Characterization of the most common diagnoses in a population of adolescents and young adults attended by a Healthcare Service Provider (HSP) in Bogotá, Colombia

Introduction

The World Health Organization (WHO) is the entity responsible for establishing age ranges that allow for the study of different life stages worldwide. According to this, adolescence is defined as a transitional stage between childhood and adulthood, characterized by the emergence of juvenile traits, making it difficult to define a specific age range. Therefore, it is better to focus on the adaptive, functional, and decisive value of this stage. However, for statistical purposes, adolescence is defined as the period between 10 and 21 years old, divided into early, middle, and late stages. Similarly, youth is defined as the period of social consolidation between 21 and 24 years old. In Colombia, Law 375 of July 4, 1997, for the purposes of participation and social rights, establishes young people between the ages of 14 and 26 [1].

Similarly, the WHO became the coordinating entity of various organizations in the 19th century to formulate and in 1893 establish the International Statistical Classification of Diseases and Related Health Problems (ICD) with the aim of enabling systematic data recording for the analysis, interpretation, and comparison of morbidity and mortality across different places and time periods [2].

Currently, the ICD has 11 editions, with the tenth version (ICD-10) being the most well-known and widely used, as it was in effect from 1990 until January 2022 and is still used in countries and health entities not updated to ICD-11 [3].

The 21 chapters in which the ICD-10 is organized allow for the observation of the disease grouping pattern proposed by William Farr in the 19th century, and the coding utilizes an alphanumeric organization with a letter in the first position associated with the chapter to which the code belongs, and a number in the second, third, and fourth positions. Therefore, the possible codes range from A00.0 to Z99.9, excluding the letter U, which is reserved for additional codes [2].

The Colombian healthcare system, within its fundamental strategies for medical care, presents Primary Healthcare services, defined as a set of values, principles, and structural attributes that complement the healthcare system. Its effective action is carried out through its essential attributes (first contact, longitudinally, comprehensiveness of care, and care coordination) and their derivatives (family-centered care and community orientation) [4]; also, the health system has developed strategies and policies for healthcare focused on adolescents and young adults, such as the “Adolescent and Youth Friendly Health Services (SSAAJ translated to Spanish)”, which is fundamentally a strategy of social oversight that seeks differentiated responses by health services for the population between 10 and 29 years of age in order to guarantee their sexual and reproductive rights; another example is the “National Policy on Childhood and Adolescence”, which seeks mainly through the life course approach, to generate welfare conditions, promote access to opportunities with equity and incidence of children and adolescents [5], 6].

Our healthcare system is not immune to global trends, including growing fiscal pressure driven by factors such as population aging, the adoption of new technologies, and the overutilization of existing technologies, among others, which should lead us to consider the importance of efficient and evidence-based health spending [7]. Therefore, diagnostic tests as diagnostic and disease monitoring tools are frequent practice in global healthcare and play a fundamental role in clinical decision-making. As a result, they have a significant economic impact on healthcare systems. For instance, in 2014, it was estimated that 1.7 % of the total Medicare budget – equivalent to $10 billion – was allocated to diagnostic tests, amounting to $10 billion in absolute terms. Therefore, efficient resource allocation in healthcare systems is essential to ensure their sustainability [8].

Due to the objectives, the lack of consensus and for practical purposes of this work, we will establish the stage of youth between the ages of 13 and 24, subdividing it into adolescents, between 13 and 18 years old, and young adults, between 19 and 24 years old. Remembering the importance of this stage in individuals’ lives as a period of profound physical, emotional, and social changes [3]; it is defined as a critical period because health habits that will affect the entire life are acquired, individuals begin to interact in society, and face changes in social roles [1], 4], 9]. Being such a sensitive stage in individual development, it is crucial for the healthcare system to understand this population and obtain data about health patterns in these two age groups. Similarly, analyzing these patterns could contribute to health resource planning, facilitating more precise, effective, and sustainable primary care [7]. The study by Abreu et al. clearly exemplifies the importance of the previously mentioned points. This study highlights the growing relevance of adolescent medicine due to the increase in the number of consultations. The results indicate that mental disorders were predominant in women and young adults, with a higher prevalence of eating disorders, anxiety, and mood disorders. Additionally, differences in usage patterns were observed according to sex and age, with a higher number of visits by women and younger adolescents, and a greater prevalence of obesity in the latter [10]. It is important to highlight that, when evaluating the literature on the most common pathologies in adolescents and young adults, it is observed that mental disorders predominate as the most treated group of diseases. This trend could lead to other causes of consultation in these age groups, such as chronic or acute diseases, receiving less attention than necessary.

