Strategies used to increase chlamydia screening in general practice: a qualitative study

OBJECTIVES: To explore strategies used by chlamydia screening co-ordinators and practice staff to implement genital chlamydia screening within general practices. METHODS: Qualitative phenomenological study using individual semi-structured telephone interviews. Screening co-ordinators were selected purposively in Phase 1 and 2 areas of the Department of Health National Chlamydia Screening Programme in England, where there was significant screening in general practice. Open questions were asked about: the factors that determined high chlamydia screening rates; maintaining motivation for screening; and strategies to increase screening in general practices. RESULTS: Co-ordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalized screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time-saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. Chlamydia screening was sustained through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the 'at-risk' population from the screening team. Co-ordinators' enthusiasm and project management skills were as important as sexual health experience. Co-ordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public. CONCLUSIONS: All practice staff need to be encouraged to become champions of the chlamydia screening programme through education, especially aimed at older clinicians and receptionists. The National Health Service should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.     

An intervention to increase mammography screening by residents in family practice

Two groups of residents in family practice were used to evaluate the effectiveness of a multifaceted educational program that was designed to increase resident compliance with screening for breast cancer. In the experimental group, residents were given a two-hour seminar that responded to the literature on the difficulties of implementing preventive care in clinical practice; group consensus was developed for a more regular (exact frequency left to each resident) screening for women aged over 35 years, and specific barriers to breast cancer screening were analyzed and solutions presented whenever possible. In addition, these residents received two behavioral cues after the intervention to stimulate and reinforce referrals for mammography screening. The study was conducted over a period of one year, including a five-month preintervention period, a three-month post-intervention period, and a three-month follow-up period. As predicted, the increase in mean referral rate for the experimental group was significantly greater than for the comparison group. This increased rate of referral for mammogram was maintained for six months after the intervention. This intervention is easily reproducible in many residency training programs, especially those in family medicine and other small primary care programs.     

What needs to change to increase chlamydia screening in general practice in Australia? The views of general practitioners

Background  

Australia is considering implementing a chlamydia screening program in general practice. The views of general practitioners (GPs) are necessary to inform the design of the program. This paper aimed to investigate Australian GPs' views on how chlamydia screening could work in the Australian context.     

A randomized trial of strategies to increase chlamydia screening in young women

OBJECTIVE: Despite the recommendations of numerous clinical practice guidelines, testing of at-risk women for Chlamydia trachomatis infection remains low. We evaluated an intervention to increase guideline-recommended chlamydia screening. METHOD: In a two-by-two factorial design randomized trial conducted in 2001-2002, 23 primary care clinics at Group Health Cooperative in Washington State were randomized to either control (standard) or intervention (enhanced) guideline implementation arms. Clinic-level intervention strategies included use of clinic-based opinion leaders, individual measurement and feedback, and exam room reminders. A second patient-level intervention, a chart prompt to screen for chlamydia, was delivered in a random sample of 3509 women. The outcome measure was post-intervention chlamydia testing rates among sexually active women ages 14-25. RESULTS: The clinic-level intervention did not significantly affect overall chlamydia testing (odds ratio (OR) = 1.08, 95% confidence interval (CI) 0.92-1.26, P = 0.31). However, testing rates increased significantly among women making preventive care visits (OR, Pap test visit = 1.23, 95% CI, 1.01-1.51, P = 0.04; OR, physical exam visit = 1.22, 95% CI 1.06-1.42, P = 0.009, intervention vs. control clinics). The chart prompt intervention had no significant effect (OR = 1.08, 95% CI 0.94-1.23, P = 0.27). CONCLUSIONS: Interventions to improve guideline-recommended chlamydia testing increased testing among women making preventive care visits. Additional organizational change and/or patient activation strategies may improve plan-wide testing, particularly among asymptomatic women.     

Opportunism is NICE idea for chlamydia screening

Between 1995 and 2004, a frightening increase in most sexually transmitted diseases in the UK included a 223% rise in genital chlamydia, with 104,155 reported cases in 2004, making it the most commonly reported STD. Although many questions are yet to be answered after the release of the NICE review of the evidence for the effectiveness of screening for genital chlamydial infection in sexually active young women and men, the evidence seems to say a big ‘yes' to opportunistic screening of any patient under 25, whatever they have walked through the door for. However, NICE, in its evidence statements, did not consider the added value of partner notification/contact tracing - a job effectively managed in GUM clinics but not always undertaken by GPs.     

