Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls

Abstract

Context: Chlamydia trachomatis infection is a serious public health concern that disproportionately affects adolescent girls. Although annual C trachomatis screening of sexually active adolescent girls is recommended by health professional organizations and is a Health Employer Data and Information Set (HEDIS) performance measure, this goal is not being met.

Objective: To test the effectiveness of a system-level, clinical practice improvement intervention designed to increase C trachomatis screening by using urine-based tests for sexually active adolescent girls identified during their routine checkups at a pediatric clinic.

Design, setting, and participants: A randomized cluster of 10 pediatric clinics in the Kaiser Permanente of Northern California health maintenance organization, where adolescent girls aged 14 to 18 years had a total of 7920 routine checkup visits from April 2000 through March 2002.

Intervention: Five clinics were randomly assigned to provide usual care and 5 to provide the intervention, which required that leadership be engaged by showing the gap between best practice and current practice; a team be assembled to champion the project; barriers be identified and solutions developed through monthly meetings; and progress be monitored with site-specific screening proportions.

Main outcome measure: Chlamydia trachomatis screening rate for sexually active 14- to 18-year-old girls during routine checkups at each participating clinic.

Results: The population of adolescents was ethnically diverse with an average age of 15.4 years. Twenty-four percent of girls in the experimental clinics and 23% in the control clinics were sexually active. Of the 1017 patients eligible for screening in the intervention clinic, 478 (47%) were screened; of 1194 eligible for screening in the control clinic, 203 (17%) were screened. At baseline, the proportion screened was 0.05 (95% confidence interval [CI], 0.00-0.17) in the intervention and 0.14 (95% CI, 0.01-0.26) in the control clinics. By months 16 to 18, screening rates were 0.65 (95% CI, 0.53-0.77) in the intervention and 0.21 (95% CI, 0.09-0.33) in the control clinics (time period by study group interaction, F(6,60) = 5.33; P<.001). The average infection rate for the experimental clinics was 5.8% (23 positive test results out of 393 total urine tests and a total of 3986 clinic visits) vs 7.6% in controls (12 positive test results out of 157 tests and 3934 clinic visits).

Conclusions: Implementation of this clinical practice intervention in a large health maintenance organization system is feasible, and it significantly increased the C trachomatis screening rates for sexually active adolescent girls during routine checkups.