintenance in the inpatient setting for counseling and interventions surrounding obesity and immunizations.12–18 Additionally, adolescents seem open to receiving preventive care services while hospitalized. A recent study of hospitalized adolescents showed that 37% desired STI testing and 57% wished that contraception was offered while in the hospital.19 Although hospitalization may present an opportunity to provide sexual health maintenance services for adolescents, recent studies have shown poor documentation and a lack of screening and/or interventions offered to hospitalized patients, especially for male and younger adolescents.20,21
Our aim in this study was to describe the frequency of sexual and contraception history documentation in hospitalized adolescents and identify additional subgroups of patients who may benefit from more vigilant screening, including those with technology dependence and those transferring from the PICU to the wards.
Methods
Study Setting
We conducted a retrospective chart review of adolescent patients 11 years of age and older who were discharged from the pediatric hospitalist service at a 150-bed, tertiary-care, academic medical center located in the Pacific Northwest from July 2017 to June 2018. This included adolescents with general medical diagnoses and those awaiting placement in inpatient psychiatric facilities after presentation with ingestion or suicidal ideation. All patients were seen by both resident and attending physicians. All documentation occurred in an electronic health record (EHR). The history and physical examination (H&P) template used by residents for new admissions included a section for the documentation of social history but no specific prompts for eliciting or documenting sexual or contraception history.
Ethics
The Oregon Health and Science University Institutional Review Board deemed this study exempt from review. All charts were reviewed by study team members, and no personal health information was shared outside of the organization.
Inclusion and Exclusion
All adolescents ≥11 years of age discharged from the pediatric hospitalist service during the designated time period were included. This included patients who were admitted directly to the hospitalist service as well as those transferred from the PICU. We chose 11 years of age because this is the age the Bright Futures guideline recommends starting screening for STI risk and aligns with the age designation of “adolescence.”22
For patients who experienced multiple hospitalizations during the study period, only the first was included. Three patients who were gender nonconforming were described separately because of the small sample size.
Data Collection
Patients discharged during the study time period were compiled from the hospital billing database. Two research assistants (RAs) served as the primary chart reviewers. The RAs were trained by the principal investigator, who also reviewed charts that were flagged by the RAs for questions. For charts that met inclusion criteria, the full admission H&P, transfer note, and discharge summary in the EHR were read and examined by the reviewer for documentation of the patients’ sexual and contraceptive history. Data were entered into a secure Research Electronic Data Capture database created for this study.
Dependent Variables
The primary outcomes of interest were the presence or absence of sexual history and contraception history documentation in any section of the H&P, transfer note, or discharge summary. This was recorded as a binary (yes or no) variable. If sexual history was documented, the reviewer recorded the reported specifics regarding sexual activity.
Independent Variables
Demographic and admission data were extracted directly from the EHR and included age at admission, gender, race and/or ethnicity as reported by the parent, insurance type (private versus public), discharge diagnosis category, secondary diagnoses category, primary admission versus PICU transfer, and length of stay. Discharge diagnoses were grouped into a binary variable of admission type: medical versus psychiatric and/or ingestion. Medical categories included the following: gastrointestinal, skin and/or musculoskeletal, neurologic, respiratory, genitourinary, ear nose and throat, genetic, oncologic, and other. Secondary diagnosis categories included the following: gastrointestinal, skin and/or musculoskeletal, neurologic, respiratory, ingestion, genitourinary, ear nose and throat, and primary psychiatric illness. Gender of the admitting resident physician on the H&P note as well as the time of the day during which the patient first arrived on the floor, categorized as daytime (8 am–7:59 pm) and nighttime (8 pm–7:59 am), were recorded.
Technology-Dependent Patients
Technology dependence was defined as being in any of the medical technology categories listed in Table 2. The category of “other” included many different technologies (eg, bilevel positive airway pressure, insulin pump, baclofen pump, hearing aids, Hemovac, and urethral catheter dependence). To determine which of the technology-dependent patients were developmentally and cognitively appropriate for screening sexual and contraceptive health, we reviewed the charts of the 42 patients who had any documented medical technology dependence. Two members of the research team (J.M.W. and J.P.A.) independently reviewed the H&P, transfer note, discharge summary, progress notes, and consult notes until the reviewer was able to characterize the patient’s cognitive and developmental ability in 1 of 3 categories: not developmentally appropriate for screening, developmentally appropriate for screening, or unable to determine. By using a process similar to that described previously,20 developmental appropriateness was determined by reviewing documentation of school attendance and other contextual features in the history of present illness and social history that could help indicate developmental level. There were 3 patients with a discordant assessment whose charts were reviewed independently by a third reviewer (A.F.), who served as the tiebreaker.
Data Analysis
Bivariate analyses used χ2 tests to assess statistically significant (P < .05) differences in patient (age, gender, etc) and admission characteristics (length of stay, admission time, etc) related to sexual history and contraception documentation. We examined how technology dependence was associated with our dependent variables. In our preliminary analyses, it became apparent that any technology dependence had a strong correlation with not having sexual or contraception history documented; no patients with technology dependence had sexual history documented, and only 1 patient had contraception history documented. Given this difference in outcomes, in the final primary analysis, patients with any technology dependence were analyzed separately.
