Leverage Existing Resources with the Chlamydia and Gonorrhea Prevalence Monitoring Toolkit National Reproductive Health Conference Monday, August 4

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1 Leverage Existing Resources with the Chlamydia and Gonorrhea Prevalence Monitoring Toolkit National Reproductive Health Conference Monday, August 4 Charlie Shumate, MPH, CHES Wendy Nakatsukasa-Ono, MPH

2 Disclosure Cardea was funded to produce The Chlamydia and Gonorrhea Prevalence Monitoring Toolkit by a cooperative agreement by the Office of Population Affairs, within the Office of the Assistant Secretary for Health in collaboration with the Division of STD Prevention within the Centers for Disease Control and Prevention (Federal Grant # 5 FPTPA ). The planners and presenters of this CE activity have disclosed no conflict of interest including no relevant financial relationships with any commercial companies pertaining to this activity.

3 Cardea s STDRHTTAC Prevalence Monitoring Team Karen Shiu MPH Charlie Shumate MPH, CHES Sarah Salomon MPH

4 Objectives Identify key indicators for assessing screening efforts Understand how to use key indicators for prevalence monitoring (PM) Gain confidence in using interactive allocations tools Develop an action plan for implementing PM practices introduced in the toolkit

5 Pop Quiz Does your organization/agency currently use data to monitor CT/GC prevalence? Yes No

6 Tell Us How does your organization/agency use CT/GC data to monitor prevalence? How are they using data to inform decisions?

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8 Purpose of the Toolkit The purpose of this toolkit is to support state and local STD and FP programs and STD, FP and other clinic administrators and managers in monitoring and evaluating CT/GC screening efforts. We introduce key indicators for assessing screening efforts, explain how each indicator is useful and how to calculate it, and provide examples of each indicator.

9 INTRODUCTION

10 Definitions Prevalence Monitoring Collecting and analyzing programmatic data to assess positivity within a given clinic or networks of clinics. Prevalence The percentage of a population that has an infection over a given period of time.

11 Definitions Positivity Screening Coverage The percentage of valid CT/GC tests with a positive result. The percentage of unduplicated sexually active patients screened for a CT/GC within the past year.

12 Definition Digestion The percentage of valid CT/GC tests with positive results is the definition of A. Screening Coverage B. Prevalence Monitoring C. Positivity D. Prevalence

13 Benefits of Prevalence Monitoring Quality Improvement Promote Health Equity Ensure Cost Effectiveness

14 Table 1: Benefits of PM

15 Questions? Thoughts?

16 Screening Recommendations GC Recommendation Grade: B Recommendation All sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection.

17 Screening Recommendations CT Recommendation Grade: A Recommendation

18 CT Positivity by State (2011)

19 THE TOOLKIT

20 Parts of the Toolkit Introduction Methods Context & Interpretation Ask the Epidemiologist Appendices

21 Key Indicators

22 Prevalence Monitoring: Rationale 1 The importance of periodic review of screening coverage Assess provider adherence to clinical screening protocols Identify trends Evaluate the success of quality improvement initiatives to increase screening

23 Indicator-Screening Coverage The percentage of unduplicated sexually active patients screened for CT/GC within the past year Definition Data Source Practice Management System/clinic EHR Screening Coverage Variables Needed Stratification Tips Pt id, dt of visit, Provider id, tested for CT/GC, sexually active Demographic/ Behavioral

24 Calculating Screening Coverage

25 Prevalence Monitoring: Rationale 2 The importance of periodic review of positivity Identify trends Reveal shifts in infection patterns/prevalence Assess disease burdens between groups/populations Serve as a proxy for CT prevalence in clinical settings

26 Indicator-Positivity The percentage of valid CT/GC tests with a positive result. Lab test results or clinic EHR Definition Data Source Positivity Variables Needed Stratification Tips Total # of valid CT/GC test results #, of +CT/GC test results Demographic/ Behavioral

27 Calculating Positivity

28 USING THE INDICATORS

29 Stratifying Data Know Your Data Less is Better Clearly Defined Stratification Tips Reference Screening Criteria and Protocols

