California Family Health Council Business Meeting April 15, 3013

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California Family Health Council Business Meeting April 15, 3013 The Evidence Behind the New Title X Guidelines

Deliverables CDC MEC 2010 Contraceptive e Practice CDC SPR 2013 Title X Clinical Policies 2013 CDC STD Treatment

infertility Program Requirements Introduction The Law, Regulations and Guidelines Application Process Project

Delivery and Infrastructure Building Client Encounters Title X Program Guidelines This guideline revision

Title X Program guidelines that also provide a service and contribution to the greater reproductive health

review of evidence, and gaps identified, to inform OPA s future research efforts Goals of the Title X Guidance

Prioritize provision of core family planning services Allow flexibility for recommended services A id i h h d b

1 California Family Health Council Business Meeting April 15, 3013 The Evidence Behind the New Title X Guidelines Michael S. Policar, MD, MPH Clinical Professor of Ob,Gyn, & RS UCSF School of Medicine policarm@obgyn.ucsf.edu The best bike team. period No commercial disclosures for this lecture Evidence Based Guidelines for Family Planning Title X Deliverables CDC MEC 2010 Contraceptive e Practice CDC SPR 2013 Title X Clinical Policies 2013 CDC STD Treatment Guidelines 2010 STD Practice F screening M screening Preconception Achieving pregnancy Preg determination Basic infertility Program Requirements Introduction The Law, Regulations and Guidelines Application Process Project Management Client Services Required Services Program Guidance Introduction Title X Clinical Requirements Service Delivery and Infrastructure Building Client Encounters Title X Program Guidelines This guideline revision process is unlike previous updates and revisions The end goals To produce evidence based or evidence informed Title X Program guidelines that also provide a service and contribution to the greater reproductive health community To create a process and mechanism for keeping the Guidelines current (similar to CDC MEC) To use the review of evidence, and gaps identified, to inform OPA s future research efforts Goals of the Title X Guidance Revision Process 1. Utilize best evidence to design preventive services 2. Prioritize provision of core family planning services Allow flexibility for recommended services A id i h h d b fi Avoid services where harms exceed benefits 3. Support client decisions re: services received or declined 4. Remove barriers to care for the client and provider 5. Improve clinic efficiency 6. Anticipate changes in source of primary care arising from the Affordable Care Act

Well Woman Preventive Services in Family Planning Clinics Well Woman Preventive Services in Family Planning Clinics Comprehensive Well woman services Non-reproductive primary care Comprehensive Well

It depends on the patient for women s health care providers The Musts The Shoulds Leave to 1 o care Well Woman Preventive Services in Family Planning Clinics Recommended, but optional, services ( the

site specific specific policies and protocols How Are Core Family Planning Preventive Services Different from Well Woman Care?

2 Well Woman Preventive Services in Family Planning Clinics Well Woman Preventive Services in Family Planning Clinics Comprehensive Well woman services Non-reproductive primary care Comprehensive Well woman services Ceiling Reproductive Encouraged (Shoulds) Reproductive Floor Family Planning Core (Musts) Family Planning for primary care providers Who Is the Target Audience? It depends on the patient for women s health care providers The Musts The Shoulds Leave to 1 o care Well Woman Preventive Services in Family Planning Clinics Recommended, but optional, services ( the shoulds ) at any given visit are based upon Individual client choice Avoiding duplication of services recently ordered or given by other clinicians Provider attitudes and preferences, as reflected in site specific specific policies and protocols How Are Core Family Planning Preventive Services Different from Well Woman Care? Core FP preventive services focus upon Avoiding pregnancy or becoming pregnant Safe and effective contraceptive use Protection of reproductive health Additional preventive services may be performed by The patient s primary care provider (PCP), or Her family planning clinic, in the absence of a PCP Given limitations of time and resources, provision of core family planning services is our top priority! Family Planning Preventive Services The Musts Discuss and counsel Reproductive life plan Safe and effective contraceptive use Screen for reproductive coercion, BC sabotage Sexual behaviors and STI risk screening Screen for tobacco, alcohol, and drug use Family history of breast and ovarian cancer

