Evolving Thoughts on Chlamydia in a Large MCO

Joanne Armstrong, MD, MPHRegional Women’s Health Medical DirectorAetna, Inc

Assistant Professor Obstetrics and GynecologyBaylor College of MedicineHouston, TX

Structure 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

1999-2000: Ct Perspective

No specific programs for ChlamydiaEmbedded 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

1999-2000: 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 expensesCompetition against other programs for $$Rewards not easily measured in the numbers

Purchasers not demanding programs

HEDIS 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/oLiterature inadequately describes

prevalence of CT in insured non-adolescent populations.

Cost-benefit analyses lacking in MCO populations Difficult for health plan to support

HEDIS

HEDIS 2000: Physician PerspectiveAetna Ob Gyn National QA committee

Agree with screening sexually active <20 group

Resistance to routine screening >20y/oExisting guidelines do not promote this (CDC,

ACOG)Published studies do not reflect their populationPerception 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

October 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 MedicineObstetrics and Gynecology Associates, PATexas Dept of HealthAetna

Research 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, PClarge single specialty, private ObGyn group

practice, Houston, TX.

Intervening Events: 2001

USPSTF recommendationsHEDIS 2000 results for health plan

and market Aetna 16.6% Houston market: 17%

Retrospective 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 Risk=ACOG or CDC definition

Retrospective Study Findings:October 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.

Cross 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 infection=ACOG or CDC definition

CS Results: Demographic and behavioral characteristics, October 2001 Mean age: 22.5 years, 16% <20 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

CS Results: Chlamydia Prevalence*

N # Pos. % P Total 443 23 5.2

Age<20 69 4 5.8 .820-25 374 19 5.1

Sexually active + Age<20 59 4 6.8 .620-25 340 17 5.0

*amplified probe

CS Results: Comparison of amplified to non-amplified probe

Assay N Test + Test - Kappa P Total Study 443 Amplified probe 23(5.2%) 420(94.8%) Non-amplified probe 16(3.6%) 427 (96.4%) 0.81 .008 Age<20 69

Amplified probe 4(5.8%) 65(91.2%)

Non-amplified probe 2(2.9%) 67(97.1%) 0.65 0.16 Age 20-25 374 Amplified probe 19(5.1%) 355(94.9%) Non-amplified probe 14(3.7%) 360(96.3%) 0.84 0.03

Conclusions: 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.

Actions: November 2001

Represented to OB GYN QA Committee Study findings USPSTF recommendations HEDIS rates

Physician perception changed Advised to disseminate information

External DisseminationLocal

Physician educationBaylor College of Medicine-5/2001; OGA-5/2001Women’s Hospital Grand Rounds-4/2002Mailing to 4,000 OB GYNs, Peds, PCPs Houston-2/2002

Lab educationWorking with contracted lab to educate MDs about tests

available-2/02

Public Health authorities 2/02City of Houston Health DeptSchool of Public HealthHarris County Medical Society

External DisseminationLocal

Baylor College of Medicine-5/2001; OGA-5/2001 Women’s Hospital Grand Rounds-4/2002 Mailing to 4,000 OB GYNs, Peds, PCPs Houston-2/2002 Contracted lab to work on physician education re:tests

2/02State 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

External 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

Internal initiatives

All HMO members informed about USPSTF recommendation in Pap reminders-2000

National and local QA committeesMarket initiatives

Direct member education linked to BCPs use-Phila

Physician education modules-Alabama Follow up barrier analysis-Houston

National HEDIS strategies ???

Lessons 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.