Effect of a Clinical Practice Improvement Intervention on Chlamydial Screening Among Adolescent Girls

Chlamydia trachomatis is the most commonly reported bacterial STD in the United States. Three million to four million cases occur annually, disproportionately among adolescent girls. The disease is asymptomatic in more than 75 percent of cases, and an untreated infection may lead to severe reproductive morbidity. Chlamydia trachomatis infections cost the U.S. health care system $3 billion to $4 billion each year.

Although broad-based Chlamydia trachomatis screening programs have been shown to be effective, only 20 percent of sexually active young women ages 15-25 who go to HMOs are screened. Barriers to screening include adolescent embarrassment about discussing reproductive health, lack of confidentiality, or fear of a pelvic examination. Health care organizations may not provide a setting conducive to confidential care, and health care practitioners may feel uncomfortable discussing sexuality with their adolescent patients. Until recently, Chlamydia trachomatis endocervical sampling was the standard diagnostic test, requiring a pelvic examination. The advent of urine-based Chlamydia trachomatis nucleic acid amplification tests means that Chlamydia trachomatis can be diagnosed without a pelvic exam. Such testing has been documented to be cost-effective, acceptable to adolescents, and accurate.

The current study developed a clinical practice improvement intervention to increase Chlamydia trachomatis screening for eligible adolescent girls during routine checkups at Kaiser Permanente of Northern California pediatric clinics. Between April 2000 and March 2002, ten KP clinics participated in the study. Adolescents up to age 18 are seen for primary care in this HMO's pediatric clinics. In a given year, about 48,600 of the 97,000 enrolled girls ages 14-18 made at least one clinic visit. A third of them had a checkup. The clinics were randomly assigned: five to use the experimental intervention, five to serve as controls.

At the experimental clinics, the research team engaged HMO leadership by showing the gap between best practice and current practice; assembled an onsite team to champion the project; identified barriers and developed solutions through monthly meetings of the research team facilitator and the adolescent care team; and monitored performance progress through site-specific performance indicators and a customized information infrastructure. Since practitioners were inconsistent in asking about and recording patients' sexual activity, the researchers developed an anonymous exit poll in which adolescents self-reported their sexual activity. They also initiated a universal urine-sample collection at clinic check-in, to ensure confidentiality about screening.

The clinics served an ethnically diverse population with a median age of 15. Sixteen percent were black, 17 percent Asian, 16 percent Latina, 38 percent white, 11 percent multiethnic, and 2 percent other.

Over the study period, 478 (47 percent) of 1,017 eligible adolescent girls were screened for Chlamydia trachomatis in the experimental clinics. Of the 1,194 eligible girls at the control clinics, 203 (17 percent) were screened. Thus, the intervention significantly increased Chlamydia trachomatis screening rates among adolescent girls coming in for routine checkups at Kaiser Permanente pediatric clinics. Testing revealed a 5.8 percent infection rate at the experimental clinics, versus 7.6 percent at the control clinics.

"In developing our intervention," the authors wrote, "we recognized that to implement changes in screening practices successfully, it was necessary to couple the C trachomatis screening guidelines and advanced C trachomatis testing capabilities with a multifaceted, systems-level intervention that addressed the needs of the health care professional and the patient, and targeted barriers at all levels of clinical practice."

They concluded that the next steps for improving screening practices are to train HMO personnel to implement the intervention in all clinic settings, to evaluate cost-effectiveness using a number of different scenarios, and to apply the intervention method and clinic team approach to other clinical problems in other settings to "improve clinical outcomes on an ad hoc or continuous basis."

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