1. Using Test Kit Allotments to Reduce Chlamydia Screening in Low Risk Females for Re-allocation to Higher Risk Populations and Higher Yield Venues Rabins C 1, Holmes S 1, Renier E 1, Zimmerman R 1, Sylvester T 2 1 STD Program, Illinois Department of Public Health, Springfield, IL, USA 2 Division of Laboratories, Illinois Department of Public Health, Springfield, IL, USA

2. Abstract Using Test Kit Allotments to Reduce Chlamydia Screening in Low Risk Females for Re-allocation to Higher Risk Populations and Higher Yield Venues Charlie RabinsCharlie Rabins1, Stephen Holmes1, Edward Renier1, Richard Zimmerman1, and Tony Sylvester2. (1) Sexually Transmitted Diseases Program, Illinois Department of Public Health, 525 W. Jefferson, Springfield, IL, USA, (2) Division of Laboratories, Illinois Department of Public Health, 825 N. Rutledge, Springfield, IL, USA Background: Illinois STD-Related Infertility Prevention Project (IIPP) selective screening criteria recommend that sexually active females attending IIPP screening sites receive a test for chlamydia at least annually if they are either under 25 years of age or 25 years of age and older with a risk factor. An analysis of chlamydia screening data among females at selected IIPP screening sites during 2000 to 2004 indicated that an annual average of 55,691 (38.7%) chlamydia tests were among females 25 years of age and older at a projected cost of $696,138. Objective: To assess the use of test kit allotments to reduce chlamydia testing in females not meeting the selective screening criteria enabling expanded testing in higher risk populations and higher yield venues. Method: IIPP chlamydia screening data among females for 2004 was analyzed by age group and an allocation algorithm was developed and implemented in 2005 to encourage increased testing among females under 25 years of age and males while reducing testing in females 25 years of age and older with no identified risk factors. Result: A preliminary analysis of 2005 IIPP testing data (year 1 - implementation) indicates that testing in females 25 years of age and older was reduced by 14.6% (7,733 tests) enabling these tests to be available for re-allocation to higher risk populations and higher yield venues or a reduction in testing costs of up to $96,663. Conclusion: Implementing test kit allotments is an effective strategy to reduce chlamydia testing in low risk females enabling expanded testing in higher risk populations and higher yield venues. Implications: In an era of level or decreased funding for chlamydia screening, reducing testing in low risk females can free up resources for expanding testing in higher risk populations and higher yield venues without increased funding.

3. Background -1 Illinois Infertility Prevention Project (IPP) Resources - 2004 Tests = 222,516  Females: 168,565: 76% Tests (7.2% Pos)  Males: 53,843: 24% Tests (11.3% Pos)  Costs  Testing ~ $2.8 Million  Staffing ~ $100,000 Funding Federal ~ $1.1 Million State ~ $1.8 Million Title X FP ~ $300,000 (Lab and Clinic Support) Cook County Jail – 22,289 Tests in 2005 37 Providers Pay for Tests (3,250)

4. Background -2 Illinois IPP Chlamydia Testing Females By Testing Site Type, 2004 Provider Type # Provider Types % of Provider Type Positive Tests Negative Tests Total Tests Percent Positive HIV ANONYMOUS CTS205.4%417117525.8% DRUG TREATMENT CENTER10.3%619019626.8% SCHOOL BASED CLINIC277.2%4052,7423,14714.8% FAMILY PLANNING13034.9%5,51988,29793,8166.3% PRENATAL CLINIC82.1%2674,3014,5686.2% HOSPITAL (IP and ER)71.9%1441,3971,54110.3% CORRECTIONAL FACILITY164.3%1,53512,53014,06512.3% NON-CATEGORICAL HEALTH DEPT.308.0%1483,6693,8174.0% NEIGHBORHOOD HEALTH CENTER287.5%61011,58112,1915.3% PMD - DOWNSTATE318.3%2604,2324,4926.1% PMD - CHICAGO5113.7%6979,1739,8707.6% STD CLINIC4812.9%2,65520,78423,43912.8% UNIVERSITY HEALTH CENTER51.3%491,1261,1754.4% Total *373100.0%12,131157,215169,3467.7% * Excludes several low volume site types

5. Background -3 Decreasing Federal & State Funding in 2003 Prevented:  Expanding Testing Among Females & Males In High Yield Populations and Venues  Expanding Urine Based Testing  Implementing Retesting for Positive Females Anecdotal Data Suggested Significant Amount of IPP Testing in Low Yield Populations With Low Predictive Value Positives Attempts to Encourage Voluntary Adherence to IPP Screening Guidelines Were Overall Unsuccessful

6. In difficult times use a mirror, you will find both cause and resolution! Source: 365 Tao: Daily Meditations – Deng Ming-Dao

