Region II IPPRegion II IPPScreening Assessment ResultsScreening Assessment Results

Region II IPP Advisory MeetingRegion II IPP Advisory MeetingNovember 1, 2006November 1, 2006

Kelly Opdyke, MPHKelly Opdyke, MPHCicatelli Associates Inc.Cicatelli Associates Inc.

Region II IPP Workplan, 2006-2007Region II IPP Workplan, 2006-2007

PRIORITY 2: Incorporate Analysis of PRIORITY 2: Incorporate Analysis of Regional Prevalence Monitoring Data Regional Prevalence Monitoring Data for Regional and Local Data-Directed for Regional and Local Data-Directed Planning and Quality AssurancePlanning and Quality Assurance GOAL: IPP data will direct the most cost GOAL: IPP data will direct the most cost

effective implementation of screening and effective implementation of screening and treatment funds.treatment funds.• OBJECTIVE 2B: OBJECTIVE 2B: Identify what percentage of Identify what percentage of

eligible women are being screened on an annual eligible women are being screened on an annual basis among select sites participating in the basis among select sites participating in the Region II IPP.Region II IPP.

Region II IPPRegion II IPPMinimum Screening CriteriaMinimum Screening Criteria

Title X Family Planning ClinicsTitle X Family Planning Clinics All women ≤ 24 years of age attending the All women ≤ 24 years of age attending the

clinic for an initial or annual visit will be clinic for an initial or annual visit will be screened for chlamydia.screened for chlamydia.

STD ClinicsSTD Clinics All women ≤ 29 years of age attending the All women ≤ 29 years of age attending the

STD clinic will be screened for chlamydia.STD clinic will be screened for chlamydia.

2007 Proposed CDC2007 Proposed CDCIPP “Measures of Effectiveness”IPP “Measures of Effectiveness”

Measure 1Measure 1““Proportion of Family Planning clinics Proportion of Family Planning clinics

adhering to regional screening criteria”adhering to regional screening criteria”

Measure 2Measure 2““Chlamydia screening coverage estimate Chlamydia screening coverage estimate

for 15-19 year old sexually active for 15-19 year old sexually active women seen in Family Planning Clinics”women seen in Family Planning Clinics”

Screening Coverage – Nat’l DataScreening Coverage – Nat’l Data

2005 FPAR Data (OPA)2005 FPAR Data (OPA):: 58% of FP clients are under age 25 years58% of FP clients are under age 25 years 50% of FP clients age 15-24 were tested for CT 50% of FP clients age 15-24 were tested for CT

at least once in 2005at least once in 2005

2004 HEDIS Measure (NCQA)2004 HEDIS Measure (NCQA):: 45% of females age 16-25 in Medicaid plans 45% of females age 16-25 in Medicaid plans

were screened for CT at least once in 2004were screened for CT at least once in 2004 30% of females age 16-25 in commercial plans 30% of females age 16-25 in commercial plans

were screened for CT at least once in 2004were screened for CT at least once in 2004

Region II IPPRegion II IPP2005 Screening “Audit”2005 Screening “Audit”

Purpose:Purpose: Estimate chlamydia screening coverage Estimate chlamydia screening coverage

among eligible female patients according among eligible female patients according to Region II IPP minimum screening to Region II IPP minimum screening criteriacriteria

Pilot regional methodology for assessing Pilot regional methodology for assessing screening coverage and adherence to screening coverage and adherence to screening criteria in anticipation of CDC screening criteria in anticipation of CDC proposed measures of effectivenessproposed measures of effectiveness

Female Ct Testing & Positivity by Female Ct Testing & Positivity by Provider Type and Project AreaProvider Type and Project Area

FP Females < 25 Yrs# Tests % Pos

NJ 24,202 24,202 7.7%7.7%

NYC 9,011 9,011 4.1%4.1%

NYS 61,687 61,687 4.8%4.8%

PR 3,934 3,934 5.3%5.3%

USVI 546 546 20.3%20.3%Region II Total

99,38099,380 5.6%5.6%

Region II IPP CY2005

STD Females < 30 Yrs# Tests % Pos

NJ 3,573 3,573 13.1%13.1%

NYC 13,568 13,568 11.8%11.8%

NYS 7,163 7,163 11.6%11.6%

PR 2,356 2,356 8.4%8.4%

USVI 180 180 25.0%25.0%Region II Total

26,84026,840 11.7%11.7%

Region II IPPRegion II IPP2005 Screening “Audit” (cont’d)2005 Screening “Audit” (cont’d)

