Region II IPP Screening Assessment Results

1
Region II IPPScreening Assessment Results

• Region II IPP Advisory Meeting
• November 1, 2006
• Kelly Opdyke, MPH
• Cicatelli Associates Inc.

2
Region II IPP Workplan, 2006-2007

• PRIORITY 2 Incorporate Analysis of Regional
  Prevalence Monitoring Data for Regional and Local
  Data-Directed Planning and Quality Assurance
• GOAL IPP data will direct the most cost
  effective implementation of screening and
  treatment funds.
• OBJECTIVE 2B Identify what percentage of
  eligible women are being screened on an annual
  basis among select sites participating in the
  Region II IPP.

3
Region II IPPMinimum Screening Criteria

• Title X Family Planning Clinics
• All women 24 years of age attending the clinic
  for an initial or annual visit will be screened
  for chlamydia.
• STD Clinics
• All women 29 years of age attending the STD
  clinic will be screened for chlamydia.

4
2007 Proposed CDCIPP Measures of Effectiveness

• Measure 1
• Proportion of Family Planning clinics adhering
  to regional screening criteria
• Measure 2
• Chlamydia screening coverage estimate for 15-19
  year old sexually active women seen in Family
  Planning Clinics

5
Screening Coverage Natl Data

• 2005 FPAR Data (OPA)
• 58 of FP clients are under age 25 years
• 50 of FP clients age 15-24 were tested for CT at
  least once in 2005
• 2004 HEDIS Measure (NCQA)
• 45 of females age 16-25 in Medicaid plans were
  screened for CT at least once in 2004
• 30 of females age 16-25 in commercial plans were
  screened for CT at least once in 2004

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Region II IPP2005 Screening Audit

• Purpose
• Estimate chlamydia screening coverage among
  eligible female patients according to Region II
  IPP minimum screening criteria
• Pilot regional methodology for assessing
  screening coverage and adherence to screening
  criteria in anticipation of CDC proposed measures
  of effectiveness

7
Female Ct Testing Positivity by Provider Type
and Project Area
Region II IPP CY2005
8
Region II IPP2005 Screening Audit (contd)

• Methodology
• Analyze a statistically significant number of
  randomly selected eligible patient charts from
  CY2005
• 3.4 sample in FP sites
• 7.4 sample in STD sites
• Compare observed vs. expected proportion screened
• Expect 85 screening coverage in FP
• Expect 90 screening coverage in STD

9
Region II IPP2005 Screening Audit (contd)

• Sample
• From Apr-Sep 2006, a total of 4,700 records were
  collected from 208 clinic sites in NJ, NYC, NYS
  and PR
• FP 2,726 records from 164 clinics (91 of 180
  sites)
• STD 1,789 records from 36 clinics (63 of 57
  sites)
• Other 185 records from 8 other clinics in NYC
  NYS
• (2 Adolescent HC, 3 College HC, and 3 Community
  HC)
• 64 records fell outside age criteria for clinic
  type and were excluded from analysis
• (Removed 3 FP, 26 STD, 35 other)

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Data Collection Tool

• Clinic ID
• Client ID
• Age of client
• Was client tested for chlamydia?
• If NO chlamydia test done, reason for not testing
  (select all that apply)
• Client refused
• No new risk
• Not sexually active
• Tested / treated for chlamydia in past 30 days
• Referred for Treatment
• Not recorded in chart
• Other (specify)

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Results FP Clinics

• Overall, 86.0 (2,343/2,723) of females under age
  25 seen for initial or annual exam were tested
  for Ct (95CI 84.7-87.3 )
• By clinic site, the prop. screened ranged from 0
  to 100, with a weighted avg of 89.8.
• Most common reasons for not testing (n380)
• Client refused 31.8
• No new risk 16.1
• Not sexually active 12.1
• Menses/Bleeding 9.2
• Tested/Txd in last 30 days 8.7
• No pelvic exam 2.1

NOTE No overlap between menses/bleeding and
no pelvic exam responses.
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FP Screening Coverage(Expected 85)
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Results FP Clinics (contd)

