Impact of a Targeted Provider Intervention to Improve Chlamydia Screening Practices in a Large California Family Planning Program Joan M. Chow 1, MPH, DrPH Jane Guo, MS 1, Mary Bradsberry 2, Heike Thiel de Bocanegra, PhD 2, Susann Steinberg, MD 3, and Gail Bolan, MD 1 California Department of Health Services (CDHS) 1 Sexually Transmitted Disease Control Branch 3 Office of Maternal Child and Adolescent Health and Office of Family Planning 2 University of California, San Francisco 2006 CDC National STD Prevention Conference, May 7-11, 2006

Background  Chlamydia (CT) screening guidelines recommend annual screening of young females  Integration of CT screening standards important in family planning (FP) programs  FP Programs need to develop:  Reliable methods to assess screening  Interventions to improve screening where needed  Program-wide and provider-specific interventions have increased screening in managed care  Shafer M-A et al. JAMA 2002;288(22):

Goal & Objective Intervention Goal:  To improve chlamydia screening rates in FP settings Evaluation Objective:  To evaluate the impact of a provider-specific intervention to improve baseline CT screening rates among young female FP clients

 >1 million enrolled female family planning clients (≤200% FPL) in California  >2000 participating public and private Medi-Cal clinician providers  >200 participating laboratories  All FDA-approved CT tests included in benefits  Program standards include annual CT screening of females 25 years and younger  Median CT screening rate was 53% in FY 01/02

Distribution of chlamydia screening rates by FPACT provider sector LOW

Distribution of chlamydia screening rates by FPACT provider sector LOW MEDIUM

Distribution of chlamydia screening rates by FPACT provider sector LOW HIGHMEDIUM

Methods: Provider-specific Chlamydia screening estimates Data available: Client enrollment, Medi-Cal provider enrollment, and paid claims data based on fee-for-service Numerator: Chlamydia tests (CPT-4 codes) paid for female clients age within 12 months of being served in a given year Denominator: Female clients age years served in a given year Chlamydia screening measure: Proportion of clients served that were tested within 12 months of last visit in the FY

Methods: Provider-Specific Intervention 1.June 2003: Clinical Practice Alert and training coupons sent to all Family PACT providers (n~2000) 2.Sept 2003: Letter with provider-specific CT screening data sent to (n=879) Family PACT providers who served at least 100 females age in FY 01/02

Provider-specific Letter: Dear FPACT Provider… You served X females age years and you screened X%: Low Performance (<50% CT screening) –“Your CT testing rates are well below average and quality improvement activities to improve these rates should be implemented.” Middle Performance (50-79%) –“Your CT testing rates indicate that there is some need for improvement in order to ensure that the majority of young women in your practice are tested. ” High Performance (80% and higher) –“Your CT testing rates indicate that you are doing well in testing the vast majority of young women in your practice. You are to be congratulated. if you would be willing to share methods for implementing a successful CT testing program for young women, we would appreciate hearing from you.”

Impact of provider-specific chlamydia screening letters on median screening rate by baseline rate and provider sector

Impact of provider-specific chlamydia screening letters on median screening rate for low performance providers

Percent of providers with more than 5% increase over baseline screening rate post- mailing by performance and provider sector

Limitations  Screening coverage estimates  Paid claims data only  Provider number may represent the behavior of an individual provider or many providers  Provider intervention  No verification whether letters actually reached the provider/s  Length of follow-up time post-intervention  Assumption that behavior change is best captured in short-term  Will change be sustained over the long-term?  Ecologic association between intervention and impact  Observational versus randomized clinical trial design  Other concurrent interventions to increase screening

Conclusion and Caveat  A one-time provider-specific intervention including chlamydia screening data feedback can result in statistically significant short-term improvements in screening rates among low performing providers  One-time interventions may have limited sustained effects

Recommendations  Programs should regularly communicate provider-specific screening data and messages directly to provider  Programs should monitor provider-specific screening performance over time  Follow-up low performance with technical assistance to assess barriers to screening

Acknowledgements  CDHS Office of Family Planning  Jan Treat  CDHS STD Control Branch  Laura Packel  UCSF Bixby Center for Reproductive Health Research & Policy  Carrie Lewis  Denis Hulett  Mariah Crail  Leslie Watts  Michael Policar