By Jacky M. Jennings, PhD, Associate Professor, Department of Pediatrics; Director, Center for Child & Community Health Research, Johns Hopkins University School of Medicine; Gale Burstein, MD, MPH, FAAP, Commissioner, Erie County Department of Health; Alison Muse, MPH, Director, Emerging Infections Program, New York State Department of Health; and, Gowri Nagendra, MPH, PTC Program Director, NYC STD Prevention Training Center
This article originally appeared in the Winter 2018 issue of NACCHO Exchange, which is now available for download.
Overview: Chlamydia in the U.S.
The rate of reported Chlamydia trachomatis cases has increased in the U.S. since 2013, following a decline from 2011–2013. With nearly 1.6 million cases reported in 2016, chlamydia remains the most common notifiable sexually transmitted disease (STD) in the country. Nearly 70% of chlamydia cases are reported among women, particularly adolescent and young adult women (15-24 years of age), who account for 63% of new diagnoses. In fact, rates are highest among young adult women (20-24 years of age), followed closely by adolescent women (15-19 years of age). Young African-American women are disproportionately affected by the disease, having more than five times the prevalence of non-Latino white women.
Adolescents, especially adolescent women, are more susceptible to chlamydia infections for both biological and social reasons. Adolescent women are more likely to have cervical ectopy, a condition in which columnar cells, typically found within the cervical canal, are located on the outer surface of the cervix. Though ectopy is normal among this age group, columnar cells are more susceptible to infection. In addition, adolescents and young adult women experience barriers to screening and treatment, including: inability to pay; lack of transportation; long waiting times; conflict between clinic hours and work/school schedules; stigma of seeking STD services; and, concerns around confidentiality, particularly since sexual and reproductive health-related services involve billing statements sent home to the primary insured (i.e., parents).
While chlamydia infections among women are typically asymptomatic, untreated infection can result in pelvic inflammatory disease (PID), increased risks of ectopic pregnancy, chronic pelvic pain, and tubal-factor infertility. Chlamydia infections also increase the risk of HIV transmission. Chlamydia-infected pregnant women can pass the infection to their infants during delivery, potentially resulting in eye infection and pneumonia. Due to the large disease burden and risks associated with infection, the Centers for Disease Control and Prevention (CDC) recommends sexually active women 25 years of age and younger get screened at least once per year. But despite the National Commission on Prevention Priorities ranking chlamydia screening among young women as one of the ten most cost-effective preventive services, many at risk are not being tested. Lower-than-desired screening rates can be attributed to a number of factors including low awareness among both providers and adolescents, and limited resources.
Though there is little available information regarding where adolescent and young adult women are most likely to be screened for STDs, private physician offices and health maintenance organizations have been the highest reporting sources for chlamydia cases for nearly a decade. STD and family planning clinics remain an important and confidential option, particularly for adolescents, who may not want their parents’ health insurance billed. However, nearly two-thirds of health departments experienced cuts to their STD program budgets in 2013-2014, resulting in reduced clinic hours at 42% of sites and clinic closures at 7% of sites. As public funding for STD prevention and control continues to decline, ensuring that all healthcare providers screen for chlamydia is critical to detecting, treating, and preventing new infections. The two case studies presented in this article are examples of innovative efforts to integrate routine adolescent and young adult chlamydia screening into primary care practices.
Case Study #1: Chlamydia Screening Initiative: Provider Detailing to Increase Chlamydia Screening Among Adolescent and Young Adult Women
In 2016, Baltimore City had the third-highest chlamydia rate in the country among counties and independent cities; yet many young women fail to receive routine screening. Healthcare Effectiveness Data and Information Set (HEDIS) suggests that the screening rates in 16- to 24-year-old sexually active females in the state of Maryland range from 59% to 70% among Medicaid insurers, but are lower among commercial HMO (45.1%) and PPO (42.3%) insurers. In response, the Baltimore City Health Department (BCHD) and the Center for Child and Community Health Research (CCHR) collaborated to develop the Chlamydia Screening Initiative, a public health detailing program focused on increasing routine chlamydia screening among healthcare providers of females under 25 years of age. Through the evaluation of this public health detailing program, the CCHR is assessing the barriers, facilitators, attitudes, and gaps in knowledge surrounding chlamydia screening and morbidity reporting, and formulating a set of specific recommendations to BCHD on how to improve chlamydia screening rates throughout Baltimore City. Additionally, CCHR is assessing the cost-effectiveness of the initiative and the extent to which it improves screening rates and reporting of chlamydia infection.