We performed multivariable binomial logistic regression with dependent variables of either sexual health documentation or contraception documentation. The primary independent variable examined was gender, with other independent variables included in the multivariable model if significant at P < .15 in the bivariate analyses described above.
Results
Sample Characteristics
A total of 207 patients met inclusion criteria and were included in the study. After chart review, 42 patients (20.3%) were analyzed separately, with 38 technology-dependent patients being included in the final analysis (Fig 1). The primary analysis included 165 patients (Table 1).
Flowchart of patient selection.
Sexual and Contraception History Documentation With Technology-Dependent Adolescents Excluded
Sexual History Documentation
Among adolescents included in the primary analysis, only 24.8% had a sexual history documented in the H&P, transfer note, or discharge summary (Table 1). Female and older patients were more likely to have a sexual history documented (31.7% female versus 14.1% male patients [P = .01]; 35.3% age 15–19 vs 13.8% age 11–14 [P = .001]). Adolescents who were admitted from the emergency department or were directly admitted to the pediatric hospitalist service were more likely to have a sexual history documented than those who were transferred from the PICU (29.5% vs 15.1%; P = .05). Patients with private insurance were more likely to have sexual history documented (34.2% private versus 17.0% public; P = .03), as were those with psychiatric and/or ingestion discharge diagnoses (32.4% psychiatric and/or ingestion versus 19.1% medical diagnoses; P = .05).
Among those patients with sexual history documented, 58.5% were noted to be sexually active. Among this subset, 65.6% of female and 33.3% of male patients were sexually active (P = .08). There was no significant difference in sexual activity between age groups (66.7% age 15–19 vs 36.4% age 11–14; P = .08) or between patients with medical versus psychiatric and/or ingestion discharge diagnoses (P = .33). In addition, of the patients who were sexually active (n = 24), 18 (75.0%) had documentation on their partners’ sex or sexes, 15 (62.5%) had documentation on condom use, 14 (58.3%) had documentation on the number of partners, 8 (33.3%) had documentation on previous STI history, 4 (16.7%) had documentation on type of sexual experiences (oral, vaginal, anal, etc), and 1 (4.2%) had documentation on trading money for sex.
The multivariable logistic regression includes variables significant at P < .15 in the bivariate analysis, including patient age, insurance, PICU versus direct admission to the hospitalist service, type of admission, number of secondary diagnoses, and length of stay. In this model, the disparity by gender in having sexual history documented persisted with an adjusted odds ratio (aOR) of 3.4 (95% confidence interval [CI]: 1.4–8.1) for female versus male patients. In this full model, private insurance (aOR = 2.54; 95% CI 1.1–5.7), direct admission to the hospitalist service (aOR = 4.3; 95% CI 1.5–12.1), and older age (aOR 3.4; 95% CI 1.4–8.0) were also significantly associated with sexual history documentation. The other variables in the model were not significant.
Contraception History Documentation
Of adolescents, 8.5% had their contraception history documented in the H&P, transfer note, or discharge summary (Table 1). Female and older patients were more likely to have a contraception history documented than male and younger patients (11.9% female versus 3.1% male patients [P = .05]; 12.9% age 15–19 vs 3.8% age 11–14 [P = .03]). Among patients with sexual history documented, only 4 were offered contraception. All of those offered were female patients in the older age category.
In the multivariable regression model for documentation of contraception with both independent variables of age and gender included, neither variable was significantly associated with increased documentation.
Gender Nonconforming
There were 3 patients who identified as gender nonconforming, all of whom were of female-to-male gender identity. Their average age was 15. All 3 were admitted with the discharge diagnosis of intentional overdose and/or ingestion. Of the 3, 2 had sexual history documented and were noted to be sexually active. Only 1 had contraception history documented. One had technology dependence (insulin pump) and was deemed developmentally appropriate for screening. However, this patient did not have sexual history or contraception documented.
Technology-Dependent Patients
There were 38 patients with technology dependence included in the subgroup analysis (Table 2). Among patients with any technology dependence, 0 had a sexual history documented and only 1 had a contraception history documented. Approximately half of the patients (52.6%) had only 1 device, whereas 47.4% had >1. Enteric feeding tubes were the most common devices, found in 55.3% of patients. Of the 38 patients, 12 (31.5%) were deemed developmentally appropriate for screening, whereas 26 (68.4%) were not. Patients deemed not developmentally appropriate for screening had a higher average number of devices (P = .02) and were more likely to have 3 or more devices (P = .05), medical rather than psychiatric and/or ingestion discharge diagnoses (P = .03), and enteric feeding tubes (P = .001).
Description of Technology-Dependent Patients
Discussion
In this study, sexual and contraception history documentation was low for all adolescents but especially low for male patients, younger patients, those who were transferred from the PICU, and those with technology dependence. Although consistent with similar studies, these findings are worrisome given the opportunity hospitalization presents to provide health care maintenance services to adolescents.20,21 Unique to our study was the inclusion of patients with technology dependence and patients transferred from the PICU. For patients with technology dependence, sexual and contraception history documentation was nearly nonexistent, and for those transferring from the PICU, sexual history documentation was much lower than for those directly admitted to the hospitalist service. These findings highlight the challenge in providing preventive medicine services to hospitalized adolescents, wherein competing priorities may make conducting and documenting these discussions difficult.