Accuracy of women's recall of opportunistic recruitment for cervical cancer screening in general practice

Abstract: Evaluation of strategies to improve opportunistic recruitment via general practice of women overdue for a cervical smear requires an accurate behavioural measure. As part of an experimental trial to evaluate the effect of a postgraduate workshop on preventive care, we conducted this methodological study to determine the accuracy of women's recall of an opportunistic discussion about cervical screening, by comparing it against audiotapes ( n = 524). Taking the taped evidence of the trainee's verbal behaviour as the gold standard, sensitivity was 85 per cent (95 per cent confidence interval (CI) 73.1 to 92.0 per cent) and specificity was 78 per cent (CI 73.9 to 81.6 per cent). Given the low rate of opportunistic recruitment by trainees in the main study, only one–third of positive recollections by women of an opportunistic discussion about cervical screening were correct. Until other measures have been validated, women's recall may continue to be used to measure general practitioners' behaviour, but an appreciation of likely bias is recommended.     

Cost-effectiveness of an intervention to increase cancer screening in primary care settings

BACKGROUND: The main goal was to conduct a cost-effectiveness analysis of an intervention designed to increase cancer screening rates in primary care settings serving disadvantaged populations. The Cancer Screening Office Systems intervention reminded clinicians whether screening mammography, Pap smears, and/or fecal occult blood tests were up-to-date in eligible patients and then established a division of office responsibilities to ensure that tests were ordered and completed. METHODS: The cost-effectiveness analysis was predicated on data generated from a cluster-randomized controlled trial of Cancer Screening Office Systems conducted at eight clinics participating in a county-funded health insurance plan in Florida. Cost numerators were computed from estimated time inputs of both clinical personnel and patients valued at nationally representative wages as well as expenses for Cancer Screening Office Systems-related materials and overhead. Effectiveness denominators were constructed from net changes in screening rates observed experimentally over a 12-month follow-up. Two types of incremental cost-effectiveness ratios were computed: the cost per extra screening test by type and the cost per life-year saved without and with Cancer Screening Office Systems. RESULTS: Cancer Screening Office Systems produced statistically significant increases in screening rates, and these gains more than outweighed the costs of the intervention viewed from either payer or societal perspectives. CONCLUSIONS: Cancer Screening Office Systems are a cost-effective means of addressing cancer-related health disparities.     

Testing and screening for chlamydia in general practice: a cross‐sectional analysis

Objectives: Chlamydia screening is widely advocated. General practice registrars are an important stage of clinical behaviour development. This study aimed to determine rates of, and factors associated with, registrars' chlamydia testing including asymptomatic screening. Methods: A cross‐sectional analysis of data from Registrars Clinical Encounters in Training (ReCEnT), a cohort study of registrars' consultations. Registrars record details of 60 consecutive consultations in each GP‐term of training. Outcome factors were chlamydia testing, asymptomatic screening and doctor‐initiated screening. Results: Testing occurred in 2.5% of 29,112 consultations (398 registrars) and in 5.8% of patients aged 15–25. Asymptomatic screening comprised 47.5% of chlamydia tests, and 55.6% of screening tests were doctor‐initiated. Chlamydia testing was associated with female gender of doctor and patient, younger patient age, and patients new to doctor or practice. Asymptomatic screening was associated with practices where patients incur no fees, and in patients new to doctor or practice. Screening of female patients was more often doctor‐initiated. Conclusions: GP registrars screen for chlamydia disproportionately in younger females and new patients. Implications: Our findings highlight potential opportunities to improve uptake of screening for chlamydia, including targeted education and training for registrars, campaigns targeting male patients, and addressing financial barriers to accessing screening services.     