MethodologyMethodology:: Analyze a statistically significant number of Analyze a statistically significant number of

randomly selected eligible patient charts from randomly selected eligible patient charts from CY2005CY2005 3.4% sample in FP sites3.4% sample in FP sites 7.4% sample in STD sites7.4% sample in STD sites

Compare observed vs. expected proportion Compare observed vs. expected proportion screenedscreened Expect 85% screening coverage in FPExpect 85% screening coverage in FP Expect 90% screening coverage in STDExpect 90% screening coverage in STD

Region II IPPRegion II IPP2005 Screening “Audit” (cont’d)2005 Screening “Audit” (cont’d)

SampleSample:: From Apr-Sep 2006, a total of 4,700 records From Apr-Sep 2006, a total of 4,700 records

were collected from 208 clinic sites in NJ, NYC, were collected from 208 clinic sites in NJ, NYC, NYS and PRNYS and PR FPFP: 2,726 records from 164 clinics (91% of 180 sites): 2,726 records from 164 clinics (91% of 180 sites) STDSTD: 1,789 records from 36 clinics (63% of 57 sites): 1,789 records from 36 clinics (63% of 57 sites) OtherOther: 185 records from 8 other clinics in NYC & NYS: 185 records from 8 other clinics in NYC & NYS

• (2 Adolescent HC, 3 College HC, and 3 Community HC)(2 Adolescent HC, 3 College HC, and 3 Community HC)

64 records fell outside age criteria for clinic type 64 records fell outside age criteria for clinic type and were excluded from analysisand were excluded from analysis (Removed 3 FP, 26 STD, 35 other)(Removed 3 FP, 26 STD, 35 other)

Data Collection ToolData Collection Tool Clinic IDClinic ID Client ID Client ID Age of clientAge of client Was client tested for chlamydia?Was client tested for chlamydia? If NO chlamydia test done, reason for not testing If NO chlamydia test done, reason for not testing

(select all that apply):(select all that apply): Client refusedClient refused No new riskNo new risk Not sexually activeNot sexually active Tested / treated for chlamydia in past 30 daysTested / treated for chlamydia in past 30 days Referred for TreatmentReferred for Treatment Not recorded in chartNot recorded in chart Other (specify)Other (specify)

Results – FP ClinicsResults – FP Clinics Overall, Overall, 86.0%86.0% (2,343/2,723) of females under (2,343/2,723) of females under

age 25 seen for initial or annual exam were age 25 seen for initial or annual exam were tested for tested for Ct Ct (95%CI: 84.7%-87.3% )(95%CI: 84.7%-87.3% ) By clinic site, the prop. screened ranged from 0% to By clinic site, the prop. screened ranged from 0% to

100%, with a weighted avg of 89.8%.100%, with a weighted avg of 89.8%. Most common reasons for not testing (n=380):Most common reasons for not testing (n=380):

Client refusedClient refused 31.8%31.8% No new riskNo new risk 16.1%16.1% Not sexually activeNot sexually active 12.1%12.1% Menses/BleedingMenses/Bleeding 9.2% 9.2% Tested/Tx’d in last 30 daysTested/Tx’d in last 30 days 8.7% 8.7% *No pelvic exam*No pelvic exam 2.1% 2.1%

*NOTE: No overlap between “menses/bleeding” and “no pelvic exam” responses.

FP Screening CoverageFP Screening Coverage(Expected 85%)(Expected 85%)

Project Project AreaArea

# Sites# Sites Sample Sample SizeSize

% Screened (95% CI)% Screened (95% CI)

NJ 4343 864864 87.0%87.0% (84.8%-89.3%) (84.8%-89.3%)

NYC 99 170170 98.8%98.8% (97.2%-100%) (97.2%-100%)

NYS 7474 1,5351,535 87.9%87.9% (86.3%-89.5%) (86.3%-89.5%)

PR 3838 154154 47.4%47.4% (39.5%-55.3%) (39.5%-55.3%)