3 Metabolic Family Planning Preventive Services The Musts Screening interventions BP, BMI (if using a hormonal contraceptive) T2DM, lipid screening (as indicated for clinical decisions regarding CHC use) STI Routine chlamydia screening <26 yo Offer HIV screening Targeted STI screening as indicated Cancer Offer cervical cancer screening Offer breast cancer screening CHC (combined hormonal contraception): OC, ring, patch USPSTF 2012 Triple A 2012 Summary of Cervical Cancer Guidelines Under 21 years old years old Years old [D] Every 3 y Co test: Q5 Cytology: Q3 >65 years old Hyst, benign ** Every 3 y Co test: Q5* ** 2012 Cytology: Q3 ACOG 2012 hrhpv test Avoid Every 3 y Co test: Q5* Cytology: Q3 Never Reflex only Co test or reflex ** * Preferred ** If adequate prior screening with negative results Co test: cervical cytology plus hrhpv test Cytology: cervical cytology (Pap smear) alone [D] Other Important Messages Women at any age should not be screened annually by any screening method For women 65 and older Adequate screening is defined as 3 consecutively negative results in prior 10 years, or 2 negative co tests, most recently within 5 years If screening stopped, do not restart for any reason Women treated for CIN 2+ or AIS must be regularly screened for 20 years, even if 65 or older With cytology alone Q 3 years or HPV+ cytology Q5 years Co testing Strategy as Health Policy Pros Cons Slightly more accurate than More false positives, esp. if cytology alone done too frequently Higher negative predictive High cost/ year of life saved value than cytology alone if done too frequently Longer screening interval Many providers do not have available if desired by patient EMRs or other systems to prevent overuse Breast Self Examination (BSE) Two very large RCTs (Shanghai, Russia) Mortality, survival equal in treatment and controls SBE no better than coincidental discovery of mass USPSTF 2009:[ D ] recommends against teaching BSE American Cancer Society 2003 At > 20 years old, inform of benefits, limitations If BSE chosen, provide instruction in use Acceptable not to do BSE or to do irregularly Goal of BSE is increased breast awareness Clinical Breast Exam (CBE) Most studies evaluate MG + CBE, not CBE alone Accuracy of CBE Sensitivity: 54%, specificity: 93 94% 10% of breast cancers detected on CBE alone, especially in younger women Most recommendations: start CBE at 40; perform annually (concurrent with mammogram) except USPSTF 2009: [ I ] recommendation ACS 2003: every 3 years, then annually ACOG 2003: start at 20, then annually

4 Screening Mammography Guidelines Age (years) USPSTF 2009 Recommendation Screen if specified high risk factors Discuss pros and cons of screening* Encourage screening* Strongly encourage screening* Discuss pros and cons of screening* >75 Little data *When done, perform routine mammography biennially Routine Mammography Guidelines American College of Ob Gyn (ACOG) 2011 American College of Radiology (ACR) 2010 American Cancer Society (ACS) 2011 Annual screening starting at 40 years of age American College of Physicians years old based on individual risks Every 1 2 years starting at 50 years old World Health Organization 2009 Every 1 2 years between Discuss and counsel Screening Family Planning Preventive Services The Shoulds Recommended for optimal repro health Preconception counseling, including folate supplementation, if planning pregnancy Depression screening Obesity counseling Tobacco, drug use cessation: advice, referrals Hereditary breast and ovarian cancer counseling Vaccination status: DTaP, HPV, Hep B, rubella, seasonal influenza Blood pressure, BMI (if using non-hormonal contraception) Discuss and counsel Screening Leave To Primary Care Interventions unrelated to core family planning Healthy diet counseling Dental health Injury prevention Breast cancer preventive medication Tobacco and drug use cessation interventions Administer vaccines: DTaP booster, HPV, Hepatitis B, influenza, rubella Colorectal cancer screening DM, hyperlipidemia screening (unrelated to BCM) Skin cancer screening (high risk) Thyroid disease (high risk) Routine Interventions to Avoid Test Bacteriuria screening with urinalysis Genital herpes screening Gonorrhea screening in low risk persons Syphilis screening in low risk persons Bacterial vaginosis and trichominiasis screening Hepatitis B screening Hepatitis C screening in low risk persons Ovarian cancer screening in low risk women BRCA mutation testing in low risk women Pelvic Exam at the Well Woman Visit ACOG Committee Opinion 524; August 2012 Women younger than 21 years Pelvic exam only when indicated by medical history Screen for GC, chlamydia with vaginal swab or urine Women aged 21 years or older Women aged 21 years or older ACOG recommends an annual pelvic examination No evidence supports or refutes routine exam if low risk If asymptomatic, pelvic exam should be a shared decision Individual risk factors, patient expectations, and medicolegal concerns may influence these decisions If TAH BSO, decision left to the patient if asymptomatic