• Adjusted overall screening coverage in FP is
  89.6 (2,343/2,614) (95CI 88.4-90.8)
• In Puerto Rico, most common reasons for not
  testing were (n81 of 154 sampled)
• Not recorded in chart 24.7
• Client absent for medical exam 22.2
• No physician available 16.0
• Menses/Bleeding 16.0
• Client did not assist for med exam 8.6
• Client refused 6.2

Adjusted by removing 109 records for clients
not screened because of no new risk, not
sexually active, tested/txd in last 30 days
or referred for treatment
14
Results STD Clinics

• Overall, 74.4 (1,312/1,763) of females under age
  30 seen in STD clinics were tested for Ct (95CI
  72.4-76.5)
• By clinic site, the prop. screened ranged from
  16.7 to 100, with a weighted avg of 75.3.
• Most common reasons for not testing (n451)
• Tested/Txd in last 30 days 37.9
• Other reason for visit 27.3
• Referred for treatment 21.7
• Other (not specified) 15.3
• Not recorded in chart 6.9

15
STD Screening Coverage(Expected 90)
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Results STD Clinics (contd)

• Adjusted overall screening coverage in STD is
  83.2 (1,312/1,576) (95CI 81.4-85.0)
• Among clients not screened because of other
  reason for visit (n123 of 451 not tested)
• Emergency contraception only 57.7
• HIV/syphilis/blood test only 19.5
• Treated for another STD 13.8
• Hepatitis vaccine 6.5

Adjusted by removing 187 records for clients
not screened because of no new risk, not
sexually active, tested/txd in last 30 days
or referred for treatment
17
Results Other Clinic Types

• Overall, 71.3 (107/150) of females under age 25
  were tested for Ct (95CI 64.1-78.6)
• By clinic site, the prop. screened ranged from
  36.8 to 100, with a weighted avg of 69.2.
• Most common reasons for not testing (n43)
• Other reason for visit 34.9
• Not recorded in chart 16.3
• No new risk 11.6
• Tested/Txd in last 30 days 11.1
• Client refused 9.3

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Screening Coverage in Other Sites(No Baseline).
Criteria Females age lt 25
Data submitted for sites in NYC and NYS only
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Results Other Clinic Types (contd)

• Adjusted overall screening coverage in
  Adolescent, College, and Community HCs was 79.3
  (107/135) (95CI 72.5-86.1)
• Consider expanded assessment of screening
  coverage in Adolescent HC for future analysis
• 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/txd in last 30 days or
referred for treatment
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Discussion

• Chlamydia screening coverage among females who
  meet the Region II IPP minimum screening criteria
  is high (gt80) overall, but varies by provider
  type, project area, and clinic site.
• Programs should utilize local data to target
  efforts to increase screening coverage.
• Screening coverage estimates are based on reason
  not tested at this visit (cross-sectional)
• CDC guidelines recommend at least annually
• Screening may take place at another visit in the
  year
• In all clinic types, reason why females who fit
  age criteria are not screened should be routinely
  recorded in client chart to facilitate follow-up

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Discussion (contd)

• In FP clinics, client refusal accounts for a
  large proportion (31.8) of those not screened.
• Screening coverage may be improved in part by
  educating providers on strategies for increasing
  clients acceptance of testing.
• In STD clinics, adjusted screening coverage could
  increase from 83.2 to 89.3 if females lt 30 yrs
  seen for EC or HIV/blood test only were routinely
  screened for chlamydia
• Programs should consider local screening criteria
• Further analysis should focus on more clearly
  defining potential barriers to screening.
• (e.g. What does not sexually active mean?)

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Implications/Discussion

• Region II IPP minimum screening criteria for FP
  include only those women who have an initial or
  annual (i.e. pelvic) exam
• In the past, chlamydia testing required the
  collection of a cervical specimen.
• Highly-sensitive urine-based NAATs (nucleic acid
  amplification tests) provide an opportunity for
  expanded screening to additional high-risk
  clients.