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Interventions to Improve Sexually Transmitted Disease Screening in Clinic-Based Settings

Taylor, Melanie M. MD, MPH*†; Frasure-Williams, Jessica MPH; Burnett, Phyllis BS; Park, Ina U. MD, MS

doi: 10.1097/OLQ.0000000000000294
Original Study

Background: The asymptomatic nature and suboptimal screening rates of sexually transmitted diseases (STD) call for implementation of successful interventions to improve screening in community-based clinic settings with attention to cost and resources.

Methods: We used MEDLINE to systematically review comparative analyses of interventions to improve STD (chlamydia, gonorrhea, or syphilis) screening or rescreening in clinic-based settings that were published between January 2000 and January 2014. Absolute differences in the percent of the target population screened between comparison groups or relative percent increase in the number of tests or patients tested were used to score the interventions as highly effective (>20% increase) or moderately effective (5%–19% increase) in improving screening. Published cost of the interventions was described where available and, when not available, was estimated.

Results: Of the 4566 citations reviewed, 38 articles describing 42 interventions met the inclusion criteria. Of the 42 interventions, 16 (38.1%) were categorized as highly effective and 14 (33.3%) as moderately effective. Effective low-cost interventions (<$1000) included the strategic placement of specimen collection materials or automatic collection of STD specimens as part of a routine visit (7 highly effective and 1 moderately effective) and the use of electronic health records (EHRs; 3 highly effective and 4 moderately effective). Patient reminders for screening or rescreening (via text, telephone, and postcards) were highly effective (3) or moderately effective (2) and low or moderate cost (<$1001–10,000). Interventions with dedicated clinic staff to improve STD screening were highly effective (2) or moderately effective in improving STD screening (1) but high-cost ($10,001–$100,000).

Conclusions: Successful interventions include changing clinic flow to routinely collect specimens for testing, using EHR screening reminders, and reminding patients to get screened or rescreened. These strategies can be tailored to different clinic settings to improve screening at a low cost.

From the *Division of STD Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA; †Arizona Department of Health Services, STD Program, Phoenix, AZ; ‡STD Control Branch, Division of Communicable Disease Control (DCDC), Center for Infectious Diseases (CID), California Department of Public Health (CDPH), Sacramento, CA; and §Baltimore Department of Public Health, Baltimore, MD

Conflict of interest: None declared.

Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent views of the Centers for Disease Control and Prevention, Arizona Department of Health Services, and California Department of Public Health.

Correspondence: Melanie Taylor, MD, MPH, CDC/NCHHSTP/DSTDP, 1645 East Roosevelt, Phoenix, AZ 85006. E-mail: MDT7@CDC.GOV.

Received for publication January 9, 2015, and accepted April 16, 2015.

Sexually transmitted diseases (STDs) are among the most commonly reported diseases in the United States and impose an estimated $15.6 billion dollars in lifetime direct medical costs per year.1 Bacterial STDs including chlamydia (CT), gonorrhea (GC), and syphilis can be asymptomatic at genital, oropharyngeal, and rectal sites in men and women.2 Screening asymptomatic individuals, promptly treating patients and partners, and rescreening-infected persons to detect repeat infection are key components of STD control and prevention.2

Screening and treatment of CT and GC prevents sequelae in women such as pelvic inflammatory disease, chronic pelvic pain, tubal factor infertility, and ectopic pregnancy.3–5 Sexually transmitted diseases facilitate HIV transmission and acquisition.6,7 Among men who have sex with men (MSM), screening for rectal CT/GC may be a cost-saving strategy to prevent HIV infection.8 Therefore, STD screening and treatment are key components of reproductive health as well as comprehensive HIV prevention.

