Extending Preventive Care to Pediatric Urgent Care A Partnership Between: University of California, San Francisco & Kaiser Permanente Northern California Mary-Ann Shafer MD & Kathleen Tebb PhD Presentation to STD Prevention Conference March 10, 2004 Funded by the Centers for Disease Control and Prevention & The Agency for Health Care Research and Quality Today I will present our most recent work, Extending Preventive Care to Pediatric Urgent Care. This is truly a work done in partnership with our colleagues at Kaiser Permanente Medical Group of Northern California.

Background Facts About Chlamydia Trachomatis (CT) Rate is 6-12% in teen females 70-80% are asymptomatic 10-20% untreated  PID infertility NAATs 90-95% sensitivity/specificity Nat’l Guidelines  annual CT screen As you are aware, CT is a significant public health problem. It is the most common STI in teens with a prevalence rate between 6-12% among adolescent females. Of particular concern is that most infections are asymptomatic. CT if untreated can lead to pelvic inflammatory disease which then can result in infertility, ectopic pregnancy and chronic pelvic pain. The relatively new Nucleic Acid Amplification Tests applied to first void urines offers a simpler, accurate and reliable screening tool. As a result, Professional organizations (AMA, CDC, ACOG, AAP) and national policy groups US PSTF (United States Preventive Services Task Force) Healthy People 2010 recommend at least annual screening for all sexually active adolescent females. However few are screened. According to a report by the National Committee on Quality Assurance, less than 20% of eligible women (15-24yo) receiving health care through managed care organizations are being screened.

Background cont. Clinical Practice Improvement intervention (CPI) increased CT screening of sexually active teens at pediatric well care visits (WCVs) Yet, over 50% of adolescents are seen only for urgent care visits (UCVs), in any given year Our previous work developed, implemented and evaluated a Clinical Practice Improvement intervention that resulted in a significant increase in the number of sexually active adolescents, both male and female, who were screened during well care visits. However, during our research we became acutely aware that even within an insured population of an HMO, that over 50% of youth only use urgent care visits for their source of health care and therefore receive no preventive services.

We published our findings on the impact of our CPI in JAMA in 2002 JAMA December 11, 2002

Learning Objectives Review the development, implementation and evaluation of a systems-based intervention for CT screening Understand utilization patterns of teens seen in well versus urgent care Discuss the translation of the CPI model to different clinical settings The learning objectives for today’s presentation include reviewing the development, implementation and evaluation of a systems-based intervention for CT screening Understanding the utilization patterns of teens seen in well vs urgent care Discussing the translation of the model to different clinical settings

Study Objectives Develop a modified CPI (clinical practice improvement) intervention to address barriers to CT screening during UCVs Examine feasibility of CT screening attending pediatric UCVs in a large HMO

Methods Setting Large HMO in Northern California: KPMG 2 Pediatric clinics participating in the previous well-care CPI intervention 14-18 yo females seen for UCVs ~4,000 enrolled 14-18 yo adolescent females in 2 sites For our current study, we chose Kaiser Permanente Northern California as our setting for several reasons. First it serves the largest # of teens (1:3 in CA). It also has a central data system, health care standards for practitioners and resources that can be utilized. Yet at the same time, there’s a component of local leadership and independent decision-making so that this setting embodies some attractive aspects of smaller group practices.

Methods KP Pediatric Setting cont. Well-Care Visit Appointment required Physical exam (every 2-3 yrs) 20 minute visit Urgent-Care Visit Same/ next day visit Sick/ non-ER visit 10 minute visit Same physical setting as WCV Same providers & staff as WCV Kaiser Permanent departments of pediatrics have a system where most primary care patient visits are either well care visits or urgent-care visits. WCC visits are characterized by the following: an appt is required days ahead of time, the visit includes a physical exam which is done approximately at 2-3 year intervals and the visit is scheduled for 20 minutes. UCV in contrast are made the same or next day, care usually is at the acute illness level and not requiring an emergency room visit; the visit is scheduled for 10 minutes; the same physical space and same providers are used for both WCV and UCV.

Methods Design Pre-Post test study Provider survey (anonymous) to assess attitudes toward screening in UCV Teen survey (anonymous) for sex active rate Comparison of baseline CT screening rates to 6 month post-test rates In this preliminary study, we employed a pre-post test study design. A provider survey was given to all pediatricians at the two targeted clinic sites-anonymously to assess their attitudes toward screening in UCV at baseline. A teen survey was anonymously given to all teens coming to UCV to determine the sexual activity rate in that setting. Finaly , a comparison of baseline CT screening rates to post-test rates 6 months later.