Objectives

To characterize the most used ICD-10 diagnoses in the population aged 13–24 who received care at Javesalud HSP (Healthcare Service Provider) in Bogotá, Colombia; between June 2022 and June 2023.

Methodology

This was a secondary descriptive analysis of a database provided by Javesalud HSP, which is an ambulatory network with a model of care based on family medicine that provides primary care services in Colombia in 11 different locations. It provides care to close to 150,000 users, has 450 collaborators, and offers academic internships to 1,000 students annually.

This analysis considered the type of identification documents, sex, age, primary diagnosis ICD-10 code, and consultation date. Patients aged between 13 and 24 years treated by this healthcare provider from June 1, 2022, to June 30, 2023, were included, totaling 11,802 consultations. Initially, data analysis was performed using Microsoft Excel^® to select study variables: type of identification document, age group, sex, and diagnosis (as represented in Table 1). Subsequently, using R and Rstudio, we conducted a descriptive statistical analysis. This entailed the calculation of frequency and measures of central tendency according to age group and gender. This information was then used to create box plots, bar charts, frequency tables, and pie charts to visualize the relationship between the described variables. Then, we perform a bivariate analysis, for each one of the two population groups evaluating the similarity of the diagnoses between male, and female, with a statistical significance level at p<0.05 and a 95 % confidence interval. This information will allow us to confirm that the reasons for consultation are different according to sex, a hypothesis based on the available scientific literature.

For the discussion, we divide the diagnoses into “procedural” and “non-procedural” based on whether they belong to chapter XXI or not. Due to the large number of principal diagnoses represented in this chapter, a key characteristic of these diagnoses is that they do not refer to diseases or external causes. Instead, they relate to situations when the patient is in contact with the health system, regardless of whether the patient is sick, or whether they are experiencing problems that affect their health, without being classified as the disease itself [11].

Results

Table 2, shows that our database comprises 11,802 consultations recorded between June 1, 2022, and June 30, 2023. Of the total consultations, more than two-thirds, 8,006 (67.84 %), were attended by female patients, while 3,796 consultations (32.16 %) were attended by male patients. In terms of age distribution, according to the six-year age groups we established, young adults (aged 19–24 years) accounted for a higher number of consultations, totaling 6,774 (57.4 %), while adolescents (aged 13–18 years) accounted for 5,028 (42.6 %) consultations. Furthermore, this table organizes the diagnostic codes and procedures given to our entire population into their respective chapters of the ICD-10 [2]. It shows that out of the total 21 chapters, 14 are the most prevalent. Chapter XXI (Factors influencing health status and contact with health services, codes Z00.0 to Z99.9) has the highest frequency with a total of 912 consultations, while Chapter VIII (diseases of the ear and mastoid process, codes H60 to H95) has the lowest frequency with 215 occurrences. Chapters with fewer than 200 consultations were grouped under “other chapters”, representing only 5.87 % of the total population.

The distribution of males and females in the adolescent group indicates that most consultations occurred between the ages of 14 and 17, with a median age of 15 years for males and 16 years for females. Conversely, in the young adult group, most consultations were made between 20 and 23 years, with a median age of 22 years for both sexes. Bivariate analysis revealed statistically significant differences (p<0.05) between the sexes in both age groups regarding diagnoses and procedures.

Table 3 presents the correlation between the most prevalent diagnoses and the specified age ranges for both males and females.

For males in the adolescent age group, the main non-procedural diagnosis corresponds to unspecified acne (L709) with 154 consultations (30.62 %), followed by acne vulgaris (L700) with 105 (20.87 %). The third most common diagnosis, with 75 (14.91 %) consultations, is unspecified allergic rhinitis (J304). As for procedural codes, the most prevalent diagnosis is the examination of adolescent developmental status (Z003) with a total of 64 (12.72 %), followed by consultations for the care and supervision of other healthy children or infants (Z762) with 55 results (10.93 %), and general medical examination (Z000) with 50 (9.94 %).

On the other hand, for young male adults, the most prevalent procedural diagnosis is the general medical examination (Z000) with 130 (34.85 %), followed by consultations for counseling on human immunodeficiency virus [HIV] (Z717) with 30 (8.04 %). Regarding non-procedural diagnoses, unspecified acne (L709) with 59 (15.82 %) was the most prevalent, followed by unspecified lumbago (M545) with 38 (10.19 %), joint pain (M255) with 32 (8.58 %), and lastly, acne vulgaris (L700) with 31 (8.31 %).

