With 1.75 million cases reported to the Centers for Disease Control and Prevention (CDC) in 2018, chlamydia is the most commonly reported notifiable condition in the United States.1 2 3 4 5 6 7
If identified, chlamydia is easily treated with antibiotics. However, most chlamydia infections are asymptomatic, especially in women.8 9 10
The CDC,11 12 13 14 15 16
Although chlamydia screening rates increased approximately 20 percentage points from 2001 to 2009, they have since plateaued. Between 2009 and 2015, screening rates have been steady at around 58% among Medicaid-insured clients and 49% among commercially insured clients.17 18
The Institute for Healthcare Improvement (IHI) has demonstrated that learning collaboratives can effectively close the gap between what is known and what is practiced. The IHI Breakthrough Series model facilitates improvement by bringing together teams from various organizations to increase the same measure. Teams participate in an iterative improvement process at their own organizations and also have the opportunity to discuss implementation barriers with other organizational teams as they progress toward a common goal.19
Providers of family planning services—clinical services that help clients prevent or achieve pregnancy—are well positioned to increase screening. Family planning providers consistently provide sexually transmitted disease (STD) services, which are considered to be within the scope of family planning care, and the clients served in family planning settings are disproportionately young and female.20
Given the rising rates of the chlamydia and the need for effective strategies to increase chlamydia screening, we sought to explore whether and how learning collaboratives could be used to facilitate increased screening in family planning settings. Through this experience, we also hoped to add to the literature about what strategies are feasible and impactful, as well as barriers and facilitators to increased screening rates.
MATERIALS AND METHODS
Between 2016 and 2019, we facilitated 3 separate chlamydia screening learning collaboratives with a total of 37 clinics that provide family planning services funded by the Planned Parenthood Federation of America (PPFA), the US Department of Health and Human Services, Office of Population Affairs (OPA), and the New York State Department of Health (NYSDOH; Table 1 ). The PPFA's network of affiliate clinics represent private, standalone family planning providers, whereas OPA- and NYSDOH-funded clinics include health departments, hospital-based clinics, federally qualified health centers, and private, standalone family planning organizations.
TABLE 1 -
Descriptive Characteristics of Clinics That Participated in 3 Cohorts of Chlamydia Screening Learning Collaboratives
Cohort
Funder
Dates
Description of Participating Clinics
No. Participating Clinics
1
Planned Parenthood Federation of America
September 2016–May 2017*
Planned Parenthood Affiliates (i.e., standalone family planning organizations)
19
2
Office of Population Affairs
June 2017–November 2017
Title X Family Planning Grantees and Subrecipients (i.e., health departments, federally qualified health centers, standalone family planning organizations)
8†
3
New York State Department of Health
September 2018–March 2019
NYS Family Planning Program Providers (i.e., health departments, hospital-based clinics, federally qualified health centers, standalone family planning organizations)
10
*The PPFA collaborative was longer because the collaborative covered 2 topics: chlamydia screening and access to contraception. Sessions alternated between the 2 topics.
†The collaborative began with 9 clinics, but one clinic dropped out 1 month after the collaborative started because of shifts in funding.
We applied a consistent learning collaborative approach adapted from the IHI Breakthrough Series model for each of the 3 cohorts, which we detail in this section. In brief: participating clinics worked to improve the proportion of clients screened for chlamydia each month, implemented a standard set of recommended practices, attended virtual learning sessions, reported updates on quality improvement efforts and chlamydia screening data monthly, and provided qualitative feedback in an online final assessment.
Participating Clinics
To recruit learning collaborative participants, we sent a call for registrations to all organizations within each funders' network. Organizations (which, in many cases, oversaw multiple clinic locations) volunteered to participate and selected a single clinic to participate as the pilot implementation clinic.
Participating clinics were representative of their networks in the diversity of organizational type, including health departments, hospital-based clinics, federally qualified health centers, and standalone family planning organizations. Four (40%) in 10 of NYSDOH clinics were located in the urban center of New York City, whereas the other 6 were geographically spread across the suburban and rural parts of the state. The national PPFA and OPA learning collaboratives included clinics from across the country. In all 3 collaboratives, there was a broad range in the sizes of clinics in terms of number of staff and clients seen.
