Joanne Armstrong, MD1,2Haleh Sangi-Haghpeykar, PhD1Alice Shen, MD1

1. Baylor College of Medicine Houston, Texas2. Dept Womens Health, AetnaChlamydia Screening Practices in the Private Sector: Who, How Much, and Why?

How big is the problem?3M infections/year; 80%

Prevalence1,2Teens: 5%-10%Adults: 3%-6%Self-reported adherence with screening guidelines poor330% PCPs54% ObGynsHEDIS 20034

HEDIS 2000: 16.8% < 20 yrs;13.8% < 26 yrs

Health Plan Experience

Outreach to greater than 125,000 physiciansChlamydia Tool kits Screening and laboratory guideline updatesPatient fact sheetsPatient self assessment toolsCMEsFeedback on HEDIS performanceLunch and learns-mid-level practitionersAnnual preventive health remindersCollaborations with national labsHealth Plan Initiatives

Whats the Reward?HEDIS: Commercial Plans

A National Survey of Genital Chlamydia trachomatis Screening Practices and Attitudes of U.S. Obstetrician GynecologistsJoanne Armstrong, MDHaleh Sangi-Haghpeykar, PhDAlice Shen, MD

Baylor College of Medicine Houston, Texas

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

Identify barriers and facilitators to compliance with screening guidelinesStudy Objectives

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

Identify barriers and facilitators to compliance with screening guidelinesStudy Objectives

National survey 1,100 OBGYNs randomly selected from AMA Master File

Inclusion criteriaBoard certifiedFull time, direct patient care>50% time caring for commercially insured (HMO, PPO, FFS, indemnity, Medicaid MCO)Women ages 15-25 Exclusion criteriaFederal, state, county, city-funded setting, medical schools, training programs, researchers, admin, non-direct patient careSurvey undeliverable, MD retired, deceasedDoes not meet inclusion criteria

Study Design

Survey content:Chlamydia screening practicesKnowledge and utilization of currently available screening testsBarriers and facilitators to screening.

3 different patient sub-groupsPregnant womenNon-pregnant, sexually active, 75% of timeStudy Design

Survey content:Chlamydia screening practicesKnowledge and utilization of currently available screening testsBarriers and facilitators to screening.

3 different patient sub-groupsPregnant womenNon-pregnant, sexually active, 75% of timeStudy Design

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

Results1,100 surveys sent to Ob/Gyn Physicians410 completed, eligible returned surveys42.7% response rate

Respondent DemographicsPhysician Profile99.3% Board certified; 95.6% in private practice 70.8% Male; 79.4% WhiteMean age 49 years with 20 years of practiceWorkloadMean 39.3 hour work week; 94.2 patients per week37.2% OB visits, 62.7% GYN visitsPractice 96.6% in primary care or sub-specialty care office84% in solo or single-specialty group practice69.1% with ownership interest in their practice78.3% contracted with a MCOPatient Profile61.6% White; 18.0% Black; 12.6% Hispanic36.2% aged 13-26 years; 71.7% privately insured

Screening frequency by patient subgroup

Demographic Variables Associated with Screening* non-pregnant, sex active age 20-25 years* Denotes screening all sexually active women ages 20-26 years at least 75% of time.

Sheet1

DemographicsScreeners N=34Non-screeners N=376Adj. OR (CI)P

MD Race/Ethnicity (%)

White55.981.610.001

Black23.53.84.5(1.2, 15.6)

Demographics Not Associated with ScreeningMD demographicsAge, Gender, Years in practicePractice StructureSolo vs. groupPatient and work volumePractice EconomicsOwnership interestMCO affiliationInsurance status of patients

Current Experience with CT and Comparison of Screeners* to Non-ScreenersDenotes screening all sexually active women ages 20-26 years at least 75% of time.**Denotes mean response 1= strongly agree, 5=strongly disagree

