OBJECTIVES:

Hospitalization provides an opportunity to address sexual health needs of adolescents who may not otherwise receive regular medical care. We investigated documentation of a sexual health discussion with adolescents hospitalized at our medical center to determine if previous primary care physician (PCP) visits in the same health system were associated with sexual health documentation during the hospital admission.

METHODS:

We retrospectively identified adolescents aged 13 to 17 years discharged from the pediatric general ward. Documented discussion of sexual health was reviewed in the electronic medical record. Previous PCP visits were identified from the affiliated primary care clinics within 12 months before hospitalization. We also queried follow-up PCP visits within 90 days of discharge to determine if a sexual health discussion during hospitalization was followed-up in the outpatient setting.

RESULTS:

We analyzed 394 patients (49% girls; median age 15 years), of whom 122 (31%) had documentation of a sexual health discussion while hospitalized and 75 (19%) had previous PCP visits in our health system. On multivariable analysis, older age (P < .001), female sex (P = .016), admission from the emergency department (P < .001), and a genitourinary primary problem at admission (P = .007), but not previous PCP visits, were associated with increased likelihood of sexual health documentation.

CONCLUSIONS:

Although discussion of sexual health was uncommon overall for hospitalized adolescents, we noted that nearly 4 in 5 adolescents for whom this was documented had not recently visited a PCP in our health system. These findings highlight hospitalization as a unique opportunity for sexual health intervention among adolescents who may not regularly see a PCP.

Sexual health is a critical component of adolescent health in the United States. Adolescents are at increased risk for adverse health outcomes, including sexually transmitted infections (STIs),1  unintended pregnancy,2  higher-risk pregnancies, and birth complications.3  Primary care physicians (PCPs) play a pivotal role in sexual health education for adolescents, and the outpatient setting has been the main target of efforts to improve adolescent sexual health care.4  Multiple national organizations recommend adolescents attend annual PCP visits, during which sexual health care should be discussed.58  However, many adolescents lack access to preventive care or do not regularly attend PCP visits.912  Even when adolescents attend PCP visits, they may not receive sexual health care.13  Therefore, authors of recent studies have explored the role of pediatric hospitalists in providing sexual health services within the hospital setting.1419  Adolescents who are hospitalized desire counseling from hospitalists on sexual health and contraception,19,20  yet only approximately half of hospitalized adolescents have documentation of sexual history or sexual activity status.1618  Pediatric hospitalists report numerous barriers to addressing sexual health concerns with adolescent patients, including time constraints, lack of knowledge regarding contraception methods and confidentiality laws, and concern about follow-up after emergency contraception.1418 

Discussion of sexual health during a hospitalization provides an opportunity to reach adolescents who may not otherwise be regularly seen by health care providers or who have unmet sexual health needs.15  Yet it is unclear whether discussions of sexual health in the hospital setting indeed reach patients not established with a PCP in the same medical system. For patients previously seen in the same health system, hospitalists may have more pertinent history on the patient and may be more confident that the patient would be able to follow-up with a PCP regarding their sexual health care. In a survey of >200 pediatric physicians, >80% agreed that initiating a new contraceptive in the hospital setting was appropriate, but only 42% asked hospitalized adolescents about sexual health.14  Several hospital-specific barriers to initiating contraception were identified by participants, including concern about follow-up after discharge, belief that the PCP should initiate contraception, and feeling more comfortable if another physician would initiate contraception.14  In this retrospective study, we reviewed charts of hospitalized adolescents at an academic medical center to determine if previous visits with a PCP in the same health system were associated with sexual health documentation (SHD) during the hospital admission.

The primary study outcome was SHD, defined as any documentation of sexual activity status or sexual health history during the hospital admission. Secondary outcomes included follow-up interventions at subsequent PCP visits, including SHD, pregnancy testing, STI testing, and human papillomavirus (HPV) vaccine administration. We retrospectively reviewed charts of hospitalized adolescents aged 13 to 17 years who were discharged from the pediatric general ward at a large academic tertiary care center in the southeastern United States between 2016 and 2018. This age range was determined on the basis of likelihood of sexual activity and age-specific unit admission criteria. Less than 10% of American youth report sexual debut before age 13, and likelihood of sexual activity increases with age.21  At our hospital, 18-year-old patients are occasionally admitted to a separate adult medicine unit, and therefore the upper age limit was set at 17. This study was certified exempt by the university’s institutional review board.

