WI State Report
RVIPP Meeting
Chicago: February 2-3, 2011
Wisconsin State ReportRVIPP Meeting Chicago: February 2-3, 2011
Timeliness to Treatment Update: STD Treatment Audit in FP PPW STD Treatment Audit in FP non-PPW
New Initiatives & Updates: Rural Prevalence Project Milwaukee School Based Testing Trends
2009-2010 Milwaukee Jail Screening Project Condom Survey EPT
Timeliness to Treatment STD Treatment Audit in PPW
Audit provided an opportunity to examine Quality Assurance measures in FP
Treatment rates for chlamydia and gonorrhea Compare treatment rates generated from Treatment Audit
to treatment rates generated from WEDSS reported morbidity data
Re-testing rates for chlamydia and gonorrhea Included in STD Treatment Audit
STD Treatment Audit in PPW conducted in June 2010 STD Treatment Audit in non-PPW to be rolled March
2011 The results of this first audit effort will provide baseline
measures for standard of care expectations in FP statewide
Timeliness to Treatment STD Treatment Audit: PPW
Summary of Treatment Audit in 25 PPW Clinics Maximum of 25 charts reviewed per clinic: (20 females,
5 males) Positive CT and/or GC test results for males and females
High volume clinics: randomly select maximum of 25 positives from 4th quarter 2009
Medium volume clinics: randomly select maximum of 25 positives from 4th quarter 2009
Low volume clinics: select positives from 2009 up to a maximum of 25 positives
STD Treatment Audit: PPW
Electronic Excel Spreadsheet Each clinic entered data from chart
review electronically Grand total site summary of results
PPW Females Positive for Ct Rx rates Re-test Rates
STD Treatment Audit: PPWTreatment Rate for Females Positive for CT
Overall CT Treatment Rate in Females:431 Females + for CT 367/431 treated (85%) Treated women (n=367):
18% ( 67) patients >=25 26% ( 97) patients <19 55% (203) patients >=19 <25
Days to Treatment (N=367) 98% (359/367) Rx <=30 days; 92% (338/367)% Rx <=14days 83% (359/431) Rx <=30 days; 78% (338/431)% Rx <=14days
Range: 0-133 days Average: 7 days Same day RX: 30% (109) patients > 14 days 8% ( 29) patients > 30 days 2% ( 8) patients
STD Treatment Audit: PPWTreatment Rate for Females Positive for CT
Overall CT Non-treatment Rate in Females:
431 Females + for CT64/431 not treated (15%)Non-treated women (n=64):
17% (11) patients >=25 25% (16) patients <19 58% (37) patients >=19 <25
PPW Audit Rx Rate Compared to WEDSS Reported Morbidity Rx Rate Females Positive for Chlamydia
2009 Data
Data Source 2009
Overall Rx Rate Rx Rate <=14 Days
Rx Rate <=30 Days
Audit PPW (N=431) 85% 78% 83%
WEDSS PPW (N=1576)
75% 72% 75%
WEDSS All FP (N=2594)
78% 76% 78%
STD Treatment Audit: PPWRe-testing Rate among CT Positive Females
2010 PPW Audit Results for Re-testing 42% PPW Females Re-tested (153/367) Positive at Re-test:
12% (19 patients/153)
Days to Re-test Range: 0-329 days Average: 107 days Re-tested <30 days: 13% (20) Re-tested <90 days: 48% (73) Re-tested >=90 days*: 52% (80)
*Recommended time frame
STD Treatment Audit: PPWRe-testing Rate among CT Positive Females
Plan to evaluate rates of re-testing in FP as a quality assurance measure in FP clinics
Plan to include ‘Re-tested?’ field in PPW STD Tx Audit Tool in July 2010
PPW will add a required field for ‘Re-tested?’ to Electronic Medical Record when ready in July 2011
Recommendations to re-test in FP Program Guidelines will include males and females
When have SSC changes from prevalence evaluations finalized, will add these changes and ‘Re-screened?’ field to laboratory request form at SLH
STD Treatment AuditNext Steps
Will improve electronic spreadsheet before rolling out non-PPW Audit based on PPW Audit experience Facilitate consistency in data collection Facilitate analysis
Lots of data to sort through Adherence to SSC GC Rx rates and timeliness Males Demographics (age/race, etc.)
