Joanne Armstrong, MD 1,2 Haleh Sangi-Haghpeykar, PhD 1 Alice Shen, MD 1

1. Joanne Armstrong, MD1,2 Haleh Sangi-Haghpeykar, PhD1 Alice Shen, MD1 1. Baylor College of Medicine Houston, Texas 2. Dept Women’s Health, Aetna Chlamydia Screening Practices in the Private Sector: Who, How Much, and Why?

2. Background • How big is the problem? • 3M infections/year; 80% <25 y/o; 80% asymptomatic • Screening helpful • Decreases prevalence when widely instituted1 • Decreases infection sequelae by 50%2 • Limited success in translating screening benefits to women in the private health sector • Most Americans receive STD care private sector from “private practice” physicians3 • Little data on extent and quality of care in private sector. • Schafer, JAMA 2002;288 (22):2846 • Scholes, N Engl J Med 1996;334(21):1362 3. Brackbill. Fam Plann Perspect. 1999;31(1):10-5

3. Private Sector • Prevalence1,2 • Teens: 5%-10% • Adults: 3%-6% • Self-reported adherence with screening guidelines poor3 • 30% PCPs • 54% ObGyns • HEDIS 20034 • <19 years: 26.7% • 20-<26 yrs: 24.6% Significant quality concern exists in private sector 3. Hobgen Obstet Gynecol 2002;100(4):801-7. 4. http://www.ncqa.org/sohc2003/chlamydia_screening.htm

4. Health Plan Initiatives • Outreach to greater than 125,000 physicians • Chlamydia Tool kits • Screening and laboratory guideline updates • Patient fact sheets • Patient self assessment tools • CMEs • Feedback on HEDIS performance • Lunch and learns-mid-level practitioners • Annual preventive health reminders • Collaborations with national labs

5. What’s the Reward?HEDIS: Commercial Plans

6. A National Survey of Genital Chlamydia trachomatis Screening Practices and Attitudes of U.S. Obstetrician Gynecologists Joanne Armstrong, MD Haleh Sangi-Haghpeykar, PhD Alice Shen, MD Baylor College of Medicine Houston, Texas

7. Study Objectives • Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women • Identify barriers and facilitators to compliance with screening guidelines

8. Study Objectives • Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women • Identify barriers and facilitators to compliance with screening guidelines

9. Study Design • National survey • 1,100 OBGYNs randomly selected from AMA Master File • Inclusion criteria • Board certified • Full time, direct patient care • >50% time caring for commercially insured (HMO, PPO, FFS, indemnity, Medicaid MCO) • Women ages 15-25 • Exclusion criteria • Federal, state, county, city-funded setting, medical schools, training programs, researchers, admin, non-direct patient care • Survey undeliverable, MD retired, deceased • Does not meet inclusion criteria

10. Study Design • Survey content: • Chlamydia screening practices • Knowledge and utilization of currently available screening tests • Barriers and facilitators to screening. • 3 different patient sub-groups • Pregnant women • Non-pregnant, sexually active, <20 years • Non-pregnant, sexually active, 20-25 years • Comparison of screeners vs. non-screeners • “Screener” = Screens >75% of time

11. Study Design • Survey content: • Chlamydia screening practices • Knowledge and utilization of currently available screening tests • Barriers and facilitators to screening. • 3 different patient sub-groups • Pregnant women • Non-pregnant, sexually active, <20 years • Non-pregnant, sexually active, 20-25 years • Comparison of screeners vs. non-screeners • “Screener” = Screens >75% of time

12. Study Design • Mailed in 3 waves-March 2003 1. FedEx: survey, information sheets, $15 gift cheque 2. Reminder Postcard 3. Priority Mail: survey • Reviewed and approved by BCM IRB

13. Results • 1,100 surveys sent to Ob/Gyn Physicians • 410 completed, eligible returned surveys • 42.7% response rate

14. Respondent Demographics • Physician Profile • 99.3% Board certified; 95.6% in private practice • 70.8% Male; 79.4% White • Mean age 49 years with 20 years of practice • Workload • Mean 39.3 hour work week; 94.2 patients per week • 37.2% OB visits, 62.7% GYN visits • Practice • 96.6% in primary care or sub-specialty care office • 84% in solo or single-specialty group practice • 69.1% with ownership interest in their practice • 78.3% contracted with a MCO • Patient Profile • 61.6% White; 18.0% Black; 12.6% Hispanic • 36.2% aged 13-26 years; 71.7% privately insured

15. Screening frequency by patient subgroup

16. Demographic Variables Associated with Screening* non-pregnant, sex active age 20-25 years * Denotes screening all sexually active women ages 20-26 years at least 75% of time.

17. Demographics Not Associated with Screening • MD demographics • Age, Gender, Years in practice • Practice Structure • Solo vs. group • Patient and work volume • Practice Economics • Ownership interest • MCO affiliation • Insurance status of patients

18. Current Experience with CT and Comparison of Screeners* to Non-Screeners • Denotes screening all sexually active women ages 20-26 years at least 75% of time. • **Denotes mean response 1= strongly agree, 5=strongly disagree

19. Screening Test Utilization of Screeners compared to Nonscreeners

20. Conclusions • Physicians poorly compliant with screening guidelines • Magnitude of non-compliance even greater than physician self-report, particularly for non-pregnant aged 20-25 years (54% vs 8.5%). • Perception of prevalence is low. • Non-screeners more likely to believe that infection prevalence is too low to warrant routine screening. • Majority have no target prevalence above which screening is indicated. Those who do, have high threshold (10%). • Significant quality concerns…and opportunities.. identified in chlamydia screening in commercially insured women