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Evolving Thoughts on Chlamydia in a Large MCO Joanne Armstrong, MD, MPH Regional Women’s Health Medical Director Aetna, Inc Assistant Professor Obstetrics and Gynecology Baylor College of Medicine Houston, TX Structure and Complexity of Network Managed Care Health benefits company

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Evolving thoughts on chlamydia in a large mco l.jpg

Evolving Thoughts on Chlamydia in a Large MCO

Joanne Armstrong, MD, MPH

Regional Women’s Health Medical Director

Aetna, Inc

Assistant Professor Obstetrics and Gynecology

Baylor College of Medicine

Houston, TX


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Structure and Complexity of Network Managed Care

  • Health benefits company

    • 19 million members

    • Spectrum of HMO and non-HMO based products

  • Network based provides

    • 100,000 PCPs, 23,000 Ob-Gyns, 3,000 hospitals, national and local laboratories; vendors

    • Individually and IPA/PMG contracted

  • National programs with variation by region, plan design, legal mandates, etc.

    • Cannot impose practice standards


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1999-2000: Ct Perspective

  • No specific programs for Chlamydia

  • Embedded within broader strategy for STDs

    • Open access to PCPs, Ob Gyns, Peds

    • Comprehensive care and follow up care available.

    • Open access to labs, including new amplified tests

    • Comprehensive pharmacy services.

       No access barriers to testing any insured member at any desired interval.

      No financial barriers to testing


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1999-2000: Barriers to Greater Involvement

  • Perception barriers-MCO

    • “The Top 25”

      • STDs not on list of high cost or high frequency diagnoses

        • Coding specificity problems

      • Program expenses

      • Competition against other programs for $$

      • Rewards not easily measured in the numbers

    • Purchasers not demanding programs


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HEDIS 2000: MCO Perspective

  • Administrative data poor at identifying truly at-risk

  • Not consistent with existing guidelines (CDC, ACOG)

  • HEDIS is overly broad esp. wrt 20-25 y/o

  • Literature inadequately describes prevalence of CT in insured non-adolescent populations.

  • Cost-benefit analyses lacking in MCO populations

     Difficult for health plan to support HEDIS


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HEDIS 2000: Physician Perspective

  • Aetna Ob Gyn National QA committee

    • Agree with screening sexually active <20 group

    • Resistance to routine screening >20y/o

      • Existing guidelines do not promote this (CDC, ACOG)

      • Published studies do not reflect their population

      • Perception that CT is not prevalent in insured populations

      • Resist time spent on this issue

    • Prediction: minimal buy-in by physicians

  • Actions:

    • Chart review of CT point prevalence in 6 practices across country

      • 1% prevalence


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October 2000

  • Problem

    • Internal data and physician perception does not match public health perception or HEDIS objectives.

  • Action:

    • Collect data outside of health plan:

    • Study support:

      Baylor College of Medicine

      Obstetrics and Gynecology Associates, PA

      Texas Dept of Health

      Aetna


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Research Objectives

  • Determine rate of testing among commercially insured women ages 15-25 in conventional practice. (Part 1)

  • Determine CT prevalence in commercially insured women ages 15-25. (Part 2)

  • Setting: OGA, PC

    • large single specialty, private ObGyn group practice, Houston, TX.


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Intervening Events: 2001

  • USPSTF recommendations

  • HEDIS 2000 results for health plan and market

    • Aetna 16.6%

    • Houston market: 17%


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Retrospective Study (Part 1): October 2000

  • Objective:

    • Describe testing practices of MDs in conventional practice setting.

  • Design

    • Retrospective study

    • 600 women, 15-25 y/o, commercially insured, requiring pelvic exam between 4/01 and 10/01.

  • Outcome

    • Rate of testing in high risk women.

      • High Risk=ACOG or CDC definition


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Retrospective Study Findings:October 2001

  • 27% population had at least one risk factor (ACOG/CDC)

    • 30.9% patients with risk factors were tested

    • 36% of sexually active teens tested

  • 98% population had ‘HEDIS risk factor’

    • 22% of all HEDIS population tested

  • All testing was done with non-amplified nucleic acid hybridization cervical swabs.


