Region II IPP Screening Assessment Results

1. Region II IPPScreening Assessment Results Region II IPP Advisory Meeting November 1, 2006 Kelly Opdyke, MPH Cicatelli Associates Inc.

2. Region II IPP Workplan, 2006-2007 • PRIORITY 2: Incorporate Analysis of Regional Prevalence Monitoring Data for Regional and Local Data-Directed Planning and Quality Assurance • GOAL: IPP data will direct the most cost effective implementation of screening and treatment funds. • OBJECTIVE 2B: Identify what percentage of eligible women are being screened on an annual basis among select sites participating in the Region II IPP.

3. Region II IPPMinimum Screening Criteria Title X Family Planning Clinics • All women ≤ 24 years of age attending the clinic for an initial or annual visit will be screened for chlamydia. STD Clinics • All women ≤ 29 years of age attending the STD clinic will be screened for chlamydia.

4. 2007 Proposed CDCIPP “Measures of Effectiveness” Measure 1 “Proportion of Family Planning clinics adhering to regional screening criteria” Measure 2 “Chlamydia screening coverage estimate for 15-19 year old sexually active women seen in Family Planning Clinics”

5. Screening Coverage – Nat’l Data 2005 FPAR Data (OPA): • 58% of FP clients are under age 25 years • 50% of FP clients age 15-24 were tested for CT at least once in 2005 2004 HEDIS Measure (NCQA): • 45% of females age 16-25 in Medicaid plans were screened for CT at least once in 2004 • 30% of females age 16-25 in commercial plans were screened for CT at least once in 2004

6. Region II IPP2005 Screening “Audit” Purpose: • Estimate chlamydia screening coverage among eligible female patients according to Region II IPP minimum screening criteria • Pilot regional methodology for assessing screening coverage and adherence to screening criteria in anticipation of CDC proposed measures of effectiveness

7. Female Ct Testing & Positivity by Provider Type and Project Area Region II IPP CY2005

8. Region II IPP2005 Screening “Audit” (cont’d) Methodology: • Analyze a statistically significant number of randomly selected eligible patient charts from CY2005 • 3.4% sample in FP sites • 7.4% sample in STD sites • Compare observed vs. expected proportion screened • Expect 85% screening coverage in FP • Expect 90% screening coverage in STD

9. Region II IPP2005 Screening “Audit” (cont’d) Sample: • From Apr-Sep 2006, a total of 4,700 records were collected from 208 clinic sites in NJ, NYC, NYS and PR • FP: 2,726 records from 164 clinics (91% of 180 sites) • STD: 1,789 records from 36 clinics (63% of 57 sites) • Other: 185 records from 8 other clinics in NYC & NYS • (2 Adolescent HC, 3 College HC, and 3 Community HC) • 64 records fell outside age criteria for clinic type and were excluded from analysis • (Removed 3 FP, 26 STD, 35 other)

10. Data Collection Tool • Clinic ID • Client ID • Age of client • Was client tested for chlamydia? • If NO chlamydia test done, reason for not testing (select all that apply): • Client refused • No new risk • Not sexually active • Tested / treated for chlamydia in past 30 days • Referred for Treatment • Not recorded in chart • Other (specify)

11. Results – FP Clinics • Overall, 86.0% (2,343/2,723) of females under age 25 seen for initial or annual exam were tested for Ct (95%CI: 84.7%-87.3% ) • By clinic site, the prop. screened ranged from 0% to 100%, with a weighted avg of 89.8%. • Most common reasons for not testing (n=380): • Client refused 31.8% • No new risk 16.1% • Not sexually active 12.1% • Menses/Bleeding 9.2% • Tested/Tx’d in last 30 days 8.7% • *No pelvic exam 2.1% *NOTE: No overlap between “menses/bleeding” and “no pelvic exam” responses.

12. FP Screening Coverage(Expected 85%)

13. Results – FP Clinics (cont’d) • † Adjusted overall screening coverage in FP is 89.6% (2,343/2,614) (95%CI: 88.4%-90.8%) • In Puerto Rico, most common reasons for not testing were (n=81 of 154 sampled): • Not recorded in chart 24.7% • Client absent for medical exam 22.2% • No physician available 16.0% • Menses/Bleeding 16.0% • Client did not assist for med exam 8.6% • Client refused 6.2% † Adjusted by removing 109 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

14. Results – STD Clinics • Overall, 74.4% (1,312/1,763) of females under age 30 seen in STD clinics were tested for Ct (95%CI: 72.4%-76.5%) • By clinic site, the prop. screened ranged from 16.7% to 100%, with a weighted avg of 75.3%. • Most common reasons for not testing (n=451): • Tested/Tx’d in last 30 days 37.9% • Other reason for visit 27.3% • Referred for treatment 21.7% • Other (not specified) 15.3% • Not recorded in chart 6.9%

15. STD Screening Coverage(Expected 90%)

16. Results – STD Clinics (cont’d) • † Adjusted overall screening coverage in STD is 83.2% (1,312/1,576) (95%CI: 81.4%-85.0%) • Among clients not screened because of “other reason for visit” (n=123 of 451 not tested): • Emergency contraception only 57.7% • HIV/syphilis/blood test only 19.5% • Treated for another STD 13.8% • Hepatitis vaccine 6.5% † Adjusted by removing 187 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

17. Results – Other Clinic Types • Overall, 71.3% (107/150) of females under age 25 were tested for Ct (95%CI: 64.1%-78.6%) • By clinic site, the prop. screened ranged from 36.8% to 100%, with a weighted avg of 69.2%. • Most common reasons for not testing (n=43): • Other reason for visit 34.9% • Not recorded in chart 16.3% • No new risk 11.6% • Tested/Tx’d in last 30 days 11.1% • Client refused 9.3%

18. Screening Coverage in Other Sites(No Baseline). Criteria: Females age < 25 Data submitted for sites in NYC and NYS only

19. Results – Other Clinic Types (cont’d) • † Adjusted overall screening coverage in Adolescent, College, and Community HC’s was 79.3% (107/135) (95%CI: 72.5%-86.1%) • Consider expanded assessment of screening coverage in Adolescent HC for future analysis • Is screening coverage lower than in other FP sites? † Adjusted by removing 15 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

20. Discussion • Chlamydia screening coverage among females who meet the Region II IPP minimum screening criteria is high (>80%) overall, but varies by provider type, project area, and clinic site. • Programs should utilize local data to target efforts to increase screening coverage. • Screening coverage estimates are based on reason not tested at this visit (cross-sectional) • CDC guidelines recommend at least annually • Screening may take place at another visit in the year • In all clinic types, reason why females who fit age criteria are not screened should be routinely recorded in client chart to facilitate follow-up

21. Discussion (cont’d) • In FP clinics, client refusal accounts for a large proportion (31.8%) of those not screened. • Screening coverage may be improved in part by educating providers on strategies for increasing clients’ acceptance of testing. • In STD clinics, adjusted screening coverage could increase from 83.2% to 89.3% if females < 30 yrs seen for EC or HIV/blood test only were routinely screened for chlamydia • Programs should consider local screening criteria • Further analysis should focus on more clearly defining potential barriers to screening. • (e.g. What does “not sexually active” mean?)

22. Implications/Discussion • Region II IPP minimum screening criteria for FP include only those women who have an initial or annual (i.e. pelvic) exam • In the past, chlamydia testing required the collection of a cervical specimen. • Highly-sensitive urine-based NAATs (nucleic acid amplification tests) provide an opportunity for expanded screening to additional high-risk clients.