STDs Regaining Lost Ground through a StateWide PublicPrivate Partnership

1
STDs Regaining Lost Ground through a State-Wide
Public/Private Partnership

• The California Chlamydia Action Coalition
• Gail Bolan M.D.
• Chief, STD Control Branch
• California Department of Health Services

2
ChlamydiaRates by GenderCalifornia, 1991-2000
Rate per 100,000
Note Gender "Not Specified" ranged from 0.4 to
7.8 of cases in any given year. Since this
disease is often asymptomatic, reported cases may
reflect chlamydial infections identified
through screening programs offered primarily to
women. Source California Department of Health
Services, STD Control Branch
Provisional Data 01/03/2001
3
ChlamydiaRates by Gender and Age
GroupCalifornia, 2000
Male Rate per 100,000 Female
Note Since this disease is often asymptomatic,
reported cases may reflect chlamydial
infections identified through screening
programs offered primarily to women. Source Cal
ifornia Department of Health Services, STD
Control Branch
Provisional Data 01/03/2001
4
Source California Department of Health
Services, STD Control Branch
Provisional Data 03/22/2001
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Prevalence of Chlamydia Infections in 15-19 Year
Old Adolescent Girls by Health Care Setting,
California, 1999
Source California Department of Health Services,
STD Control Branch Los Angeles Infertility
Prevention Project and San Francisco Infertility
Prevention Project
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Why Chlamydia Why Now?

• Most common communicable disease reported disease
  in California
• Over 90,000 reported cases in 2000
• Over 75 of cases are seen in the private sector
• Significant health consequences
• Most common cause of preventable infertility
• Facilitates sexual transmission of HIV
• New technology new opportunity
• Urine tests single dose treatment easier to
  reach, treat cure at-risk populations
• HEDIS increases private sector interest
• Potential public/private partnership

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Chlamydia Action Coalition Timeline

• October 1998 Strategic Planning Meeting
• March 1999 Release of Chlamydia Action Plan
• January 2000 5 year CHCF grant awarded to
  implement the Chlamydia Action Plan
• July 2000 Governor awarded 1.3 million dollars
  to support chlamydia awareness
• annual grants to local STD programs
• four regional health educators to support local
  efforts

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Chlamydia Coalition Members

• State and local health departments
• Managed Care Organizations
• Community Based Organizations
• Private providers and professional societies
• Family Planning, school-based, and correctional
  programs

• Womens Health Organizations
• Laboratories and University researchers
• Diagnostic and pharmaceutical companies
• Policymakers and the public
• California Health Care Foundation

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Chlamydia Action Coalition Mission

• Primary and secondary prevention of chlamydia and
  the complications of chlamydia through
  coordinated public and private state-wide efforts.

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Chlamydia Action Coalition Goals

• Increase access to and use of high-quality
  screening and clinical services for chlamydia
• Increase partner evaluation, treatment and
  counseling
• Promote awareness of the chlamydia epidemic,
  prevention strategies and the costs of the
  disease and its complications among providers,
  policymakers and the public
• Enhance health information systems to monitor,
  evaluate and improve chlamydia screening and
  other intervention efforts

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Chlamydia Screening- Goal and Rationale

• Goal To identify and treat asymptomatic
  infection
• Rationale
• Reduce complications of chlamydia in an
  individual
• 56 reduction in PID in HMO with CT screening
  outreach program
• Reduce the reservoir of asymptomatic individuals
• Over 50 reduction in CT prevalence in clinics
  with routine screening over 5 year period
• Cost-effective strategy

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Current Clinic-Based Chlamydia Screening
Recommendations Include

• HEDIS (Health Plan and Employer Data Information
  Set) Indicator
• Sexually Active Women 16-25 annually
• CDC 1998 Treatment Guidelines
• Adolescents annually
• Women 20-24 years of age initially and then if
  new or multiple partners in past 3 months and not
  consistently using barrier protection

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California Department of Health ServicesOffice
of Family Planning
Family PACT Goals
Promote optimal reproductive health Decrease
unintended pregnancy Decrease sexually
transmitted infections
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Family PACT ServicesEvaluation--Counseling--Manag
ement