7. Background - 4 The Illinois Infertility Prevention Project (IPP) Screening Criteria recommends testing:  all sexually active females 24 years of age and younger for chlamydia and gonorrhea at least annually  females 25 years of age and older who have one or more risk factors

8. Background - 5 STD Signs or Symptoms  Vaginal Discharge  Mucopurulent Cervicitis  Pelvic Inflammatory Disease Sex Partner of Person Recently Diagnosed With Chlamydia or Gonorrhea Sex Partner Risk (within past 3 months)  New sex partner  >1 sex partner  Sex partner with additional sex partners Prior STD History in Past 3 years IUD Insertion Pregnancy Risk Factors for Females 25 Years of Age and Older

9. Objective Determine if Evidence Based Test Kit Allotments to Illinois IPP Chlamydia Screening Sites Reduces Testing in Low Risk Females 25 Years of Age and Older

10. Methods-1 Analyzed 4 Yrs Testing Data By Testing Site Type By Sex and Age Group to Determine Extent of Testing in Females 25 Years of Age and Older

11. IPP* Chlamydia Testing In Females By Age Group, Illinois, 2000 to 2003 % Total Tests % Positive *IPP – Infertility Prevention Project % Total Tests % Positive

12. IPP Chlamydia Testing In Females At Illinois Family Planning Clinics By Age Group, Illinois, 2000 to 2003 % Total Tests% Positive

13. RVIPP* Chlamydia Testing In Females By Age Group, FP Clinics, 1998 to 2003 % Total Tests% Positive RVIPP = Region V Infertility Prevention Project: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

14. RVIPP Chlamydia Testing In Females, 2005 Family Planning Clinics By State & Age Group % Total Tests % Positive

15. 2003 Illinois IPP Estimated Testing Costs All Screening Sites*, Females By Age Group 90,600 Tests 8,270 Positives Identified (9.1%) Assume $12.50 per NAAT $1,132,500 $137 per Positive Identified 55,981 Tests 1,833 Positives Identified (3.3%) Assume $12.50 per NAAT $699,762 $382 per Positive Identified Ages 25 and Older Under Age 25 * Testing by IDPH Labs and Excludes Payors and CCDPH FP

16. 2003 Illinois IPP Estimated Testing Costs Family Planning Clinics*, Females By Age Group 58,185 Tests 4,317 Positives Identified (7.4%) Assume $12.50 per NAAT $727,312 $168 per Positive Identified 25,718 Tests 791 Positives Identified (3.0%) Assume $12.50 per NAAT $321,475 $406 per Positive Identified Ages 25 and Older Under Age 25 * Testing by IDPH Labs and Excludes CCDPH FP and Payors

17. Illinois IPP Chlamydia Testing in 2003 Females 25 Years of Age and Older Projected Laboratory Testing Costs Before Implementation of Allotment Systems Test Source Total Tests All Ages Num. Test >=25 Age Pct. Test >=25 Age Pct. Pos. >=25 Age Pct. Met Criteria >=25 Age Pct. Outside Criteria >=25 Age Cost of Testing Outside Criteria >=25 Age All 144,24955,40838%3.3%24,380 44% 25,488 46% $318,600 Family Planning 83,90325,71831%3.1%9,516 37% 16,202 63% $202,525 Criteria = Selective Screening Criteria

18. Methods-2 Developed List of Potential Reallocation Options/Methods With Pros and Cons Tested Models to Determine Optimal Testing Reallocation and Algorithm Presented Data to IPP Partners to Gain Support and Reach Consensus on Methodology and Algorithm

19. Illinois IPP Chlamydia Test Kit Allotment Algorithm By Testing Site Type Change in Test Kits Provided In 2005 vs. 2004 Testing Site Type Females < 25 yrs Females >= 25 yrs Females >= 25 yrsMales If CT pos < 4.5% If CT pos > 4.5% Title X FP110%90% Cut110% Non-Title X FP110%90% Cut110% Corrections110% Other Sites110%90% Cut110% STD Clinics*110%110%*110% School Based HC200 tests over projected 2004 totals *STD clinics >= 27 years 110% = Increase in Test Kits

20. Methods-3 Determined that Controlling Test Kits Shipped to Testing Sites By IDPH Lab Was Best Strategy for Illinois IPP Obtained Approval From IDPH Administration & Warned About Disgruntled Sites & Blowback Developed Implementation Needs, Plan and Timeline  Data Systems Needed to Link & Monitor Lab Testing & Test Kit Ordering  Communication and Marketing to Testing Sites

