# Presentation: 784778

## Integrating STD Standards of Care into Family Planning Services: Evaluation of chlamydia screening practices and development of a quality improvement intervention

**Joan M Chow****1****, Laura J Packel****1****, **
**Linda Creegan****1****, Heidi M Bauer****1****, **
**Jan Treat****2****, Gail Bolan****1**
- 1Sexually Transmitted Disease Control Branch,
- 2Office of Family Planning,
- California Department of Health Services

- CDC National STD Prevention Meeting, Philadelphia, March 8, 2004

**Notes:**
I would like to thank my co-authors Laura Packel, Linda Creegan, Heidi Bauer, Jan Treat and Gail Bolan for their contribution to this work.

## Presentation Overview

- Baseline assessment of chlamydia screening coverage in a large family planning program
- Development of provider-specific intervention
- Summary of provider feedback about the intervention
- Next steps in the evaluation

**Notes:**
I would like to start with an overview of the presentation.  First, I will be describing the baseline assessment of chlamydia screening coverage for a large family planning program.  This will be followed by how we used these data to develop a provider-specific intervention. Lastly, I’ll summarize some of the anecdotal feedback that we received from providers and next steps planned to evaluate the intervention. 

## Background

- Chlamydia screening guidelines recommend annual screening of young females
- Integration of chlamydia screening standards important in family planning programs
- Low screening coverage (<50%)
- Programs need to develop
- Reliable methods to assess screening
- Interventions to improve performance
- Evaluate provider screening rate after the provider-targeted intervention

**Notes:**
National guidelines as set by the Centers for Disease Control and US Preventive Services Task Force recommend annual chlamydia screening for young women aged 25 years and younger.
Integration of chlamydia screening standards are particularly important for family planning providers since they serve a significant number of women in this age group.  This is an opportunity to screen and identify asymptomatic chlamydia infection to prevent adverse reproductive health outcomes.
However, preliminary estimates indicate low screening coverage and in many settings, screening is less than 50%.
Programs serving young women need to 1) develop reliable methods to assess chlamydia screening rates, and 2) to develop interventions to improve provider screening performance.

## Study Goals & Objectives

*Study Goal:* To improve chlamydia screening rates
*Study Objectives:*
- Assess baseline proportion of female clients age 15-25 years screened for chlamydia by specific provider
- Inform providers of screening performance plus targeted message

**Notes:**
The overall goal of this study is to improve chlamydia screening by family planning providers.
The specific study objectives are threefold:
First, to assess the baseline proportion of female clients age 15-25 years who are screened for chlamydia by a provider and
Secondly, to inform providers of their screening performance accompanied by a targeted message based on their baseline level of performance and
Thirdly, to evaluate provider screening performance after the targeted quality improvement intervention.

## Methods: Assessment of Chlamydia Screening Coverage

*Program Characteristics:*
- California Family PACT comprehensive reproductive health program provides family planning and STD services
- Eligible: Californians ≤ 200% Federal Poverty Level
- Public and private sector providers

**Notes:**
The California Family PACT comprehensive reproductive health services program has served over one million female and male clients annually since 1997.
The goal of the program is to improve access to family planning and STD services for Californians at or below the 200% federal poverty level. 
Providers of these family planning services include Medi-Cal enrolled providers from both the public and private sector.

## Methods: Chlamydia screening estimates

- Data:
- Client enrollment, Medi-Cal provider enrollment, and paid claims data based on fee-for-service
- Chlamydia tests identified by CPT-4 codes
- Denominator: female clients age 15-25 for FY 2001-2002
- Numerators: Testing in FY 2000/2001 or year before or after

**Notes:**
The methods used to estimate chlamydia screening rates comes from three main sets of data: client enrollment, Medi-Cal provider enrollment, and paid claims for clinical and laboratory services reimbursed on fee for service.
All chlamydia tests were identified based on CPT-4 codes.
Clients that were included in the screening coverage denominators were female clients age 15-25 who had a clinical service in FY 2001-2002.
Testing was captured in the screening coverage numerator if the testing was done either in FY 2001-2002, or in the year before or the year after.  This estimate would constitute a liberal estimate of screening coverage.