• Contraceptive methods
• Temporary and permanent
• Pregnancy testing
• STI screening and treatment
• HIV screening and referral
• Cancer screening and referral
• Hepatitis B Vaccine
• Emergency contraception

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Family PACT/HCFA Demonstration Project

• California, specifically the OFP, has always been
  progressive in providing comprehensive
  reproductive health services
• Medi-Cal programs include family planning
  services but do not address the more
  comprehensive approach and only includes women to
  100 of poverty
• OFP work with the Rate Development Branch of the
  Medi-Cal Policy Division to develop and
  administer the 1115 demonstration waiver
• California has extensive experience in the
  implementation of Medicaid waivers
• Well designed evaluation plans were important

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Family PACT/HCFA Demonstration Project

• There were several sensitive issues related to
  HCFA accepting this proposal
• relationship between a prevention and a diagnosis
  and treatment program
• social security numbers
• others
• For more information
• contact Anna Ramirez, Chief, Office of Family
  Planning, California Department of Health
  Services, 916-654-0357
• other resources www.hcfa.gov/medicaid/1115/defaul
  t.htm

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Piloting of Chlamydia HEDIS Measure in 3
California Settings

• Plans Family PACT MMC Kaiser
• Proportion of
• Eligible Women
• Screened (Median) 50 27 40

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Possible Chlamydia Screening Barriers

• Awareness and information gaps
• Discomfort in discussing sexual issues
• Parental presence during adolescent visit
• Fear of embarrassment, loss of confidentiality
  and disclosure to parents or partner
• Challenges of a culturally and linguistically
  diverse population
• Invasive nature of less expensive tests

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Chlamydia Action Coalition Efforts
(www.ucsf.edu/castd)

• Chlamydia Clinical Practice Guidelines
• Tool box to assist in implementation
• More detailed information on sexual history
  taking, diagnostic tests, HEDIS specifications,
  cost-effectiveness model, patient and provider
  information sheets, public health laws, CME home
  study module
• Interventions to improve screening
• MMCD QI Initiative
• Web-based interactive provider training
• Provider level evaluation

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Chlamydia Partner Management Strategies

• Patient referral
• Provider or clinic referral
• Health Department referral
• Patient delivered partner therapy (PDPT)
• Rationale
• Untreated infection in male partner is a risk
  factor for repeat infection in women
• Repeat infections place women at increased risk
  of upper tract complications
• Single dose therapy is very safe and easy to
  administer
• Most male partners have a higher risk in daily
  living
• In a randomized controlled trial, PDPT decreased
  the rate of re-infection by 20 (from 15 to 12)

21
Patient Delivered Partner Therapy Legislation in
CA (Ortiz bill SB 648)

• Enacted January 1, 2001
• Amendment to the Business and Professions and
  Health and Safety Codes
• Sets forth exceptions to the Medical Practice Act
  and is does not constitute unprofessional conduct
• Notwithstanding any other provision of law, a
  physician, nurse practitioner, certified
  nurse-midwife, and physician assistant who
  diagnoses a sexually transmitted chlamydia
  infection may prescribe to that patients sexual
  partner or partners without examination of that
  patients partner or partners

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Guidelines for Patient Delivered Partner Therapy
CA SB 648

• To maximize patient and public health benefit
  while minimizing risk
• Draft Guidelines for Comment
• To provide information on the most appropriate
  patients, medication and counseling procedures
• Diagnosis Uncomplicated genital chlamydia
  infection
• Priority patients Females with male partners
• First-line Attempt to bring partners in for
  evaluation and treatment
• Partners Males who are uninsured or unlikely to
  seek medical services

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Guidelines for Patient Delivered Partner Therapy
CA SB 648

• Draft Guidelines for Comment
• Medication Azithromycin 1 gram (250 mg tablets x
  4) orally once
• Number of doses are limited to the number of sex
  partners in past 60 days
• Education materials must accompany medication
• Patient counseling Abstinence until 7 days after
  treatment and until 7 days after partners have
  been treated
• Adverse reactions Call LDH or report to
  1-866-556-3730 (toll-free)
• Evaluation Recommend re-test patients for
  chlamydia 3-4 months after treatment

