FPNTC FAMILY PLANNING NATIONAL TRAINING CENTER CHLAMYDIA SCREENING CHANGE PACKAGE MARCH 2020 FPNTC.ORG FPNTC is supported by the Office of Population Affairs of the U.S. Department of Health and Human Services (FPTPA006028-01-00). The information presented does not necessarily represent the views of OPA, HHS, or FPNTC member organizations. INTRODUCTION hlamydia is the most commonly There are significant racial disparities in chlamydia reported notifiable disease in the United rates, where the rate among Black women is 5.6 States.1 In 2016, there were over 1.6 times greater than the rate among White women.1 million cases of chlamydia reported to While usually asymptomatic, if left untreated, Cthe Centers for Disease Control and Prevention chlamydia infection in women can lead to pelvic (CDC).2 The highest chlamydia rates are among inflammatory disease (PID), a major cause of adolescent (ages 15-19) and young adult (ages infertility, ectopic pregnancy, and chronic pelvic 20-24) women.3 pain.1 Chlamydial infection also increases The highest rates are among women ages 15-19 and susceptibility to the transmission of human 20-24, with a rate of 3,070.9 and 3,779.0, immunodeficiency virus (HIV).1 Chlamydia is easily respectively, compared to a rate of 657.3 cases per detected and, if identified, treatable with antibiotics. 100,000 among women of all age groups (Figure 1).1 FIGURE 1. Source: CDC Sexually Transmitted Disease (STD) Surveillance Report, 2016 (Figure 5)1 Chlamydia—Rates of Reported Cases by Age Group and Sex, United States 2016 Rate (per 100,000 population) Men Women 4000 3200 2400 1600 800 0 Age Group 0 800 1600 2400 3200 4000 12.7 10-14 91.1 832.6 15-19 3070.9 1558.6 20-24 3779.0 1003.4 25-29 1657.8 538.3 30-34 688.2 311.3 35-39 341.8 167.3 40-44 154.2 91.9 45-54 57.9 30.1 55-64 15.8 5.5 65+ 2.2 305.2 Total 657.3 CHLAMYDIA SCREENING CHANGE PACKAGE | MARCH 2020 1 SCREENING GUIDELINES Because of the high burden and risks associated For men who have sex with men (MSM) the STD with chlamydia infection, and the asymptomatic Screening Recommendations are to screen “at least nature of the infection, health care providers annually for sexually active MSM at sites of contact rely heavily on screening tests.4 CDC and the (urethra, rectum) regardless of condom use, and U.S. Preventive Services Task Force (USPSTF) every 3 to 6 months if at increased risk.”5 have developed screening recommendations for According to the USPSTF, “…current evidence is chlamydia. According to the CDC STD Treatment insufficient to assess the balance of benefits and Guidelines: 4 harms of screening for chlamydia and gonorrhea in “Annual screening of all sexually active women men.”7 The CDC STD Treatment Guidelines state that, aged <25 years is recommended, as is screening “Among women, the primary focus of chlamydia of older women at increased risk for infection (e.g., screening efforts should be to detect chlamydia, those who have a new sex partner, more than prevent complications, and test and treat their one sex partner, a sex partner with concurrent partners, whereas targeted chlamydia screening partners, or a sex partner who has a sexually in men should only be considered when resources transmitted infection). Although CT incidence permit, prevalence is high, and such screening does might be higher in some women aged ≥25 years not hinder chlamydia screening efforts in women.”5 in some communities, overall the largest burden of A National Committee for Quality Assurance (NCQA), infection is among women aged <25 years.”5,6 National Quality Forum (NQF)-endorsed measure The CDC STD Treatment Guidelines and CDC STD based on the USPSTF clinical guidelines is widely Screening Recommendations also include guidance used to monitor the percentage of women 16-24 for screening men.4,5 years of age who were identified as sexually active and who had at least one test for chlamydia during “Although evidence is insufficient to recommend the measurement year.7 Yet in 2015, half (49.8%) routine screening for C. trachomatis in sexually of sexually active female enrollees ages 16-24 in active young men because of several factors plans reporting Healthcare Effectiveness Data (e.g., feasibility, efficacy, and cost-effectiveness), and Information Set (HEDIS) were screened for the screening of sexually active young men chlamydia.8 Because of these low screening rates, should be considered in clinical settings with a chlamydia screening is a public health priority. high prevalence of chlamydia (e.g., adolescent Increasing the percentage of sexually active women clinics, correctional facilities, and STD clinics) or 24 years and younger enrolled in either Medicaid in populations with high burden of infection (e.g., or commercial insurance who are screened for MSM).”4 chlamydia is a HEDIS measure, and a Healthy People 2020 goal.3,9 2 CHLAMYDIA SCREENING CHANGE PACKAGE | MARCH 2020 GOALS OF THE CHANGE PACKAGE The