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)
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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?
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
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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
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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.