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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

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Susan DeLisle , ARNP, MPH National Chlamydia Coalition Partnership for Prevention

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Outline

A Focus On

Chlamydia screening

Susan DeLisle, ARNP, MPH

National Chlamydia Coalition

Partnership for Prevention


Outline

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

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

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

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

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

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

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

Burden of Infection

Sexually active people aged 14-24

have about 3x the chlamydia prevalence of sexually active adults aged 25-39

Prevalence, %

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


Chlamydia prevalence in sexually active females aged 14 24 in the united states

Chlamydia Prevalence in Sexually Active Females Aged 14-24 in the United States

Prevalence, %

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

Chlamydia—Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2010

*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.

Percentage

40

Private Physician/HMO*

STD Clinic

35

Other HD* Clinic

30

Family Planning Clinic

Emergency Room

25

20

15

10

5

0

Men

Women


Sequelae pid and tubal factor infertility

Sequelae: PID and Tubal Factor Infertility

infertility

  • 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

chlamydia

20%

10-20%

ectopic

pregnancy

pelvic

inflammatory

disease

9%

10-20%

gonorrhea

18%

chronic

pelvic

pain


A picture is worth

A Picture is Worth…


Pelvic inflammatory disease pid

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

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

Infertility Services are Costly

  • Tubal factor infertility, caused by Chlamydia trachomatisor by Neisseriagonorrhoeae, 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

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

How Compliant are Providers with Annual Chlamydia Screening?

2010 Chlamydia Screening HEDIS Rates

Health Plan Type

Age (yrs) Commercial HMO (%) Medicaid HMO (%)

_____ ________________ ____________

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

HEDIS Chlamydia Screening Rates


Hedis chlamydia screening rates1

HEDIS Chlamydia Screening Rates


Hedis chlamydia measure

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

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

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

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

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

Wrap Up/Summary Slides


Other evidenced based interventions

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 Chlamydia screening rates in all settings:

      • Young women screened increased 8%-22%

      • Increases in confidential risk assessment, education, and counseling


Common themes

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

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

Accessing the Tools

  • Available at:

    • National Chlamydia Coalition: http://ncc.prevent.org/

    • AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandouts.htm

    • SAHM: www.adolescenthealth.org/Clinical_Care_Resources/2721.htm

    • ACOG: www.acog.org/goto/teens


Thank you

Thank You

  • We’d love to work with you


Outline

Practice Models

And

Resources


Other evidenced based interventions1

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 Chlamydia screening rates in all settings:

      • Young women screened increased 8%-22%

      • Increases in confidential risk assessment, education, and counseling


Common themes1

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 available1

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 tools1

Accessing the Tools

  • Available at:

    • National Chlamydia Coalition: http://ncc.prevent.org/

    • AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandouts.htm

    • SAHM: www.adolescenthealth.org/Clinical_Care_Resources/2721.htm

    • ACOG: www.acog.org/goto/teens


Thank you1

Thank You

  • We’d love to work with you


Meeting ncqa goals for adolescent chlamydial screening beyond

Meeting NCQA Goals for Adolescent Chlamydial Screening & Beyond

Kathleen Tebb, PhD

Division of Adolescent & Young Adult Medicine

Department of Pediatrics


Presentation overview

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

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

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 clinicianduring preventive visit


Guideline implementation

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

Methods

  • Settings:

  • RCT: Large HMO in Northern California

    • Preventive Visits

    • Acute Care Visits

    • Sustainability

    • Translatability: HMO and Australia


Outline

Clinical Practice Improvement Model

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain


Outline

Clinical Practice Improvement Model

  • Leadership

  • Best practices

  • Define gap

  • Raise Awareness

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain


Outline

Clinical Practice Improvement Model

  • ACTeam

  • Skill building

  • Tool Kit

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain


Outline

Site Specific Flow Chart

Cue

Charts

Room

Patient

MD/NP

VISIT

Urines

To Lab

Follow-Up

ID eligible teens

Stamp charts

Urine collection

Assess risk

Preventive counsel

If SA+

Lab req

confid. #

RN contacts CT + teen

Teen comes to clinic for Rx

RN enters Rx in STD log book

MA refrigerates urines

MA enters teen name, confidential # in log book

  • Runner takes urines to lab


Outline

Clinical Practice Improvement Model

Engage

  • Customize

  • Measure success

Team Building

Re-Design Clinical Practice

Sustain the Gain


Outline

Clinical Practice Improvement Model

Engage

  • Monitor performance

  • Time series analysis

  • Continuous improvement

Team Building

Re-Design

Clinical Practice

Sustain the Gain


Outline

Rapid Cycle

Changes

  • ACTeam Meeting

  • Set Goal

  • Identify barriers

  • Decide solution

  • Try it out

  • Reassess

  • Repeat “cycle”

% Change in STD Screening Rate

S t a t u s Q u o

Time in months


Ct screening rate

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 shafer tebb et al jama 2002

Girls (14-18) Screened in Well CareShafer, Tebb et al., JAMA 2002

p<0.001

Intervention Time Period in Months


Problem

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

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

Girls (14-18) Screened in Urgent CareTebb et al., Archives 2009


Translation and sustainability

Translation and Sustainability

  • Can the intervention be translated into wider clinical practice?

  • Can intervention effects be sustained post-research?


Outline

Girls Screened Post-Intervention

% Sexually Active Girls Screened

TRIP

ACTIVITIES

Intervention Time Period in Months


Synthesis of intervention components

Synthesis of Intervention Components

  • One-size does not fit all

  • CPI useful but not essential to improve chlamydial screening


Tools rooming letter for parents

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.


Conclusions

Conclusions

  • Simple, quick practice changes are feasible, acceptable & sustainable

  • Capitalizes upon existing resources & staff

  • Smallchanges LARGE effects over time

  • Effective in different settings - well & urgent

  • Not HMO specific, translating & implementing in 17 GP clinics in New S. Wales Australia


Conclusions1

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.


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