Can patient education and practice improvements increase screening for sexually transmitted disease among adolescent girls?
HMO clinics that implemented a multifaceted intervention—including team development, performance monitoring, and clinical practice improvements such as flowcharts, universal urine specimen collection, and an educational campaign—significantly boosted the proportion of adolescent girls who were screened for Chlamydia infection.
Why is this important?
Expert recommendations to screen sexually active adolescent girls for Chlamydia infection are not widely followed in routine clinical practice. This gap in quality results in many missed opportunities to treat patients who have contracted this sexually transmitted disease without knowing it and who remain at risk of developing potentially severe complications.
Interventions
A large group-model health maintenance organization (HMO) tested the effectiveness of an intervention to increase compliance with screening guidelines for an ethnically diverse population of adolescent girls (ages 14 to 18 years) during checkup visits (Shafer et al. 2002). Ten pediatric HMO clinics were randomly assigned to provide usual care or to implement the intervention. To reduce screening barriers, all clinics used a urine test (rather than culture obtained through pelvic exam). The intervention included the following components:
- engaging clinic leadership and raising awareness of the gap in quality;
- building teams at each clinic to implement the intervention, including identifying and addressing barriers to improvement;
- customizing clinic flowcharts to summarize patient information from multiple sources;
- instituting universal urine specimen collection at patient registration (but only specimens from sexually active girls, as determined confidentially by the practitioner, were sent for laboratory analysis);
- raising awareness about screening through an educational campaign; and
- sustaining gains through continuous performance monitoring.
Findings
Before the intervention, the 10 clinics did not differ significantly in the proportion of sexually active adolescent girls screened for Chlamydia infection at preventive health visits; both groups had very low rates of such screening.
The screening rate in the intervention group increased to a level significantly higher than in control clinics by four to six months after the start of the intervention, and remained so throughout most of the post-intervention period. By 16 to 18 months after the intervention, the proportion of sexually active girls screened for Chlamydia had increased to 65 percent (from 5 percent before the intervention) (Shafer et al. 2002).
Implications
A multifaceted, systems-level intervention can increase rates of screening for Chlamydia infection in organized group practice and may be replicable to other similar practice settings. The study authors suggested that the intervention might also be implemented in urgent care settings, since many adolescents do not make preventive health visits (Shafer et al. 2002).
Improvement Ideas and Resources
Service delivery for sexually transmitted diseases can be facilitated by public health collaboration, regulatory and performance incentives and monitoring, and supportive information infrastructure (Chorba et al. 2004).
Measure:
In this cluster-randomized controlled trial, the 10 largest pediatric clinics affiliated with a large HMO were selected for participation from those that were willing, had no adolescent-specific clinic, had a minimum of 500 sexually active adolescent girls (ages 14 to 18 years) visiting for routine checkups each year, and served an ethnically diverse population. Sites were randomly assigned to intervention or usual care; site staff were blinded to study conditions and assignment. Screening rates were determined using a patient encounter and laboratory database. Site-specific sexual activity rates were determined using an anonymous survey administered after routine checkup visits. Among adolescent girls ages 14 to 18 years who had 7,920 routine checkup visits during the April 2000 through March 2002 study period, 1,017 and 1,194 were estimated to be eligible for screening in the intervention and control sites, respectively. Estimated screening rates were calculated (number of Chlamydia tests done divided by the product of the number of girls seen for checkups and the sexual activity rate) at baseline and six consecutive three-month periods during the intervention (only baseline and final rates are shown in the chart). A statistical test (repeated measures analysis of variance) of time period by study group interaction effect found that the change in screening rates differed significantly for the intervention and control sites (Shafer et al. 2002).
Limitations:
The study was not able to link actual sexual histories to screening for specific individuals, but calculated clinic-based population rates.
Source:
The study used patient survey, encounter, and laboratory data and was conducted by researchers at the University of California, San Francisco, School of Medicine; Kaiser Permanente; and the Lucile Salter Packard Children's Hospital at Stanford Medical Center (Shafer et al. 2002).
References:
* Indicates source of data used in the chart(s).Chorba, T., D. Scholes, J. Bluespruce et al. 2004. Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery. American Journal of Medical Quality 19 (4): 14556.
* Shafer, M. A., K. P. Tebb, R. H. Pantell et al. 2002. Effect of a Clinical Practice Improvement Intervention on Chlamydial Screening Among Adolescent Girls. Journal of the American Medical Association 288 (22): 284652.