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Role of Laboratories in STD Prevention and
Control Efforts

• Quality Laboratory Services
• Maximize test performance characteristics
• Laboratory Quality Indicators and Performance
  Measures
• Laboratory HEDIS Measures
• Laboratory Diagnostic Guidelines for Clinicians
• Timely recommendations as testing technologies
  change
• Coalition has recommended amplification test
  technology as the preferred test method to use in
  California because of increased sensitivity and
  non invasive nature
• Electronic Transfer of Data for Surveillance

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Chlamydia HEDIS Data Warehouse

• Centralized Data Warehouse with Electronic
  Transmission of Chlamydia Screening Data
• Collection of HEDIS numerator data
• Prevalence Monitoring
• Coordinate with ELR of communicable diseases

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Lab Slip

Electronic
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Chlamydia HEDIS Data Warehouse Project Development

• Contract with Synergy Consulting, Inc.
• Conduct a feasibility analysis and develop a
  business plan
• Stakeholder interviews
• Top 10 Laboratories (chlamydia test volume)
• Health Plans (Commercial and Medi-Cal)
• Model Projects

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Chlamydia HEDIS Data Warehouse Laboratory Issues

• HIPAA and regulations changes may be needed
• Not receive complete patient information
• Use diverse data standards and message formats in
  different systems
• Funding
• Little incentive
• Need to link with CD ELR systems and not create a
  separate system

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Chlamydia HEDIS Data Warehouse Health Plan Issues

• Using administative data and chart reviews to
  calculate HEDIS which is costly
• Need unique patient identifier
• Have technology to receive a variety of message
  formats
• Very supportive if can do everything planned

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Chlamydia HEDIS Data Warehouse Other Issues

• No statewide security standards
• No statewide coordination
• Need to coordinate with national NEDSS efforts
• Inconsistant data requirements between systems

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Chlamydia Action Coalition Action Steps-
Awareness

• Provider Education
• Medical newsletters, slide sets and web-based
  training
• CA STD/HIV Prevention Training Center grand
  rounds
• Public Education
• CA HIV/AIDS clearinghouse to include STD
  materials, allows bulk purchasing
• Chlamydia Awareness Prevention Project (CAPP)
• Member newsletters
• Chlamydia Action Coalition Website
• www.ucsf.edu/castd
• State-wide media campaign

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Chlamydia Action Coalition Action Steps- Policy

• STD purchasing specifications for MMCD contract
  health plans
• Legislation on patient-delivered partner
  treatment signed by the Governor effective
  January 2001
• Hire policy analyst to assess funding streams for
  CT screening treatment in California
• Media advocacy campaign

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Chlamydia Action Coalition Action Steps- Research

• Cost effectiveness of male screening in Managed
  Care
• Best approaches for screening in non- traditional
  community-based settings
• Evaluate sexual and social networks of and
  partner management strategies for Managed Care
  members with chlamydia
• Factors associated with chlamydia in women gt25
  years of age

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Gonorrhea, Rates by Gender, California, 1991-2000
Rate per 100,000
Note Gender "Not Specified" accounted for less
than 0.4 of all cases. Source California
Department of Health Services, STD Control Branch
Provisional Data 03/22/2001
36
Gonococcal Isolate Surveillance
ProjectResistance to Ciprofloxacin Decreased
Susceptibility to CefiximeCalifornia Sites,
1991-2000
Source Centers for Disease Control and
Prevention, Gonococcal Isolate Surveillance
Project, Sexually Transmitted Disease Clinic Sites
37
Primary Secondary Syphilis, Rates by Gender,
California, 1980-2000
Rate per 100,000
Source California Department of Health
Services, STD Control Branch
Provisional Data 03/22/2001
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Primary Secondary Syphilis, Rates by Gender,
California, 1991-2000
Rate per 100,000
Source California Department of Health
Services, STD Control Branch
Provisional Data 03/22/2001
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