Kharbanda EO, Stuck L, Molitor B, Nordin JD. Missed Opportunities for Pregnancy Prevention Among Insured Adolescents. JAMA Pediatr. 2014;168(12):e142809. doi:10.1001/jamapediatrics.2014.2809
Birth to a teenaged mother is associated with adverse health and social outcomes. Adolescents at risk for pregnancy may not receive needed reproductive health services at primary care visits.
To review services provided at outpatient visits in the year prior to pregnancy among adolescents in a US Midwestern integrated health care delivery system.
Design, Setting, and Participants
Retrospective medical record review of continuously insured adolescents aged 15 to 19 years experiencing pregnancy in a nonprofit Minnesota health care organization.
Main Outcomes and Measures
Primary care visits in the year prior to pregnancy.
Adolescents experiencing a pregnancy with stable insurance coverage had an estimated average of 2.7 primary care visits in the 12 months prior to becoming pregnant. Medical record review revealed that 57% did not have documentation of sexual activity and 47% did not have documentation of reproductive health counseling. These rates varied by health care professional type and visit type. Only 35% had contraception prescribed within 12 months of becoming pregnant and only 1 had a long-acting contraceptive prescribed.
Conclusions and Relevance
Our data highlight the need for primary care professionals to review health behaviors and pregnancy risk at all adolescent encounters.
Despite declines,1 pregnancy rates among teenagers in the United States remain higher than most developed nations. In 2010, the US teenaged pregnancy rate was 57.4 per 1000 adolescents aged 15 to 19 years and more than half of these pregnancies ended in a live birth.1 Of additional concern, across the United States, teenaged pregnancy and teenaged birth rates are substantially higher in traditionally underserved communities.2,3
Primary care visits may provide key opportunities for pregnancy prevention. Both the American Academy of Pediatrics and the Society for Adolescent Health and Medicine recommend that adolescents receive annual preventive health visits, which include a comprehensive risk assessment.4,5 However, many adolescents do not comply with these recommendations and may be more likely to present to primary care sites for acute or episodic care.6 Thus, addressing risk for pregnancy and other reproductive health needs at every adolescent health encounter are encouraged.7
Missed opportunities is a term used frequently to describe visits to a child’s medical home where vaccines that are due or overdue are not administered.8 For pregnancy prevention, a missed opportunity would be a primary care visit where reproductive health needs were not addressed. In this report, among insured teenagers experiencing a first pregnancy, we reviewed outpatient health care visits in the 12 months prior to pregnancy to evaluate potential missed opportunities for pregnancy prevention.
HealthPartners (HP) is a consumer-governed family of nonprofit Minnesota health care organizations, serving 1.4 million medical and dental health plan members, primarily in Minnesota. Female adolescents with HP insurance are 73% white, 16% African American, 8% Asian, and 3% Hispanic, and 37% have at least 1 period of enrollment in public insurance. HealthPartners Medical Group (HPMG) includes 21 primary care clinics located primarily within the Twin Cities metropolitan region and surrounding suburbs. The HPMG primary care clinics are staffed by more than 200 physicians and advanced practitioners within pediatrics, family medicine, and obstetrics and gynecology. The HPMG primary care clinics have used the EpicCare electronic health record for all medical records and orders (including prescriptions) since 2004. This study was approved by the HP institutional review board; patient consent was waived.
To identify teenaged pregnancies for each calendar year from 2007 through 2010, we first selected adolescents aged 15.0 to 19.9 years with continuous HP insurance coverage, defined as coverage spanning at least 350 days of a given year. Continuous insurance coverage was required to ensure complete capture of data. Pregnancies were then identified using a validated algorithm based on claims, administrative, and birth data.9
To assess potential missed opportunities for pregnancy prevention, among teenagers with continuous insurance in the year when pregnancy occurred and in the 12 months prior to estimated pregnancy start, primary care visits were first identified from automated claims data. To be eligible for medical record review, adolescents with first pregnancies with end dates between January 1, 2007, and December 31, 2010, were required to have continuous insurance and at least 1 outpatient visit in the 12 months prior to pregnancy. From this cohort, we selected a random sample of 203 adolescents experiencing pregnancy for medical record review. The goals of the medical record review were to validate whether visits identified through automated data could be classified as potential missed opportunities and to describe the content of these visits. Abstracted data were entered directly into a REDCap data entry form.10 Two trained nurses used standardized tools for medical record review. Ten percent of patients with a total of 44 visits were reviewed by both abstractors.
Preventive, acute, or follow-up visits with a physician, nurse practitioner, or physician’s assistant in pediatrics, family practice, or obstetrics and gynecology were counted as potential missed opportunities. Nurse-only visits and urgent care visits were excluded. Documentation of sexual activity was determined through text review of clinical notes. Reproductive health counseling was determined from clinical notes and included use of terms such as abstinence, delay of sexual activity, safe sex, birth control, or condoms. Contraception prescribed included new prescriptions for or documentation of ongoing use of hormonal contraception, an intrauterine device, or the etonogesterel implant, with the latter 2 classified as long acting. A specific recommendation to use male or female condoms was also classified as contraception prescribed. Documentation that reproductive health care was received with another health care professional or at another facility was also recorded.
