Chlamydia Screening of At-Risk Young Women in Managed Health Care: Characteristics of Top-Performing Primary Care Offices

Chlamydia screening coverage estimates derived using healthcare effectiveness data and information system procedures and indirect estimation vary substantially

BACKGROUND

Screening coverage is an important determinant of chlamydial control program success.

OBJECTIVES

The aim of this study was to compare chlamydial screening coverage estimates.

METHODS

We compared 9 estimates among women aged 15 to 25 years in Washington State, 2009. Four used Healthcare Effectiveness Data and Information System (HEDIS) procedures among Group Health enrollees. Separate HEDIS estimates assessed all enrollees and the subset of women who used services; for each group, separate estimates defined the sexually active population using HEDIS methods or National Survey of Family Growth (NSFG) data. Three indirect screening estimates used census and NSFG data to define the population's size and derived the number of tests performed by dividing the number of reported cases by test positivity defined using data from different laboratories, adjusted for repeat testing. A fourth indirect estimate was adjusted for reason for testing. A direct-indirect estimate combined data on the number of tests performed in reporting laboratories and an indirect estimate of tests performed elsewhere.

RESULTS

Healthcare Effectiveness Data and Information System procedures and NSFG data yielded similar estimates of the percentage of women who were sexually active (60% vs. 61%). Screening coverage estimated by HEDIS was higher among Group Health users (43.6%) than among all enrollees (34.2%). Indirect screening coverage estimates varied from 46.4% to 68.7%. The direct-indirect estimate, which included a direct measure of the number of tests performed to identify 52% of reported cases, was 57.6%.

CONCLUSIONS

Most sexually active women aged 15 to 25 years in Washington State were screened for chlamydia in 2009. Healthcare Effectiveness Data and Information System methods may underestimate screening coverage. Health departments can derive population-based coverage estimates using data from large laboratories.

The role of Medicaid managed care interventions in Chlamydia screening by physicians

BACKGROUND

Chlamydia trachomatis (CT) guidelines call for annual screening of all sexually active young females. In previous studies, Medicaid health maintenance organizations (HMOs) did not consistently recommend CT and other sexually transmitted disease guidelines, but physicians with HMO practices were more likely to comply with guidelines than those without HMO practices. This study examines the relationship between HMO interventions and physician adherence to annual (CT) screening guidelines for sexually active young (ages 15-25) females.

METHODS

Medicaid HMOs (N = 17) of California were surveyed regarding their interventions to increase physician adherence with national CT screening guidelines in 2002. Primary care physicians (N = 941) who contracted with these HMOs were also surveyed on their frequency (always/usually) of CT screening. Data were analyzed using logistic regression models.

RESULTS

HMO-reported recommendations for CT screening and other interventions were associated with significantly higher odds of frequent CT screening by contracted physicians in unadjusted models. HMO recommendations to screen young females increased the odds of frequent CT screening, but other interventions were no longer significantly associated after controlling for physician characteristics. Physicians also had higher odds of reporting frequent CT screening if they had received training in the past, had received feedback from their contracted HMOs, or reported having access to national CT screening guidelines. Physician gender, specialty, years of clinical experience, and other factors were also significantly associated with the odds of frequency of CT screening.

DISCUSSION

Improving physician adherence with CT screening guidelines requires a refinement of current approaches with targeted interventions that are tailored to the characteristics of physicians. In addition, interventions are more likely to be effective if provided in formats that are perceived and acknowledged by physicians.

Chlamydia testing in general practice in Australia

OBJECTIVES

We aimed to ascertain how frequently Australian general practitioners (GPs) test patients for chlamydia and to determine GP, patient and encounter characteristics where tests occurred.

METHODS

We identified all GP, patient and encounter characteristics associated with higher testing rates, April 2000 to March 2007, using the Bettering the Evaluation and Care of Health data. Multiple logistic regression was used to measure the effect of each GP, patient and encounter characteristic.

RESULTS

Data were available for 689 000 encounters from 6890 GPs, of which 2236 were test encounters. Testing rates increased significantly between 2000 and 2007 (P < 0.0001). The rate of testing was higher for female patients (4.2 per 1000, 95% confidence interval (CI): 3.8-4.5) than males (2.0; 95% CI: 1.8-2.2). Predictors of higher chlamydia testing were: female GP (adjusted odds ratio (AOR): 1.84; 95% CI: 1.60-2.1); GP age (<35 v. 55+, 2.17; 95% CI: 1.65-2.85); practice in a major city (1.34; 95% CI: 1.18-1.52); large practice (5+ GP practice v. solo, 1.69; 95% CI: 1.27-2.25); graduated in Australia (1.22; 95% CI: 1.04-1.44); patient sex and younger age, being new to the practice (1.65; 95% CI: 0.47-1.86), Indigenous (3.46; 95% CI: 2.64-4.54), late in the study (twice as likely in 2006-07 than in 2000-01) and 'opportunity to test' (AOR: 32.25; 95% CI: 27.25-38.16).

CONCLUSIONS

Chlamydia testing rates have increased in general practice in Australia, with higher rates in females. Initiatives to overcome barriers to testing (especially for male patients and older male GPs) need to be established and evaluated.

Home-based chlamydia testing of young people attending a music festival--who will pee and post?