21. Results Summary Reduction in Testing Among Females Ages >=25 at Family Planning (22%) and NonFamily Planning (20%) Clinics Reduction in Positive Tests Among Females Ages >=25 at Family Planning (19%) and NonFamily Planning (20%) Clinics Increase (45%) in Adherence to Selective Screening Criteria 11,493 Fewer Test Among Females Ages >=25 Now Available for Expansion in Higher Risk Populations and Venues (355 Fewer Positive Tests Detected) 2,973 Fewer Tests Among Females Ages <25 and 246 Fewer Positive Tests Detected

22. Illinois IPP Chlamydia Testing 2003 & 2005 Females 25 Years of Age and Older Family Planning Clinics* Change in Screening Criteria Adherence and Projected Laboratory Testing Costs Time Period and Change Total Tests All Ages Num. Test >=25 Pct. Test >=25 Pct. Pos. >=25 % Met Criteria % Outside Criteria Cost of Testing Outside Criteria 2003 Before 83,90325,71831%3.1%9,516 37% 16,202$202,529 2005 After 77,26719,94326%3.2%10,969 55% 8,974$112,179 Change (6,636)(5,775)22%3%49%45% * Includes Title X and non-Title X – excluding CCDPH and Payors

23. Illinois IPP Chlamydia Testing Females 25 Years of Age & Older Family Planning vs. NonFamily Planning FP Total Tests NonFP Total Tests FP Total Positives NonFP Total Positives 2003 25,72029,131791 3.1% PR 1,012 3.4% PR 2005 19,94323,370642 3.2% PR 806 3.4% PR Change -5,777-5,716-149-206 % Change -23%-20%-19%-20% PR = Positivity RateNonFP = Non Family Planning Clinics

24. Illinois IPP Chlamydia Testing Females Under 25 Years of Age Family Planning vs. NonFamily Planning FP Total Tests NonFP Total Tests FP Total Positives NonFP Total Positives 2003 58,18630,6554,317 7.4% PR 3,857 12.5% PR 2005 57,33128,5374,202 7.3% PR 3,726 13.1% PR Change -855-2,118-115-131 % Change -1%-7%-3% PR = Positivity RateNonFP = Non Family Planning Clinics

25. Chlamydia Tests In Females All IPP Testing Sites, By Age Group, Illinois, 2003 vs. 2005 Age Group 2005 Number Tests 2003 Number Tests Change Number Tests Percent Change Tests 15-1939,21940,795-1,576-3.9% 20-2444,87945,885-1,006-2.2% 25-2918,92922,274-3,345-15.0% 30-3410,57313,563-2,990-22.0% 35-396,1268,173-2,047-25.0% 40-443,9585,355-1,397-26.1% 44-492,2502,884-634-22.0% 50-549281,364-436-32.0% 55+5981,238-640-51.7% Unknown166557-391-70.2%

26. Chlamydia Positives In Females All IPP Testing Sites, By Age Group, Illinois, 2003 vs. 2005 Age Group 2005 Number Positives 2003 Number Positives Change Number Positives Percent Change Positives 15-194,5504,491591.3% 20-243,1603,391-231-6.8% 25-298851,079-194-18.0% 30-34322413-91-22.0% 35-39128156-28-17.9% 40-445791-34-37.4% 44-493438-4-10.5% 50-541216-4-25.0% 55+1110110.0% Unknown922-13-59.1%

27. Conclusions Implementing Test Kit Allotments Is an Effective Strategy to Reduce Testing in Low Risk Females Allotments May Contribute to Unintended Reduction in Testing Among Higher Risk Women Under 25 Years of Age Reanalysis of Age Specific Screening Criteria for Illinois IPP Is Needed With Possible Increase to Age 32 for Females At Some Sites

28. Lessons Learned - 1 Support from Partners & Leaders Essential Implement Allotments at Beginning of Year Notify Sites of Allotment 2-3 Months Prior to Implementation & Provide Rationale and Site Specific Retrospective Data Call or Meet With Sites With High Percentage of Low Yield Testing Prior to Implementation After Implementation, Review & Provide Prospective Data At Least Quarterly and Call Sites with Adherence Problems

29. Lessons Learned - 2 Expect Unintended Benefits & Challenges Flexibility & Patience Required – One Size Doesn’t Fit All Documenting Activities and Outcomes Facilitates Evaluation and Information Transfer Implementing, Managing and Monitoring Test Kit Allotments Is Very Labor Intensive

30. Acknowledgements Steve Holmes – Allotment Database Development & Data Tabulation Ed Renier – Allotment Enforcement IDPH STD Program & Lab Staff IDPH Administration IPP Members & Testing Site Staff RVIPP Members & HCET Alfred E. Neuman – Mentoring

31. IPP Chlamydia Allotment Project Recipient of Illinois Department of Public Health 2005 Exceptional Achievement Award

32. Presentation Addendum Test Kit Utilization & Allotment Data Base Images