As part of registration, we encouraged clinics to identify administrative, clinical, and frontline staff to be part of their improvement efforts. Some clinics opted to define larger improvement teams with consistent involvement of a broad range of staff in learning collaborative activities, whereas other clinics opted to have one point person who coordinated the improvement efforts and brought in individuals from other departments as needed. On average, 4 people from each clinic were involved in learning collaborative activities (range, 1–9).
We encouraged organizations with multiple clinic locations to replicate improvements from the pilot implementation clinic to other clinics after the collaborative. Clinics did not pay to participate, nor did they receive any compensation beyond covered travel expenses for a kickoff meeting.
Chlamydia Screening Change Package
The foundation of the learning collaborative was the Chlamydia Screening Change Package , a document that summarizes evidence-based recommended practices for increasing chlamydia screening.21 Chlamydia Screening Change Package , the authors conducted a MEDLINE search of United States–based articles published between January 2010 and June 2015 with the search terms: chlamydia, screening, rate, recommendation, strategy, and best practice. The search yielded 113 abstracts. Two authors reviewed the articles and found 31 to be relevant. The authors then conducted a search of published work in gray literature and guidelines, and reviewed the references of those publications, to complement the literature search. The authors identified 4 major themes that captured relevant findings from the literature review and categorized findings accordingly: (1) missed opportunities for screening, (2) effective counseling, (3) specimen collection, and (4) cost. From this, the authors devised 4 recommended practices to inform the quality improvement initiative. Staff at the CDC's Division of STD Prevention reviewed and provided input on the findings and recommended practices at multiple points.
The 4 recommended practices in the Chlamydia Screening Change Package are the following: (1) reduce missed opportunities for screening by making screening part of routine clinical preventive care; (2) use normalizing and opt-out language to explain screening; (3) use the least invasive, high-quality, recommended laboratory technologies for screening; and (4) use diverse payment options to reduce cost as a barrier for the client and the facility (Fig. 1 ). For each recommended practice, the Chlamydia Screening Change Package identified promising strategies from the literature as possible change ideas for clinics to test for improvement.
Figure 1: Recommended practices and promising strategies for increasing chlamydia screening (originally printed in the Chlamydia Screening Change Package ).
Learning Sessions and Action Periods
Learning collaboratives began with an in-person kickoff meeting to describe the recommendations in the Chlamydia Screening Change Package , introduce the Model for Improvement and Plan-Do-Study-Act approach to quality improvement, and support clinics to develop an initial clinic-level improvement plan.22
The Plan-Do-Study-Act cycle is a scientific method for rapidly testing a change. It involves planning the change, implementing it, observing the results, and then acting accordingly—adapting, adopting, or abandoning the change.
Clinics then participated in 5 monthly virtual learning sessions to discuss recommended practices, ongoing challenges, lessons learned, and successes with peers. The PPFA learning collaborative differed slightly from the other 2 in that the collaborative also covered the topic of contraceptive access; the collaborative was twice as long and the session topics alternated between chlamydia screening and access to contraception.
Between virtual sessions, clinics implemented change ideas, documented the results of those activities in their improvement plan, and then submitted the updated improvement plan to the learning collaborative facilitators for feedback. During the collaboratives, clinics participated in at least one phone call with the learning collaborative facilitators to discuss the implementation of the improvement plan (some clinics asked for subsequent meetings). In the final session, clinics delivered 10-minute presentations of their overall successes and next steps for replication after the collaborative.
Data Reporting
Clinics submitted monthly chlamydia screening data to the learning collaborative facilitators. For the purpose of quality improvement, we defined a monthly screening measure: the number of clients screened in the reporting month divided by the total number of female clients seen for family planning services between ages 15 and 24 years seen at the clinic in the reporting month. The lower limit of 15 was used to be consistent with how clinics already captured chlamydia test data. For ease of calculation, clinics were not required to remove clients who were not sexually active from the denominator. Clinics were required to exclude nonfamily planning clients (i.e., clients obtaining services other than those related to preventing or achieving pregnancy) from the denominator because of the focus of funding agencies on these clients. Limitations of this measure are discussed later.
