Using Provider Incentives and an Opt-Out Strategy in a Successful Quality Initiative to Increase Chlamydia Screening

      Abstract

      Background

      Chlamydia trachomatis (CT) is a highly prevalent sexually transmitted infection in adolescents that can lead to serious complications. San Francisco has one of the highest rates of CT infections in the United States. At baseline, screening rates at the Children's Health Center were significantly below national and network levels. This project aimed to increase screening rates for female patients age 16–24 from 29.2% to 44% in an 18-month period.

      Methods

      The organization engaged providers, residents, and nursing staff to understand the root causes and choose the screening approach. The following strategies were used to implement this approach in primary and urgent care: (1) universal urine collection, (2) provider and staff education, and (3) adoption of faculty Maintenance of Certification (MOC) credit and resident physician financial incentives.

      Results

      The annual screening rate for CT in primary care female patients 16–24 years old increased from 29.2% to 61.5% in 18 months, and improved to 71.2% one year after the project. Screening rates for female patients over age 15 seen in the colocated urgent care also increased significantly. The research team found no instances of false positive results and had 4 positive results in high-risk patients who initially reported abstinence.

      Conclusions

      The intervention design and engagement of stakeholders with incentives was associated with significant and sustainable improvements in the CT screening rate for female adolescent primary care patients. This work shows how universal opt-out screening can be a sustainable and effective method to address common barriers to increasing screening for CT in adolescents.
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Torrone E
        • et al.
        Prevalence of Chlamydia trachomatis genital infection among persons aged 14–39 years—United States, 2007–2012.
        MMWR Morb Mortal Wkly Rep. 2014 Sep 26; 63: 834-838
        • Centers for Disease Control and Prevention
        National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
        Sexually Transmitted Disease Surveillance 2018. Oct 2019; (Accessed Mar 18, 2020.)
        • Gottlieb SL
        • Xu F
        • Brunham RC
        Screening and treating Chlamydia trachomatis genital infection to prevent pelvic inflammatory disease: interpretation of findings from randomized controlled trials.
        Sex Transm Dis. 2013; 40: 97-102
        • US Preventive Services Task Force
        Final Recommendation Statement: Chlamydia and Gonorrhea: Screening.
        Sep 2014 (Accessed Mar 2020.)
        • Workowski KA
        • Bolan GA
        Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015.
        MMWR Recomm Rep. 2015 Jun 5; 64: 1-137
      1. (Pocket Guide)
        • American Academy of Pediatrics
        Hagan JF Shaw JS Duncan PM Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Mar 18, 2020 (Pocket GuideAccessed)
      2. Centers for Disease Control and Prevention. Chlamydia Screening Data, HEDIS and Managed Care. Oct 29, 2013. Accessed Mar 18, 2020.https://www.cdc.gov/std/chlamydia/hedis.htm. Published October 29, 2013.

      3. National Committee for Quality Assurance. Chlamydia Screening in Women (CHL). Accessed Mar 18, 2020.https://www.ncqa.org/hedis/measures/chlamydia-screening-in-women/.

      4. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Sexually Transmitted Disease Surveillance 2018: Table 6. Chlamydia—Reported Cases and Rates of Reported Cases in Selected Metropolitan Statistical Areas (MSAs) in Alphabetical Order, United States, 2014–2018. Aug 20, 2019. Accessed Mar 18, 2020.https://www.cdc.gov/std/stats18/tables/6.htm.

      5. Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set): Technical Specifications and Resource Manual for Federal Fiscal Year 2019 Reporting. (Updated: Aug 2019.) Accessed Mar 18, 2020.https://www.medicaid.gov/medicaid/quality-of-care/downloads/medicaid-adult-core-set-manual.pdf.

      6. Centers for Medicaid & Medicare Services; National Committee for Quality Assurance. Health Insurance Exchange: 2019 Quality Rating System Measure Technical Specifications. Sep 2018. Accessed Mar 18, 2020.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/QRS-2019-Measure-Technical-Specifications.pdf.