Similar to other studies, female patients in our study were more likely to have a sexual history documented than male patients were.20 Some have speculated that this gender disparity for sexual health documentation reflects providers’ concerns that risky sexual behavior disproportionately affects girls (ie, pregnancy and pelvic inflammatory disease). This notion is further reflected in the AAP’s current strong recommendations for yearly STI testing in girls as opposed to its weaker recommendation for boys.4 Although girls may be more at risk for undesired results of sexual encounters, the disparity in documentation may be a sign that providers are inadvertently putting more of the burden and responsibility of safe sex on girls. Future guidelines should help address this disparity.
In our study, older adolescents were more likely to have sexual and contraception history documented than younger adolescents were. On the basis of the recommendations set forth by the AAP and published in the Bright Futures guidelines, screening for sexual activity and contraceptive needs should begin at age 11.22 The results of our study and others suggest that providers are not adequately screening adolescents in the younger age groups.20 Because younger adolescents potentially have the least sexual experience and education, early and consistent screening and guidance is necessary so that when adolescents do engage in sexual behavior, they will have the information to do so as safely as possible.
Our study also found that adolescents who transfer from the PICU to the wards have lower sexual health documentation rates than do direct admissions to the wards. This likely stems from the high acuity of the PICU and need for triaging certain aspects of care, such as adolescent sexual health, to when patients are less critically ill. Nonetheless, similar to those managing the other groups with lower documentation rates, hospitalists should recognize patients transferred from the PICU as a population in which more attention to sexual and contraception history documentation may be needed. This is particularly important for patients admitted to the PICU for intentional ingestions and suicidal ideation because this population has higher rates of sexual activity and therefore higher risk for pregnancy and STIs.23
Finally, within our study, patients with technology dependence had the lowest rates of sexual and contraception documentation. Among this group, no patients had sexual history documented and only 1 had contraception history documented. There are several factors that may explain this disparity. First, technology-dependent patients often take extra time and effort for admitting providers given that they often have long medication lists, have disease processes involving multiple systems, and tend to be more medically fragile. This may allow less time for anticipatory guidance, education, and screening for sexual health and contraception needs. Second, technology-dependent patients often rely heavily on their parents to manage their specific medical devices, making it difficult to separate the parents from the encounter to ask the sex-specific questions in an interview. Third, physicians may exhibit a stereotyping cognitive bias and not regard patients with technology dependence as being interested in or capable of sexual activity and hence may not think to screen them. However, previous studies have shown that patients with medical complexity exhibit no difference in sexual behaviors than those without chronic medical conditions and are likely at higher risk of sexual abuse.6,24–29 For these reasons, a recent AAP technical report has emphasized the importance of sexual history taking in adolescents with medical complexity.6 It is notable that within our group of 38 technology-dependent patients, 12 were deemed developmentally appropriate for screening, thus providing further support for screening this group of patients.
Because this study was conducted in a single academic center, it may not be generalizable to other settings. We reviewed only admission notes, transfer notes, and discharge summaries. A potential area of bias in our study is that documentation could have occurred elsewhere in the record, which would underestimate the documentation in our results. In the separated analysis, gender nonconforming patients had a high rate of sexual history documentation, although the sample was small. Future studies could focus on this group as a potential confounder. Although we had high interprovider agreement in assessing developmental appropriateness for technology-dependent patients, a standardized tool would be helpful to ensure better accuracy and reliability. To our knowledge, no tool exists to assess developmental readiness for sexual health screening, and therefore, we believe this would be an important area of future research. Finally, our study chose technology dependence to represent medical complexity because it was a simplified version of existing definitions of medical complexity.30 However, in our study, there were patients with medical complexity but without technology dependence who were grouped with patients without medical complexity. Because some of these “nontechnology-dependent medically complex” patients may not be developmentally appropriate for screening, our rates of sexual history and contraception documentation may be artificially low. Again, the development of a screening tool for identifying readiness for sexual health screening would mitigate this issue.
Conclusions
Our study found that hospitalized adolescents did not receive adequate sexual and contraception history documentation. This was especially true for younger adolescents, male adolescents, adolescents transferring from the PICU, and adolescents with technology dependence. Because adolescents have historically low rates of health supervision visits, hospitalization represents a prime opportunity to provide preventive medicine services to this population. Providing these services must involve both discussions of preventive medicine topics with patients and subsequent documentation of those discussions. Quality-improvement initiatives to improve documentation in hospitalized adolescents, particularly children with technology dependence or medical complexity, are potential next steps.
Acknowledgments
The authors thank the following individuals for their support and input into the project: Megan Aylor, MD; Sarah Green, MD; Windy Stevenson, MD; Tammy Wagner, MD; Tracy Bumsted, MD, MPH; Colin Fisher, MD; and Megan Jacobs, MD. The authors also thank Jose Rodriquez for his assistance in data collection.
Footnotes
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
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