30 Possible Variables to Stratify On Demographic Behavioral Age Multiple Sex Partner Sex New Sex Partner SES Condom Use Race/ Ethnicity Partner Concurrency Visit Type Sex With

31 Example: Positivity

32 Example: Screening Coverage

33 Stratification Check You suspect your agency may be missing opportunities to screen young women for CT/GC and you wish to examine staff s adherence to screening protocols at the same time. Which variables would you use to stratify you screening coverage data? A. Gender/Sex B. Provider ID and visit type C. Age D. Insurance type

34 Questions? Thoughts?

35 CONTEXT AND INTERPRETATION ASK THE EPIDEMIOLOGIST

36 Context Matters: Challenges to Data Interpretation Positivity only considers patients who were tested. 33% CT+ 100% coverage

37 Context Matters: Challenges to Data Interpretation Positivity only considers patients who were tested. 67% CT+ 50% coverage

38 Context Matters: Challenges to Data Interpretation Positivity only considers patients who were tested. 0% CT+ 50% coverage

39 Context Matters: Challenges to Data Interpretation What are examples of changes or events that could affect overall positivity in a clinic?

40 Context Matters: Challenges to Data Interpretation Changes in positivity most often reflect changes in programmatic activities Screening policies/protocols Change in client mix (e.g. closure of nearby clinic) Provider/staff turnover Scaling up of retesting or other targeted screening efforts

41 Section contains Ask the Epidemiologist Hypothetical Q&A Recommended tools and resources External resources (e.g. webinar archives, articles) Appendices & interactive tools for working with data

42 Ask the Epidemiologist Our positivity for females screened is under 3%. How can we increase it?

43 Ask the Epidemiologist Our positivity is above 3%, but test resources are limited. We can t screen all women under age 25. How can we maximize resources?

44 Q1 & Q2: How can we increase positivity/maximize resources? Adjust screening criteria/policies/procedures to emphasize screening patients who are more likely to be positive What is known about patients who are most likely to be infected? How can you use data to better inform the changes you have to make?

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46 Interactive Test Allocation Worksheet Models allocation of screening resources according to age/risk Screen all adolescents Use remaining tests to screen age Diagnostic testing only for women >26 Computes estimated increase in screening yield MS Excel-based

47 Chlamydia and/or Gonorrhea-infected women and men should be retested approximately 3 months after treatment If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care in the 12 months following initial treatment.

48 Repeat Infections are Common Repeat infection with Chlamydia and Gonorrhea among females: A systematic review of the literature Overall median reinfection with CT=13.9% (0-32%) Overall median reinfection with GC=11.7% (2.6-40%) Peak rates of reinfection at 8-10 months Evidence-Based Interventions for Increasing Chlamydia and Gonorrhea Retesting Rates. Howard, H. and Nakatsukasa-Ono, W. July 2012

49 Studies Consistently Show Low Retesting Rates Howard et al. (CA, ) Family PACT-Quest clients: 43% retested Chow J. (CA, NSTDP 2010) Family planning Medicaid waiver: 24% Managed care: 51% Opdyke K. (Region X IPP, NSTDP 2010) Family planning and STD clinics: 28% Goldenkranz S. (Region X IPP, NSTDP 2010) Family planning: 28% STD: 34%

50 Pathway to Re-testing Positive CT result Informed to return for re-screening Returns for re-screening Re-tested Low client return rates + many missed opportunities = few women retested

51 Analyzing Retesting Rates Challenging to compute Quality improvement initiatives can target patients and/or providers Important to monitor both return rates & missed opportunities Increasing retesting will increase overall positivity

52 Retesting Resources Reinfection Estimates Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis. 2009;36(8): Evidence-Based Interventions for Increasing Chlamydia and Gonorrhea Resting Rates Holly Howard, MPH (California Department of Public Health, STD Control Branch) & Wendy Nakatsukasa-Ono, MPH (Cardea Services), July 2012 Recording and slides available at

53 % CT Positive Analysis Results: CT reinfection rates are many times higher than baseline positivity rates; high across all age groups Baseline CT Positivity Rate CT Reinfection Rate >35 Age Group (female patients only) 10 Evidence-Based Interventions for Increasing Chlamydia and Gonorrhea Retesting Rates. Howard, H. and Nakatsukasa-Ono, W. July 2012

54 Ask the Epidemiologist Our providers are busy. We don t have time to screen all patients. How can we increase screening coverage?