We collected 3 months of baseline data (defined as the 3 months before the learning collaborative kickoff) and 3 months of end point data (defined as the final 3 months of the learning collaborative) in all 3 collaboratives. We collected 3 months of postcollaborative data (defined as the 3 months after the final learning collaborative session) for the NYSDOH and OPA learning collaboratives.
We calculated baseline, end point, and postcollaborative screening rates for each clinic by averaging baseline, end point, and post data, respectively. We averaged the data for 3 months to normalize the rates at each time point.
We report median screening rates at baseline, end point, and postcollaborative because the median is less sensitive to influence from outlier data points than the average. We assessed statistical significance by calculating paired t tests comparing baseline to end point and baseline to postcollaborative screening rates.
Final Assessment
After each collaborative ended, we collected a brief online assessment about barriers and facilitators to screening. The assessment also included quantitative measures that looked at the frequency with which the 4 recommended practices were implemented. Although the assessments were largely consistent, we altered the wording of some questions after PPFA affiliate clinics expressed confusion about how to respond. Clinics completed one assessment jointly. The authors then reviewed and coded the qualitative comments according to common themes related to barriers and facilitators.
RESULTS
Learning Collaborative Participation and Data Submission
Clinic participation in the collaboratives—including session attendance and submission of progress reports, screening data, and final assessments—is reported in Table 2 .
TABLE 2 -
Level of Participation and Data Reporting Among Participating Clinics
Average No. (%) Clinics Represented Per Session
Percent of Monthly Progress Reports Submitted
No. (%) Clinics With Complete Screening Data at:
No. (%) Final Assessments Completed
Baseline
End Point
Post
PPFA (n = 19)
15 (78)
52
19 (100)
17 (89)
Not collected
16 (84)
OPA (n = 8)
8 (100)
93
8 (100)
8 (100)
6 (75)
8 (100)
NYSDOH (n = 10)
9 (90)
81
10 (100)
10 (100)
10 (100)
9 (90)
NYSDOH indicates New York State Department of Health; OPA, Office of Population Affairs; PPFA, Planned Parenthood Federation of America.
Screening Rates
Median screening rates increased by 11%, 22%, and 24% in the 3 collaboratives (P values of <0.01, 0.05, and 0.02, respectively; Table 3 ). Increases were sustained after the collaboratives ended, although the changes did not reach statistical significance. At least 75% of clinics increased screening rates in each collaborative.
TABLE 3 -
Changes in Chlamydia Screening at Participating Clinics
Median Screening at Baseline
Median Screening at End point
Median Screening at Post
Percent Change Baseline to End pointP Value)
Percent Change Baseline to PostP Value)
No. (%) of Clinics That Increased Screening
PPFA (n = 19)
62 (28–87)
69* (44–86)
Not collected
11 (P < 0.01)
NA
15 (79)
OPA (n = 8)
50 (20–80)
62 (39–88)
78 (41–90)
22 (P = 0.05)
54 (P = 0.10)
6 (75)
NYSDOH (n = 10)
41 (20–55)
51 (23–78)
50 (19–67)
24 (P = 0.02)
21 (P = 0.08)
8 (80)
*Two clinics did not provide complete end point data (i.e., they did not submit data during the last 3 months of the collaborative). We calculated an end point average using the last 3 months of data they submitted.
NYSDOH indicates New York State Department of Health; OPA, Office of Population Affairs; PPFA, Planned Parenthood Federation of America.
Final Assessment
Of the 37 clinics that participated, we obtained final assessments from 33 (89%). In all 3 collaboratives, the most commonly implemented recommended practice among clinics (100% OPA, 100% NYSDOH, 88% PPFA) was to use normalizing and opt-out language to introduce screening to clients. One clinic that increased its chlamydia screening rate from 20% at baseline to 75% at 3-month follow-up attributed its success to training staff to consistently use opt-out and normalizing language.