TOTAL 164164 2,7232,723 86.0%86.0% (84.7%-87.3%) (84.7%-87.3%)

Results – FP Clinics Results – FP Clinics (cont’d)(cont’d)

† † Adjusted overall screening coverage in FP is Adjusted overall screening coverage in FP is 89.689.6%% (2,343/2,614) (95%CI: 88.4%-90.8%) (2,343/2,614) (95%CI: 88.4%-90.8%)

In Puerto Rico, most common reasons for not In Puerto Rico, most common reasons for not testing were (n=81 of 154 sampled):testing were (n=81 of 154 sampled): Not recorded in chartNot recorded in chart 24.7%24.7% Client absent for medical examClient absent for medical exam 22.2%22.2% No physician availableNo physician available 16.0%16.0% Menses/BleedingMenses/Bleeding 16.0%16.0% Client did not assist for med examClient did not assist for med exam 8.6% 8.6% Client refusedClient refused 6.2% 6.2%

† Adjusted by removing 109 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

Results – STD ClinicsResults – STD Clinics

Overall, Overall, 74.4%74.4% (1,312/1,763) of females under (1,312/1,763) of females under age 30 seen in STD clinics were tested for age 30 seen in STD clinics were tested for Ct Ct (95%CI: 72.4%-76.5%)(95%CI: 72.4%-76.5%) By clinic site, the prop. screened ranged from 16.7% By clinic site, the prop. screened ranged from 16.7%

to 100%, with a weighted avg of 75.3%.to 100%, with a weighted avg of 75.3%. Most common reasons for not testing (n=451):Most common reasons for not testing (n=451):

Tested/Tx’d in last 30 daysTested/Tx’d in last 30 days 37.9%37.9% Other reason for visitOther reason for visit 27.3%27.3% Referred for treatmentReferred for treatment 21.7%21.7% Other (not specified)Other (not specified) 15.3%15.3% Not recorded in chartNot recorded in chart 6.9% 6.9%

STD Screening CoverageSTD Screening Coverage(Expected 90%)(Expected 90%)

Project Project AreaArea

# Sites# Sites Sample Sample SizeSize

% Screened (95% CI)% Screened (95% CI)

NJ 55 376376 68.6%68.6% (63.9%-73.3%) (63.9%-73.3%)

NYC 1010 1,0371,037 77.8%77.8% (75.3%-80.3%) (75.3%-80.3%)

NYS 1010 178178 88.8%88.8% (84.2%-93.4%) (84.2%-93.4%)

PR 1111 172172 51.7%51.7% (44.2%-59.2%) (44.2%-59.2%)

TOTAL 3636 1,7631,763 74.4%74.4% (72.4%-76.5%) (72.4%-76.5%)

Results – STD Clinics Results – STD Clinics (cont’d)(cont’d)

† † Adjusted overall screening coverage in STD is Adjusted overall screening coverage in STD is 83.2%83.2% (1,312/1,576) (95%CI: 81.4%-85.0%) (1,312/1,576) (95%CI: 81.4%-85.0%)

Among clients not screened because of “other Among clients not screened because of “other reason for visit” (n=123 of 451 not tested):reason for visit” (n=123 of 451 not tested): Emergency contraception onlyEmergency contraception only 57.7%57.7% HIV/syphilis/blood test onlyHIV/syphilis/blood test only 19.5%19.5% Treated for another STDTreated for another STD 13.8%13.8% Hepatitis vaccineHepatitis vaccine 6.5% 6.5%

† Adjusted by removing 187 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

Results – Other Clinic TypesResults – Other Clinic Types

Overall, Overall, 71.3%71.3% (107/150) of females under age (107/150) of females under age 25 were tested for 25 were tested for Ct Ct (95%CI: 64.1%-78.6%)(95%CI: 64.1%-78.6%) By clinic site, the prop. screened ranged from 36.8% By clinic site, the prop. screened ranged from 36.8%

to 100%, with a weighted avg of 69.2%.to 100%, with a weighted avg of 69.2%.