55 Q3: How can we increase screening coverage? Look for ways to improve efficiency and remove unnecessary barriers to testing

56 Increasing Screening Coverage Data analysis can identify specific gaps in services Comprehensive visit Total # tested for CT Total # of patients Screening coverage Yes % No (e.g. pregnancy test only, birth control pick-up, other visits) %

57 Clinical Resources Region X IPP patient self-obtained vaginal swabs Instruction placards patients Vaginal swabs toolkit for providers Available at: Basic Tenets of Clinic Efficiency: Best Practices and Lessons Learned (2011) Blackburn, P and Pace, A Webinar recording available at: basic-tenets-of-clinicefficiency-best-practices-and-lessons-learned

58 Ask the Epidemiologist Are there different options for getting the data I need to calculate positivity and screening coverage?

59 Screening Coverage Screening coverage calculations require patient counts and services provided Should be available through administrative information system regardless of EHR

60 Positivity Requires test result data Numerator and denominator are tests, not patients Can be challenging to extract from some EHRs

61 Positivity: Alternative Options Request a report from each of the laboratories you use for CT/GC testing Data should be in a line-listed.xls/xlsx or.csv file

62 TOOLS

63 Walkthrough the toolkits toolbox Tool 1- Line listed data Tools 2- Screening allocation worksheet Tool 3- Annotated chart worksheet

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66 Positivity: Alternative Options If only one lab is used, you may be able to request an aggregate summary report Specify how data should be stratified e.g. by sex and age groups (15-19, 20-24, 25-30, 31+)

67 Female Positivity by Race/Ethnicity (2010) Race/Ethnicity % of female tests % CT+ % GC+ Non-Hispanic white Non-Hispanic black Asian Native Hawaiian/Pacific Islander American Indian Hispanic ethnicity Other/Multi Missing

68 Annotated Positivity and Screening Coverage Graphs MS Excel-based Enter monthly data and notes Annotated graphs are automatically generated

69 Tests vs. Patients Some EHRs can export user data but not test-record data User data can be used to calculate clinic prevalence (% of patients with positive test result) If most patients are tested only once per year, prevalence and positivity will be similar

70 Tests vs. Patients Re-testing affects positivity but not prevalence Caution: If your agency does a lot of resting, or is implementing quality improvement initiatives related to retesting, it is important to used positivity rather than prevalence.

71 Questions? Thoughts?

72 ACTION PLANNING

73 Plan Act PDSA Do Study

74 Steps Identify staff for your local CT/GC PM team Identify and define your CT/GC disparity Define your aims and objectives for CT/GC control Identify your CT/GC control strategy Think through your evaluation plan

75 Steps Think through your implementation plan Build sustainability into your control strategy Create a communication plan Time to write your plan Disseminate and ask for feedback

76 An Action Planning Walk-Through Name of Project: Expanded testing to older women Project Coordinator: Short description: Goal of action plan:

77 An Action Planning Walk-through Tasks Timeline Staff

78 An Action Planning Walk-through Activity Measure of success

79 Action Planning Examples Name of Project: Self-collected vaginal swabs Project Coordinator: Short description: Goal of action plan:

80 An Action Planning Walk-through Tasks Timeline Staff

81 An Action Planning Walk-through Activity Measure of success

82 DISCUSSION

83 Office of Population Affairs Thank You! CDC Division of STD Prevention

84 Contact Information Charlie Shumate, MPH, CHES Research Manager (512) Wendy Nakatsukasa-Ono, MPH Vice President (206) or (206)