The most prevalent procedures for adolescent females are general counseling and advice on contraception (Z300) with 212 (21.33 %), followed by general gynecological examination (Z304) with 64 (6.44 %) and examination of adolescent developmental status (Z003) with 61 (6.14 %). As for non-procedural diagnoses, unspecified acne (L70.9) ranks highest with 144 (14.49 %), followed by acne vulgaris (L700) with 86 (8.65 %), headache (R51) with 79 (7.95 %), unspecified abnormal vaginal and uterine bleeding (N939) with 67 (6.74 %), dizziness and fainting (R42) with 65 (6.54 %), followed by unspecified allergic rhinitis (J304) with 59 (5.94 %), and lastly, other unspecified abdominal pains (R104) with 54 (5.33 %).

For young adult women, we observe that the code for general counseling and advice on contraception (Z300) is the most prevalent procedure with 369 (23.65 %) consultations, followed by special screening examination for cervical cancer (Z124) with 291 (18.65 %) consultations, followed by general gynecological examination (Z304) with 216 (13.85 %), followed by general medical examination (Z000) with 167 (10.71 %), confirmed pregnancy (Z321) with 116 (7.44 %), and Consultation for counseling on human immunodeficiency virus [HIV] (Z717) with 101 (6.47 %). Regarding non-procedural diagnoses, the most prevalent is polycystic ovary syndrome (E282) with 106 (6.79 %), followed by unspecified acne (L709) with 102 (6.54 %) occurrences, and lastly, headache (R51) with 92 (5.9 %).

The following additional findings emerged during the characterization process. First, a higher number of consultations was observed in the year 2022, with June of the same year having the highest number (1,060 consultations) and April 2023 having the lowest number (748 consultations), reflecting a gradual and slight decrease in the number of monthly consultations over the evaluated period. Secondly, it was determined that 275 consultations (2.33 %) were attributable to consultations conducted for patients with identity documents issued exclusively for foreign and migrant populations (foreigner identification cards, special residence permits, permits for temporary protection, and safe conduct).

Discussion

Adolescents and young adults constitute a notable demographic segment, as evidenced by the latest census in Colombia (2018), which reported approximately 17.64 % of the population, equivalent to 8,512,798 people [13]. Hence, the importance of providing them with appropriate health treatment and follow-up becomes evident. The relevance of intervening early in this population lies in their favorable response capacity to preventive and corrective interventions, as opposed to a later approach that may face the entrenched presence of health risk behaviors [11].

This study allowed us to observe the behavior of the mentioned population regarding reasons for consultation at HSP Javesalud from June 1, 2022, to June 30, 2023. The results show the difference in the number of consultations according to gender (2.1:1 female/male); data that coincides with results from other studies [15], where it was established that young women more frequently consulted primary care centers seeking health promotion and prevention, while men opted for emergency room visits or non-traditional care centers seeking curative management of acute events [15], 16]. Although we cannot determine the reason for these gender differences in consultation frequency given the limited information provided, some authors justify the higher number of consultations because women have a worse perception of their health, a higher number of symptoms, more reporting of chronic diseases [17], and partially due to consultations related to reproductive reasons [18]. Similarly, we could deduce that the disparity in consultation frequency between adolescents and young adults is due to the dependence of the former on their parents or guardians in all aspects of life, which limits decision-making and the initiation of health-related actions [19], 20].

With the data obtained from the most frequent procedures in the studied general population, we can notice that promotion and prevention activities are based on topics related to sexual and reproductive education, accounting for approximately 15 % of the consultations. Among males aged 19–24, HIV infection counseling predominates, while among females aged 13–24, consultations related to family planning and contraception prevail. This aligns with similar studies indicating that the most frequent reasons for consultation among young individuals were related to prenatal care, counseling on sexually transmitted diseases, and contraception [15], 21]. Regarding bivariate analysis, in both age groups, we found that the diagnoses and procedures were not similar when compared by sex, with a statistically significant p-value (p<0.05). This disparity observed between female and male consultants, we consider that it is complex to establish this finding as extrapolated to the entire population and attributable to a single cause. Regarding the previous diagnoses, we can suggest that the frequency of these diagnoses is due to the demand induced as part of the prevention and prognosis strategies indicated by the Colombian national government’s legislation.