Agreement between medical record abstractors was measured using the AC1 statistic.11 Final assessment of the number of potential missed opportunities was based on the number of primary care visits determined for the full cohort of adolescents experiencing pregnancy, with an adjustment factor applied based on findings from medical record review. Data analysis was generated using SAS software.
Of 31 210 adolescent females aged 15.0 to 19.9 years with at least 1 year of continuous insurance enrollment from January 1, 2007, through December 31, 2010, we identified 829 pregnancies including 648 (78%) first pregnancies. Of these, 203 (25% of all pregnancies and 31% of first pregnancies) were randomly selected for medical record review.
Using automated data, adolescents had a mean of 4.1 primary care visits in the 12 months prior to becoming pregnant. In medical record review, of 559 total visits among 203 patients identified from automated data, 159 visits (28%), or an average of 2.75 visits per patient, were determined to be nurse visits for vaccines or urgent care visits misclassified as occurring in primary care. These visits were excluded, resulting in the exclusion of 18 patients as they then had no eligible primary care visits for medical record review. For the remaining 185 patients, 400 visits identified from automated data sources were confirmed to be outpatient primary care visits with a medical doctor, nurse practitioner, or physician assistant. Using a conservative correction factor (0.67) applied to the full cohort, the adjusted estimated number of potential missed opportunities was 2.7 (σ = 2.2) per pregnant teenager. Characteristics of all pregnancies identified and the final subset of 185 pregnancies included in the medical record review are in Table 1.
Agreement between the 2 medical record abstractors for all variables was exceptional (AC1s >0.80). Medical record review revealed that across 400 primary care visits in the year prior to pregnancy, 57% did not have documentation of sexual activity and 47% did not have documentation of any form of reproductive health counseling. These rates varied by health care professional type and visit type. In only 35% of visits within 12 months of becoming pregnant was contraception prescribed. Only 1 patient was prescribed long-acting contraception. Table 2 further describes potential missed opportunities. Receipt of reproductive health care with a different health care professional within the medical group or outside of the medical group was documented for 6% and 3% of patients, respectively.
While broad economic and social factors play an important role in teenaged pregnancy, the availability and correct use of contraception are key proximal factors. One strength of this study was the ability to link adolescents who became pregnant with their health care use, including manual review of primary care visits, in the 12 months prior to becoming pregnant. With this linkage, we were able to estimate that teenagers experiencing pregnancy had, on average, 2.7 outpatient primary care visits in the 12 months prior to pregnancy and that about half of these visits were true missed opportunities. We are only aware of 1 prior study that examined missed opportunities for pregnancy prevention. Using data from the 1999 Youth Risk Behavior Surveillance survey, Burstein et al12 found that only 43% of high school female teenagers reported sexual health counseling at their last preventive health visit; we observed substantially higher rates of sexual health counseling at preventive visits. However, in the year prior to pregnancy, adolescents were most likely to present for acute or follow-up care where reproductive health counseling and provision of contraception were less common. Furthermore, prior work from our group demonstrated that up to one-third of insured adolescents have no preventive health visits between the ages of 13 and 17 years6; thus, we chose to define all primary care visits as potential opportunities for reproductive health counseling and provision of contraception.
Limitations of the current study included our assumption that teenaged pregnancies were unintentional and thus pregnancy-prevention efforts were needed. In addition, we were not able to identify and review medical records of reproductive health visits occurring at Title X family planning or school-based clinics. Like many other states, in Minnesota, minors may independently consent to receive contraceptive services in any setting; insured adolescents may prefer publicly funded family planning sites over primary care to ensure confidentiality. Thus, our medical record review may have underestimated contraceptive use in the year prior to pregnancy. On the other hand, few primary care professionals documented that patients were receiving reproductive health services at an outside site. In addition, the study population was insured and from a single region and thus may not be generalizable to adolescents receiving care in other settings. For example, in another large health delivery system, with support from clinical leaders and practice redesign, increased chlamydia screening in adolescents has been achieved.13 Finally, we were only able to capture counseling and other services if documented.
By linking adolescents who became pregnant with their health care use prior to pregnancy, we demonstrated that reproductive health counseling and provision of effective contraception were suboptimal, especially at acute or follow-up visits. Our data highlight the need for primary care professionals to review health behaviors and pregnancy risk at all adolescent encounters.
Corresponding Author: Elyse O. Kharbanda, MD, MPH, HealthPartners Institute for Education and Research, 3311 E Old Shakopee Rd, Bloomington, MN 55425 (firstname.lastname@example.org).
Accepted for Publication: October 9, 2014.
Published Online: December 1, 2014. doi:10.1001/jamapediatrics.2014.2809.
Author Contributions: Dr Kharbanda had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kharbanda.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Kharbanda, Stuck.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Stuck, Molitor.
Obtained funding: Kharbanda.
Administrative, technical, or material support: Molitor, Nordin.
Study supervision: Kharbanda.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by a Discovery Grant from HealthPartners Institute for Education and Research.
Role of the Funder/Sponsor: HealthPartners Institute for Education and Research had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We acknowledge Laurie VanArman, LPN, and Dianne Eggen, BS (nursing), MPH, from the HealthPartners Institute for Education and Research for their work conducting medical record reviews. They were funded to do medical record reviews via the HealthPartners Institute for Education and Research Discovery Grant.