BACKGROUND

Chlamydia is most common among young people, but only a small proportion of Australian young people are tested annually. Home-based chlamydia testing has been piloted in several countries to increase testing rates, but uptake has been low. We aimed to identify predictors of uptake of home-based chlamydia testing to inform future testing programs.

METHODS

We offered home-based chlamydia testing kits to participants in a sexual behaviour cross-sectional survey conducted at a music festival in Melbourne, Australia. Those who consented received a testing kit and were asked to return their urine or vaginal swab sample via post.

RESULTS

Nine hundred and two sexually active music festival attendees aged 16-29 completed the survey; 313 (35%) opted to receive chlamydia testing kits, and 67 of 313 (21%) returned a specimen for testing. One participant was infected with chlamydia (1% prevalence). Independent predictors of consenting to receive a testing kit included older age, knowing that chlamydia can make women infertile, reporting more than three lifetime sexual partners and inconsistent condom use. Independent predictors of returning a sample to the laboratory included knowing that chlamydia can be asymptomatic, not having had an STI test in the past six months and not living with parents.

CONCLUSIONS

A low proportion of participants returned their chlamydia test, suggesting that this model is not ideal for reaching young people. Home-based chlamydia testing is most attractive to those who report engaging in sexual risk behaviours and are aware of the often asymptomatic nature and potential sequelae of chlamydia infection.

Comparison of clinical evaluation of genitourinary symptoms in female adolescents among primary care versus emergency department physicians

OBJECTIVE

To compare clinical approaches to assessment and treatment of female adolescents with genitourinary symptoms among primary care and emergency department (ED) physicians.

DESIGN

A chart review was performed of the evaluation and treatment of 472 patients presenting between July 1, 2005, and June 30, 2006.

SETTING

Suburban and tertiary care EDs and primary care settings.

PARTICIPANTS

Female patients age 13-21 years with genitourinary symptoms.

INTERVENTIONS

None.

OUTCOME MEASURES

Physician assessment of sexual history, performance of pelvic exam and sexually transmitted infection (STI) tests, empiric treatment of suspected STIs.

RESULTS

Patients seen in primary care settings were more likely to be asked about sexual history, including contraceptive use, than patients in the ED (P<0.001). After adjustment for age and race, there was no statistically significant difference between the ED and primary care sites in performance of pelvic exams or gonorrhea and chlamydia tests. However, there was a higher likelihood that older adolescents would undergo pelvic exams (P=0.001), and STI testing (P=0.002) than younger patients. There was no significant difference in empiric treatment of patients with positive STI tests between ED and primary care sites or across the age spectrum.

CONCLUSIONS

ED physicians should obtain sexual histories on patients with genitourinary symptoms. Both primary care and ED clinicians should consistently test for STIs in sexually active patients who have genitourinary symptoms. Physicians in both settings should have a low threshold for testing and empirically treating adolescents with symptoms or physical exam findings consistent with STIs.

Health-seeking behaviors and sexually transmitted diseases among adolescents attending an urban pediatric emergency department

INTRODUCTION

Adolescents are often seen in Emergency departments (ED) for urgent care. Rates of treatable sexually transmitted diseases (Neisseria gonorrhoeae and Chlamydia trachomatis) are highest in this age group. This study examines the prevalence of these sexually transmitted diseases (STDs) and the health seeking characteristics of adolescents presenting to an urban pediatric ED.

METHODS

Participants were enrolled between January 2000 and July 2004. Urine specimens (tested for the STDs) and a questionnaire data form (demographics and health seeking behaviors) were collected and scanned into a computer database, and results were merged for analysis. Prevalence rates were calculated for gonorrheal and chlamydial infections.

RESULTS

A total of 1,621 participants were enrolled. Prevalence rates for C. trachomatis and N. gonorrhoeae were 9.8% (95% CI 8.6, 11.1) and 3.4% (95% CI 2.6,4.2), respectively. Test results did not differ significantly by race (p= 0.29). Reporting of a regular health care provider vs no regular provider did not significantly impact the likelihood of having a positive test result, 10.7% (95% CI 9.1, 12.4) vs 12.1% (95% CI 5.4, 18.8) (p=0.69). The prevalence of STDs was higher among uninsured (16.3, 95% CI 12.3, 20.3) and those participants covered by Medicaid (13.3, 95% CI 10.6, 16.1) compared to those reporting private insurance (6.0, 95% CI 4.2, 7.7).

CONCLUSION

This study confirms a high prevalence of treatable STDs among adolescents in an urban ED setting and provides information on frequency of ED usage and health-seeking behaviors among adolescents.

Urine gonococcal/Chlamydia testing in adolescents

PURPOSE OF REVIEW

This review will highlight the recent literature findings regarding urine-based Chlamydia and gonorrhea testing in adolescents.

RECENT FINDINGS

Rates of Chlamydia trachomatis are increasing, likely due to increased detection efficiency, but have not yet begun to decrease. Neisseria gonorrhoeae is at an all-time low. Urine-based testing for sexually transmitted infections is readily available and convenient but underutilized. Interesting approaches to a more universal screening program, including self-collected, mail-in urine samples, have been shown to be effective.

SUMMARY

In spite of recommendations urging universal screening for C. trachomatis and N. gonorrhoeae and the availability of highly accurate and convenient tests, screening rates for adolescents and young adults remain below the universal recommendations. Strategies to improve screening rates should take advantage of urine-based screening methodologies for sexually transmitted infections because of their cost-effectiveness as well as the convenience for patient and provider.