Evolving Thoughts on Chlamydia in a Large MCO

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Evolving Thoughts on Chlamydia in a Large MCO

• Joanne Armstrong, MD, MPH
• Regional Womens Health Medical Director
• Aetna, Inc
• Assistant Professor Obstetrics and Gynecology
• Baylor College of Medicine
• Houston, TX

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Structure and Complexity of Network Managed Care

• Health benefits company
• 19 million members
• Spectrum of HMO and non-HMO based products
• Network based provides
• 100,000 PCPs, 23,000 Ob-Gyns, 3,000 hospitals,
  national and local laboratories vendors
• Individually and IPA/PMG contracted
• National programs with variation by region, plan
  design, legal mandates, etc.
• Cannot impose practice standards

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1999-2000 Ct Perspective

• No specific programs for Chlamydia
• Embedded within broader strategy for STDs
• Open access to PCPs, Ob Gyns, Peds
• Comprehensive care and follow up care available.
• Open access to labs, including new amplified
  tests
• Comprehensive pharmacy services.
• ? No access barriers to testing any insured
  member at any desired interval.
• ? No financial barriers to testing

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1999-2000 Barriers to Greater Involvement

• Perception barriers-MCO
• The Top 25
• STDs not on list of high cost or high frequency
  diagnoses
• Coding specificity problems
• Program expenses
• Competition against other programs for
• Rewards not easily measured in the numbers
• Purchasers not demanding programs

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HEDIS 2000 MCO Perspective

• Administrative data poor at identifying truly
  at-risk
• Not consistent with existing guidelines (CDC,
  ACOG)
• HEDIS is overly broad esp. wrt 20-25 y/o
• Literature inadequately describes prevalence of
  CT in insured non-adolescent populations.
• Cost-benefit analyses lacking in MCO populations
• ? Difficult for health plan to support HEDIS

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HEDIS 2000 Physician Perspective

• Aetna Ob Gyn National QA committee
• Agree with screening sexually active lt20 group
• Resistance to routine screening gt20y/o
• Existing guidelines do not promote this (CDC,
  ACOG)
• Published studies do not reflect their population
• Perception that CT is not prevalent in insured
  populations
• Resist time spent on this issue
• Prediction minimal buy-in by physicians
• Actions
• Chart review of CT point prevalence in 6
  practices across country
• 1 prevalence

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October 2000

• Problem
• Internal data and physician perception does not
  match public health perception or HEDIS
  objectives.
• Action
• Collect data outside of health plan
• Study support
• Baylor College of Medicine
• Obstetrics and Gynecology Associates, PA
• Texas Dept of Health
• Aetna

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Research Objectives

• Determine rate of testing among commercially
  insured women ages 15-25 in conventional
  practice. (Part 1)
• Determine CT prevalence in commercially insured
  women ages 15-25. (Part 2)
• Setting OGA, PC
• large single specialty, private ObGyn group
  practice, Houston, TX.

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Intervening Events 2001

• USPSTF recommendations
• HEDIS 2000 results for health plan and market
• Aetna 16.6
• Houston market 17

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Retrospective Study (Part 1) October 2000

• Objective
• Describe testing practices of MDs in conventional
  practice setting.
• Design
• Retrospective study
• 600 women, 15-25 y/o, commercially insured,
  requiring pelvic exam between 4/01 and 10/01.
• Outcome
• Rate of testing in high risk women.
• High RiskACOG or CDC definition

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Retrospective Study FindingsOctober 2001

• 27 population had at least one risk factor
  (ACOG/CDC)
• 30.9 patients with risk factors were tested
• 36 of sexually active teens tested
• 98 population had HEDIS risk factor
• 22 of all HEDIS population tested
• All testing was done with non-amplified nucleic
  acid hybridization cervical swabs.

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Cross Sectional Study (Part 2) October 2000

• Objective
• Determine prevalence of infection
• Compare prevalence rates using 2 different assays
• Non amplified vs. DNA strand displacement
  amplified probe
• Study Design CS
• 455/600 women, 15-25 y/o, commercially insured
• Amplified and non amplified cervical swabs
• Sexual risk factor questionnaire at completion of
  exam.
• HR for infectionACOG or CDC definition

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CS Results Demographic and behavioral
characteristics, October 2001

• Mean age 22.5 years, 16 lt20 years old
• White 67, black 15
• Unmarried 74
• Nulligravid 72
• Annual/new gyn 73, obstetrical 8
• Asymptomatic 83 95 w/o sequelae
• Sexually active 91
• Inconsistent use of barriers 66
• Contraceptive use 60 (hormonal 48, condoms11)
• New or multiple partner past 12 months 29
• STD dx or tx past 12 months 15
• 82 with at least one high risk factor

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CS Results Chlamydia Prevalence
N Pos. P Total 443
23 5.2 Age lt20 69 4 5.8
.8 20-25 374 19 5.1 Sexually active
Age lt20 59 4 6.8 .6 20-25 340
17 5.0
amplified probe
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CS Results Comparison of amplified to
non-amplified probe
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Conclusions commercially insured population

• Testing underperformed in routine practice
• Risk factors are common when systematically
  assessed.
• Prevalence is higher than anticipated (5.2)
• Amplified probes are more sensitive.
• Optimal risk factor ascertainment identified 83
  of infections.
• HEDIS identified 91 of infections
• Estimate that 75 of infections undetected.

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Actions November 2001

• Represented to OB GYN QA Committee
• Study findings
• USPSTF recommendations
• HEDIS rates
• Physician perception changed
• Advised to disseminate information

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External Dissemination

• Local
• Physician education
• Baylor College of Medicine-5/2001 OGA-5/2001
• Womens Hospital Grand Rounds-4/2002
• Mailing to 4,000 OB GYNs, Peds, PCPs
  Houston-2/2002
• Lab education
• Working with contracted lab to educate MDs about
  tests available-2/02
• Public Health authorities 2/02
• City of Houston Health Dept
• School of Public Health
• Harris County Medical Society

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External Dissemination

• Local
• Baylor College of Medicine-5/2001 OGA-5/2001
• Womens Hospital Grand Rounds-4/2002
• Mailing to 4,000 OB GYNs, Peds, PCPs
  Houston-2/2002
• Contracted lab to work on physician education
  retests 2/02
• State wide
• Texas Dept. Health-8/2001, 1/2002
• Houston Dept Health, Harris Co Medical Society
  2/2002
• National
• Aetna Physician Newsletter-123,000 MDs-2/2002
• Professional meetings ASRM-10/2001 National STD
  meetings-abstract 352
• AAHP-1/2002

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External Dissemination

• State wide
• Texas Dept. Health-8/2001, 1/2002
• National
• Aetna Physician Newsletter-123,000 MDs-2/2002
• Professional meetings ASRM-10/2001 National STD
  meetings-abstract 352
• AAHP-1/2002

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Internal initiatives

• All HMO members informed about USPSTF
  recommendation in Pap reminders-2000
• National and local QA committees
• Market initiatives
• Direct member education linked to BCPs use-Phila
• Physician education modules-Alabama
• Follow up barrier analysis-Houston
• National HEDIS strategies ???

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Lessons learned

• Identify barriers to health plan and physician
  buy-in.
• Recognize importance of appropriate data for
  health plan to make decisions.
• Generate data to get buy-in within health plan
• Partner with community to identify barriers,
  disseminate findings, facilitate change.