## Distribution of chlamydia screening coverage by public vs. private provider type

**Notes:**
This graph summarizes the distribution of chlamydia screening rates for public versus private sector Family PACT providers.  These providers served at least 100 female clients age 15-25 in FY 2001/2002.
The distribution of public providers in the green bars is more concentrated in the 40-60% screening rates with 26% of Family PACT providers with chlamydia screening rates of 51-60%. The private providers in the blue bars are relatively more distributed across all screening rates with only 15% of private providers screening 51-60% of their young clients for chlamydia. 
However, overall the median chlamydia screening rate was 53%, not significantly different between the public and private providers.
Lastly, <10% of public and private providers were screening >80% of young women seen in FY 2001/2002.

## Methods: Provider Quality Improvement Intervention

- June 2003: Clinical Practice Alert and training coupons sent to all Family PACT providers (n~2000)
- Sept 2003: Letter with provider-specific CT screening data sent to Family PACT providers who served at least 100 females age 15-25 in FY 01/02 (n=879)

**Notes:**
In June 2003, a Clinical Practice Alert that described program chlamydia screening guidelines for females age 25 and younger was sent out to approximately 2000 Family PACT providers.  In addition, a coupon to attend for free an STD/HIV Prevention Training Center STD update was included.
In Sep 2003, this was followed by a letter with provider-specific screening data.  This was sent to each Family PACT provider that served at least 100 females age 15-25 years in FY 2001/2002.  The letter contained the numbers of females they served in this age group and the proportion of these women that received a chlamydia test either in that same year or in the year before or after.
In addition to their screening rate, a specific note regarding their level of performance was included.

## Slide 9

**Notes:**
This is an excerpt from the Clinical Practice Alert that was sent out to all Family Planning providers.  
The screening recommendations are highlighted here in yellow and reads:
“Screen all sexually active females 25 years of age and younger annually for chlamydia.  Additional CT screening only as clinically indicated.”

## CT Screening Letter Intervention

**Low Performance (<50% CT screening)**
*“**Your CT testing rates are well below average and quality improvement activities to improve these rates should be implemented.”*
**Mid-level Performance (50-79%)**
*“**Your CT testing rates indicate that there is some need for improvement in order to ensure that the majority of young women in your practice are tested.**”*
**High Performance (80% and higher)**
*“**Your CT testing rates indicate that you are doing well in testing the vast majority of young women in your practice.  You are to be congratulated. if you would be willing to share methods for implementing a successful CT testing program for young women, we would appreciate hearing from you.”*

**Notes:**
In the CT screening letters, there were three levels of performance noted: Low performance, mid-level, and high performance.  Low level performance was defined as a provider who screened less than 50% of the young women seen in FY 2001/2002, mid-level was those who screened 50-79% of the young women seen, and high level was those who screened at least 80%.
The CT letters also contained targeted messages what follow-up actions were recommended based on the screening rate.
[Read the text]
The letters also included a phone contact in the Office of Family Planning for further consultation

## Provider Telephone Feedback 

- Providers were encouraged to phone OFP with questions/concerns
- Standardized phone contact sheet used to monitor provider concerns
- Information collected :
- Possible reasons for screening level
- Current  screening policy
- Request for technical assistance

**Notes:**
Providers were encouraged to phone the Office of Family Planning with any questions or concerns about the letters but they were not required to do so.
When  a provider did call, the nurse consultant used a standardized phone contact sheet to document provider concerns and questions.
This contact sheet collected possible reasons for the provider’s screening level, what the current clinic screening policy was, and any requests for training or technical assistance on these issues.

## Provider Telephone Feedback

|  | N | % |
| --- | --- | --- |
| Screening rate |  |  |
|   <50% | 27 | 6.8 |
|   50-79% | 16 | 3.8 |
|   ≥80% | 2 | 3.6 |
| Total | 45 | 5.1 |

**Notes:**
This table shows the proportion of providers who called the Office of Family Planning after receiving the chlamydia screening letters.
Overall, given that phone contact wasn’t required, it is not surprising that only about 5% of all providers called the office within 2-3 months after the mailing.
The group with the most number of feedback calls was the group with a less than 50% screening rate.
There was no difference by provider type

## Provider Reported Reasons for Low Screening

- Laboratory not billing Family PACT
- No pelvic examination performed
- Patient refusal
- Patient low risk
- Patient screened prior to Family PACT enrollment

**Notes:**
During the telephone contacts with providers, various reasons for low screening were discussed.  
The most common reasons that were cited were 
1) The laboratory was not billing chlamydia tests to the Family PACT program and
2) No pelvic examination was performed and thus a specimen was not taken for chlamydia testing.  Examples of these types of visits tended to be for emergency or injectable contraception, or pregnancy test only.
Other reasons for low screening rates included patient refusal, patient considered low risk, and patient was already screened in another program such as prenatal services prior to enrollment in Family PACT.

## Screening practices reported by responding providers

- Screen only females age 15-25 annually
- Screen those with behavioral risk factors regardless of age
- Screen everyone routinely including both females ≤ 25 and >25

**Notes:**
When asked about current screening policy, there were a variety of policies in effect that ranged from adhering strictly to the program guidelines to screening those with risk factors regardless of age, to screening everyone regardless of age.
Overall, most or only some of the responding providers were following the state CT screening guidelines summarized in the clinical alert.

## Limitations to Data

- Screening coverage estimates
- Paid claims data only
- Provider number does not represent an individual provider
- Provider intervention
- Unknown whether letters actually reached the provider/s
- Evaluation of intervention
- Preliminary feedback was voluntary

**Notes:**
Some limitations should be considered.
In terms of screening coverage estimates, it should be noted that these data are based on paid claims for laboratory tests.  Laboratories may have performed testing but did not submit a claim that was paid.
The provider number is a billing number for payment purposes and may represent either one provider or a group of providers.  The estimate of screening coverage may not accurately represent any one provider’s screening behavior.
With respect to the provider intervention, it is not known whether letters actually reached the clinical providers.  The letters may have gone just to the billing office without being distributed to the clinical staff.
The evaluation of this intervention to date consists of voluntary feedback through phone calls to the Office of Family Planning.  A more systematic attempt to get representative feedback from all providers is planned to evaluate the impact of the evaluation.

## Next Steps:

- 1) _**Medical Record Validation of claims data**_
- Sample charts for Family PACT female clients age 15-25 years in FY 01/02
- Identify chlamydia test in past 12 months of current visit
- Compare with estimates from claims data
- 2) _**Provider evaluation**_
- 	Phone survey of random sample of providers to see if received letter and impact on practice
- 3) _**Assess CT screening rates**_** pre- and post-provider-specific CT screening quality improvement intervention **

**Notes:**
The next steps for follow-up are 3-fold.
Medical record validation
Provider evaluation and follow-up
Pre- and post CT screening rate assessment
For the medical record validation, we will be focusing on those providers who responded by phone who had concerns about the accuracy of the screening coverage estimates because of unpaid laboratory tests.
We propose to conduct a targeted chart review sample for young female clients in which we will identify if a chlamydia test was documented either in the current visit or in the previous 12 months.
We could then compare the chart review results for screening coverage with the claims data estimates for validation.  
If disparities are found, future modifications of the claims data estimates may be needed before further screening data are sent.
For the provider evaluation, we propose to conduct a phone survey of a random sample of providers to see if they actually received the letter and to ask about any impact of the letter on their screening practices.
For the assessment of CT screening rates pre- and post-provider-specific CT screening quality improvement intervention, we will be focusing on rates in the 2-3 month period before and after the intervention.

## Conclusions

- Baseline screening coverage was only 53%
- Intervention needed to improve
- Provider-specific screening data important for targeting training
- <50% screening rate as priority
- Dissemination of provider screening data encourages feedback
- Annual monitoring of provider screening needed to evaluate impact of letter intervention
- Continued quality intervention likely necessary

**Notes:**
In conclusion, the analysis of claims data showed that the baseline median screening rate for Family PACT was 53%.
Clearly, this level of screening fell short of the target of all young females being screened, and an intervention was needed to improve this rate.
Provider-specific screening data enabled us to target specific providers who may need additional training or technical assistance.  Those in the less than 50% group constitutes a high program priority. 
The dissemination of screening coverage data can actually encourage dialogue about the relevance of program screening policy to specific clinic populations and also initiate further investigations into the validity of the methods used for estimation.
Additional monitoring of provider-specific screening would be helpful to fully assess the impact of this type of data feedback as well as for assessing other provider interventions.
And lastly, continued quality improvements addressing screening rates are likely necessary in the future.
Thank you and I am now open for questions.