MINNEAPOLIS – A few simple administrative changes made some big differences at clinics that screen for chlamydia, increasing the number of screenings and saving more than $40,000 in just 1 year.
Chlamydia is the most common nationally reportable infectious disease, with 1.4 million cases diagnosed in the U.S. in 2011. Yet it’s also one of the most underdiagnosed, Elizabeth Torrone, Ph.D. said at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.
Despite its ability to hide in plain sight, chlamydia can have serious health consequences for young women, said Dr. Torrone, an epidemiologist at the CDC.
"It’s most common in young women and it’s usually asymptomatic, but 1 in 10 infections results in pelvic inflammatory disease, which can have adverse effects on reproduction. CDC recommends annual screening for all sexually active women aged 25 or younger, and for older women who are at high risk for infection," such as those with new or multiple sexual partners.
Chlamydia rates seem to have increased significantly in the past decade, but that’s most likely the result of increased screening. "The more we look for it, the more we find." But screening still doesn’t match up to the CDC guidelines, she said. "Since 2001, screening among females aged 16-24 years has increased to 60% of those targeted compared to 30% before 2001. But older women still have higher screening rates than necessary, because only about 1% of the positives occur in women aged 25-39 years."
She described how three health departments have tackled the problem, and the benefits they reaped from a few low-cost changes in their screening routine.
San Francisco Enforces the Guidelines
In San Francisco, health department family planning clinics were charged with screening any woman younger than 25 years, and all women who were pregnant or getting an intrauterine birth control device inserted. But clinicians still could screen other groups: The lab requisition slip had an "other" indication, where clinicians could write in any other reason they thought a screen was necessary.
In 2008, Dr. Torrone said, 64% of the chlamydia screening in these clinics was done on women older than 26 years. "This led us to conclude they were over-screening the older population," she said.
To address the problem, the health department simply removed the "other" box on the lab slip, leaving only three choices: younger than 26 years, pregnant, or IUD insertion. The labs rejected any specimen without one of these valid reasons for testing marked.
"The only way you could screen a woman older than 26 was if she was pregnant or having an IUD inserted. So this really forced our clinicians to adhere to the screening guidelines," she said.
When they compared screening in 2008 with 2009 – after the new slips came out – there was a 25% decrease in the number of tests on women 26 and older, and a 4% increase in positive tests – indicating that more young women were being screened.
The change also dramatically decreased costs, Dr. Torrone said. "For every screen, the cost decreased by 3.5%, resulting in a savings of almost $40,000."
Kentucky’s Experience
In 2009, to assure that clinics were screening appropriately and to make screening financially feasible, CDC implemented a program designed to produce at least a 3% positivity rate at any clinic that screened for chlamydia.
"In Kentucky, 75 sites participating in [the program] had a positivity rate of less than 3% in women younger than 26, so CDC offered some assistance in getting that increased," she said.
The plan included site-specific feedback to those clinics not meeting the 3% rule. Feedback included the clinic’s positivity rate, implementing risk-based screening criteria, and individual technical assistance to help out in some sites.
By 2010, 54 sites were reporting positivity rates of less than 3%. * "Obviously Kentucky still has some work to do, but they plan to target high-volume sites and intensify communication and teamwork with providers."
Specimen Pooling in Idaho
Specimen pooling proved effective in Idaho, a state with a relatively low number of positive chlamydia tests. Specimen pooling is a two-step lab procedure that batches samples. Each batch has a single test. If the result is negative then every sample in that batch is negative, eliminating individual sample testing. If the batch tests positive, then every sample in that group must be tested.
The technique saves money on every specimen that goes into a negative batch, Dr. Torrone said.
It’s most cost-effective in areas with low chlamydia prevalence.
In 2009, the Idaho Bureau of Laboratories instituted the pooling technique. In July of that year, 1,300 samples were submitted. Using the pooling technique, the lab ran 727 tests to identify all the positive samples.