Transcript Chlamydia
A FOCUS ON CHLAMYDIA SCREENING Susan DeLisle, ARNP, MPH National Chlamydia Coalition Partnership for Prevention Outline The National Chlamydia Coalition Why Chlamydia Screening is a HEDIS Measure Epidemiology of Chlamydia Why Care About Chlamydia Disease outcomes Cost Implications for health plans National HEDIS and other performance data Perceived Barriers to Screening Resources and Tools National Chlamydia Coalition (NCC) Formed in 2008 Comprised of over 40 organizations Health care professional organizations Insurers Non-profit organizations Local, state, federal government representatives Managed by Partnership for Prevention Funded by the Centers for Disease Control and Prevention National Chlamydia Coalition: Mission Address the high burden of chlamydia in adolescents and young adults by promoting equal access to comprehensive and quality health services Purpose in Attending this Meeting Learn what’s working and what’s not Promote chlamydia screening Exchange ideas to increase chlamydia screening Provide resources, tools, tips, and assistance Why Chlamydia Screening is a HEDIS Measure Cost effective and cost beneficial Grade A USPSTF Measure for women <25 years of age Screening works! to prevent long term and costly consequences Indicator of adolescent and maternal health The Problem: Chlamydia Most commonly reported nationally notifiable disease in the US Over 1.3 million cases reported in 2010 Estimated 2.8 million cases occur each year Direct medical costs: $678 million/year Often asymptomatic (up to 80% of cases) Devastating sequelae CDC Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 Weinstock H, Berman S, Cates W Jr. Perspect Sex Reprod Health 2004 Chesson HW, et al. Perspect Sex Reprod Health 2004 Chlamydia—Rates by State, United States and Outlying Areas, 2010 NOTE: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 422.6 per 100,000 population. Burden of Infection Prevalence, % Sexually active people aged 14-24 have about 3x the chlamydia prevalence of sexually active adults aged 25-39 Age group (years) NHANES, National Health and Nutrition Examination Survey, 1999-2008 Sexual activity =“yes” response to “Have you ever had sex?” Sex = vaginal, anal, or oral sex 9 Prevalence, % Chlamydia Prevalence in Sexually Active Females Aged 14-24 in the United States NHANES, National Health and Nutrition Examination Survey, 1999-2008 Sexual activity =“yes” response to “Have you ever had sex?” Sex = vaginal, anal, or oral sex 10 Chlamydia—Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2010 Percentage 40 35 Private Physician/HMO* STD Clinic 30 Other HD* Clinic Family Planning Clinic 25 Emergency Room 20 15 10 5 0 Men Women *HMO = health maintenance organization; HD = health department. NOTE: These categories represent 72.5% of cases with a known reporting source. Of all cases, 11.6% had a missing or unknown reporting source. Sequelae: PID and Tubal Factor Infertility infertility chlamydia pelvic inflammatory disease 9% ectopic pregnancy gonorrhea chronic pelvic pain Infectious Complications Neonatal pneumonia or eye infections in 60-70% of infants born to untreated mothers At least 2-5 fold increased risk of HIV Infection A Picture is Worth… Pelvic Inflammatory Disease (PID) Symptoms are often vague 85 % of women delay seeking medical care for PID Frequently misdiagnosed because there is no test for PID Delaying care increases the risk of infertility and ectopic pregnancy Why Screen Sexually Active Females? 80%-90% of chlamydial infections in women have no symptoms Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that screening programs can lead to a reduction in the incidence of PID by as much as 60% Reducing the incidence of PID can reduce infertility Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34(21): 1362-66. Infertility Services are Costly Tubal factor infertility, caused by Chlamydia trachomatis or by Neisseria gonorrhoeae, is estimated to affect as many as 18% of women using Assisted Reproductive Technology (ART) 12% of women in the U.S. ages15-44 have ever used infertility services Infertility treatments are associated with an increased risk of multiple order births, which carry health risks for women and infants, and increased costs Source: Centers for Disease Control and Prevention, A National Public Health Action Plan for the Detection, Prevention, and Management of Infertility. 2012 Infertility Services are Common Among women 15-44 7.4% are affected by infertility About 12% have impaired fecundity Each year, more than 1.1 million women of reproductive age seek medical help to become pregnant 7.3 million women have received infertility services, including counseling and diagnosis, in their lifetimes Source: Centers for Disease Control and Prevention, A National Public Health Action Plan for the Detection, Prevention, and Management of Infertility. 2012 How Compliant are Providers with Annual Chlamydia Screening? 