For more than a decade, both the Centers for Disease Control and Prevention and the United States Preventive Services Task Force have recommended routine STD screening for sexually active young women.2,9 The Centers for Disease Control and Prevention also recommends repeat screening for CT and GC approximately 3 months after treatment2 to identify reinfection. Despite national recommendations, numerous studies have demonstrated suboptimal annual CT screening and rescreening rates, ranging from 22.3% to 44%, in a variety of clinical settings.10–13 Although national recommendations exist for annual STD screening among MSM, screening rates are also unacceptably low: 2% to 10% for rectal and pharyngeal GC, 14% to 29% for urethral GC, and 66% to 86% for syphilis.14,15

Clinics can implement interventions to improve screening and rescreening to reduce STD prevalence, reduce long-term sequelae, and meet federal requirements to demonstrate improvement in health outcomes.16 Opportunities to leverage expanding insurance coverage of persons for preventive services can further maximize public health resources for STD screening. Successful interventions require investing financial and staff resources and overcoming barriers at the system, provider, and patient levels.17 To guide STD programs, primary care providers, clinics, and other public health programs in prioritizing cost-effective STD screening interventions, we performed a literature review of recent interventions to increase STD screening and rescreening in community-based clinics.

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METHODS

Publication Review and Inclusion Criteria

We conducted a systematic review of published articles evaluating interventions to improve STD screening in clinic-based settings using MEDLINE for studies published between January 1, 2000, and January 31, 2014. Publications describing clinic-based interventions to increase STD screening (CT, GC, and syphilis) and rescreening were reviewed for inclusion. The MEDLINE search was performed using the following key words: STD/STI, chlamydia, gonorrhea, MSM, or syphilis. These key words were individually combined with testing or screening intervention and community clinics or primary care. Chlamydia and GC retesting was entered as a separate search term (Fig. 1). Publications with abstracts not containing descriptions of interventions to improve STD/sexually transmitted infection (STI) screening were not reviewed. Citation lists of published studies were reviewed for additional relevant publications. Review articles summarizing interventions to improve STD screening were used to obtain additional studies for inclusion.18–21 Additional inclusion criteria were publication in the English language and analysis using a control group or a before-and-after comparison. Analyses published as meeting proceedings or in conference abstracts were excluded. We also excluded studies that reported on patient or provider intent to screen but not actual screening performance, and interventions conducted outside community clinic settings (i.e., home-based testing, online testing services, outreach settings, and case investigation situations).

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Assessing Quality of Randomized Controlled Trials

A modified Jadad score (total possible 7 points) was used to assess the quality of the randomized controlled trials (RCTs) included in our analysis (n = 11).22 Two reviewers (J.F.W. and I.U.P.) independently reviewed and scored each trial. Trials scoring 5.5–7/7 were considered high quality studies, those scoring 4 or 5/7 were of moderate quality, and those scoring 3/7 or worse were considered of poor quality.

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Elements of Data Collection

Following MEDLINE review, selected studies were organized into 4 intervention types based on target population and intervention methods: (1) structural interventions and clinic incentives, (2) screening/testing reminders incorporated into electronic health records (EHR), (3) provider education, and (4) patient education and reminders. Intervention types 1 to 3 aimed to increase STD screening among patients seen in clinic for routine care. Intervention type 4 sought to bring patients into a clinic specifically to undergo STD screening or rescreening. Proportions of persons screened and rescreened in intervention and control groups or preintervention and postintervention periods were summarized. Studies that evaluated multiple interventions were listed more than once in the tables. The primary outcome of interest was the absolute percent increase in the number of tests performed or patients screened. Where absolute percent increase was not available or calculable, relative percent increase was used.

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Evaluation of Effectiveness

The absolute difference in the percent of the target population screened (percent screened in intervention group minus percent screened in comparison group) was used to score effectiveness of the interventions. Where absolute difference was not calculable, relative percent increase in the number of tests performed or patients tested preintervention and postintervention was used ([(number of tests or patients tested in intervention group minus tests or patients tested in comparison group)/number of tests or patients tested in the comparison group] × 100). Categories used to rank intervention effectiveness were as follows: highly effective was a ≥20% absolute increase in percent screened or at least 100% relative increase in number of tests or patients tested; moderately effective was a 5% to 19% absolute increase in percent screened or 10% to 99% relative increase in number of tests or patients tested, regardless of reported statistical significance; and not effective was a <5% absolute increase in percent screened or <10% relative increase in number of tests or patients tested, regardless of reported statistical significance.

