Not All Washington-Area Primary Care Practices Offer All Needed Adolescent Reproductive Health Services
Adolescent sexual and reproductive health services--especially confidential services--are not universally available from primary care practices in the Washington, DC, area, according to a 1998-1999 survey of physicians and office staff.1 Pediatric and family medicine practices are significantly more likely than internal medicine practices to see adolescent patients. However, family medicine practices are significantly more likely than pediatric practices to offer pelvic examinations, contraceptive services and sexually transmitted disease (STD) testing, and to do so without notifying adolescents' parents; internal medicine practices are more likely than pediatric practices to provide pelvic examinations, STD testing and confidential STD testing. Adolescents may be misinformed about confidential services, as office staff are often not aware of physician confidentiality policies.
To assess the availability and confidentiality of adolescent health services, researchers surveyed physicians and office staff of private primary care practices in the Washington, DC, metropolitan area. Using a local directory of physicians, the researchers selected all medical practices specializing in one of three primary care areas: pediatric and adolescent medicine, family medicine and internal medicine. Between February and July 1998, interviewers called 481 practices, and conducted telephone surveys with the office staff who answered. Between November 1998 and February 1999, the researchers conducted a mail survey of all physicians from practices whose office staff completed the telephone survey. In all, 170 practices were represented in both surveys.
The mail and telephone surveys asked about services offered (pelvic examinations, contraceptive services, STD testing), whether the practice saw adolescent (18-year-old or younger) patients and how many it saw per week, and whether confidential services were available for adolescents. Characteristics of the physicians were determined from survey questions and information from the local directory. The researchers matched the data from the practices that completed both surveys, and measured the agreement between office staff and physicians. To measure the association between practice characteristics and the availability of services or agreement between office staff and physicians, the researchers used logistic regression analysis, controlling for variables found to be significant in previous research.
According to the telephone interviews, significantly higher proportions of pediatric (100%) and family medicine (93%) practices than of internal medicine practices (57%) saw adolescent patients. At almost all pediatric and internal medicine practices (93-96%), a receptionist, office manager or registered nurse answered the phone; in contrast, 25% of family medicine practices had medical assistants or doctors answering the phone. Fifty-two percent of internal medicine practices had physicians who, on average, had graduated from medical school within the past 20 years, compared with 38% of pediatric and 28% of family medicine practices. According to the mail survey, a significantly higher proportion of pediatric and family medicine practices than of internal medicine practices saw adolescent patients (98-99% vs. 86%) and saw more than five adolescents per week (82-83% vs. 9%).
Among the 137 practices that had at least one physician who reported seeing adolescents and were not missing office staff or physician responses to service provision questions in either the mail or the telephone survey, significantly greater proportions of family medicine and internal medicine practices (71-97%) than of pediatric practices (43-80%) reported that pelvic examinations, contraceptive services and STD testing were available to adolescents. (Among pediatricians, the most common reasons for not offering pelvic examinations were lack of equipment and expertise, and the most common reasons for not offering contraceptive services were that they do not offer pelvic examinations and lack of expertise.) Physicians and office staff from the same practices gave discordant answers to 16-39% of the questions; the highest level of disagreement was between physicians and office staff of pediatric practices about whether they provided STD testing to adolescents.
Among the 92 practices that offered services for medically emancipated adolescents, 32- 49% of the office staff and 63-91% of the physicians reported that contraceptive services and STD testing were available to adolescents without parental knowledge; there were no significant differences in these proportions by practice type. Physicians and office staff of all three types of practices gave discordant answers to 45-63% of questions; the highest level of disagreement was between physicians and office staff of internal medicine practices about whether contraceptive services were available without parental knowledge.
In logistic regression analysis, family medicine practices were significantly more likely than pediatric practices to offer pelvic examinations (odds ratio, 77.6), contraceptive services (42.1), STD testing (6.9) and confidential services (4.1-8.2); internal medicine practices were more likely than pediatric practices to provide pelvic examinations (13.6), STD testing (21.6) and confidential STD testing (6.9). Having more than 50% board-certified physicians in a practice was significantly associated with increased odds of offering confidential contraceptive services (3.2), whereas having a practice that sees more than five adolescents per week was associated with increased odds of offering STD testing and confidential STD testing (4.2-4.7). Furthermore, solo male practitioners, solo female practitioners and all-male group practices were significantly less likely than group practices with at least one female physician to offer confidential services (0.1-0.2). Solo female practitioners and all-male group practices had reduced odds of offering contraceptive services (0.1-0.2), and all-male group practices had reduced odds of offering pelvic examinations (0.1).
Finally, a greater proportion of office staff and physicians of pediatric practices (77% and 70%, respectively) than of internal medicine (42% and 12%) or family medicine practices (69% and 50%) reported having a specific office policy on adolescent confidentiality. The level of disagreement between physicians and office staff ranged from 38% to 50%. In regard to other "adolescent-friendly" policies, most practices (70-97%) reported offering same-day urgent appointments, whereas greater proportions of family medicine practices than of the other two types required less than a $50 up-front fee from patients without insurance (25-53% vs. 9-52%) or offered a sliding-scale fee based on ability to pay (50-61% vs. 27-50%).
The researchers acknowledge that "there may be large regional variation in availability of confidential services based on state law, the supply of primary care providers, availability of alternative sites for health care, and local attitudes toward providing confidential services to adolescents." Even so, they comment that their results "show that care for medically emancipated conditions for adolescents is not universally available in primary care practices," and that "confidential care is even less accessible to adolescents." These findings suggest that many teenagers may decide not to seek sexual and reproductive health services because such services are not offered by their regular doctors or because they are worried that their parents will find out.--J. Rosenberg
1. Akinbami LJ, Gandhi H and Cheng TL, Availability of adolescent health services and confidentiality in primary care practices, Pediatrics, 2003, 111(2):394-401.