goal of this change package is to support an » BEST PRACTICE 2. Use normalizing and opt- increase in Title X grantees’ chlamydia screening out language to explain chlamydia screening rates. Improvement can be tracked using the HEDIS to all women 24 years and younger, women chlamydia screening measure: >24 who are at increased risk, and men at increased risk. Use sample scripts and staff role The percentage of women 16‐24 years of age plays to help standardize the conversation.4 who were identified as sexually active and who had at least one test for chlamydia during » BEST PRACTICE 3. Use the least invasive, the measurement year.3 high quality, recommended laboratory technologies for chlamydia screening with Although this HEDIS measure focuses on women timely turnaround. Make all optimal urogenital 16-24 years of age, improvement activities should specimen types available, including self- address all women and men at risk of chlamydia, as collected vaginal swabs for women.4 defined above.4 » BEST PRACTICE 4. Utilize diverse payment Based on a review of the literature, four best practice options to reduce cost as a barrier for the recommendations and suggested strategies for client and the facility. Inform clients about implementation of these practices have been self-pay, sliding fee schedules, and insurance identified: enrollment options. » BEST PRACTICE 1. Include chlamydia screening as a part of routine clinical preventive care for women 24 years and younger, women >24 who are at increased risk,i and men at increased risk.ii Use clinic support systems to systematically screen sexually active clients at least once a year based on age and sex, or risk.4 i Women at increased risk for infection are defined by the CDC STD Treatment Guidelines as, for example, “those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection.” ii According to the STD Treatment Guidelines, “targeted chlamydia screening in men should only be considered when resources permit, prevalence is high, and such screening does not hinder chlamydia screening efforts in women. More frequent screening for some women (e.g., adolescents) or certain men (e.g., MSM) might be indicated.” CHLAMYDIA SCREENING CHANGE PACKAGE | MARCH 2020 3 FIGURE 2. Driver Diagram Include chlamydia screening as a part Establish standing orders and a standardized workflow of routine clinical that includes assessing the need for chlamydia screening preventive care for women 24 and Prepare for screening based on sex and younger, women age before the client is seen >24 and men MEASURABLE AIM: who are at risk Increase percentage Share screening rate data with staff and providers of women 16-24 who were identified as sexually active and Use normalizing and Use client education materials and visual aids that recommend screening based on age and sex who had at least one opt-out language to explain chlamydia test for chlamydia screening to women Use sample scripts and have staff practice during the ages 24 years and normalizing and opt-out language measurement year younger, and for women >24 and Avoid asking the client if she thinks she/he is at risk men who are at risk Use the least invasive, Make self-collected vaginal swabs available high-quality recommended laboratory Make provider-collected vaginal swabs technologies available for clients having a pelvic exam for chlamydia screening, with timely turnaround Use urine sample for screening males Utilize diverse Optimize billing, coding, revenue cycle payment options management and patient fee collection to reduce cost as a barrier for the client Ensure client confidentiality and provide safety and the facility net screening to those who need it 4 CHLAMYDIA SCREENING CHANGE PACKAGE | MARCH 2020 HOW TO USE THIS CHANGE PACKAGE This change package will support sites to develop a A supplementary set of tools that can support comprehensive strategy for increasing chlamydia implementation of these strategies can be found screening among clients at greatest risk. on FPNTC.org. Specifically, this change package can help support FPNTC Sexually Transmitted Disease Services your efforts to: Training Package: For more information on chlamydia screening » Increase awareness of best practice strategies resources through the Family Planning National associated with opt-out chlamydia screening Training Center, see the training package on Sexually among women 24 years and younger. Transmitted Disease Services. » Increase awareness of best practice strategies Quality Improvement eLearning Modules: associated with increasing chlamydia screening For more information on quality improvement, see for women >24 who are at increased risk, and the training package on Quality Improvement (QI). men at increased risk.5 A five-part eLearning series builds knowledge » Compare best practice recommendations and related to conducting quality improvement in the strategies with existing practices in your clinic.