Clinics affiliated with the hospital system that provide primary care to pediatric patients include family medicine, pediatrics, adolescent medicine, and internal medicine and pediatrics clinics. Other clinics in the area are unaffiliated with the hospital system and include private practices and local health departments. Affiliated clinics use the same electronic medical record (EMR) as the hospital, and therefore these clinic records are readily available to hospitalists. However, unaffiliated clinics use separate charting systems, and their records may not be readily available to hospitalists. Patients whose home address was outside the primary care clinics’ catchment area (same county or contiguous counties) were excluded from the study because these patients are not typically seen by our PCPs for preventive care. We also excluded patients with developmental delay, patients who were transferred to another health care facility at discharge, and patients who died during the hospital stay. The earliest eligible hospital admission for each patient was included in our analysis.

Following a previous study,18  we first examined each chart to ensure that the patient met inclusion criteria. Among eligible charts, the hospital admission history and physical examination notes (H&P) were examined for SHD, the primary outcome. In addition to reading the full H&P, a keyword search for “sex” was conducted in the EMR. If SHD was present, we recorded in which section it was present (eg, history of present illness, social history, or assessment and plan). For patients with SHD, the chart was further reviewed for the role of the documenting provider, parents’ presence in the room at the time of this discussion, partner gender, number of partners, use of contraception, history of pregnancy, history of STIs, and HPV vaccination status (series not initiated, series initiated but incomplete, series complete). We also recorded the gender identity and sexual orientation of the patient as documented in the chart.

The primary independent variable was having ≥1 PCP visit in the same hospital system within the 12 months preceding hospital admission. We also queried the number of patients with any visits to an obstetrics and gynecology clinic in the same hospital system. Additional data extracted from the EMR included patient age, sex, race and/or ethnicity, hospital length of stay, presence of psychological comorbidities in the problem list at admission, primary insurance coverage, and admission from the emergency department (ED). Patients admitted from the ED may be more likely to have sexual health included on the H&P or may be less likely to regularly see a PCP who would address sexual health needs in an outpatient setting. Within 90 days after hospital discharge, we queried information for any visits with one of the affiliated PCPs mentioned above. Secondary outcomes included SHD, HPV vaccination, STI testing, and pregnancy testing at subsequent PCP visits.

Data were summarized as counts with percentages or medians with interquartile ranges (IQRs). We compared study variables according to whether patients had visited a PCP in the same health system in the past 12 months using χ2 tests or Fisher’s exact tests for categorical data, and Wilcoxon rank tests for continuous data. For the multivariable analysis, we used logistic regression with a forward stepwise selection of covariates. To avoid excluding potential confounding variables whose association with the outcome approached but did not reach the conventional threshold for statistical significance, P < .2 was considered as the threshold for covariate inclusion in the model. Outpatient visits were included in the model regardless of statistical significance to evaluate the predetermined hypothesis about this variable. Stata/SE 15.1 (Stata Corp, College Station, TX) was used for data analysis, and P < .05 was considered statistically significant.

We identified 455 potentially eligible patients, of whom 33 were excluded because of developmental delay, 27 were excluded because they were not discharged from the hospital, and 1 was excluded because of PICU admission. Among the remaining 394 patients (194 girls and 200 boys), the median age was 15 years (IQR: 14–16), and SHD was documented for 122 patients (31%). Gender identity was documented for 2 transgender patients (female to male), neither of whom had SHD during hospitalization. Sexual orientation was documented for 5 patients, 3 of whom had SHD (identifying as bisexual, lesbian, and heterosexual, respectively). The remaining 2 patients with documentation of sexual orientation did not have any documentation of sexual activity status or sexual health history. Because so few patients had documented gender identity or sexual orientation in the chart, these factors were not examined further.

