FP clinic chlamydia screening coverage: Some method issues and results

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Aubrey Jordan Higgins
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1 FP clinic chlamydia screening coverage: Some method issues and results D. Fine, S. Goldenkranz and W. Nakatsukasa-Ono Region X IPP Advisory Committee Meetings February 7, 2012

2 Background Context Part of a larger analysis of CT positivity Social determinants, clinic characteristics and individual-level measures Focus today on FP clinic CT screening coverage Definition, yet again Method issues and their effect on coverage Coverage and race/ethnicity Coverage and CT positivity

3 Recent theoretical frameworks propose multi-level models to describe STI transmission Social determinants, e.g. community poverty, crime Neighborhood indicators, e.g. racial composition Clinic characteristics, e.g. CT screening coverage Sexual network characteristics, e.g. SP concurrency Individual risk behaviors

4 Multi-level models imply multiple data sources IPP: Individual behaviors, sexual network and CT test Other data sources needed to describe social determinants and clinic service characteristics Challenges bringing these data together within IPP

5 Methods Data sources, Region X CY2010 1) Title X FP client clinic visit records (CVRs) 2) U.S. Census 2010/2000 tables 3) IPP CT test records

6 1) Data: 2010 Region X FP client clinic visit records 219,921 Title X FP visit records, female clients aged y Clinics Patients N % N % Total % 137, % 100+ FP clients/clinic % 134,301 97% FP clinic in IPP data % 104,549 76% 100+ clients/clinic and in IPP % 102,294 74% 100+, in IPP, consistent CT data 85 35% 57,837 42%

7 2) Data: U.S. Census 2010/2000 ZCTA records Areal community summary measures ZIP-code tabulation areas: drawn around US Postal Service ZIP-code routes Measures Race and ethnicity populations (SF1, 2010 Census) Socioeconomic position (SF3, 2000 Census) Measures summarized as ordered categories Followed federal guidance (e.g. FPL) or past research

8 3) Data: 2010 Region X IPP clinics Clinics N % Total clinics % FP/RH % STD 45 12% Community/migrant health 35 10% School-based 34 9% Adult & juvenile corrections 17 5% Other* 41 11% *Other: prenatal, college health, adolescent, Indian health, HIV C&T, other expansion

9 3) 2010 Region X IPP and FP clinics All clinics: 79,664 CT tests, female clients aged y Clinics CT Tests N % N % FP clinics % 63, % FP clinics in Title X CVR % 53,858 84% FP Title X w/ 100+ clients % 49,470 78%

10 Sample for analysis Critical to select sites where FP CVR and IPP data systems have consistent clinic CT testing volumes Step 1: Explored documentation of CT test done in Title X FP CVR data CVR item: Was a chlamydia test done at that visit? Sometimes not documented or exported from clinic database Used IPP client ID and other variables to identify if a CT test was, in fact, done in FP Title X CVR file Improved CT screening coverage estimates

11 Sample for analysis Critical to select sites where FP CVR and IPP data systems have consistent clinic CT testing volumes Step 2: Assessed conformance between clinics IPP test volume and CT testing in FP CVR data Some higher CT test volume vs. IPP test records Others higher IPP test volume vs. CVR CT testing Set benchmark of CT volume/patient difference between CVR and IPP no greater than 20%

12 Important: Program practices and data Why discrepancies between FP clinic CVR CT tests done and FP clinic IPP tests done? A few reasons Clinics sending Title X CT tests to other non-phl labs that bill Medicaid or private insurance increases clinic revenue. These tests (and labs) do not use the IPP lab slip. FP clinics testing female clients who are not eligible for Title X (i.e., no CVR generated) but eligible for IPP. Title X and non-title X FP patients at same site.

13 Region X 2010 IPP CT tests Sample progression Clinics CT Tests* N % N % FP clinics % 63, % FP clinics in Title X CVR % 53,858 84% FP Title X w/ 100+ clients % 49,470 78% FP Title X clinics, 100+, consistent CVR-IPP test volume 85 44% 35,718 56% *Female clients aged years.

