Joanne Armstrong, MD1,2 Haleh Sangi-Haghpeykar, PhD1 Alice Shen, MD1 1. Baylor College of Medicine Houston, Texas 2. De

1.  Joanne Armstrong, MD1,2 Haleh Sangi-Haghpeykar, PhD1 Alice Shen, MD1 1. Baylor College of Medicine Houston, Texas 2. Dept Women�s Health, Aetna

2. 2 How big is the problem? 3M infections/year; 80% <25 y/o; 80% asymptomatic Screening helpful Decreases prevalence when widely instituted1 Decreases infection sequelae by 50%2 Limited success in translating screening benefits to women in the private health sector Most Americans receive STD care private sector from �private practice� physicians3 Little data on extent and quality of care in private sector. These findings have not been translated into benefit in the private sector despite fact that majority of women receive STD care in private sector from private practice physicians. There is, in fact, little data on the extent and quality of STD care in the private sector. These findings have not been translated into benefit in the private sector despite fact that majority of women receive STD care in private sector from private practice physicians. There is, in fact, little data on the extent and quality of STD care in the private sector.

3. 3 Prevalence1,2 Teens: 5%-10% Adults: 3%-6% Self-reported adherence with screening guidelines poor3 30% PCPs 54% ObGyns HEDIS 20034 <19 years: 26.7% 20-<26 yrs: 24.6% ?Significant quality concern exists in private sector

4. 4 HEDIS 2000: 16.8% < 20 yrs; 13.8% < 26 yrs

5. 5 Outreach to greater than 125,000 physicians Chlamydia Tool kits Screening and laboratory guideline updates Patient fact sheets Patient self assessment tools CMEs Feedback on HEDIS performance Lunch and learns-mid-level practitioners Annual preventive health reminders Collaborations with national labs

9. 9 What�s the Reward?HEDIS: Commercial Plans HEDIS means scores 2000-2003HEDIS means scores 2000-2003

10. A National Survey of Genital Chlamydia trachomatis Screening Practices and Attitudes of U.S. Obstetrician Gynecologists

11. 11 Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women Identify barriers and facilitators to compliance with screening guidelines

12. 12 Describe genital chlamydia screening practices of obstetrician/gynecologists caring for commercially insured women Identify barriers and facilitators to compliance with screening guidelines

13. 13 National survey 1,100 OBGYNs randomly selected from AMA Master File Inclusion criteria Board certified Full time, direct patient care >50% time caring for commercially insured (HMO, PPO, FFS, indemnity, Medicaid MCO) Women ages 15-25 Exclusion criteria Federal, state, county, city-funded setting, medical schools, training programs, researchers, admin, non-direct patient care Survey undeliverable, MD retired, deceased Does not meet inclusion criteria

14. 14 Survey content: Chlamydia screening practices Knowledge and utilization of currently available screening tests Barriers and facilitators to screening. 3 different patient sub-groups Pregnant women Non-pregnant, sexually active, <20 years Non-pregnant, sexually active, 20-25 years Comparison of screeners vs. non-screeners �Screener� = Screens >75% of time

15. 15 Survey content: Chlamydia screening practices Knowledge and utilization of currently available screening tests Barriers and facilitators to screening. 3 different patient sub-groups Pregnant women Non-pregnant, sexually active, <20 years Non-pregnant, sexually active, 20-25 years Comparison of screeners vs. non-screeners �Screener� = Screens >75% of time

16. 16 Mailed in 3 waves-March 2003 1. FedEx: survey, information sheets, $15 gift cheque 2. Reminder Postcard 3. Priority Mail: survey Reviewed and approved by BCM IRB

17. 17 Results 1,100 surveys sent to Ob/Gyn Physicians 410 completed, eligible returned surveys 42.7% response rate

18. 18 Respondent Demographics Physician Profile 99.3% Board certified; 95.6% in private practice 70.8% Male; 79.4% White Mean age 49 years with 20 years of practice Workload Mean 39.3 hour work week; 94.2 patients per week 37.2% OB visits, 62.7% GYN visits Practice 96.6% in primary care or sub-specialty care office 84% in solo or single-specialty group practice 69.1% with ownership interest in their practice 78.3% contracted with a MCO Patient Profile 61.6% White; 18.0% Black; 12.6% Hispanic 36.2% aged 13-26 years; 71.7% privately insured . .

19. 19 Screening frequency by patient subgroup

20. 20 Demographic Variables Associated with Screening* non-pregnant, sex active age 20-25 years

21. 21 Demographics Not Associated with Screening MD demographics Age, Gender, Years in practice Practice Structure Solo vs. group Patient and work volume Practice Economics Ownership interest MCO affiliation Insurance status of patients

22. 22 Current Experience with CT and Comparison of Screeners* to Non-Screeners

23. 23 Risk Assessment Behaviors of Screeners* compared to Non-Screeners

24. 24 Screening Test Utilization of Screeners compared to Nonscreeners

25. 25 Conclusions Physicians poorly compliant with screening guidelines Magnitude of non-compliance even greater than physician self-report, particularly for non-pregnant aged 20-25 years (54% vs 8.5%). Perception of prevalence is low. Non-screeners more likely to believe that infection prevalence is too low to warrant routine screening. Majority have no target prevalence above which screening is indicated. Those who do, have high threshold (10%). Significant quality concerns�and opportunities.. identified in chlamydia screening in commercially insured women

26. 26 Current Influences on Screening Practices

27. 27 Barriers to Screening Reported by Nonscreeners Epidemiological factors Perceived low prevalence (p=<.0001) Lower health priority (p=.02) Physician/patient comfort concerns MD uncomfortable (p=.009) Unacceptable to patients (p=.006) Economic concerns Decrease practice income (p=.01) Not a billable service (p=.002) Availability of tests (p=.05)

28. 28 Future Influences for Screening Practices

29. 29 Conclusions: Barriers Perception of low prevalence Yet, no threshold to drive routine screening until 10%! Lack of uniformity of screening guidelines Most rely on ACOG, but not a differentiator Discomfort of RA/screening Economic issues Time, cost, hassle factor Facilitated by increased convenience of test. ? No single barrier identified �. Conclusions relative to barrier:Conclusions relative to barrier:

30. 30 Conclusions: Facilitators ACOG adoption of age-based screening Patient demand Physician awareness Convenience of testing Economic incentives ? �interventions must also be multifaceted