Among patients included in the study, 75 of 394 (19%) had a PCP visit in our health system in the 12 months before hospital admission. This included 61 of 394 (15%) patients seen in the pediatric clinic, 8 of 394 (2%) patients seen in the internal medicine and pediatrics clinic, and 12 of 394 (3%) patients seen in the family medicine clinics (some patients were seen at multiple locations). A total of 4 patients had obstetrics and gynecology visits in the 12 months before hospital admission, although 3 of these patients had also been seen by a PCP during this period. Outpatient clinic use and patient characteristics are summarized in Table 1 according to whether patients had SHD during the hospital stay. Patients with SHD were more likely to be female (62% vs 43%; P = .001), older (median age of 16 vs 15 years; P < .001), and admitted from the ED (64% vs 48%; P = .003). Among the primary reasons for admission, genitourinary and psychiatric problems were more common among the patients who had SHD; however, presence of a psychological comorbidity on the problem list did not differ between the 2 groups (P = .670). Comparing an overall measure of PCP use in the 12 months before admission, 28 of 122 patients (23%) with SHD had recently visited a PCP in the same health system, as opposed to 47 of 272 patients (17%) without SHD, but this difference was not statistically significant (P = .185).

TABLE 1

Patient Characteristics According to SHD During Inpatient Admission (N = 394)

VariableSHD Absent (n = 272)SHD Present (n = 122)P
Age, median (IQR), y 15 (13–16) 16 (14–17) <.001 
Sex, n (%)   .001 
 Male 154 (57) 46 (38) — 
 Female 118 (43) 76 (62) — 
Race and/or ethnicity, n (%)   .428 
 Non-Hispanic Black 128 (47) 60 (50) — 
 Non-Hispanic white 115 (42) 43 (36) — 
 Other 28 (10) 16 (13) — 
Medicaid coverage, n (%) 156 (61) 78 (64) .545 
Primary reason for admission, n (%)   .005 
 Gastrointestinal 49 (18) 18 (15) — 
 Hematologic and oncologic 35 (13) 11 (9) — 
 Infectious disease 28 (10) 14 (11) — 
 Trauma 27 (10) 4 (3) — 
 Genitourinary 18 (7) 22 (18) — 
 Psychiatric 13 (5) 11 (9) — 
 Neurologic 10 (4) 6 (5) — 
 Other 92 (34) 36 (30) — 
Psychological comorbidity at admission, n (%) 27 (8) 14 (11) .670 
Admission from the ED, n (%) 130 (48) 78 (64) .003 
Year of hospitalization, n (%)   .785 
 2016 104 (38) 43 (35) — 
 2017 96 (35) 43 (35) — 
 2018 72 (26) 36 (30) — 
Hospital length of stay, median (IQR), d 2 (1–3) 2 (1–3) .301 
Primary care visit in last 12 mo, n (%) 47 (17) 28 (23) .185 
VariableSHD Absent (n = 272)SHD Present (n = 122)P
Age, median (IQR), y 15 (13–16) 16 (14–17) <.001 
Sex, n (%)   .001 
 Male 154 (57) 46 (38) — 
 Female 118 (43) 76 (62) — 
Race and/or ethnicity, n (%)   .428 
 Non-Hispanic Black 128 (47) 60 (50) — 
 Non-Hispanic white 115 (42) 43 (36) — 
 Other 28 (10) 16 (13) — 
Medicaid coverage, n (%) 156 (61) 78 (64) .545 
Primary reason for admission, n (%)   .005 
 Gastrointestinal 49 (18) 18 (15) — 
 Hematologic and oncologic 35 (13) 11 (9) — 
 Infectious disease 28 (10) 14 (11) — 
 Trauma 27 (10) 4 (3) — 
 Genitourinary 18 (7) 22 (18) — 
 Psychiatric 13 (5) 11 (9) — 
 Neurologic 10 (4) 6 (5) — 
 Other 92 (34) 36 (30) — 
Psychological comorbidity at admission, n (%) 27 (8) 14 (11) .670 
Admission from the ED, n (%) 130 (48) 78 (64) .003 
Year of hospitalization, n (%)   .785 
 2016 104 (38) 43 (35) — 
 2017 96 (35) 43 (35) — 
 2018 72 (26) 36 (30) — 
Hospital length of stay, median (IQR), d 2 (1–3) 2 (1–3) .301 
Primary care visit in last 12 mo, n (%) 47 (17) 28 (23) .185 

—, not applicable.