Regarding adolescent and young adult males, the behavior of the main reasons for consultation differed for each age group. Among adolescents, there is a predominance of two subgroups. Firstly, dermatological disorders related to acne represent 51.49 % of the consultations, which is consistent with the high frequency of this condition, with prevalences ranging from 80 to 90 % in adolescents and young adults [22]. As the current evidence suggests, acne can be considered a chronic condition due to its relapsing and remitting nature, insidious and prolonged onset, and the psychological and social components associated with this disorder. Secondly, the primary diagnosis among the younger age group corresponds to the cluster of medical check-ups performed on children and adolescents, accounting for 33.59 % of the reasons for consultation. This high percentage may be related to the changing perception of health that has emerged in recent years, emphasizing the period following the COVID-19 confinement [23], state prevention strategies such as the Technical Standard for Early Detection of Developmental Disorders [24], and the role of caregivers and parents in adolescent health [25].

Similarly, when evaluating the main diagnoses by age group, we can observe that for females, the most frequent diagnoses were similar but in different proportions. In young adult females, consultations related to contraception represent a higher percentage than in adolescent females. This may be due to several factors such as lack of information (particularly among younger adolescents), socio-cultural factors, and administrative barriers [26]. On the other hand, among the most frequent diagnoses in both age groups are Headache (R51) and Abnormal vaginal and uterine bleeding, unspecified (N939), findings shared with a study conducted in Portugal. This same study shows that the main diagnoses in both sexes were obesity and psychiatric disorders, while in our study, they were diagnosed 115 (0.97 %) and 431 (3.65 %) times each, respectively [7]. Related to this article, where they found that referral ratio from the primary care center/hospital was more frequent in female adolescents with a statistically significant p-value, can be comparable with our findings that show statistically significant p-value when comparing diagnosis in females and males, both groups have completely different diagnosis in both age-groups.

It is important to highlight that, although not evident among the most frequent diagnoses, mental health problems are a highly prevalent condition, particularly in the population group we evaluated. This may have multiple causes, among them that healthcare services in Colombia, due to the contracting handled by insurers and the way the healthcare system is organized, favor HSPs to focus on certain specific areas, such as the HSP that provided us with the database, which focuses on early diagnosis, prevention and promotion of mental health problems, referring to an HSP in charge of mental health. This situation also occurred with oral-health related diagnostics, despite being common during adolescence and young adulthood, the HSP did not have this data in the same database, minimizing the likelihood that anyone consults for an oral health diagnosis, in future studies it is important to include these diagnoses.

The initial limitation of this study was the organization of the database, which included repeated or incomplete data entries, resulting in a significant decrease in the total number of records. Similarly, during the analysis, multiple junk codes were used, which lack specificity and therefore do not allow for accurate characterization of the diagnoses relevant to our age group. This may result in false claims about the studied population. Also, we can consider the presence of selection bias since the selected sample is not representative of the general population of the country, since the HSPs database included only contributive system consults performed in Bogotá. Our nation has deep inequalities between the rural and urban youths, for example, they have a poverty rate of 40 and 25 % respectively (being the extreme poverty rate at 17 and 5 %), more difficulties for access to public services (39.3 vs. 23.6 %), post-secondary education (6 vs. 28 %) and lower enrollment in the contributive system (16 vs. 52 %) [27].

In addition to the recommendations provided regarding the direct findings of this study, we consider it important to enhance the training of healthcare personnel in the use of the ICD to avoid the use of non-specific codes or codes not indicated for a patient, which may lead to errors both in clinical care and when conducting studies on behavioral trends in various population groups. It is also important to mention there are still unsatisfied research needs in our country and Latin America since there is a scarce bibliography on this topic.

Conclusions

This research provides valuable insight into the consultation profiles of adolescents and young adults in primary care centers in Bogotá, Colombia. By delving deeper into this demographic group, a more comprehensive understanding of their needs and particularities is achieved, directly impacting the improvement of health service delivery. In addition, this study has a significant influence on the effective implementation of a wide range of strategies aimed at promoting and preserving health. This leads to research not only providing a more accurate picture of the behavior and demands of this population group, such as SSAAJ National Police (Adolescent and Youth Friendly Health Services), but also multiple modalities of Javesalud care.

The project also lays the foundations for more effective and personalized care according to their specific characteristics, and needs, based on this. HSPs can carry out activities, courses, or workshops to strengthen the clinical skills of health professionals for the most common pathologies (for example, to improve the resolution in general medicine/pediatrics when treating acne) and consultation reasons (for instance enhancing the content and education of family planning, pregnancy prevention, and preconceptional consultations) of this population.

Adolescents and young adults constitute a group with epidemiological characteristics of great complexity, marked by a multiplicity of variables and significant interpersonal diversity. In this regard, it is imperative to conduct detailed studies in this age segment and, in turn, implement strategies that contribute to the promotion of their development and future well-being.