Most common reasons for not testing (n=43):Most common reasons for not testing (n=43): Other reason for visitOther reason for visit 34.9%34.9% Not recorded in chartNot recorded in chart 16.3%16.3% No new riskNo new risk 11.6%11.6% Tested/Tx’d in last 30 daysTested/Tx’d in last 30 days 11.1%11.1% Client refusedClient refused 9.3% 9.3%

Screening Coverage in Other SitesScreening Coverage in Other Sites(No Baseline). Criteria: Females age < 25(No Baseline). Criteria: Females age < 25

Clinic Clinic TypeType

# Sites# Sites Sample Sample SizeSize

% Screened (95% CI)% Screened (95% CI)

Adol HC 22 5454 68.5%68.5% (56.1%-80.9%) (56.1%-80.9%)

College HC

33 6363 63.5%63.5% (51.6%-75.4%) (51.6%-75.4%)

CHC 33 3333 90.9%90.9% (81.1%-100%) (81.1%-100%)

TOTAL 88 150150 71.3%71.3% (64.1%-78.6%) (64.1%-78.6%)

Data submitted for sites in NYC and NYS onlyData submitted for sites in NYC and NYS only

Results – Other Clinic Types Results – Other Clinic Types (cont’d)(cont’d)

† † Adjusted overall screening coverage in Adjusted overall screening coverage in Adolescent, College, and Community HC’s was Adolescent, College, and Community HC’s was 79.3%79.3% (107/135) (95%CI: 72.5%-86.1%) (107/135) (95%CI: 72.5%-86.1%)

Consider expanded assessment of screening Consider expanded assessment of screening coverage in Adolescent HC for future analysiscoverage in Adolescent HC for future analysis Is screening coverage lower than in other FP sites?Is screening coverage lower than in other FP sites?

† Adjusted by removing 15 records for clients not screened because of ““no new risk”, “not sexually active”, “tested/tx’d in last 30 days” or “referred for treatment”

DiscussionDiscussion Chlamydia screening coverage among females Chlamydia screening coverage among females

who meet the Region II IPP minimum screening who meet the Region II IPP minimum screening criteria is high (>80criteria is high (>80%) %) overall, but varies by overall, but varies by provider type, project area, and clinic site.provider type, project area, and clinic site. Programs should utilize local data to target efforts to Programs should utilize local data to target efforts to

increase screening coverage.increase screening coverage. Screening coverage estimates are based on Screening coverage estimates are based on

reason not tested reason not tested at this visitat this visit (cross-sectional) (cross-sectional) CDC guidelines recommend at least annuallyCDC guidelines recommend at least annually Screening may take place at another visit in the yearScreening may take place at another visit in the year

In all clinic types, reason why females who fit In all clinic types, reason why females who fit age criteria are not screened should be routinely age criteria are not screened should be routinely recorded in client chart to facilitate follow-uprecorded in client chart to facilitate follow-up

Discussion (cont’d)Discussion (cont’d)

In FP clinics, client refusal accounts for a large In FP clinics, client refusal accounts for a large proportion (31.8%) of those not screened.proportion (31.8%) of those not screened.

Screening coverage may be improved in part by educating Screening coverage may be improved in part by educating providers on strategies for increasing clients’ acceptance of providers on strategies for increasing clients’ acceptance of testing.testing.

In STD clinics, adjusted screening coverage could In STD clinics, adjusted screening coverage could increase from 83.2% to 89.3% if females < 30 yrs seen increase from 83.2% to 89.3% if females < 30 yrs seen for EC or HIV/blood test only were routinely screened for for EC or HIV/blood test only were routinely screened for chlamydiachlamydia

Programs should consider local screening criteriaPrograms should consider local screening criteria Further analysis should focus on more clearly defining Further analysis should focus on more clearly defining

potential barriers to screening.potential barriers to screening. (e.g. What does “not sexually active” mean?)(e.g. What does “not sexually active” mean?)

Implications/DiscussionImplications/Discussion

Region II IPP Region II IPP minimum screening criteriaminimum screening criteria for FP include only those women who for FP include only those women who have an initial or annual (i.e. pelvic) examhave an initial or annual (i.e. pelvic) exam

In the pastIn the past, chlamydia testing required the , chlamydia testing required the collection of a cervical specimen.collection of a cervical specimen.

Highly-sensitive urine-based NAATs Highly-sensitive urine-based NAATs (nucleic acid amplification tests) provide (nucleic acid amplification tests) provide an opportunity for expanded screening to an opportunity for expanded screening to additional high-risk clients.additional high-risk clients.