As part of the public health detailing program, trained public health detailers are educating providers in six federally qualified health centers (FQHCs) with 18 eligible sites in Baltimore City about offering routine chlamydia screening to young women. The six FQHCs were chosen based on their geographic location in high chlamydia morbidity areas in Baltimore City, annual patient visits, and percentage of female patients aged 15-24. Two public health detailers and a project coordinator were hired and trained to conduct the public health detailing, which draws from a pharmaceutical representative model in which trained individuals visit assigned clinical sites and have one-on-one interactions with providers and staff. This interaction builds relationships over time with the intention of influencing changes in clinical practice behavior and simultaneously provides an opportunity to assess knowledge, skills, attitudes, and practices among providers within healthcare settings.
The detailers received one week of training, which included a training session with a company, OnCall, to learn pharmaceutical best practices on detailing. The detailers were also trained to be evaluators. The detailers visit each FQHC and, after conducting a baseline interview, they present the STI Action Kit, which includes information regarding current best practices and recommendations on screening for chlamydia, epidemiologic risk profiles of local neighborhoods (i.e., chlamydia morbidity maps), and local resources for providers and patients.
As a part of this initiative, baseline (pre-detailing) and follow-up (post-detailing) evaluation questionnaires for providers and clinic managers were developed to determine the impact of public health detailing for chlamydia screening. These questionnaires assess changes in knowledge, attitudes, and practices surrounding chlamydia screening, and identify both barriers and facilitators to chlamydia screening. These questionnaires were programmed into a REDCap data management system, which is HIPAA-compliant, and the detailers used tablets to administer the questionnaire. Additionally, process tools (i.e., number of weekly visits, refusals, etc.) were developed to monitor the progress of detailing in the field. Additionally, CCHR is assessing the extent to which the initiative improved screening rates and reporting of chlamydia infection, as well as the cost-effectiveness of the program.
Secondarily, CCHR and BCHD are using laboratory data to evaluate whether chlamydia screening rates increased. Specifically, CCHR is using Quest’s chlamydia testing data from the previous three years to determine whether screening rates increased in Baltimore City FQHCs before and after detailing. The screening data is being merged with chlamydia positive report information to see if changes in screening resulted in changes in positive chlamydia report data within a site, and in comparison with similar sites in Baltimore City.
As the Chlamydia Screening Initiative is ongoing, only baseline findings were available at the time of publication. During baseline detailing, 100% (n=6) of FQHCs were visited. A total of 94% (17 out of 18) of clinic sites have met the detailing evaluation goal, defined as greater than 75% of providers (i.e., medical doctor, physician assistant, nurse practitioner) and 100% of clinic managers have been baseline interviewed. In addition, over 250 STI Action Kits have been delivered across sites. Follow-up surveys are being conducted six months after baseline visits.
Given the high morbidity of chlamydia among young females, primary care providers need to prioritize routine chlamydia screening. A public health detailing project can support this goal by educating and supporting providers and establishing relationships between providers and their local health department. Other jurisdictions may want to consider using public health detailing for similar efforts to disseminate key public health messages.