5 Is The Screening Pelvic Exam Outdated? Screen for Preferred test GC, Ct NAAT: vaginal swab or urine sample Cervical cancer Not recommended until 21 years old Cytology every 3 5 yrs afterward, if total hyst for benign disease Ovarian cancer USPSTF rec. against bimanual exam Vulvar lesions Unnecessary if asymptomatic Vaginal infxn Unnecessary if asymptomatic Myomas Unnecessary if asymptomatic Family PACT Update Preparing clients for full implementation of the ACA LIHPs (limited income health program) 2013 Medi Cal expansion Covered California (state health insurance exchange) New clinical practice policies Cervical cytology benefit limited to years old, unless reason for exception documented on lab slip Webinar on Family planning vs. family planning related services Will Family PACT Cover Cervical Cytology For Women Under 21 Years Of Age? Family PACT covers cervical cytology screening only when provided in conjunction with family planning services On May 1, 2013, routine cytology screening for women < 21 years of age will no longer be covered unless exception The provider must document on the cytology request form Requires repeat cervical cytology to reevaluate prior ASC US, LSIL, or a CIN 1 biopsy result Immunocompromised status Requires post treatment surveillance Family Planning (FP) SPA: Covered Services Contraceptive services for women and men FP related conditions identified at a FP visit STI screening, diagnosis, and treatment (except drugs for HIV and hepatitis) Lower urinary tract infections Genital skin infections and disorders HPV vaccination Treatment of major contraceptive complications Pay for Performance (P4P) Two major factors drive changes in clinician behavior Financial incentives Performance evaluations, relative to peers Over the past 20 years, managed care plans have tied these concepts in the Quality Bonus More recently, payments to PCPs are adjusted by Case mix index/ severity of illness (CMI/SOI) Performance, as judged by quality metrics Will become a major input to payments, contracts, and resource allocation in the future How Is Quality Currently Measured in Sexual And Reproductive Health (SRH) 2013 HEDIS measures (NCQA) Cervical cancer screening Breast cancer screening Chl di i Chlamydia screening HPV vaccine for female adolescents Management of urinary incontinence in older adults Osteoporosis testing in older women Entry into prenatal care Postpartum care

Family PACT Provider Profiles Selecting a Family Planning Quality Indicator Quality indicators Chlamydia screening rates < 25 yo Chlamydia screening rates > 25 yo Utilization indicators Annual

N from U.S. born adult patients New indicator this week!! Average cervical cytology interval Must meet all of the following criteria 1. Clinically relevant topic 2.

6 Family PACT Provider Profiles Selecting a Family Planning Quality Indicator Quality indicators Chlamydia screening rates < 25 yo Chlamydia screening rates > 25 yo Utilization indicators Annual reimbursement per client Annual office visits per client % of visits coded at highest level New patients (99204) Established patients (99214) Administrative indicators SSN from U.S. born adult patients New indicator this week!! Average cervical cytology interval Must meet all of the following criteria 1. Clinically relevant topic 2. Intervention that will measure an outcome or a process to improve outcomes 3. Objectively measurable 4. Performance is under the influence of the provider 5. Ability to compare provider performance to peer group or benchmark (or both) over time intervals Selecting a Family Planning Quality Indicator Where will the performance data come from? Claims data sets: CPTs, ICD 9s, local codes Medical record (chart review) Called hybrid methodology when combined Electronic medical records Client satisfaction surveys Mailed surveys after care Exit interviews Possible Family Planning Quality Indicators Indicator Pros Cons Pregnancy and abortion rates Initiation or current use of Tier 1 methods Discussion of reproductive life plan Ask One key question Direct outcome measure Superior rates of pregnancy prevention At minimum, insures that SRH issues are discussed At minimum, pregnancy intendedness discussed Differentiation of planned vs. unintended pregnancies Method choice should not be influenced by provider No evidence that this positively impacts outcomes No evidence that this positively impacts outcomes One Key Question Family Planning Quality Indicators: What s Next? Development of a set of SRH competencies for all health care providers Equates SRH with other important health issues not just a lifestyle issue Develop quality indicators based upon competencies Approach HEDIS to develop new SRH indicator(s) Office of Population Affairs should take the lead, working with CDC and family planning organizations

Removing Unnecessary Barriers to Contraceptive Services

Title X Grantee Meeting July 31, 2013 Seattle, WA Removing Unnecessary Barriers to Contraceptive Services Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine policarm@obgyn.ucsf.edu