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Effect of a Clinical Practice Improvement Intervention on Chlamydial Screening Among Adolescent Girls
Mary-Ann B. Shafer, MD;
Kathleen P. Tebb, PhD;
Robert H. Pantell, MD;
Charles J. Wibbelsman, MD;
John M. Neuhaus, PhD;
Ann C. Tipton, MD;
Sharon Brown Kunin, MS;
Timothy H. Ko, DrPH, MPH;
David M. Schweppe, MPH;
David A. Bergman, MD
JAMA. 2002;288:2846-2852.
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, F6,60 = 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.
Author Affiliations: Divisions of Adolescent Medicine and General Pediatrics, Department of Pediatrics (Drs Shafer, Tebb, and Pantell and Ms Brown Kunin) and Department of Epidemiology and Biostatistics (Dr Neuhaus), School of Medicine, University of California, San Francisco; Kaiser Permanente, San Francisco (Dr Wibbelsman) and Oakland, Calif (Drs Tipton and Ko and Mr Schweppe); and Department of Pediatrics, Lucile Salter Packard Children's Hospital at Stanford Medical Center, Stanford, Calif (Dr Bergman).
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