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

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.

1. Schafer, JAMA 2002;288 (22):28462. Scholes, N Engl J Med 1996;334(21):1362

Background

3. Brackbill. Fam Plann Perspect. 1999;31(1):10-5

3

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

Private Sector

3. Hobgen Obstet Gynecol 2002;100(4):801-7.4. http://www.ncqa.org/sohc2003/chlamydia_screening.htm

5

Outreach to greater than 125,000 physiciansChlamydia Tool kits – Screening and laboratory guideline updates– Patient fact sheets– Patient self assessment tools

CMEsFeedback on HEDIS performanceLunch and learns-mid-level practitionersAnnual preventive health remindersCollaborations with national labs

Health Plan Initiatives

9

What’s the Reward?

HEDIS: Commercial Plans

Age 2000 2001 2002 2003

Aetna NCQA Aetna NCQA Aetna NCQA Aetna NCQA

<20 16.8 18.5 16.3 23.6 16.3 24.5 16.0 26.7

20-26 13.8 16.0 14.0 20.7 15.2 22.1 15.4 24.6

A National Survey of Genital Chlamydia trachomatis Screening Practices and Attitudes of U.S.

Obstetrician Gynecologists

Joanne Armstrong, MDHaleh Sangi-Haghpeykar, PhD

Alice Shen, MD

Baylor College of Medicine Houston, Texas

11

Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women

Identify barriers and facilitators to compliance with screening guidelines

Study Objectives

12

Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women

Identify barriers and facilitators to compliance with screening guidelines

Study Objectives

13

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

Study Design

14

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

15

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

16

Mailed in 3 waves-March 20031. FedEx: survey, information sheets, $15 gift cheque2. Reminder Postcard3. Priority Mail: survey

Reviewed and approved by BCM IRB

Study Design

17

Results

1,100 surveys sent to Ob/Gyn Physicians

410 completed, eligible returned surveys

42.7% response rate

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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

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Screening frequency by patient subgroup

PatientSub-group

Never screen

%

Screen <25%

%

Screen 25-49%

%

Screen 50-74%

%

Screen >75%

%

Pregnant 12.7 6.4 5.3 4.3 63.9

Non-pregnant, <20 yrs

35.2 15.6 13.4 11.7 21.6

Non-pregnant 20-25 yrs

48.5 20.8 12.3 7.0 8.5

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Demographic Variables Associated with Screening* non-pregnant,

sex active age 20-25 years

Demographics Screeners N=34

Non-screeners

N=376

Adj. OR (CI)

P

MD Race/Ethnicity (%)White 55.9 81.6 1 0.001Black 23.5 3.8 4.5(1.2, 15.6) <.0001

Asian 17.7 11.1Hispanic 2.9 3.4

Patient Age (%)

<13 1.2 113-19 10.9 11.520-26 28.7 24.4 0.0227-40 33.2 31>40 25.9 31.3

Patient Race (%)

White 44.9 63.1 <.0001Black 27.8 17.1 0.0003Hispanic 18.7 12 0.01Asian 7.9 6.1

* Denotes screening all sexually active women ages 20-26 years at least 75% of time .

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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

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Current Experience with CT and

Comparison of Screeners* to Non-Screeners

Total Screeners Non-screeners

N=410 N=34 N=376Number of CT cases diagnosed

Past 6 months 6.2 + 10.7 7.6 6 Past year 11.4 + 19.1 14.2 11.1Number of PID cases diagnosed Past 6 months 3.3 + 9.0 3.3 3.3 Past year 6.0 + 17.2 5.3 6.1Estimate of CT prevalence in primary practice

<3% 39.7 26.5 40.93%-5% 35.7 26.5 36.55.1%-10% 17.8 23.5 17.3>10% 6.8 23.5 5.2 0.001

Target prev above which screening indicated

Yes 20.6 23.5 20.3No 79.5 76.5 79.7If yes, what percent? (%) 10

Low prev. makes screening unnecessary** 1.8 2.6 1.6 0.001

P

•Denotes screening all sexually active women ages 20-26 years at least 75% of time.

•**Denotes mean response 1= strongly agree, 5=strongly disagree

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Screening Test Utilization of Screeners compared to

Nonscreeners

Total Screeners Non-screeners

N=410 N=34 N=376Screening tests used most frequently (%)

Not sure 6.9 6.1 8.1Laboratory culture 5.2 3 6.2EIA 6.7 9.1 7.5DNA probe 47.3 39.4 55.3

Nucleic acid amplification test 21.5 39.4 23 0.04

Attitude about NAATs * N=223

Tests not available for use 26.1 11.5 13.2Test not available through a contracted laboratory 30.6 22.1 14.2

Tests are too complicated to use 0.1 0 <1.0

Tests are too expensive for patients 33.3 0 18.9 0.02

Tests are not covered by insurance 30.6 3 16.8Tests do not offer any advantage over other tests 20.7 3.9 10.9

*Number represents percent of respondents who strongly agree or agree

P

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ConclusionsPhysicians 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 Significant quality concerns…and opportunities.. identified in chlamydia screening in commercially insured womenscreening in commercially insured women