For the 122 patients with SHD, the majority (95 of 122 patients; 78%) had this first documented by a resident, whereas 13 of 122 patients (11%) had this documented by an attending physician and 13 of 122 patients (11%) had this documented by providers in other roles. SHD was most commonly documented in the social history section of the note (61%), as compared with the history of present illness (38%) or the assessment and plan (2%). Of the 122 patients with SHD, 28 of 122 patients (23%) endorsed sexual activity, including 10 patients aged 14 to 15 years and 18 patients aged 16 to 17 years. Parents were present during discussion of sexual health for 18 of 122 patients (15%) and were not present for 7 of 122 patients (6%); for the other 97 patients, parental presence during this discussion was unknown. Among 67 patients with documented HPV vaccination status, 37 of 67 (55%) had not started the vaccine series, 19 of 67 (28%) had started but had not completed the series, and 11 of 67 (16%) had completed the series. Contraception use was documented for 21 of 122 patients (17%), with 15 currently using contraception; STI history was documented for 6 patients (2 positive); and pregnancy history was documented for 3 patients (1 patient reporting previous pregnancy). Among the 28 sexually active patients, partner gender was documented for 18 of 28 patients (64%), and the number of partners was documented for 9 of 28 patients (32%). Documentation of specific aspects of sexual health is summarized by sexual activity status in Table 2.

TABLE 2

SHD During Inpatient Admission According to Sexual Activity Status (N = 122)

Documentation ElementNot Sexually Active (n = 94), n (%)Sexually Active (n = 28), n (%)P
Section of note   .121 
 History of present illness 32 (34) 14 (50) — 
 Social history 61 (65) 13 (46) — 
 Assessment and plan 1 (1) 1 (4) — 
Role of documenting provider   .073 
 Resident 70 (74) 25 (89) — 
 Attending physician 14 (15) — 
 Other 10 (11) 3 (11) — 
Parental presence documented 20 (21) 5 (18) .694 
Contraception use documented 3 (3) 18 (64) <.001 
HPV vaccination status documented 52 (55) 15 (54) .870 
STI history documented 2 (2) 4 (14) .025 
Pregnancy history documenteda 2 (4) 1 (5) >.999 
Partner gender documentedb — 18 (64) — 
No. partners documentedb — 9 (32) — 
Documentation ElementNot Sexually Active (n = 94), n (%)Sexually Active (n = 28), n (%)P
Section of note   .121 
 History of present illness 32 (34) 14 (50) — 
 Social history 61 (65) 13 (46) — 
 Assessment and plan 1 (1) 1 (4) — 
Role of documenting provider   .073 
 Resident 70 (74) 25 (89) — 
 Attending physician 14 (15) — 
 Other 10 (11) 3 (11) — 
Parental presence documented 20 (21) 5 (18) .694 
Contraception use documented 3 (3) 18 (64) <.001 
HPV vaccination status documented 52 (55) 15 (54) .870 
STI history documented 2 (2) 4 (14) .025 
Pregnancy history documenteda 2 (4) 1 (5) >.999 
Partner gender documentedb — 18 (64) — 
No. partners documentedb — 9 (32) — 

—, not applicable.

a

Percentages refer to a total of 57 and 19 female patients documented as not sexually active and sexually active, respectively.

b

Not assessed for patients who were documented as not sexually active.

The multivariable model predicting SHD is shown in Table 3. This analysis excluded 4 cases missing race and/or ethnicity data and 25 additional cases with perfect prediction of the outcome (ie, on the basis of a particular combination of independent variables, there was no variation in the outcome). After multivariable adjustment, having recently seen a PCP in the same health system was not associated with the odds of sexual health being documented during a hospital stay (odds ratio = 1.07; 95% confidence interval: 0.60–1.91; P = .823). Older age (P < .001), female sex (P = .016), admission from the ED (P < .001), and a genitourinary primary problem at admission (P = .007) were all associated with increased likelihood of SHD.