Sheet1

TotalScreenersNon-screenersP

N=410N=34N=376

Number of CT cases diagnosed

Past 6 months6.2 + 10.77.66

Past year11.4 + 19.114.211.1

Number of PID cases diagnosed

Past 6 months3.3 + 9.03.33.3

Past year6.0 + 17.25.36.1

Estimate of CT prevalence in primary practice

10%6.823.55.20.001

Target prev above which screening indicated

Yes20.623.520.3

No79.576.579.7

If yes, what percent? (%)10

Low prev. makes screening unnecessary**1.82.61.60.001

Sheet2

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Risk Assessment Behaviors of Screeners* compared to Non-Screeners* Denotes screening all sexually active women ages 20-26 years at least 75% of time.

Sheet1

TotalScreenersNon-screenersP

N=410N=34N=376

Performance of risk assessment patients (%)

Yes, on all patients51.882.449.10.0002

Yes, only on some patients32.211.834.10.008

No14.75.915.6

Risk Assessment tool used to screen (%)

Preprinted questionnaire262524.7

Direct inquiry by physician90.589.390.2

Inquiry by other office staff3217.934.1

Availability of written screening protocol (%)

Yes12.926.511.70.01

No78.964.780.20.03

Not sure8.28.88.1

When do MD's screen non-pregnant women?(%)

Never52057

Screening Test Utilization of Screeners compared to Nonscreeners

Sheet1

TotalScreenersNon-screenersP

N=410N=34N=376

Screening tests used most frequently (%)

Not sure6.96.18.1

Laboratory culture5.236.2

EIA6.79.17.5

DNA probe47.339.455.3

Nucleic acid amplification test21.539.4230.04

Attitude about NAATs * N=223

Tests not available for use26.111.513.2

Test not available through a contracted laboratory30.622.114.2

Tests are too complicated to use0.10

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 concernsand opportunities.. identified in chlamydia screening in commercially insured women

Current Influences on Screening Practices

Sheet1

P

Total N=410Screeners N=34Non-Screeners N=376

Screening guidelines most influential*

ACOG57.254.657.4

CDC33.336.432.9

US Preventive Services Task Force Guidelines1.301.4

Health Employer Data Information Set (HEDIS)2.502.8

Other5.89.15.5

Compliance with professional standards*

Screening guidelines of prof. societies56.56.856

Residency training29.947.128.30.01

Health plan guidelines17.529.416.40.05

HEDIS performance8.312.58

Patient concerns*

Patient requests screening81.761.883.60.007

Patient acceptance of screening34.715.636.40.02

Confidentiality of billing record19.49.120.3

*numbers represent percent of repondents strongly influenced by factor

Sheet2

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Barriers to Screening Reported by NonscreenersEpidemiological factorsPerceived low prevalence (p=

Future Influences for Screening Practices

Sheet1

TotalScreenersNon-screenersP

N=410N=34N=376

Screening influences

ACOG recommendation70.26774.1

CDC recommendation69.872.769.3

Practice influences

Practice had standard protocol for screening42.945.547.1

Patient chart flagged for eligibility26.312.529.70.04

Patient influences

Patients had fewer concerns about confidentiality16.612.118.2

Patient asked for7057.676.40.02

Economic influences

Prevalence in my patients were higher42.727.347.70.02

More Cost effective219.123.90.05

Additional reimbursement to screen26.812.130.80.02

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Sheet3

Conclusions: BarriersPerception of low prevalenceYet, no threshold to drive routine screening until 10%!Lack of uniformity of screening guidelinesMost rely on ACOG, but not a differentiatorDiscomfort of RA/screeningEconomic issuesTime, cost, hassle factorFacilitated by increased convenience of test. No single barrier identified .

Conclusions: FacilitatorsACOG adoption of age-based screening Patient demandPhysician awarenessConvenience of testingEconomic incentives interventions must also be multifaceted

These findings have not been translated into benefit in the private sector despite fact that majority of women receive STD care in private sector from private practice physicians.

There is, in fact, little data on the extent and quality of STD care in the private sector. HEDIS means scores 2000-2003.

Conclusions relative to barrier: