Extending Preventive Care to Pediatric Urgent Care
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Transcript of Extending Preventive Care to Pediatric Urgent Care
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Extending Preventive Care to Pediatric Urgent Care
A Partnership Between:University of California, San Francisco
& Kaiser Permanente Northern California
Mary-Ann Shafer MD & Kathleen Tebb PhD
Presentation to STD Prevention ConferenceMarch 10, 2004
Funded by the Centers for Disease Control and Prevention & The Agency for Health Care Research and Quality
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BackgroundBackgroundFacts About Facts About Chlamydia Trachomatis (CT)Chlamydia Trachomatis (CT)
• Rate is 6-12% in teen females
• 70-80% are asymptomatic
• 10-20% untreated PID infertility
• NAATs 90-95% sensitivity/specificity
• Nat’l Guidelines annual CT screen
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Background cont.Background cont.
• Clinical Practice Improvement intervention (CPI) increased CT screening of sexually active teens at pediatric well care visits (WCVs)
• Yet, over 50% of adolescents are seen only for urgent care visits (UCVs), in any given year
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JAMA December 11, 2002
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Learning ObjectivesLearning Objectives
• Review the development, implementation and evaluation of a systems-based intervention for CT screening
• Understand utilization patterns of teens seen in well versus urgent care
• Discuss the translation of the CPI model to different clinical settings
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Study ObjectivesStudy Objectives
• Develop a modified CPI (clinical practice improvement) intervention to address barriers to CT screening during UCVs
• Examine feasibility of CT screening attending pediatric UCVs in a large HMO
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MethodsMethods
Setting
Large HMO in Northern California: KPMG
• 2 Pediatric clinics participating in the previous well-care CPI intervention
• 14-18 yo females seen for UCVs
• ~4,000 enrolled 14-18 yo adolescent females in 2 sites
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Methods
Urgent-Care Visit
• Same/ next day visit
• Sick/ non-ER visit
• 10 minute visit
• Same physical setting as WCV
• Same providers & staff as WCV
KP Pediatric Setting cont.
Well-Care Visit
• Appointment required
• Physical exam (every 2-3 yrs)
• 20 minute visit
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MethodsMethods
Design
Pre-Post test study
• Provider survey (anonymous) to assess attitudes toward screening in UCV
• Teen survey (anonymous) for sex active rate
• Comparison of baseline CT screening rates to 6 month post-test rates
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Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
Clinical Practice Improvement Model
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Clinical Practice Improvement Model
Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Leadership
•Best practices
•Define gap
•Raise Awareness
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Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•ACTeam•Skill building•Tool Kit
Clinical Practice Improvement Model
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Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Customize•Measure success
Clinical Practice Improvement Model
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Engage
Team Building
Re-Design Clinical Practice
Sustain the Gain
•Monitor performance•Time series analysis•Continuous improvement
Clinical Practice Improvement Model
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ACTeam MeetingACTeam Meeting• Set GoalSet Goal• Identify barriersIdentify barriers• Decide solutionDecide solution• Try it outTry it out• ReassessReassess• Repeat “cycle”Repeat “cycle”
Time in months
% C
han
ge in
STD
Scre
en
ing
Rate
S t a t u s Q u o
Rapid CycleRapid CycleChangesChanges
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Urines To Lab
MD/NPVISIT
RoomPatient
MA refrigerates FVUs A enters teen name, confidential # in clinic log book LRunner takes FVU to lab
MD/NP obtains sex hx
If sexually active, MD completes CT lab slip WWWrites confid. # on chart
MA collects FVU on all 14-18 yo F TTeen takes FVU sample to exam room
CueCharts
ID eligible teensC
Charts are stamped with cue
Follow-Up
RN contacts CT + teen: confid. #
Teen comes to clinic for Rx
RN enters Rx in STD log book
Site Specific Flow Chart
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Data Bases and Analysis
Data Bases
• Registration + lab + anonymous survey of teens for clinic specific screening rates
Data Analysis
• Mann-Whitney/T-test
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Data Analyses: CT Screening Rate
Screening Rate = No. of CT tests
Sexually active teen females*
*Site specific sexual activity rates determined by anonymous survey
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RESULTS
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Urgent Care vs Well Care PopulationUrgent Care vs Well Care Population
Teen girls who utilize urgent care compared to well care visits have a higher STD risk profile:
• Older (15.7 vs 15.4 years)*
• More ethnically diverse (Cauc/Asian vs. Oth)*
• Higher sexual activity rates (42% vs 26%)*
*p<0.05
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Pediatrician Survey ResultsCT Screening Likelihood during UCV: (1=not likely, 4=very likely)
Teen Chief Complaint MD Mean Rank SD Asthma 1.26 0.52
URI 1.30 0.57
Minor trauma 1.31 0.58
Non-reproductive visit 1.64 0.74
Abdominal pain 2.84 0.90
Vaginal bleeding 2.98 1.12
Pregnancy test 3.45 0.86
Requested by patient 3.87 0.58
STD symptoms 3.91 0.44
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MD’s Top 3 Barriers to UCV Screening
1. Parents in room/confidentiality
2. Competing priorities
3. Discomfort in taking sexual history
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RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites
0
10
20
30
40
50
60
70
2000 2001 2002 2003
Year Clinic AClinic B
% S
A F
emal
es
Scre
ened
for C
T
A
A
B
B
B
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Conclusions
• CT screening in pediatric UCVs is feasible
• Significantly more teens screened for CT
• Clinic differences different results
• More research needed (e.g., RCT, more clinics)
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Implications
• CT epidemic universal screening recommended
• Most teens seen only in UCVs and they have a higher STD risk profile screen for CT in well and urgent care
“Do Today’s Work Today”
• The CPI model (rapid-cycle change) may be generalizable to other services & clinic settings
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Implications cont.
• Rapid cycle quick, dramatic & sustained
• Effective in different settings- well & urgent and likely others as well
• Capitalizes upon existing resources & staff
• Small changes LARGE effects
• Gives chronically over-worked staff sense of importance, success & control over workplace
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