Adolescent access to healthcare

Access to care has been an area of ongoing concern in the current debate over health care reform in Canada (1,2). In this issue of Paediatrics & Child Health, the Canadian Paediatric Society’s Adolescent Health Committee highlights an important access to care issue for adolescents, namely the arbitrary and variable upper age limits for admission to paediatric care facilities (page 577). The access problem for adolescents involves both ‘child’ and ‘adult’ facilities. In some situations an adolescent may be chronologically overage or underage for the local facility (child or adult) where the most appropriate care to meet his/her medical needs can be found. The arbitrarily set thresholds for admission to an institution for care vary from province to province, region-to-region, and even in some instances, within the same institution. For example, in one region, the local children’s hospital does not take major trauma patients over the age of 16 but handles patients with mental health problems up to age 19. Where should the patient over the age of 16 but under the age of 19 with major trauma and a serious mental health problem go? Given that injuries and suicide are the two most common causes of death in the adolescent age group (3), differential age-related access to these care programs does not seem to make sense.

The World Health Organization defines adolescence as the age period from 10 to 19 years (4). The age-restrictive access to care problems vary across this age group. Those in the 12 to 14 age group, even emancipated minors, may have difficulty receiving care in adult institutions for problems such as drug and alcohol addiction, even when these are the only treatment programs available in the region. In contrast, older adolescents (17 to 19 years of age) with developmental delay-related problems may be denied access to ongoing care at a children’s hospital because they are ‘over-age’, even if it is the only site in the region with a care program for this type of patient.

In many instances, the age limit restriction is more a reflection of the availability of resources than an evidence-based care decision. For example, the increasing pressure for beds in children’s hospitals due to cut backs have lead some institutions to tighten the cap on the upper age limit for admission of older adolescents, in order that younger children can still be accommodated in the facilities. Similarly, the nationally sparse resources to treat adults with drug and alcohol addictions have meant firm lower age limits for admission in many of these institutions across the country, which has resulted in the exclusion of even older adolescent patient from these treatment programs.

Needless to say, the factors behind these age limit restrictions are indeed more complex than noted above. For example, there is a growing recognition worldwide that adolescents need care that is different from that given to younger children or adults (4). Hence when questioned, institutions with rigid age limits may note that they are simply not ‘equipped’ to provide the care needed for the excluded adolescent age group. While this may be particularly relevant in the treatment of drug and alcohol addiction, since addicted adolescents are not just ‘younger’ adults, exclusion does not solve the access to a treatment program problem for the adolescents in the region with only one program available.

Where are adolescents to get their care? This is a complex question which deserves attention in all locales. In areas with a regionalized healthcare system adolescent access to care needs to be as firmly planted on the planning agenda as access to care issues for geriatric, adult and paediatric patients. In areas without regionalization, the local healthcare institutions must come together to resolve the adolescent care access dilemma and ensure that there are no age-restricted care cracks in the system.

Flexibility is emphasized in the committee statement and needs to be the watchword in program development. Adolescents are by no means a uniform population with uniform needs that shift evenly at the same age across the medical problem list. However, we paediatricians must also take care not to be too maternalistic. In our zeal to provide quality care for adolescents, there may be the temptation, especially for adolescents with complex and serious diseases who in the past would not have survived into adulthood, to want to continue to provide care even as they become adults. We can do ‘such a good job’ and the adult system ‘may not’. The history of care of cystic fibrosis (CF) patients in the past two decades in Canada provides an excellent example of how the adult system can adapt to provide care for such complex patients and do it very well. Where once adult CF patients were few and it was common to see them receiving care in a children’s hospital, there are now many of them and care in a children’s hospital is rare, as more and more regions have adult CF clinics. The key has been the development of a cadre of adult care physicians and other adult heath care providers interested in cystic fibrosis providing a smooth process for transfer from the paediatric CF clinics to the adult CF clinics (5) and an expectation in the paediatric CF clinic that all patients will transfer. Similar success has been seen in developing appropriate adult care for adult congenital heart disease patients, often with both paediatric and adult cardiologists working together in an adult clinic. Successful care models for older adolescents and young adults with severe developmental delay are also starting to emerge as this population of patients grows up. As well, a few centres have developed good models for the addiction treatment of adolescents

While each of these steps are encouraging, we still have a long way to go to ensure that across this country there is access to care for all adolescents that is appropriate for their needs. We have major deficits in many regions to access to rehabilitation care for adolescents with serious head injuries and/or major trauma, to drug and alcohol abuse programs tailored to the needs of adolescents of differing age groups, and to male adolescent rape victim treatment programs, to name just a few. There are particularly serious issues around access to appropriate care for adolescents living in rural and more remote areas of our country, especially in the Territories, the very regions with the highest proportion of the population under the age of 20 in the country (6). We need to attract healthcare providers with a special interest in adolescent care to these areas and provide them with the support and backup for dealing with complex adolescent care problems. We need to be thinking of creative new ways to meet adolescent health needs everywhere in this country. We need programs that take into account the adolescent’s care requirements, age, developmental stage, as well as the community’s resources and the availability and expertise of the local healthcare providers. Flexibility is indeed the key, as noted in the committee statement. Care for adolescents must not be short changed simply because they do not fit into rigid and arbitrary age limits for an institution’s programs, regardless of whether this is a ‘child’ or ‘adult’ facility. Adolescents have the same rights to age-appropriate care as other age groups.