Multicomponent Internet continuing medical education to promote chlamydia screening

BACKGROUND: Low Chlamydia trachomatis screening rates create an opportunity to test innovative continuing medical education (CME) programs. Few studies of Internet-based physician learning have been evaluated with objective data on practice patterns. DESIGN: This randomized controlled trial tested a multicomponent Internet CME (mCME) intervention for increasing chlamydia screening of at-risk women aged 16 to 26 years. SETTING: Eligible physician offices had > or =20 patients at risk for chlamydia as defined by the Health Plan Employer Data and Information Set (HEDIS), had at least one primary care physician (internal medicine, family medicine/general practice, pediatrics) with Internet access, and participated in the study managed care organization. The 191 randomized primary care offices represented 20 states. INTERVENTION: The intervention, available from February to December 2001, consisted of four case-based learning modules, was tailored in real time to each physician based on theory of behavior change, and included office-level feedback of chlamydia screening rates. MAIN OUTCOME MEASURE: HEDIS chlamydia screening rates for the pre-intervention (2000) and post-intervention (2002) periods. RESULTS: Pre-intervention screening rates for the intervention and comparison offices were 18.9% and 16.2% (p =0.135). Post-intervention screening rates for the intervention and comparison offices were 15.5% and 12.4%, respectively (p =0.044, adjusting for baseline performance). CONCLUSIONS: The substantial decline in chlamydia screening rates observed in the comparison offices was significantly attenuated for the intervention offices. The mCME favorably influenced chlamydia screening by primary care physicians.     

Promoting chlamydia screening with posters and leaflets in general practice - a qualitative study

Background  

General practice staff are reluctant to discuss sexual health opportunistically in all consultations. Health promotion materials may help alleviate this barrier. Chlamydia screening promotion posters and leaflets, produced by the English National Chlamydia Screening Programme (NCSP), have been available to general practices, through local chlamydia screening offices, since its launch. In this study we explored the attitudes of general practice staff to these screening promotional materials, how they used them, and explored other promotional strategies to encourage chlamydia screening.     

Effectiveness of an intervention to increase Pap test screening among Chinese women in Taiwan

This study assessed the effectiveness of a theory-based direct mail campaign in encouraging non-compliant women, aged 30 and older or younger if married, to obtain a Pap test. Participants were female family members of inpatients admitted to one of the major teaching hospitals in Taiwan during August–September 1999. A total of 424 women were recruited in the randomized intervention trial. Three months following implementation of the intervention, women in the intervention group reported a higher rate of Pap test screening than women in the comparison group (50% versus 32%) (p = 0.002). Women in the intervention group also showed higher perceived pros of a Pap test at follow-up (p = 0.031). Although women in both groups showed an increased knowledge and intention to obtain a Pap, only the intervention group had significantly higher follow-up scores on perceived pros and susceptibility. The results shows that the intervention was effective in increasing Pap test screening among Chinese women within three months. The results also support the use of Intervention Mapping, a systematic program development framework for planning effective interventions.     

Implementation of chlamydia screening in a general practice setting: a 6-month pilot study

OBJECTIVE: To determine whether screening for asymptomatic Chlamydia trachomatis infection could be undertaken in the context of a smear clinic or other sexual health consultation in general practice. METHODS: A prospective, opportunistic, cohort study was undertaken in a general practice setting. The participants were asymptomatic women aged 16-24 years and men aged 16-34 years who were screened for Chlamydia trachomatis by testing endocervical swabs or first-voided urine samples. The main outcome measure was the uptake of the screening offer and the presence or absence of chlamydia infection as indicated by the test result. RESULTS: A total of 115 patients (109 women and six men) were offered screening. Eighty-one (70%) patients accepted, with five positive results, giving an overall prevalence of 6.2% (5/81, 95% CI 1-11%). Of those offered screening when having a smear, 8.3% (3/36, 95% CI 0-17%) were positive. CONCLUSION: Screening for chlamydia can be undertaken in the context of existing services offered in general practice (e.g. a smear clinic or consultation) where contraception/sexual health is discussed.     

Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services

BACKGROUND: Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening. METHODS: In this intent-to-treat study, a total of 254 women, aged 52-69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness. RESULTS: Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost US dollars 167.62 (2000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was US dollars 818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between Us dollars 19 and US dollars 90 per additional woman screened. CONCLUSIONS: Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.