2010 Chlamydia Screening HEDIS Rates Health Plan Type Age (yrs) _____ Commercial HMO (%) Medicaid HMO (%) ________________ ____________ 16-20 40.8 54.6 21-24 45.7 62.3 The State of Health Care Quality, 2011 National Center for Quality Assurance at: http://www.ncqa.org/LinkClick.aspx?fileticket=J8kEuhuPqxk%3d&tabid=836 HEDIS Chlamydia Screening Rates 16-20 Years 60 Percentage Screened 50 40 Commercial HMO 30 Commercial PPO Medicaid HMO 20 10 0 2006 2008 2010 HEDIS Chlamydia Screening Rates 21-24 Years 70 60 Percentage Screened 50 40 Commercial HMO Commercial PPO 30 Medicaid HMO 20 10 0 2006 2008 2010 HEDIS Chlamydia Measure # Eligible women receiving chlamydia screening # Sexually active women, aged 16-24 Measure collected separately for women 16-20 and 21-24 Barriers to Screening Women in Private Sector Settings Policy Absent or conflicting chlamydia screening guidelines or policies System Competing priorities, lack of time or staff, cost effectiveness Lack of reimbursement Provider Belief that chlamydia prevalence in population is low Discomfort with taking sexual history Patient Low perception of risk, not aware of asymptomatic infection Concerns about confidentiality Health Care Reform Affordable Care Act provides full health plan coverage for U.S. Preventive Services Task Force (USPSTF) A and B graded preventive health services with no cost sharing Chlamydia screening all sexually active females under 25 years is a USPSTF Grade A recommendation Opportunities for STD Screening and Treatment New (time-saving) tools Easy and inexpensive methods to increase screening rates New tests Vaginal swab samples – self collected Urine tests for both male and females Easy treatment Single dose treatment Overcoming the Barriers Evidence based interventions exist to increase screening rates Next speaker will discuss a proven model to address Chlamydia screening Model can apply to other HEDIS measures Wrap Up/Summary Slides Other Evidenced Based Interventions NCC mini grants Used evidenced based best practices in a variety of health care settings: Private Pediatric practices Internal Medicine Family Practice Managed Care Improved Young Chlamydia screening rates in all settings: women screened increased 8%-22% Increases in confidential risk assessment, education, and counseling Common Themes Engage office staff (not just providers) to elicit barriers and identify solutions Develop “tool kit” Information on tests Tailored risk assessment Patient and parent education materials Patient flow Address Confidentiality Provide feedback on screening rates, prevalence by practice site Tools Available Resources for: Screening tips and tools Provider resources Simple risk assessment tools Ensuring confidentiality Addressing billing and EOBs Patient and parent education materials Accessing the Tools Available at: National Chlamydia Coalition: http://ncc.prevent.org/ AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderH andouts.htm SAHM: www.adolescenthealth.org/Clinical_Care_Resources/27 21.htm ACOG: www.acog.org/goto/teens Thank You We’d love to work with you PRACTICE MODELS AND RESOURCES Other Evidenced Based Interventions NCC mini grants Used evidenced based best practices in a variety of health care settings: Private Pediatric practices Internal Medicine Family Practice Managed Care Improved Young Chlamydia screening rates in all settings: women screened increased 8%-22% Increases in confidential risk assessment, education, and counseling Common Themes Engage office staff (not just providers) to elicit barriers and identify solutions Develop “tool kit” Information on tests Tailored risk assessment Patient and parent education materials Patient flow Address Confidentiality Provide feedback on screening rates, prevalence by practice site Tools Available Resources for: Screening tips and tools Provider resources Simple risk assessment tools Ensuring confidentiality Addressing billing and EOBs Patient and parent education materials Accessing the Tools Available at: National Chlamydia Coalition: http://ncc.prevent.org/ AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderH andouts.htm SAHM: www.adolescenthealth.org/Clinical_Care_Resources/27 21.htm ACOG: www.acog.org/goto/teens Thank You We’d love to work with you Meeting NCQA Goals for Adolescent Chlamydial Screening & Beyond Kathleen Tebb, PhD Division of Adolescent & Young Adult Medicine Department of Pediatrics Presentation Overview • Discuss preventive health practice guidelines for adolescents & young adults • Present an evidence-based clinical practice quality improvement model • Discuss barriers and strategies to improve chlamydial screening & health quality for adolescents & young adults Why Improve Delivery of Preventive Care for Adolescents? • Adolescents/parents view clinicians as credible resources & expect guidance • Nearly ¾ of adolescents see a primary care clinician at least 1/year • Growing evidence that motivational interview, counseling & screening promotes healthy behaviors • ACA 2010: accountability, transparency, accreditation Clinical Guidelines for Adolescent Annual Visit • Primary care clinicians are to screen for risk behaviors & remind adolescents & families about strengths • All adolescents have some time alone with clinician during preventive visit Guideline Implementation • 38% of adolescents have preventive visit. • <10% of