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Cost Analysis

Overall cost estimates for each intervention were assigned to each study by the authors based on reported costs, or estimated based on the type of intervention that was used. Where reported, actual costs were included in Tables 1–4. Categories used to rank intervention cost were as follows: (1) less than $1000, included electronic health reminders and text messaging reminders, environmental practice changes (placing test kits on examination table or universal urine collection), clinical in-service lectures, or total cost reported in publication as less than $1000; (2) $1000 to $10,000, included quality improvement projects with structured education and feedback for patients or providers inclusive of continuing medical education or Web-based education, or total cost reported in publication as ranging from $1000 to $10,000; (3) $10,001 to $100,000, included incentives for patients or providers or total cost reported in the publication as $10,001 to $100,000; and (4) more than $100,000, included quality improvement projects that hired staff or assigned focused staff, or total cost reported in the publication as more than $100,000.

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RESULTS

Search and Review Outcomes

We reviewed 4566 citations and identified 128 abstracts or articles for further review. Of those, 69 had been identified using previous search terms, 23 were rejected, and 38 met the inclusion criteria (Fig. 1). One study evaluated 2 interventions and another evaluated 4 total interventions. Thus, 42 interventions were summarized alphabetically by author and target population category in Tables 1–4.

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Sites of Interventions

Interventions were conducted in the United States (n = 17), Australia (n = 13), United Kingdom (n = 6), New Zealand (n = 2), Scotland (n = 1), Denmark (n = 1), Belgium (n = 1), and Canada (n = 1).

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Design of Studies

All of the 42 interventions included in this review compared STD screening or rescreening rates as the main outcome of a RCT (n = 14), a nonrandomized controlled trial (n = 9), an evaluation of a preintervention and postintervention period comparison (n = 18), or a controlled observational study (n = 1).

Of the 42 interventions evaluated, 16 described structural interventions (including staff positions dedicated to STD screening activities) or clinic incentives for screening (Table 1)23–38; 9 evaluated electronic and medical chart reminders (Table 2)30,39–46; 6 evaluated provider-level interventions focusing on education (Table 3)47–52; and 11 evaluated patient-level interventions, one of which described multiple interventions (Table 4).53–60 One article described both a quality improvement program and a chart prompt and is thus listed in Tables 1 and 2.39 One article described 4 patient-level interventions, each of which is listed separately in Table 4.55

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Quality of the Studies

Of the 11 randomized controlled studies, 4 studies were rated as high quality,31,32,39,48,54 6 studies were rated as moderate quality25,30,42,47 (multiple),55 and 1 study was of poor quality.52

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Target Populations and Outcomes

Of the 42 interventions evaluated, 15 (35.7%) evaluated screening of young women for CT and other STDs 24,25,27,28,30,31,41,42,47–49,51,52,54 and 2 studied screening of pregnant women.26,40 Two (4.5%) interventions targeted young men for STD screening,23,32 and 6 interventions were for both young men and women.29,39,50,53,56,58 A total of 11 interventions targeted MSM (n = 7)36,37,43,45,46,59,60 or HIV-infected MSM (n = 4) 33–35,44 for STD screening. One study targeted both and male and female HIV-infected patients for STD screening.38 There were 5 interventions that targeted CT or GC rescreening among male and female patients after initial diagnosis55,57 and one intervention that targeted repeat syphilis screening among MSM treated for syphilis.45

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Outcomes by Intervention Strategy

Of the 42 individual interventions, 16 (38.1%) were rated as highly effective in increasing STD screening and 14 (33.3%) were moderately effective in increasing screening. The remaining 12 (28.6%) interventions did not demonstrate notable or sustainable increases in STD screening as a result of the intervention.

Among 8 structural interventions that included strategic placement of specimen collection materials or automatic collection of urine or blood as part of a routine visit,23,26,28,31–35 7 were highly effective and 1 was moderately effective (Table 1). Among 8 studies that modified EHRs to remind providers to screen, 3 were highly effective and 4 were moderately effective in improving STD screening (Table 2).