14 Sample for (future) analysis 125 FP clinics 49,470 IPP tests 40 clinics excluded CT test volume differences between CVR and IPP, 20+% 85 FP clinics 35,718 IPP tests Female FP clients aged years, WSM & WSMW Now for today s topic

15 Interim Findings: CT screening coverage Clinic CT screening coverage is an important cliniclevel program measure CDC quality indicator Included in future multi-level analyses of IPP data Requires data beyond IPP, e.g. Title X FP CVRs In early 2000 s Region X first defined and assessed CT screening coverage before FPAR CT screening coverage: % of clients screened for chlamydia during some time period, like a year. No agreed-upon guidelines for categorizing screening coverage

16 CT screening coverage: Title X FP CVR 2010 How did our clinic sample selection process outlined earlier impact clinic CT screening coverage in FP Title X CVR data set? 2010 FP Title X CVR data set 219,921 visit records, female clients aged y 137,932 patients 102,294 patients from FP clinics with 100+ clients and FP clinic in IPP 57,837 patients, FP clinics with consistent CT data w/ IPP

17 CT screening coverage can be calculated Look at whether a patient was screened for CT during the past year summarize at state/region At the clinic level based on the number of patients screened for CT during the past year at each clinic Results can vary slightly depending on method Our focus: describing clinics CT screening levels

18 Distribution of clinic screening coverage, women aged years: All FP clinics, Title X CVRs 2010 % of FP Clinics 25% 20% 15% 10% Average clinic CT screening coverage: 37% % CT screening coverage <10% 10-19% 20-29% 30-39% 40-49% 50-59% 5% 60-69% 70-79% 80-89% 0% All FP Clinics, n~250 sites

19 Prior estimate of 37% clinic CT coverage based only on one measure from CVR: CT test done We enhanced this by looking at Matching on clinic and client ID from IPP to CVR Matching on clinic, visit date and date of birth from IPP to CVR Excluded cases where multiple matches on clinic, visit date and DOB

20 Clinic CT screening coverage*: All Region X Title X FP sites F r e q u e n c y N~250 clinics *Coverage based on CVR CT test done item AND enhanced matching via IPP

21 Distribution of clinic screening coverage based on different sets of FP clinics, Title X CVRs 30% 25% Average clinic CT screening coverage: 37% 48% 56% % CT screening coverage <10% % of FP Clinics 20% 15% 10% 10-19% 20-29% 30-39% 40-49% 50-59% 5% 60-69% 70-79% 0% All FP Clinics n~250 sites FP clinics in IPP* n=125 sites FP clinics in IPP enhanced match** 80-89% *FP clinics, 100+ female clients aged y in IPP, CVR CT test done measure used **FP clinics with 100+ female clients aged y in IPP, improved match, n=125

22 CT screening coverage*: Title X FP sites in IPP N = 125 clinics F r e q u e n c y *Coverage based on CVR CT test done item AND enhanced matching via IPP

23 CT screening coverage*: Sites with consistent testing volume between FP Title X and IPP F r e q u e n c y N = 85 clinics 40 of 125 FP clinics in IPP excluded due to inconsistent test volume between 2 data systems. *Coverage based on CVR CT test done item AND enhanced matching via IPP

24 Distribution of clinic screening coverage, women aged years: Title X CVRs 2010, final clinic sample % of FP Clinics 30% 25% 20% 15% 10% 5% Final Sample = 85 clinics 22% 8% 18% 28% 17% 5% % CT screening coverage 10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% 1% 1% 0% Screening coverage categories

25 CT Screening coverage estimate by sample Clinic CT Screening Coverage Mean Median Range All FP clinics, n~250 37% 40% 0 87% FP clinics, 100+ clients, IPP, n=125* 48% 49% 0 87% FP clinics, 100+ clients, IPP, n=125** 56% 55% 18 89% FP clinics, final sample, n=85*** 58% 59% 18 89% *Coverage based on CVR item CT test done **Coverage based on CVR CT test done and enhanced matching with IPP records ***Coverage based on CT test, enhanced match, limited to clinics with comparable Title X and IPP data

26 Implications Without getting into the utility of CT screening coverage Title X FP clinics overlap with IPP FP clinics, but imperfectly Title X documentation of CT test done varies from CT tests for FP clinics in IPP Program silos, billing and other agency policies affect test totals for Title X and IPP FP sites Title X FPAR coverage is not IPP FP coverage

27 FP clinic CT screening and method issues CT screening rates vary widely across clinics Overall screening rate affected by Which clinics are included in the calculation How we determine if a patient was screened or not Since we are using FP CT screening coverage to inform IPP we should Use Title X and IPP data from the same FP clinics Assess whether Title X and IPP data systems reasonably reflect the same client populations

28 Clinic CT screening coverage regardless of how it is determined varies significantly within a geographic region (at least it does in Region X) In a world of limited resources, increasing coverage is less important than adjusting it Regions, states or other jurisdictions should consider exploring: Variation in clinic CT screening coverage Factors associated with screening, and Results, i.e. infections detected