Clinical Practice Improvement Model Re-Design Clinical Practice Engage Team Building Re-Design Clinical Practice Here is an overview of a clinical practice improvement model. I’ll go through each step in the model Sustain the Gain

Clinical Practice Improvement Model Leadership Best practices Define gap Raise Awareness Engage Team Building Re-Design Clinical Practice First you have to engage the key stakeholders such as the chiefs of pediatricians as well as local leadership to champion the project. Next to gather buy-in, the case is presented as to what best practices standards are, what’s current practice and the gap between the two. This is part of an effort to raise awareness about the nature of the problem in order to get clinic buy-in. Sustain the Gain

Clinical Practice Improvement Model ACTeam Skill building Tool Kit Engage Team Building Re-Design Clinical Practice The next step is to recruit a team to work on the particular problem. This involves identifying key stakeholders to champion the project and conduct day-to-day management. Team members usually include a clinician, a nurse/medical assistant, and an clinic administrator. The team then needs skills on how to analyze their system and together they identify barriers to accomplishing the task and strategies to overcome these barriers. One example of a tool we developed was a clinic flow chart to help them consider barriers to CT screening at each point of the clinic system from the teen’s registration to confidential follow-up for positives. Tools such as the clinic flow sheet are provided to help them analyze their current system. I will show this to you later. Sustain the Gain

Clinical Practice Improvement Model Re-Design Clinical Practice Engage Customize Measure success Team Building Re-Design Clinical Practice Once they have analyzed their system, they’re ready to begin to redesign their clinical practice. Usually making small incremental changes over-time. For example in our study,providers found it too time consuming to gather urines after confidential identification of sexual activity. So all of the clinics decided to collect urines on all adolescent females at the point of registration. Many other changes are small, done incrementally, and are customized to meet local or site specific needs. This is a very attractive attribute about this kind of an intervention-local control and customization. At this point, the team has to decide on what measures will be used to mark their success and guide further refinements in the clinical practice. Sustain the Gain

Clinical Practice Improvement Model Re-Design Clinical Practice Engage Monitor performance Time series analysis Continuous improvement Team Building Re-Design Clinical Practice Once gains have been made,the team continually monitors performance using some type of time-series analysis. This is usually done with relatively small samples over short time intervals in order to mark progress made towards the goal. Reports are used to analyze gains and to ensure that changes are sustained over time. This is the basis for the continuous rapid cycle model of change. Sustain the Gain

Rapid Cycle Changes ACTeam Meeting Set Goal Identify barriers Decide solution Try it out Reassess Repeat “cycle” % Change in STD Screening Rate Here is a visual representation of the rapid cycle changes – in our model case rapid cycles are repeated on a monthly basis. Percent screened is on the y axis and the x axis is time. Now, I’ll quickly take you through a typical meeting. First ACTeam members set a screening goal for the next time period, in this case-1 month. Then they identify potential barriers towards achieving their goal. For instance, one barrier identified was having some time alone with the teen without the parent present to confidentially discuss the adolescent’s sexual history. The team then decides on a solution, at one clinic they medical assistants were asked to explain to parents that rooming teen alone was a standard part of clinic protocol and parent would be invited in at end of visit to discuss any additional questions or concerns. They then try it out and reasses it. In this case they found this was difficult for some medical assistants to communicate with parents about the confidential rooming policy-so they developed a flyer to give to parents at registration and posted one on the wall in the waiting room. They then should see an increase in screening rates as a result of their efforts. As results are reviewed, new strategies are incorporated and cycle repeats itself each month. S t a t u s Q u o Time in months

Site Specific Flow Chart Cue Charts Room Patient MD/NP VISIT Urines To Lab Follow-Up ID eligible teens C Charts are stamped with cue MA collects FVU on all 14-18 yo F TTeen takes FVU sample to exam room MD/NP obtains sex hx If sexually active, MD completes CT lab slip W WWrites confid. # on chart MA refrigerates FVUs A enters teen name, confidential # in clinic log book LRunner takes FVU to lab RN contacts CT + teen: confid. # Teen comes to clinic for Rx RN enters Rx in STD log book This is the site specific flow chart that is used as a worksheet for each monthly ACTeam meeting. I will briefly walk you through its steps. First, chards are cued, teens who are eligible (age 14-17 yo) are stamped with a cue identifier for the MA Next the patient is roomed and during this process the MA obtains a first boid urine on all 1-18 you to protect confidentiality-”in case the doctor needs it” The clnician then obtains a brief sexual history and if the teen si sexually active, the MD completes the CT lab slip, writes the confidential phone number on the chart in order to be able to contact the teen if the STI test is positive. Urines are refrigerated by the MA, the teens name if put in a confidential lab log book and the FVU is taken to the lab. Finally, the RN contracts all those who are posibit via the confidential number, the teen is directed to come to the clinic to obtain treatment and the treatment plan is also inetered into the log book.

