Title: Evolving Thoughts on Chlamydia in a Large MCO
1Evolving 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
2Structure 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
-
31999-2000 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
41999-2000 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
5HEDIS 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
6HEDIS 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
7October 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
8Research 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.
9Intervening Events 2001
- USPSTF recommendations
- HEDIS 2000 results for health plan and market
- Aetna 16.6
- Houston market 17
10Retrospective 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
-
11Retrospective 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.
12Cross 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
-
13CS 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
14CS 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
15CS Results Comparison of amplified to
non-amplified probe
16Conclusions 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.
17Actions November 2001
- Represented to OB GYN QA Committee
- Study findings
- USPSTF recommendations
- HEDIS rates
- Physician perception changed
- Advised to disseminate information
18External 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
19External 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
20External 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
21Internal 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 ???
22Lessons 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.