1. Joanne Armstrong, MD 1,2 Haleh Sangi-Haghpeykar, PhD 1 Alice Shen, MD 1 1. Baylor College of Medicine Houston, Texas 2. Dept Women’s Health, Aetna Chlamydia Screening Practices in the Private Sector: Who, How Much, and Why?

2. 2 How big is the problem? –3M infections/year; 80% <25 y/o; 80% asymptomatic Screening helpful –Decreases prevalence when widely instituted 1 –Decreases infection sequelae by 50% 2 Limited success in translating screening benefits to women in the private health sector – Most Americans receive STD care private sector from “private practice” physicians 3 –Little data on extent and quality of care in private sector. 1.Schafer, JAMA 2002;288 (22):2846 2.Scholes, N Engl J Med 1996;334(21):1362 Background 3. Brackbill. Fam Plann Perspect. 1999;31(1):10-5

3. 3 Prevalence 1,2 –Teens: 5%-10% –Adults: 3%-6% Self-reported adherence with screening guidelines poor 3 –30% PCPs –54% ObGyns HEDIS 2003 4 –<19 years: 26.7% –20-<26 yrs: 24.6%  Significant quality concern exists in private sector Private Sector 3. Hobgen Obstet Gynecol 2002;100(4):801-7. 4. http://www.ncqa.org/sohc2003/chlamydia_screening.htm

4. 4 HEDIS 2000 : 16.8% < 20 yrs; 13.8% < 26 yrs Health Plan Experience

5. 5 Outreach to greater than 125,000 physicians Chlamydia Tool kits –Screening and laboratory guideline updates –Patient fact sheets –Patient self assessment tools CMEs Feedback on HEDIS performance Lunch and learns-mid-level practitioners Annual preventive health reminders Collaborations with national labs Health Plan Initiatives

9. 9 What’s the Reward? HEDIS: Commercial Plans Age2000200120022003 AetnaNCQAAetnaNCQAAetnaNCQAAetnaNCQA < 20 16.818.516.323.616.324.516.026.7 20-2613.816.014.020.715.222.115.424.6

10. A National Survey of Genital Chlamydia trachomatis Screening Practices and Attitudes of U.S. Obstetrician Gynecologists Joanne Armstrong, MD Haleh Sangi-Haghpeykar, PhD Alice Shen, MD Baylor College of Medicine Houston, Texas

11. 11 Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women Identify barriers and facilitators to compliance with screening guidelines Study Objectives

12. 12 Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women Identify barriers and facilitators to compliance with screening guidelines Study Objectives

13. 13 National survey –1,100 OBGYNs randomly selected from AMA Master File Inclusion criteria –Board certified –Full time, direct patient care –>50% time caring for commercially insured (HMO, PPO, FFS, indemnity, Medicaid MCO) –Women ages 15-25 Exclusion criteria –Federal, state, county, city-funded setting, medical schools, training programs, researchers, admin, non-direct patient care –Survey undeliverable, MD retired, deceased –Does not meet inclusion criteria Study Design

14. 14 Study Design Survey content: –Chlamydia screening practices –Knowledge and utilization of currently available screening tests –Barriers and facilitators to screening. 3 different patient sub-groups –Pregnant women –Non-pregnant, sexually active, <20 years –Non-pregnant, sexually active, 20-25 years Comparison of screeners vs. non-screeners –“Screener” = Screens >75% of time

15. 15 Study Design Survey content: –Chlamydia screening practices –Knowledge and utilization of currently available screening tests –Barriers and facilitators to screening. 3 different patient sub-groups –Pregnant women –Non-pregnant, sexually active, <20 years –Non-pregnant, sexually active, 20-25 years Comparison of screeners vs. non-screeners –“Screener” = Screens >75% of time

16. 16 Mailed in 3 waves-March 2003 1. FedEx: survey, information sheets, $15 gift cheque 2. Reminder Postcard 3. Priority Mail: survey Reviewed and approved by BCM IRB Study Design

17. 17 Results 1,100 surveys sent to Ob/Gyn Physicians 410 completed, eligible returned surveys 42.7% response rate

18. 18 Respondent Demographics Physician Profile –99.3% Board certified; 95.6% in private practice –70.8% Male; 79.4% White –Mean age 49 years with 20 years of practice Workload –Mean 39.3 hour work week; 94.2 patients per week –37.2% OB visits, 62.7% GYN visits Practice –96.6% in primary care or sub-specialty care office –84% in solo or single-specialty group practice –69.1% with ownership interest in their practice –78.3% contracted with a MCO Patient Profile –61.6% White; 18.0% Black; 12.6% Hispanic –36.2% aged 13-26 years; 71.7% privately insured

19. 19 Screening frequency by patient subgroup Patient Sub-group Never screen % Screen <25% % Screen 25-49% % Screen 50-74% % Screen >75% % Pregnant12.76.45.34.363.9 Non-pregnant, <20 yrs 35.215.613.411.721.6 Non-pregnant 20-25 yrs 48.520.812.37.08.5

20. 20 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.

21. 21 Demographics Not Associated with Screening MD demographics –Age, Gender, Years in practice Practice Structure –Solo vs. group –Patient and work volume Practice Economics –Ownership interest –MCO affiliation –Insurance status of patients

22. 22 Current Experience with CT and Comparison of Screeners* to Non-Screeners Denotes screening all sexually active women ages 20-26 years at least 75% of time. **Denotes mean response 1= strongly agree, 5=strongly disagree

23. 23 Risk Assessment Behaviors of Screeners* compared to Non-Screeners * Denotes screening all sexually active women ages 20-26 years at least 75% of time.

24. 24 Screening Test Utilization of Screeners compared to Nonscreeners

25. 25 Conclusions Physicians 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 concerns…and opportunities.. identified in chlamydia screening in commercially insured women

26. 26 Current Influences on Screening Practices

27. 27 Barriers to Screening Reported by Nonscreeners Epidemiological factors Perceived low prevalence (p=<.0001) Lower health priority (p=.02) Physician/patient comfort concerns MD uncomfortable (p=.009) Unacceptable to patients (p=.006) Economic concerns Decrease practice income (p=.01) Not a billable service (p=.002) Availability of tests (p=.05)

28. 28 Future Influences for Screening Practices

29. 29 Conclusions: Barriers Perception of low prevalence –Yet, no threshold to drive routine screening until 10%! Lack of uniformity of screening guidelines –Most rely on ACOG, but not a differentiator Discomfort of RA/screening Economic issues –Time, cost, hassle factor –Facilitated by increased convenience of test. No single barrier identified ….  No single barrier identified ….

30. 30 Conclusions: Facilitators ACOG adoption of age-based screening Patient demand Physician awareness Convenience of testing Economic incentives …interventions must also be multifaceted  …interventions must also be multifaceted