Case Study #2: Engaging Primary Care Providers in a Quality Improvement Initiative to Improve Chlamydia Screening
Chlamydia screening of young women is a cost-effective preventive service, yet females ages 15-24 in Erie County have the highest burden of chlamydia in New York State (NYS). In 2016, reported chlamydia rates in Erie County were 3,965/100,000 among 15- to 19-year-olds and 4,025/100,000 among 20- to 24-year-olds. The National Committee for Quality Assurance estimates adherence to chlamydia screening recommendations using HEDIS data collected from commercial and Medicaid health plans. The 2016 Quality Performance Results from Erie County Health Plans indicated that chlamydia screening rates are low in both Medicaid-insured (72%) and commercially insured (62-64%) 15- to 24-year-old females.
As such, the NYS Department of Health, Erie County Department of Health, and the New York City (NYC) STD Prevention Training Center partnered with the American Academy of Pediatrics (AAP) to offer a Quality Improvement (QI) project to increase confidential sexual history documentation and chlamydia screening of sexually active adolescent and young adult females in high-volume community primary care practices in Erie County. The inclusion of male patients was optional, but all participating clinics chose to include males in their screening QI projects.
The Quality Improvement Data Aggregator (QIDA) is an AAP web-based data aggregation system. The QIDA system creates a unified structure for the collection, analysis, and reporting of quality improvement data. All project materials, including data collection instruments and QI resources, are available on an AAP QIDA website (https://www.aap.org/en-us/continuing-medical-education/mocportfolio/Pages/getinvolved.aspx) designed for this project. Participants do not need to be AAP members to participate.
So far, two chlamydia screening QI projects have been completed. The first ran from May 2015 to March 2016 in an academic-affiliated pediatric clinic, an FQHC, and a private pediatric and family medicine clinic located in high chlamydia morbidity areas. The second QI project was implemented August 2016 to June 2017 in one private pediatric clinic, one FQHC, and two community pediatric clinics located in high chlamydia morbidity areas. Each clinic’s QI team received a one-day QI training, which included chlamydia screening strategy recommendations. Baseline data were collected and strategies were tested during four Plan-Do-Study-Act (PDSA) cycles.
During the projects, the QI team nurse made monthly clinic visits and all participating clinic QI teams met for two “Learning Collaboratives” to share lessons learned and provide technical assistance and data feedback. Every eight weeks, two outcome measures were evaluated using electronic medical record (EMR) data: Sexual History Risk Assessment (i.e., percentage of 13- to 24-year-old patients with EMR documentation of sexual activity status) and Chlamydia Screening Test (i.e., percentage of sexually active patients screened for chlamydia). The goal for each outcome was 80%.
The project also examined balancing measures of unnecessary screening. For example, cases in which a chlamydia test was ordered without EMR documentation of sexual activity; instances of failure to order a chlamydia test for sexually active patients; and, occasions when a chlamydia test was refused by a patient. Specialty Board Maintenance of Certification Part IV and 20 continuing medical education hours were offered.
Outcomes were similar for the two project periods, but this article focuses on data from the second project period. From baseline data collection to the fourth PDSA cycle, sexual activity assessment and documentation increased from 64% to 94% of all 13- to 24-year-old clinic visits (see Figure 1), and chlamydia screening of sexually active patients increased from 73% to 94% (see Figure 2).
The successful strategies the clinics used that led to these results included: adapting EMR systems to document sexual activity and chlamydia screening status; using universal, standardized sexual history questions; implementing universal urine collection at registration; and, creating confidential clinic teen rooms. Barriers to change included limited staff time, time required to implement EMR changes, QI nurse’s time, staff resistance to adopting changes, and confidentiality challenges.
Through this process, the project partners learned that QI training and tools, on-site QI nurse technical assistance, and QI nurse data feedback led to improvements in the collection and documentation of adolescent sexual history, as well as the provision of chlamydia screenings in each community clinic that cares for adolescents and young adults. Although QI can be an effective strategy to engage primary care providers for practice changes, this model is labor intensive for project staff – especially QI nurses – and clinic staff, and may be difficult to replicate. In 2018, the project partners plan to pilot a virtual, web-based QI project with monthly “Learning Collaboratives” to explore a more generalizable model.