Individual Report Cards for each of 25 clinics
Rural Screening Project: non-PPW FP Clinics
Low Prevalence of CT (<3%) When prevalence is low, how do we
improve our ability to find those chlamydia positives we KNOW are in the haystack of negatives?
Rural Screening Project
4 sites in Northern Wisconsin participated in Universal screening for the months of April and May Objective: to estimate CT prevalence in
rural non-PPW clinic populations Determine if there are risk criteria
outside of the evidence based SSC currently in use in WI FP which add greater sensitivity to the risk assessment for CT and GC infection in men and women attending these clinics
Rural Screening Project
Preliminary Findings Nuances of interviewing patients
important Consider the consistency and how
questions are asked and perceived by the patient
Numbers are small, but prevalence appears to be under 3% threshold
Rural Screening Project‘North of HWY 29’
Four Agencies to be commended for their efforts Oneida Pierce Polk St. Croix
Universal Screening in April-May 2010 included risk assessment for: Current SSC for chlamydia (12 criteria) Non-SSC Reasons for Testing SSC’ (11 criteria
compiled by participating agencies) If no SSC or OC, would you have tested OC?
North of HWY 29
770 total patients (Females and Males) Females
729 total female patients 640 tested; 18 + (2.8%)
Males 41 total male patients 40 tested
12+ (30%) (11/12 met SSC; the one who did not, met OC
28 – 12/28 (43%) of negatives met an SSC 24/40 (60%) would have been tested if not
universally screening
North of HWY 29
SSC met among 18 Positive Females ? 8/18 met SSC (44%) 10/18 did not meet SSC
Off Criteria met among same 18 Positive Females? 16/18 met OC (89%); majority of these
met the >90 day OC 2/18 no OC
BUTTTTT……!!!
BUTTTT…!!!
622/640 (97%) females tested were NEG 344/622 (55%) negative females met
SSC 278/622 (45%) no SSC 514/622 (83%) met OC 108/622 (17%) no OC
Positivity* in 4 Rural Clinics 2009 vs. 2005
Clinic Females 2009 Males Females 2005 Males
Oneida 4.9% (14/286) 23.1% (9/39) 5.8% (21/362) 14.3% (8/56)
Pierce 5.4%(41/761) 13.9% (10/72) 5% (34/680) 20.2% (17/84)
Polk 4.5% (10/221) 33% (5/15) 6.5% (22/338) 28.6% (10/35)
St. Croix 5.5% (24/433) 20.8% (5/24) 6.6% (14/211) 33.3% (7/21)
*Positivity represents selectively screened individuals (not prevalence) Positivity fluctuates over the period of 2005-2009
Rural Screening Project
0
2
4
6
8
10
12
Oneida Pierce Polk St.Croix
2005
2006
2007
2008
2009
Positivity in Females in 4 non-PPW Rural Clinics 2005-2009
%Positive
Preliminary Conclusions:Lessons Learned…
Further multivariate analysis needed…but numbers are very small….
Patients in low prevalence areas may benefit from clinician directed enhancement of discussions with patients to ensure patients are understanding context of questions so their risk for infection is identified more accurately
Preliminary Conclusions:Lessons Learned…
Rural clinician group will summarize their experience and lessons learned regarding more precise interviewing techniques to increase sensitivity of current SSC
How to better define the 90 day time period of risk assessment for patients to improve accuracy of sexual history
Best methods to elicit a thorough and accurate sexual history
Provide Statewide training on these issues through Webinar/WRPHFP meeting
Preliminary Conclusions:Lessons Learned…
Why do we care about digging deeper for positives in low prevalence settings, when we have plenty of them in more urban settings?
Must address clinician trust in SSC as appropriate standard of care for patients in order for them to continue to adhere to using SSC as an accurate screening tool
Fertile ground for further examination? <25 & >= 25 years of age groups in patients meeting the
“Off Criteria” for: “Lifetime never tested females with Hx of multiple partners”
(and <25 years of age) Cap testing in females >=25 years of age unless
symptomatic and/or contact?
