Extending Preventive Care to Pediatric Urgent Care

1. Extending Preventive Care to Pediatric Urgent Care A Partnership Between: University of California, San Francisco & Kaiser Permanente Northern California Mary-Ann Shafer MD & Kathleen Tebb PhD Presentation to STD Prevention Conference March 10, 2004 Funded by the Centers for Disease Control and Prevention & The Agency for Health Care Research and Quality

2. BackgroundFacts About Chlamydia Trachomatis (CT) • Rate is 6-12% in teen females • 70-80% are asymptomatic • 10-20% untreated  PID infertility • NAATs 90-95% sensitivity/specificity • Nat’l Guidelines  annual CT screen

3. Background cont. • Clinical Practice Improvement intervention (CPI) increased CT screening of sexually active teens at pediatric well care visits (WCVs) • Yet, over 50% of adolescents are seen only for urgent care visits (UCVs), in any given year

4. JAMA December 11, 2002

5. Learning Objectives • Review the development, implementation and evaluation of a systems-based intervention for CT screening • Understand utilization patterns of teens seen in well versus urgent care • Discuss the translation of the CPI model to different clinical settings

6. Study Objectives • Develop a modified CPI (clinical practice improvement) intervention to address barriers to CT screening during UCVs • Examine feasibility of CT screening attending pediatric UCVs in a large HMO

7. Methods • Setting • Large HMO in Northern California: KPMG • 2 Pediatric clinics participating in the previous well-care CPI intervention • 14-18 yo females seen for UCVs • ~4,000 enrolled 14-18 yo adolescent females in 2 sites

8. Methods KP Pediatric Setting cont. • Well-Care Visit • Appointment required • Physical exam (every 2-3 yrs) • 20 minute visit • Urgent-Care Visit • Same/ next day visit • Sick/ non-ER visit • 10 minute visit • Same physical setting as WCV • Same providers & staff as WCV

9. Methods • Design • Pre-Post test study • Provider survey (anonymous) to assess attitudes toward screening in UCV • Teen survey (anonymous) for sex active rate • Comparison of baseline CT screening rates to 6 month post-test rates

10. Clinical Practice Improvement Model Engage Team Building Re-Design Clinical Practice Sustain the Gain

11. Clinical Practice Improvement Model • Leadership • Best practices • Define gap • Raise Awareness Engage Team Building Re-Design Clinical Practice Sustain the Gain

12. Clinical Practice Improvement Model • ACTeam • Skill building • Tool Kit Engage Team Building Re-Design Clinical Practice Sustain the Gain

13. Clinical Practice Improvement Model Engage • Customize • Measure success Team Building Re-Design Clinical Practice Sustain the Gain

14. Clinical Practice Improvement Model Engage • Monitor performance • Time series analysis • Continuous improvement Team Building Re-Design Clinical Practice Sustain the Gain

15. Rapid Cycle Changes • ACTeam Meeting • Set Goal • Identify barriers • Decide solution • Try it out • Reassess • Repeat “cycle” % Change in STD Screening Rate S t a t u s Q u o Time in months

16. Site Specific Flow Chart Cue Charts Room Patient MD/NP VISIT Urines To Lab Follow-Up ID eligible teens • C Charts are stamped with cue MA collects FVU on all 14-18 yo F • TTeen takes FVU sample to exam room MD/NP obtains sex hx If sexually active, MD completes CT lab slip • W • WWrites confid. # on chart RN contacts CT + teen: confid. # Teen comes to clinic for Rx RN enters Rx in STD log book MA refrigerates FVUs A enters teen name, confidential # in clinic log book • LRunner takes FVU to lab

17. Data Bases and Analysis Data Bases • Registration + lab + anonymous survey of teens for clinic specific screening rates Data Analysis • Mann-Whitney/T-test

18. Data Analyses: CT Screening Rate Screening Rate = No. of CT tests Sexually active teen females* *Site specific sexual activity rates determined by anonymous survey

19. RESULTS

20. Urgent Care vs Well Care Population • Teen girls who utilize urgent care compared to well care visits have a higher STD risk profile: • Older (15.7 vs 15.4 years)* • More ethnically diverse (Cauc/Asian vs. Oth)* • Higher sexual activity rates (42% vs 26%)* • *p<0.05

21. Pediatrician Survey Results CT Screening Likelihood during UCV: (1=not likely, 4=very likely)

22. MD’s Top 3 Barriers to UCV Screening • Parents in room/confidentiality • Competing priorities • Discomfort in taking sexual history

23. RESULTS: Female CT Screening Rate in Urgent Care Pilot Sites % SA Females Screened for CT A B A B B

24. Conclusions • CT screening in pediatric UCVs is feasible • Significantlymore teens screened for CT • Clinic differences different results • More research needed (e.g., RCT, more clinics)

25. Implications • CT epidemic  universal screening recommended • Most teens seen only in UCVs and they have a higher STD risk profile screen for CT in well and urgent care “Do Today’s Work Today” • The CPI model (rapid-cycle change) may be generalizable to other services & clinic settings

26. Implications cont. • Rapid cyclequick, dramatic & sustained • Effective in different settings- well & urgent and likely others as well • Capitalizes upon existing resources & staff • Small changes LARGE effects • Gives chronically over-worked staff sense of importance, success & control over workplace