TABLE 3

Multivariable Logistic Regression of SHD During Inpatient Admission (N = 375)

VariableaOR95% CIP
Primary care visit in last 12 mo 1.07 0.60–1.91 .823 
Age (y) 1.36b 1.15–1.61b <.001b 
Sex    
 Male Reference — — 
 Female 1.81b 1.12–2.95b .016b 
Medicaid coverage 1.45 0.88–2.38 .141 
Primary reason for admission    
 Gastrointestinal Reference — — 
 Infectious disease 1.22 0.49–3.09 .660 
 Hematologic and oncologic 0.95 0.38–2.37 .910 
 Genitourinary 3.42b 1.41–8.28b .007b 
 Trauma 0.36 0.10–1.23 .102 
 Psychiatric 1.63 0.55–4.81 .377 
 Neurologic 1.62 0.48–5.47 .439 
 Other 1.03 0.51–2.10 .927 
Admission from the ED 2.64b 1.59–4.37b <.001b 
VariableaOR95% CIP
Primary care visit in last 12 mo 1.07 0.60–1.91 .823 
Age (y) 1.36b 1.15–1.61b <.001b 
Sex    
 Male Reference — — 
 Female 1.81b 1.12–2.95b .016b 
Medicaid coverage 1.45 0.88–2.38 .141 
Primary reason for admission    
 Gastrointestinal Reference — — 
 Infectious disease 1.22 0.49–3.09 .660 
 Hematologic and oncologic 0.95 0.38–2.37 .910 
 Genitourinary 3.42b 1.41–8.28b .007b 
 Trauma 0.36 0.10–1.23 .102 
 Psychiatric 1.63 0.55–4.81 .377 
 Neurologic 1.62 0.48–5.47 .439 
 Other 1.03 0.51–2.10 .927 
Admission from the ED 2.64b 1.59–4.37b <.001b 

CI, confidence interval; OR, odds ratio; —, not applicable.

a

Independent variables, apart from outpatient visits before admission, were identified for model inclusion by using forward stepwise selection with a P < .2 inclusion criterion.

b

Statistically significant results.

Among patients with SHD during hospitalization, 33 of 122 (27%) had a PCP visit within 90 days of hospital discharge. Sexual health was documented for 15 of 33 patients (48%) at ≥1 PCP visit, including 10 patients for whom this was documented at a hospital follow-up visit. Among the 15 patients with SHD at a PCP follow-up visit, 8 had endorsed sexual activity while hospitalized; 6 of 8 patients (75%) had SHD at the following PCP visit, and 5 of 8 (62.5%) had ≥1 sexual health screening test or intervention performed or offered at follow-up (HPV vaccination, pregnancy test, STI test). Six of the 15 hospitalized patients endorsing sexual activity received sexual health counseling on ≥1 aspect of sexual health (eg, safe sexual practices, contraception options, sequalae of STIs), and this was again addressed at the subsequent PCP visit for all 6 patients. Eight of the 33 patients (24%) with PCP follow-up initiated contraception at the subsequent PCP visit.

Two female patients were admitted for symptomatic anemia secondary to heavy menstrual bleeding and received counseling on contraception options during hospitalization. Both patients were started on birth control at the PCP follow-up visit. For 1 patient admitted for seizure-like activity, SHD revealed high-risk sexual behavior, a previous sexual assault, and mood disorder symptoms. The patient received counseling, antidepressant pharmacotherapy, and a psychiatry referral at PCP follow-up. Finally, a patient disclosed a previous unplanned pregnancy and received contraceptive counseling during hospitalization; she began birth control at PCP follow-up.

As in previous studies, we found inconsistent SHD among providers, highlighting the need for a standardized sexual health assessment for hospitalized adolescents. The overall rate of SHD in this study was 31%, lower than the rates previously described (55%–62%).15,18  Despite the low rate of SHD, we noted that nearly 4 in 5 adolescents for whom this was documented were not established with a PCP in our health system, meaning these discussions were truly a unique chance for physicians at our center to address sexual health needs. Therefore, increasing SHD during hospitalization stands to fulfill the promise, suggested in previous studies,15  of reaching adolescents who may not otherwise have this discussion with their PCP.