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Cross Sectional Study (Part 2): October 2000

  • Objective

    • Determine prevalence of infection

    • Compare prevalence rates using 2 different assays

      • Non amplified vs. DNA strand displacement amplified probe

  • Study Design: CS

    • 455/600 women, 15-25 y/o, commercially insured

    • Amplified and non amplified cervical swabs

    • Sexual risk factor questionnaire at completion of exam.

      • “HR” for infection=ACOG or CDC definition


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CS Results: Demographic and behavioral characteristics, October 2001

  • Mean age: 22.5 years, 16% <20 years old

  • White 67%, black 15%

  • Unmarried 74%

  • Nulligravid 72%

  • Annual/new gyn 73%, obstetrical 8%

  • Asymptomatic 83%; 95% w/o sequelae

  • Sexually active 91%

  • Inconsistent use of barriers 66%

    • Contraceptive use 60% (hormonal 48%, condoms11%)

  • New or multiple partner past 12 months 29%

  • STD dx or tx past 12 months 15%

  • 82% with at least one high risk factor


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CS Results: Chlamydia Prevalence* October 2001

N # Pos. % P

Total 443 23 5.2

Age

<20 69 4 5.8 .8

20-25 374 19 5.1

Sexually active + Age

<20 59 4 6.8 .6

20-25 340 17 5.0

*amplified probe


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CS Results: October 2001Comparison of amplified to non-amplified probe


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Conclusions: commercially insured population October 2001

  • Testing underperformed in routine practice

  • Risk factors are common when systematically assessed.

  • Prevalence is higher than anticipated (5.2%)

  • Amplified probes are more sensitive.

  • Optimal risk factor ascertainment identified 83% of infections.

    • HEDIS identified 91% of infections

  • Estimate that 75% of infections undetected.


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Actions: November 2001 October 2001

  • Represented to OB GYN QA Committee

    • Study findings

    • USPSTF recommendations

    • HEDIS rates

  • Physician perception changed

    • Advised to disseminate information


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External Dissemination October 2001

  • Local

    • Physician education

      • Baylor College of Medicine-5/2001; OGA-5/2001

      • Women’s Hospital Grand Rounds-4/2002

      • Mailing to 4,000 OB GYNs, Peds, PCPs Houston-2/2002

    • Lab education

      • Working with contracted lab to educate MDs about tests available-2/02

    • Public Health authorities 2/02

      • City of Houston Health Dept

      • School of Public Health

      • Harris County Medical Society


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External Dissemination October 2001

  • Local

    • Baylor College of Medicine-5/2001; OGA-5/2001

    • Women’s Hospital Grand Rounds-4/2002

    • Mailing to 4,000 OB GYNs, Peds, PCPs Houston-2/2002

    • Contracted lab to work on physician education re:tests 2/02

  • State wide

    • Texas Dept. Health-8/2001, 1/2002

    • Houston Dept Health, Harris Co Medical Society –2/2002

  • National

    • Aetna Physician Newsletter-123,000 MDs-2/2002

    • Professional meetings: ASRM-10/2001; National STD meetings-abstract #352

    • AAHP-1/2002


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External Dissemination October 2001

  • State wide

    • Texas Dept. Health-8/2001, 1/2002

  • National

    • Aetna Physician Newsletter-123,000 MDs-2/2002

    • Professional meetings: ASRM-10/2001; National STD meetings-abstract #352

    • AAHP-1/2002


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Internal initiatives October 2001

  • All HMO members informed about USPSTF recommendation in Pap reminders-2000

  • National and local QA committees

  • Market initiatives

    • Direct member education linked to BCPs use-Phila

    • Physician education modules-Alabama

    • Follow up barrier analysis-Houston

  • National HEDIS strategies ???


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Lessons learned October 2001

  • Identify barriers to health plan and physician buy-in.

  • Recognize importance of appropriate data for health plan to make decisions.

    • Generate data to get buy-in within health plan

  • Partner with community to identify barriers, disseminate findings, facilitate change.