Milwaukee School Based Clinics Update 2010
Testing in 15 SBC began Jan 2009 Low volume of testing/positivity at first Volume and positivity picking up Tested 23% more students in 2010 Saw nearly 50% increase in CT positivity and 14% increase in GC
positivity Higher-risk kids more comfortable with health center presence? Staff
efforts?
Year # Tested #/% Pos CT #/% Pos GC
2009 276 34/12.3% 10/3.6%
2010 339 62/18.3% 14/4.1%
Milwaukee School Based Clinics Update 2010
Positivity Rates by Gender 2009-2010:Increase in CT both females and malesGC rate in females exceeds GC rate in males in 2010
Year CT % Positive GC % Positive
Female Male Female Male
2009 12.5% 11.9% 2.7% 4.8%
2010 21% 15.6% 5.7% 2.2%
Milwaukee County Jail Screening Project
CDC Funded Pilot Project (~ $25,000) 2010 Determine CT and GC positivity among women <=39 years of
age in Wisconsin jail population Provide testing, treatment and STD education session for first
400 females at time of jail booking for CT and GC
“Opt out” medical consent for testing Urine sample collected at booking for pregnancy test to be
tested for CT and GC If not treated in facility, City Health Department to provide f/u
for notification of results, treatment and f/u of partners
Organizational and personnel difficulties after Medical Director departed
One month of data available for October 2010
Milwaukee County Jail Screening Project Women Booked & Tested for CT and GC During the Month of October 2010
(N= 131)
Chlamydia (26 +)
+/Tests % Gonorrhea (10 +)
+/Tests %
Total 26/130 20% 10/131 7.6%
Black 21/83 25% 7/82 8.5%
White 4/45 8.9% 3/47 6.4%
<18 yrs 4/9 44.0% 3/10 33.0%
18-24 yrs 11/43 25.6% 3/42 7.1%
25-34 yrs 9/40 22.5% 3/40 7.5%
Sex Charges <=30
22/48 45.8% 8/49 16.3%
Sex Charges>30
2/79 2.5% 2/78 2.6%
Total Rx 11/26 42.3% 4/10 40.0%
Rx In:Rx Out:
4/26 15.4% 3/10 30.0%
7/26 26.9% 1/10 10.0%
Condom Survey
Brand sensitivity in FP clinics in Wisconsin Do we provide a variety of desirable
brands and sizes in WI FP clinics? Survey was distributed at the
DPH/WFPRHA meeting in Wausau in September 2010
17 responses
Condom Survey Results
Types & Sizes Good variety and sizes
Suppliers Global Protection Four Seasons Total Access Trojan Access FPHS IBI Synergy, Inc
Condom Survey Results
Female Condoms: Yes; 11/17 Non-latex Condoms: Yes; 16/17 Colored: Yes; 15/17 Flavored: Yes; 12/17 Other Specialty Condoms: Yes;
10/17 Provide Prescription for Condoms:
No; 15/17
Condom Survey Conclusions & Lessons Learned…
Among FP clinics responding: Good variety and specialty condoms available Non-latex available Female condoms less available Most condoms are provided on site
Future Goals: (Goals met in 2011)
Utilize FPOS to cover cost of condoms through prescriptions or FPOS reimbursement for condoms on site
Conduct patient survey (no interest/need)
Desired brands? Use female condoms if available (now more available
through Dual Protection in 2011)
EPT Update
EPT signed into Wisconsin Law May 11, 2010 Became effective May 26, 2010 EPT allowed for one dose therapy for CT, GC, Trichomoniasis
No name prescription allowed if partner name not obtainable, in which case, ‘EPT’ required to be written on prescription
Information sheets for patient/partner required by the new law and on WEB site; provider guidance soon to be on WEB site
Preliminary training for Family Planning Providers provided in July, September and November 2010
Plans for evaluation under development; WEDSS Promotion of EPT and FPOS awareness among clinical providers
and pharmacists (i.e. males added to waiver, condoms covered by waiver, etc)
Partner referral card for use in FP under development emphasizing partner test and treat gold standard; FPOS enrollment and EPT last resort
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