29 Clinic CT screening coverage and race/ethnicity

30 CT screening coverage and client race/ethnicity Hot topic Health service equity Universal screening of FP female clients aged years is not feasible CT screening can be a function of: Individual client risk factors Provider clinical decision making Clinic practices Agency policies Random stuff

31 CT screening coverage*: Racial/ethnic differences Region X FP CVRs, clinics, N = 57,837 female clients aged years 80% 71% 70% 60% 65% 60% 54% 54% 59% 57% White 50% 40% 30% 20% Black Asian HAPI AIAN Hispanic Other 10% 0% CT Screening Coverage* *Enhanced CT screening coverage: CVR CT test done AND other matching via IPP

32 Racial/ethnic differences in CT screening Important to assess coverage between racial/ethnic groups within clinics Why? Because clinics may have different overall testing levels AND different racial/ethnic client make-up 76% of 85 sites did not have enough black clients to compare white/black CT coverage within clinic For 20 sites with enough white & black FP clients 9 clinics with comparable coverage rates (+/- 6%) 10 clinics with higher black CT testing 1 clinic with higher white CT testing

33 Title X FP CVR data system has some variables besides race/ethnicity that we know are related to CT screening: Age, new/continuing patient, comprehensive exam visit, state MVA showed that all of the above, and client race/ethnicity, were related to CT screening CVRs do not have sufficient measures to assess individual-level factors related to a decision to test.

34 Clinic CT screening coverage and CT positivity

35 CT screening coverage and positivity 2010 IPP data 85 FP clinics 35,718 IPP tests among female clients aged years Overall CT positivity: 7.1% GC+ = 0.3% (n=107) FP clinic CT screening coverage merged into IPP data set via clinic ID#

36 FP clinic CT screening coverage and IPP tests 85 clinics, N = 35,718 IPP tests, women aged y 12,000 10,000 10,186 % CT screening coverage <30% # of CT tests 8,000 6,000 4,000 4,369 5,138 4,061 7,093 4, % 40-49% 50-59% 60-69% 70-79% 2, % Clinic screening coverage levels

37 % CT Positivity FP clinic CT screening coverage and IPP CT positivity 85 clinics, N = 35,718 tests, women aged y 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 298 tests 8.7% 6.0% 6.6% 4.9% 7.1% 7.6% 4,573 tests 10.2% % CT screening coverage <30% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% 0.0% Clinic screening coverage levels

38 % Clinic CT coverage % of sample % CT+ < 30% <1% 8.7% 30% - 39% 12% 6.0% 40% - 49% 14% 6.6% 50% - 59% 11% 4.9% 60% - 69% 29% 7.1% 70% - 79% 20% 7.6% 80% - 89% 13% 10.2%

39 Another way to look at it Clinic coverage level % of sample % CT+ Less than 50.0% 28% 6.4% 50.0% % 54% 6.8% 75.0% or higher 18% 9.3%

40 Should our goal be: Increase coverage? Higher CT screening coverage: higher %CT+ An open question, that needs more evidence? But we know from recent work (Goldenkranz et al., NSTDP 2010): FP clinics much more likely to screen during comprehensive/routine visits Adolescents aged y less likely to have routine visits Comprehensive/routine visits: ~30% of all visits CT+ is lower in comprehensive/routine visits Higher coverage=higher CT+ because, at least in part, those clinics are testing women beyond the minority receiving routine exams

41 CVR 2010 patient data, 85 clinics, re-visited 57,837 female FP patients aged years 26,679 (46%) tested 1 or more times* 59% tested only at a comprehensive initial/annual exam** 37% tested only at other types of non-comprehensive visits 4% tested at both types of visits As clinic CT coverage increases, the % of tests on women seen for non-routine visits increases * Based ONLY on CVR item CT test done ** In FP CVRs we have initial and annual exams: comprehensive routine visit, and other visits such as preg test, other medical etc. In IPP we have routine visit versus symptomatic, preg test etc.

42 Next steps To be continued Are clinic characteristics, including % CT screening coverage, and areal SEP related to CT+% among FP clients? Multi-level analyses of CT positivity Measures: Census, FP clinic, IPP test records 2010 Census SEP areal measures may not be available for a few more months

43 For further information: David Fine, PhD Cardea Seattle, WA p: (206) f: (206)

D. Fine, S. Goldenkranz and W. Nakatsukasa-Ono Cardea, Seattle WA National STD Prevention Conference

D. Fine, S. Goldenkranz and W. Nakatsukasa-Ono Cardea, Seattle WA National STD Prevention Conference Social Determinants, Epidemiologic Context, and Individual Risk Factors for Chlamydia (CT) Infection Among Women Attending Family Planning (FP) Clinics in the Region X Infertility Prevention Project (IPP),