        • Goyal MK
        • et al.
        Clinician adherence to recommendations for screening of adolescents for sexual activity and sexually transmitted infection/human immunodeficiency virus.
        J Pediatr. 2014; 165: 343-347
        • Centers for Disease Control and Prevention
        CDC Grand Rounds: chlamydia prevention: challenges and strategies for reducing disease burden and sequelae.
        MMWR Morb Mortal Wkly Rep. 2011 Apr 1; 60: 370-373
        • DiVasta AD
        • et al.
        Practice-based quality improvement collaborative to increase chlamydia screening in young women.
        Pediatrics. 2016; 137e20151082
        • McKee MD
        • et al.
        A learning collaborative approach to improve primary care STI screening.
        Clin Pediatr (Phila). 2018; 57: 895-903
        • Wood SM
        • et al.
        Effectiveness of a quality improvement intervention to improve rates of routine Chlamydia trachomatis screening in female adolescents seeking primary preventive care.
        J Pediatr Adolesc Gynecol. 2019; 32: 32-38
        • Jr Irwin CE
        • et al.
        Preventive care for adolescents: few get visits and fewer get services.
        Pediatrics. 2009; 123: e565-e572
        • Miller CA
        • et al.
        Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication.
        Arch Pediatr Adolesc Med. 2007; 161: 777-782
        • Tebb KP
        • et al.
        Screening for asymptomatic chlamydia infections among sexually active adolescent girls during pediatric urgent care.
        Arch Pediatr Adolesc Med. 2009; 163: 559-564
        • Goyal MK
        • et al.
        A computerized sexual health survey improves testing for sexually transmitted infection in a pediatric emergency department.
        J Pediatr. 2017; 183: 147-152.e1
        • Schneider K
        • et al.
        Screening for asymptomatic gonorrhea and chlamydia in the pediatric emergency department.
        Sex Transm Dis. 2016; 43: 209-215
        • Goodman D
        • et al.
        Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.
        BMJ Qual Saf. 2016; 25: e7
        • Hull S
        • Kelley S
        • Clarke JL
        Sexually transmitted infections: compelling case for an improved screening strategy.
        Popul Health Manag. 2017; 20: S1-S11
        • Haukoos JS
        • Hopkins E
        • Bucossi MM
        Routine opt-out HIV screening: more evidence in support of alternative approaches?.
        Sex Transm Dis. 2014; 41: 403-406
        • DiClemente RJ
        • et al.
        Association between sexually transmitted diseases and young adults’ self-reported abstinence.
        Pediatrics. 2011; 127: 208-213
        • Yussman SM
        • Urbach K.
        Introduction of universal chlamydia and gonorrhea screening in an urban school-based health center.
        J Adolesc Health. 2018; 62: S80-S81
        • Owusu-Edusei K
        • Hoover KW
        • Gift TL
        Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the U.S.
        Am J Prev Med. 2016; 51: 216-224
      7. San Francisco Health Plan. Practice Improvement Program 2019 Program Guide: Primary Care. Jan 25, 2019. (Updated: Nov 23, 2019.) Accessed Mar 18, 2020.https://www.sfhp.org/files/providers/pip/PIP_2019_Primary_Care_Program.pdf.

      8. Minnesota Department of Health. Minnesota Statewide Quality Reporting and Measurement System: Quality Incentive Payment System Framework. Aug 2017. Accessed Mar 18, 2020.https://www.health.state.mn.us/data/hcquality/docs/qipsfrmwk2017.pdf.

        • Shafer MA
        • et al.
        Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls.
        JAMA. 2002 Dec 11; 288: 2846-2852
        • Rosenbluth G
        • Tabas JA
        • Baron RB
        What's in it for me? Maintenance of Certification as an incentive for faculty supervision of resident quality improvement projects.
        Acad Med. 2016; 91: 56-59
        • Perla RJ
        • Provost LP
        • Murray SK
        The run chart: a simple analytical tool for learning from variation in healthcare processes.
        BMJ Qual Saf. 2011; 20: 46-51
        • Provost LP
        • Murray SK.
        The Health Care Data Guide: Learning from Data for Improvement.
        Jossey-Bass, San Francisco2011
        • Leichliter JS
        • Copen C
        • Dittus PJ
        Confidentiality issues and use of sexually transmitted disease services among sexually experienced persons aged 15–25 years—United States, 2013–2015.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 10; 66: 237-241
        • Gaydos CA
        et al. Performance of the APTIMA Combo 2 assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in female urine and endocervical swab specimens.
        J Clin Microbiol. 2003; 41: 304-309
        • Benneyan JC.
        Use and interpretation of statistical quality control charts.
        Int J Qual Health Care. 1998; 10: 69-73
        • Bischoff K
        • et al.
        The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement.
        BMJ Qual Saf. 2013; 22: 768-774
        • Mendelson A
        • et al.
        The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review.
        Ann Intern Med. 2017 Mar 7; 166: 341-353
        • Benzer JK
        • et al.
        Sustainability of quality improvement following removal of pay-for-performance incentives.
        J Gen Intern Med. 2014; 29: 127-132
        • Taylor MM
        • et al.
        Interventions to improve sexually transmitted disease screening in clinic-based settings.
        Sex Transm Dis. 2016; 43: S28-S41
        • Guttmacher Institute.
        New Name, Same Harm: Rebranding of Federal Abstinence-Only Programs|.
        Boyer J. Feb 28, 2018; (Accessed Mar 18, 2020.)