Data Bases and Analysis Registration + lab + anonymous survey of teens for clinic specific screening rates Data Analysis Mann-Whitney/T-test The analysis was based on three data bases: KP registration data and lab data that were analyzed by KP employees who stripped the data of all patient identifiers before the aggregate data was sent to the university research team. Data analysis for this project employed the Mann-Whitney/T-tests

Data Analyses: CT Screening Rate No. of CT tests Sexually active teen females* Screening Rate = To get a better approximation of the actual screening rate as reflected by how many eligibles were actual screened-that is among only those sexually active, we employed this method: *Site specific sexual activity rates determined by anonymous survey

RESULTS

Urgent Care vs Well Care Population Teen girls who utilize urgent care compared to well care visits have a higher STD risk profile: Older (15.7 vs 15.4 years)* More ethnically diverse (Cauc/Asian vs. Oth)* Higher sexual activity rates (42% vs 26%)* *p<0.05 From our anonymous teen survey we fount the following. Adolescent girls who use urgent care were older (significant when dealing with such a narrow age range-most aged 15 and 16. More ethnically divers, ethat is more Latinas and African Americans And had sexual activity rates that were a third higher compared to young women attending well care visits.

Pediatrician Survey Results CT Screening Likelihood during UCV: (1=not likely, 4=very likely) Teen Chief Complaint MD Mean Rank SD Asthma 1.26 0.52 URI 1.30 0.57 Minor trauma 1.31 0.58 Non-reproductive visit 1.64 0.74 Abdominal pain 2.84 0.90 Vaginal bleeding 2.98 1.12 Pregnancy test 3.45 0.86 Requested by patient 3.87 STD symptoms 3.91 0.44 From our anonymous survey of clinicians we found the following regarding their likelihood of screening for chlamydia during an urgent care visit: The scale used here is a 4 point likkert scale from 1 not likely to 4 very likely that I would screen. As you can see, the likelihood rises from a low mean rank of only 1.26 for a teen who comes in with acute asthma and 1.64 for other non-reproductive health reasons for a visit to a high of 3.91 for a woman with STD symptoms- It must be noted that the latter is not really “screening” but testing-the difference being that screening is our target and that involves obtaining specimens from those at risk individuals without symptoms who normally would not be tested.

MD’s Top 3 Barriers to UCV Screening Parents in room/confidentiality Competing priorities Discomfort in taking sexual history The clinicians also told us about the top 3 barriers to screening for chlamydia in the urgent care setting. First, parents roomed with the patient during the visit was an obvious deterrent to obtaining the requisite confidential milieu in which a discussion about sexual activity could occur. Secondly, the acuity of the problem of the teen and other clients establish obvious competing priorities. Third, many pediatricians are not trained and are uncomfortable taking sexual histories from teens.

RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites % SA Females Screened for CT A B A This is a graphical representation of the results of the change in Ct screening rates over time in our 2 pilot clinics. The % sexually active young women-the target population-who were screened is the vertical or Y axis with time in years on the horizontal or x axis. The bars in yellow represent clinic A and the bars in orange represent clinic B. At baseline in 2000, no screening for CT was being done in the urgent care setting. As time went on, there was a marked increase to almost 70% in clinic A and over 50% in clinic B. Such results show that different clinics react differently to their site specific intervention but over time make sizable gains towards their goals. B B

Conclusions CT screening in pediatric UCVs is feasible Significantly more teens screened for CT Clinic differences  different results More research needed (e.g., RCT, more clinics)

“Do Today’s Work Today” Implications CT epidemic  universal screening recommended Most teens seen only in UCVs and they have a higher STD risk profile screen for CT in well and urgent care “Do Today’s Work Today” The CPI model (rapid-cycle change) may be generalizable to other services & clinic settings

Implications cont. Rapid cycle quick, dramatic & sustained Effective in different settings- well & urgent and likely others as well Capitalizes upon existing resources & staff Small changes  LARGE effects Gives chronically over-worked staff sense of importance, success & control over workplace