Improving Adolescent & Young Adult Clinical Practice: Reviewing Guidelines & Evidence Base Charles E. Irwin, Jr., MD Project Director, AYAH-NRC May 10, 2017

Adolescent Clinical Preventive Services: 20 years of consensus & growing evidence base Growing evidence for: Effectiveness of services in positive health outcomes Health system interventions to increase clinicians’ delivery of services Guidelines in Bright Futures endorsed by major health professional groups Comprehensive Guidelines, through age 21 years 4th edition released in February 2017! (more on that shortly…)

Preventive Services for Adolescents: Major Guidelines Bright Futures up to 21 years (more on this shortly!) US Preventive Services Task Force ≥ 18 years Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (“CDC-ACIP”)

US Preventive Services Task Force (USPSTF)* “Gold Standard” for evidence-based preventive service guidelines in US Recommendations - < 18 and ≥ 18 (adult) Rigorous review of existing evidence Rating: A or B – priority preventive services; C- lower priority; D discouraged I – insufficient evidence for recommendation *http://www.uspreventiveservicestaskforce.org

Preventive Service Guidelines for Young Adults

Preventive Guidelines for Young Adults No guidelines specifically for Young Adults: Bright Futures: 18-to 21 years USPSTF ≥ 18 years ACOG, AAFP, ACP – Adult guidelines that overlap with young adult age-group CDC-ACIP

Summary of Young Adult Guidelines Guidelines can be “carved out” : A 2012 review of existing preventive services guidelines identified recommendations that intersect with the young adult age group When ages 18 to 26 years are “carved out” of existing guidelines, several recommendations can inform young adult care Many of these recommendations are evidence- based, warranting a USPSTF grade of A or B Ozer et al. 2012

USPSTF Preventive Services Recommended for Adolescents & Young Adults (with A or B recommendations)

Five Key Guideline Areas for Screening Substance Use Reproductive Health Mental Health Nutrition and Exercise Safety and Violence I’m thinking the next step is to consolidate a little? It seems like this section has two sets of similar, but not totally overlapping slides: An overview slide followed by several pages of comparing what different guidelines say to do about different topics.

USPSTF: Substance Use Guidelines Adolescent Ages 11-18 Young Adult Ages 18-26 Alcohol No recommendation √ Tobacco (education and brief counseling) (screening & cessation help)

USPSTF: Reproductive Health Guidelines Age Groups Adolescent Ages 11-18 Young Adult Ages 18-26 STI screening counseling √ if risk factors Chlamydia (Female) Chlamydia (Male) No recommendation Gonorrhea/ Syphilis

USPSTF: Reproductive Health Guidelines Age Groups Adolescent Ages 11-18 Young Adult Ages 18-26 HIV screening √ <15: if risk factors 15-19: everyone √ (everyone) Cervical Cancer Screening No recommendation 18-21: No recommendation >21: everyone

Mental Health Guidelines Adolescent Ages 11-18 Young Adult Ages 18-26 Depression Screening √* Ages 12-18 *When there are adequate systems in place to ensure accurate diagnosis, effective treatment and follow-up

USPSTF: Nutrition and Exercise Guidelines Age Groups Adolescent Ages 11-18 Young Adult Ages 18-26 Obesity/BMI √* Lipid disorder I √ [≥20 with increased risk for coronary artery disease]* Cholesterol No recommendation √ if risk factors Healthy Diet Hypertension/ Blood Pressure * topic update in progress

USPSTF: Safety and Violence Guidelines Adolescent Ages 11-18 Young Adult Ages 18-26 Family/Partner Violence √* * topic update in progress

Preventive Services & the Affordable Care Act (our current legal framework) Access to Preventive Services Provided by plans without cost-sharing to members Requirements established by: US preventive Services Task Force “A” and “B” recommendations Bright Futures Guidelines for Children and Adolescents CDC-ACIP Immunization Recommendations HRSA-supported IOM recommendations for women’s health

Emerging evidence Promising research in several additional areas suggests that preventative screening may result in adolescent behavior change. helmet use, alcohol and illicit drug use, healthy diet, suicide risk, chlamydia in boys, and and physical activity New research also suggests that limiting prescriptions of narcotics reduces opioid addiction

Featured Resources: Clinician “Cheat SHEETS” for AYAs Summary of Recommended Guidelines for Clinical Preventive Services for Adolescents up to age 18, one-page clinical tool, with supplement http://nahic.ucsf.edu/adolescent-guidelines/ Summary of Recommended Guidelines for Clinical Preventive Services for Young Adults ages 18-26, one-page clinical tool, with supplement www.nahic.ucsf.edu/yaguidelines/

www.nahic.ucsf.edu/yaguidelines/

Featured Resources: Fact Sheet Evidence-based Clinical Preventive Services for Adolescents and Young Adults: A one-page fact sheet about the evidence base in clinical preventive services, with emphasis on USPSTF recommendations . http://nahic.ucsf.edu/cpsfactsheet/