Integration of Family Planning Services into an STD Clinic

Setting

National Chlamydia Coalition MeetingFebruary 21, 2013

J. Shlay, D. McEwen, D. Bell, M. Maravi, D. Rinehart, H. Fang, S. Devine, T. Mickiewicz, S. Dreisbach

Presenter Disclosures

• Presenter: Judith C. Shlay, MD• No relationships to disclose

Why Integrate Family Planning with STD Care

• Unintended pregnancy has significant individual and public health consequences

• Similar behaviors lead to both STDs and unintended pregnancy

• Patients seeking STD services may not have another source for FP services

Our Program

• Offers FP services at least once a year to eligible males/females presenting for STD services

• Refers to primary care for ongoing contraceptive/ reproductive care needs

• Offers continuity services for teens and high-risk women who require additional support to avoid unintended pregnancy and STD/HIV

Services for Women

• STD screening, testing, and treatment

• Family Planning:– Preconception counseling– Pregnancy testing– Initial contraception (3-months) and/or emergency contraception

Services for Women

• Contraception offered at the DMHC:– Oral contraceptives – Transdermal patch – Vaginal ring – DMPA– IUDs and progestin-only implant– Condoms– Emergency contraception

• Referrals for sterilizations

Services for Men

• STD screening, testing, and treatment

• Family Planning:– Involve men in pregnancy planning and prevention– Provide accurate information on available methods,

benefits of spacing children, safe pregnancy/delivery– Preconception counseling – Contraception: offer condoms, female-directed methods

discussed

• Emergency contraception

• Referrals for vasectomies

Objectives

• Measure change in enrollment into FP services after implementation of an integrated STD/family planning record with electronic eligibility reminder

• Compare client and staff satisfaction before and after implementation

• Calculate the additional staff time and clinic costs required to offer FP services to STD clients

• Explore incident pregnancy and STD rates before and after implementation

Methods

• Quasi-experimental comparison of enrollment and patient/provider satisfaction before (2008) and after (2010) implementation

• Incident pregnancy and STD 12-months after initial visit before and after were explored

• Time and cost were calculated to perform integrated FP/STD services

• Quantitative and qualitative analyses were performed

Streamlining Clinic Processes

Registration

New Pt Visit

Sexual history STD testing Physical exam FP, if applicable NP, RN

Triage Identify symptoms Interest in FP Services

STD Follow-up

STD follow-up Physical exam prn FP, if applicable NP, RN, LPN

Express Visit

Sexual history STD screening FP, if applicable LPN, RN, NP

FP Visit Only

FP only NP, RN

Electronic Medical Record

Electronic Medical Record

Results of Integration of Services

Pre-Integration of Services (2008)

• 9,656 clients were eligible for FP services

• Males 5,842 and females 3,853 (40% female)

• Among those eligible: 51.6% received FP services:– Males 53.3% – Females 49.1%

Post-Integration of Services (2010)

• 10,021clients were eligible for FP services

• Males 5,852 and females 4,169 (42% female)

• Among those eligible: 95.3% received FP services:– Males 94.7% – Females 96.2%

Effectiveness of Contraceptive Method Provided to Client

• Receipt of method at conclusion of the clinic visit (assessed for only 2010):

– highly effective method: 24.4% to 29.9%, p<0.01– moderate effective method: 14.8% to 28.6%, p<0.01– moderate-low effective method: 33.4% to 26.3%,

p<0.01 – low effective method: 5.8%% to 2.7%, p<0.01– abstinence: 6.5% to 7.7%, p=0.01

Dual Contraceptive Use

• Dual use assessed 2010 only:– Effective dual use included LARC/hormonal

method plus condom– Less effective dual use included any other

method plus condom• Effective dual method use: 25.2% • Less effective dual method use: 4.6% • No dual use: 70.2%

Incident Pregnancy

2008*N (%)

2010*N (%)

Enrolled 86/1116 (7.7) 199/1519 (13.1)

Not-enrolled 80/411 (19.5) 7/27 (25.9)

P-value <0.01 0.05

*Denominator reflects number with follow-up information

Incident STDs

2008 N (%)

2010 N (%)

Enrolled Not-enrolled P-value* Enrolled Non-enrolled P-value*

Female:

CT 112/657 (17.0)

67/469 (14.3) 0.21 179/1370 (13.1) 3/36 (8.3) 0.61†

GC 29/657 (4.4) 14/468 (3.0) 0.22 32/1375 (2.3) 1/36 (2.8) 0.57†

Male:

CT 97/559 (17.4) 64/376 (17.0) 0.89 138/1042 (13.2) 4/36 (11.1) 1.00†

GC 33/559 (5.9) 23377 (6.1) 0.90 51/1049 (4.9) 1/36 (2.8) 1.00†

* Chi-square p-value† Fisher exact test two sided p-value

Time and Cost Study

• Additional time and cost of integrating FP services into STD visit: 4.01 minutes and $3.57

• Other additional costs:– Lab: $5.36– Overhead: $5.66– Supplies without providing LARC methods:

$1.04– Supplies including providing LARC methods:

$14.66

Time and Cost Study

• Total additional cost: – $29.25 (with LARC) – $15.63 (without LARC)

Staff Thoughts about Integrated Services

• All expressed greater job satisfaction providing integrated care

• All believe integrated FP-STD EMR facilitated more seamless care and enrollment of more eligible patients

Patient Satisfaction with Integrated Services

• Survey before and after integrated FP record in EMR– 101 patients in 2009 who received integrated services

– 168 patients in 2010 who received integrated services

• 99.5% and 99% very satisfied/satisfied (p=0.76) before and after integrated EMR

• 86.0% and 79.6% reported the services met their family planning needs (p=0.26)

Limitations

• Likely an underestimation of pregnancies and STDs since some patients never return to the clinic

• Program conducted in a clinical setting; unable to control for all potential confounders

• Formal cost-benefit analysis not performed

Conclusions

• STD clinics serve high-risk men and women, many of whom use these clinics because they lack access to reproductive health care services

• Integration of services is feasible, well accepted by staff/patients and provides two valuable services to at-risk populations in a single visit

– Focuses on overlapping health care issues and behavior

• An electronic reminder of eligibility in the EHR facilitates enrollment in FP services among STD clinic patients

Conclusions

• Integrated program appears to reduce pregnancy rates and not increase STD rates

• Offering these integrated services in an STD setting requires minimal additional time and cost

– With first dollar coverage for contraceptive services (Affordable Care Act) and STD clinics developing processes to bill for services, the ability to cover these additional costs should be realized

Questions

Additional information:

Judith Shlay, MD, MSPH

jshlay@dhha.org

303-602-3714