adolescents received a basic complement of 6 preventive recommendations. • >50% don’t have time alone with clinician • 30% forgo care in “risky areas” due to confidentiality concerns • Training and screening tools in clinical practice can increase the delivery of preventive services Methods Settings: • RCT: Large HMO in Northern California Preventive Visits Acute Care Visits Sustainability Translatability: HMO and Australia Clinical Practice Improvement Model Engage Team Building Re-Design Clinical Practice Sustain the Gain Clinical Practice Improvement Model Engage Team Building •Leadership •Best practices •Define gap •Raise Awareness Re-Design Clinical Practice Sustain the Gain Clinical Practice Improvement Model Engage Team Building • ACTeam • Skill building • Tool Kit Re-Design Clinical Practice Sustain the Gain Site Specific Flow Chart Cue Charts ID eligible teens Stamp charts Room Patient MD/NP VISIT Urines To Lab Follow -Up Urine collectio n Preventiv e counsel MA refrigerate s urines RN contacts CT + teen Assess risk If SA+ Lab req confid. # MA enters teen name, confidenti al # in log book Runner takes urines to lab Teen comes to clinic for Rx RN enters Rx in STD log book Clinical Practice Improvement Model •Customize •Measure success Engage Team Building Re-Design Clinical Practice Sustain the Gain Clinical Practice Improvement Model Engage •Monitor performance •Time series analysis Team Building •Continuous improvement Re-Design Clinical Practice Sustain the Gain % Change in STD Screening Rate Rapid Cycle Changes ACTeam Meeting • Set Goal • Identify barriers • Decide solution • Try it out • Reassess • Repeat “cycle” Time in months CT Screening Rate # CT tests _____ # Sexually active teen females* * Site specific sexual activity rates determined by anonymous survey Girls (14-18) Screened in Well Care % of Sexually Active Females Screened Shafer, Tebb et al., JAMA 2002 70% Experimental 60% Control 50% 40% 30% 20% 10% 0% Pre-Test 1-3 4-6 7-9 10-12 13-15 Intervention Time Period in Months 16-18 p<0.001 Problem….. Most (2/3) teens enrolled do not have a preventive health care visit in a given year! How do we do Today’s Work Today? Prevention in Urgent Care? Assess Needs: Teens higher risk for CT Identified Top 3 Barriers 1. Parents in room/confidentiality 2. Competing priorities & limited visit time 3. Discomfort in taking sexual history Girls (14-18) Screened in Urgent Care Tebb et al., Archives 2009 Teen Girls Screened in UC 70% Intervention Control 60% 50% 40% 30% 20% 10% 0% Baseline 1-3 4-6 7-9 Months 10-12 13-15 Translation and Sustainability • Can the intervention be translated into wider clinical practice? • Can intervention effects be sustained post-research? Girls Screened Post-Intervention 80% % Sexually Active Girls Screened 70% 60% 50% 40% 30% Intervention 20% Control 10% TRIP ACTIVITIES 0% Q2 Q4Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4 2002 2003 2004 2005 Intervention Time Period in Months 2006 Synthesis of Intervention Components • One-size does not fit all • CPI useful but not essential to improve chlamydial screening 7/18/2015 Practice Change Solution(s) Pre-visit : cue chart 14-24 yo; stamp/EHR Urine collection Universal vs. Risk-based Practice Change Solution(s) Establishing confidentiality Have & post confidentiality policy for parents Teen roomed alone at start of visit Parent-teen roomed 1st; parent asked to leave No bill; no EOB Tools: Rooming Letter For Parents Dear Parents, Our goal is to provide our patients and their families with the highest quality of health care. In partnership with parents, we want to prepare all our adolescent patients to take charge of their health as they make the transition from childhood to adulthood. To help this happen, we like to have some time with your adolescent alone at some point in the visit. The doctor will be sure to meet with you and your teen together to discuss your son or daughter’s health and to ensure that all your concerns are addressed. Thank you very much. Practice Change Assess Hx Solution(s) Brief screening checklist (Teen vitals) Clinician Hx during confidential visit Alerting Clinician Assessment placed face-down, on the front of chart Stamp coded alert onto the patient file Computer prompt Encounter Review and counsel Practice Change Solution(s) SA+ Obtain & record Clinician or MA collect; confidential contact info record on pre-completed lab slip/ chart Store Urine Transport Urines Follow-up with + Designated cooler/fridge Client vs designated staff Treat & council in clinic; partner therapy; re-test schedule (3 mo); re-screen (every 12 mo) Conclusions • Simple, quick practice changes are feasible, acceptable & sustainable • Capitalizes upon existing resources & staff • Small changes LARGE effects over time • Effective in different settings - well & urgent • Not HMO specific, translating & implementing in 17 GP clinics in New S. Conclusions • QI efforts impact both systemic change in the health delivery organization as well as individual provider behavioral change • Changes that support chlamydial screening promote delivery of a range of key adolescent preventive health services.