Patient-level interventions such as incentives and testing reminders increased screening (Table 4). Of 5 patient-level interventions (including text, telephone, or postcard reminders), 3 were highly effective and 2 were moderately effective in improving STD screening or rescreening.55,57,59,60 Offering free STD testing services in a setting where STD services had previously required payment was moderately effective in improving STD screening.56

Three studies described interventions that included dedicated staff devoted to increasing STD screening24,27,37; all 3 demonstrated improvements in screening, 2 were highly effective, and 1 was moderately effective (Table 2). Both of the studies that described financial incentives for clinics per CT test performed reported an increase in screening25,27 (Table 1). In 1 of these 2 studies, dedicated staff devoted to STD screening was combined with financial incentives to clinics for screening.27

Provider-level interventions had limited success in sustainably increasing STD screening. In this group (n = 6), only 2 of the interventions were categorized as moderately effective.50,52 All 6 provider-level interventions described continuing medical education modules, meetings, simulation videos, workshops, resource packages, or guideline updates (Table 3).

Additional interventions that did not improve STD screening included monetary55 and nonmonetary58 incentives to patients and clinics,25 motivational counseling to patients,54 paper chart reminders,30 and referring patients to an educational Web site.53

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Cost Estimates

Costs for each intervention were estimated or reported as less than $1000 for 28 (66.7%) of the interventions, $1001 to $10,000 for 7 (16.7%), $10,001 to $100,000 for 4 (9.5%), and more than $100,000 for 3 (7.1%) (Tables 1–4). Actual costs associated with intervention implementation were reported for only 5 interventions (12%; Tables 1 and 4).25,27,55,58,59 Each of these 5 interventions included incentives for clinics, providers, or patients.

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Combining Effect and Cost

Interventions that included the automatic collection of specimens as part of a routine or follow-up visit (Table 1),23,26,28,31–35 use of EHR reminders (Table 2),39–46 or the use of patient reminders (Table 4)55,57,59,60 had the greatest improvements in STD screening at the lowest cost (Fig. 2). Dedicating staff to improve STD screening was associated with the largest improvement in screening at the highest estimated cost (Table 1).24,27,37

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Case Finding and Positivity

Of the 42 interventions in this review, 18 (43%) included before-and-after data on case finding, 9 (21.4%) or the percent of attendees that were positive, 9 (21.4%). Of the 9 interventions that reported on percent of tests that were positive, 3 reported no change,42,46,58 4 reported an increase in percent positive,41,43,56,60 and 2 reported a decrease50,57 after the intervention. Of the 9 interventions that included case identification, 8 reported an absolute increase in STD cases identified,23,26,28,31,33–35,39 and 1 reported an absolute decrease in cases identified29 after the intervention (Tables 1–4).

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DISCUSSION

We systematically reviewed clinic-based interventions developed to improve CT, GC, and syphilis screening. Interventions evaluated in this review incorporated systems-level programs, EHR reminders, and patient- and provider-level activities to improve STD screening. Effects varied by type of intervention, but improvements in screening were consistent for interventions that incorporated the automatic collection of STD specimens in association with a routine or follow-up visit. The EHR reminders also led to notable improvements in STD screening. Patient reminders for testing or retesting were effective in improving screening, whereas motivational counseling and interviewing showed minimal improvement. Overall, patient and provider education was of limited benefit in improving STD screening. Cost estimates varied depending on the intervention but were lower for interventions that included the universal collection of STD testing specimens or the use of EHR reminders and were greater for those where dedicated staff was assigned to improve STD screening or incentives were provided for screening.

Increasing screening through program and protocol development (with or without assignment of a dedicated staff) was often done using the automatic collection of specimens in association with a patient visit, usually before the patient saw the provider.23,26,28,31–35 Others strategically placed specimen collection kits such that providers would remember to perform the test along with other tests due at that appointment. Routinizing collection of specimens at a variety of visit types (even visits for unrelated issues) for patient in target age group/demographic reduces missed opportunities and standardizes an effective approach to STD screening at a lower cost. Quality improvement efforts that placed dedicated staff members to facilitate STD screening also demonstrated increases in STD screening,24,27,37 albeit at a much higher cost.

