Evolving Thoughts on Chlamydia in a Large MCO Joanne Armstrong, MD, MPH Regional Women’s Health Medical Director Aetna, Inc Assistant Professor Obstetrics and Gynecology Baylor College of Medicine Houston, TX
Jan 02, 2016
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.