Reaching this goal requires overcoming challenges to discussing sexual health in the hospital setting. Adolescents are interested in receiving sexual health counseling while hospitalized, but changes in the practices of children’s hospitals to respond to this interest have been slow,19,20,22,23  and the low rate of SHD in this study may be a reflection of this latency. Provider surveys indicate that hospitalists feel uncertain about patient access to outpatient follow-up, and this uncertainty serves as a barrier to sexual health intervention during adolescent hospitalization. However, in our study, we found high rates of receipt of sexual health care among the subgroup with PCP follow-up, including vaccination, STI testing, and contraception initiation, highlighting sexual health discussion in the hospital as an opportunity to prompt sexual health care at follow-up.

In this study, having recently seen a PCP in the same health system was not associated with the odds of SHD during hospitalization. Whereas follow-up with PCPs was far from universal in our sample, these results provide an example of how SHD for hospitalized adolescents may enhance provision of sexual health counseling and services and reach adolescents who do not see a PCP regularly. Additionally, it was encouraging to find that all patients with hospital documentation of sexual activity who followed-up with a PCP after discharge were counseled on sexual health at the hospital follow-up visit.

With our hospital system serving a rural area in the southeastern United States, the results of our study offer a contrast to previous studies in which SHD during hospitalization was evaluated in urban centers.1719  Patients’ and parents’ views on sexual health may be different in our region than in urban centers, potentially contributing to provider hesitancy to discuss this topic. Two patients in this study identified as transgender, but neither patient had SHD. For youth identifying as a sexual minority, social stigma about sexuality and sexual identity can pose significant difficulties, including discrimination, social disapproval, and rejection, placing these patients at increased risk for negative health outcomes. Providers should capitalize on opportunities to discuss sexual health with this population given the increased risk of negative outcomes.2427 

Our conclusions were limited in several ways. Because of the retrospective methodology, we were limited by the assumption that lack of documentation implied lack of discussion about sexual health. Providers may not have documented this discussion if the patient denied sexual activity, if it was deemed irrelevant to the primary diagnosis, or if they felt that omitting sensitive sexual health information from documentation would help maintain patient confidentiality should the parents request their medical records in the future. Furthermore, it was not possible in most cases to confirm whether a parent was present in the room at the time of the admission H&P or to quantify the impact of this on discussion of sexual health. Our results may also not be generalizable to patients in the PICU, who were excluded from our study but are less likely to have sexual history discussed or documented than patients admitted to the general ward.28 

Our EMR provides documentation template options, some of which autopopulate sections, such as social history, in the current note with information obtained during previous encounters. This could have resulted in a slight overestimation of the rate of SHD. Although we collected data on current contraception use when available in the hospital documentation, and contraception started at PCP follow-up, we did not specifically collect data on how many patients initiated contraception during hospitalization. Because of limitations in the EMR, we were unable to identify any adolescents who had a PCP outside of this hospital system. Lastly, we did not have access to records from local health departments, which are also equipped to provide primary care and sexual health counseling services for adolescent patients in our health system. Lack of access to local health department or private practice records precluded identification of patients who followed-up with a PCP at these locations after discharge.

Our study reveals both strengths and weaknesses in the current practice of discussing sexual health with hospitalized adolescents. Encouragingly, these discussions were happening regardless of patients’ previous visits with a PCP in the same health system, and in several cases, discussion of sexual health during a hospital admission was effectively followed-up in the outpatient setting. Yet the overall rate of SHD was low, emphasizing the need to further educate providers on the importance of discussing and documenting sexual health in the hospitalized adolescent patient population. EMR modifications to support this (prompts, flags, intake assessments) would help ensure consistency of documentation. Additionally, patient education, such as a brochure or electronic module, should be made available to all hospitalized adolescents, with an opportunity to discuss questions, concerns, current practices, and future plans with their hospitalist. In future efforts, researchers should explore whether these interventions reduce sexual health risk among hospitalized adolescents, especially adolescents who lack primary care access.

Ms Clary conceptualized and designed the study, collected data, interpreted analysis results, and drafted the manuscript; Dr Tumin conceptualized and designed the study, collected data, performed the data analysis, and drafted the manuscript; Ms Cortright, Ms Buckman, and Dr Eldridge conceptualized and designed the study, interpreted analysis results, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.