Reminders in EHRs were effective at increasing STD screening39–46 and have been used to improve performance of other routine screening measures in different clinical settings.61,62 With the increase in use of EHR in community clinics and primary care settings, this may be an opportune time for clinical and public health programs to focus on EHR reminders especially for screening that has been recommended by the US Preventive Services Task Force9 such as CT screening among adolescent girls and young women. Many EHR platforms have programmable provider reminders that can be tailored to correspond to health screening recommendations.39–46,61,62

Direct provider education related to appropriate management of health conditions remains a mainstay of efforts to advance medical knowledge and clinical practice. These efforts are often the easiest to put in place, are an accepted method of acquiring information about a medical topic, and can be done quickly at a reasonable cost. However, studies we reviewed found education led to limited improvements in STD screening.53–60 These findings suggest that provider education should be considered only in combination with other highly successful methods such as EHR reminders or clinic-based protocol development.

Patient-level interventions that used incentives and motivational interviewing had little success at increasing STD screening or rescreening. Patient reminders via telephone call, text messaging, or letter increased STD screening and rescreening at a relatively low cost.55,57,59,60 The use of texting to communicate health reminders with youth has been evaluated in other clinical settings63,64 but would require knowing the patient's cell phone number and may be most appropriate for rescreening or for frequent screening of high-risk persons.

Costs are often a major component of choosing and implementing an intervention. However, few of these publications reported costs associated with implementation. Many of the multilevel interventions involved the systematic collection of STD testing specimens from eligible clients before, or as a part of, a clinician encounter. Those interventions could be done at minimal cost by changing clinic policy. Similarly, programming clinical reminders into EHRs may be done with limited additional cost and those reminders may be adapted or expanded to address local STD epidemiology. Patient reminders, some of which used cellular messaging technologies or other accessible reminder systems, were low-cost strategies that could be adapted in community clinic settings. Clinic-level advocacy for opportunistic STD screening as a standard of care for eligible patients according to national guidelines2,9 may be needed in some clinical settings to improve screening performance even in the absence of concern for cost.

There are several limitations related to the interpretation of these data. Our search did not include abstracts, meeting proceedings, or other “gray” literature; thus, unpublished studies that reported negative results are likely underrepresented. Effectiveness categories were chosen to identify high- and low-performing interventions. Programs should carefully consider moderately effective interventions in relation to their clinical care setting and patient population. The effects of the interventions we studied may be different in other clinical settings. Some multilevel interventions demonstrated significant improvements in STD screening; however, it was not possible to discern which element of the intervention was responsible in part or in full for the improvement. Cutoff values for categories of effectiveness were determined by the authors and may not reflect patient or population-level impact. For example, we did not fully account for baseline screening performance when calculating changes, so sites with low baseline screening had a greater opportunity to increase screening compared with clinics where baseline screening was already high. Interventions were not weighted or stratified based on rigor of the study methods. Our cost estimates may underestimate or overestimate the true costs of the interventions; only 5 studies reported actual costs. We did not include ancillary costs of screening such as staff time associated with collection of STD specimens in our estimates. Also, we did not include estimates of insurance reimbursement to the clinics. Thus, cost categories used in this review should be viewed as general estimates and not specific values. There were only 4 high-quality RCTs in our systematic review; therefore, our conclusions about effectiveness are largely based on observational data. Finally, although case identification is the ultimate goal of screening, we assessed the number of tests done; STD case identification, or positivity, was reported for less than half of the interventions in this review.

Screening in clinics improved the most when interventions used protocols for the universal collection of specimens or strategic placement of collection kits, electronic health reminders for providers, or reminders for patients to improve STD screening and rescreening. These interventions might be implemented in clinical settings at a minimal cost, but often require clinic- and provider-level advocacy, protocol development, and feedback on performance. Only research studies were included in our review, so it will be important for programs that implement these interventions in real-world settings evaluate and share their experience. The ability of STD programs to influence clinics to implement successful interventions depends on collaborative partnerships. Establishing those partnerships is a new task for many STD programs, one that also requires study.

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