The second most implemented recommended practice (92% PPFA, 88% OPA, 88% NYSDOH) was to reduce missed opportunities for screening by including chlamydia screening as a part of routine clinical preventive care at all visit. Before the collaborative, some staff mistakenly thought that clients seen for a specific service (such as insertion of an intrauterine device) and walk-in clients were excluded from the denominator of the chlamydia screening measure. Once we clarified that these clients are considered to be in the target screening population, making changes to identify and screen these clients yielded substantial improvements.
Although all clinics screened for chlamydia using urine and provider-collected swabs, the recommendation to make self-collected vaginal swabs available was implemented less consistently (78% NYSDOH, 71% OPA, 64% PPFA).
Of the 4 recommendations, reducing cost as a barrier was the practice with the least amount of observed changes because the clinics did not identify cost as a barrier to screening at baseline (100% OPA, 100% NYSDOH, 87% PPFA).
Facilitators of Increased Screening
In their final assessments, nearly half (47%) of clinics reported that there was value in being able to share experiences including challenges and lessons learned with other clinics, making it the most commonly reported facilitator of increased screening.
“The most valuable part was participating in learning collaborative webinars and being able to process feedback from affiliates in real time. Good to hear about others’ struggles in implementation/improvement.” PPFA learning collaborative participant
“It was an excellent experience to collaborate with sites from different parts of the country. It was very helpful to learn and share the different ideas about CT testing and client education.” OPA learning collaborative participant
In addition to learning from others, 30% of clinics reported that the dedicated space to focus on internal growth and capacity development was a facilitator of increased screening.
“We liked the fact that we could work together as a team to reach a common goal. This team exceeded goals in more than one month and really took the time to look at the stats when they did not.” OPA learning collaborative participant
“Helped us to put into action changes that we had been talking about for a while.” PPFA learning collaborative participant
Another common facilitator was increased focus on and capacity to analyze data. Thirty percent (30%) of clinics reported that there was value in monitoring monthly data because they gained data-related skills. Some clinics found that they had been underreporting screening and that rates improved as a result of more accurate data.
“Participating in the chlamydia collaborative helped to identify barriers in capturing accurate screening rates.” NYSDOH learning collaborative participant
“Participating in the collaborative helped us define our chlamydia/gonorrhea data queries more accurately. It also took us a few tries to get our data query correct.” OPA learning collaborative participant
“The most valuable part was being able to show the team the impact (data) from the intention (learning/change of practice).” PPFA learning collaborative participant
Barriers to Increased Screening
Participating clinics encountered several barriers to increasing screening. Although increased data capacity and data quality was cited as a facilitator, data were also mentioned as a barrier by 17% of clinics, making it the most common barrier reported by clinics. Although some clinics were able streamline data collection, others ran into challenges with obtaining timely, accurate data.
“One [thing] that would have made it better would have been to find a way to link completed screening orders/results directly to the client visit record.” NYSDOH learning collaborative participant
Cited by 13% of clinics, buy-in was the second most common barrier. This included leadership buy-in and buy-in of clinical providers. Because some improvements required policy and environmental changes, clinics reported that leadership support for the initiative was key.
“On a site level we were able to make changes and can see results from these changes but bigger decisions needed to be made at an affiliate level and there were challenges with upper management not 100% understanding the expectation of the program.” PPFA learning collaborative participant
The third and fourth most commonly reported barriers related to internal capacity for implementation of improvements including the time needed to conduct quality improvement activities (10%) and staff turnover (7%).
“We did a lot of shifting in roles during this project… I noticed that when we [had] a high turnover in staff, our numbers would drop. This is something to really focus on when we hire new staff.” PPFA learning collaborative participant
“We need more staff to work on such collaboratives and be able to put forward the time and effort to make it successful.”PPFA learning collaborative participant
DISCUSSION
We observed similar patterns of results in each of the learning collaboratives. Median screening rates increased by at least 11%, and those improvements were sustained through 3 months of postcollaborative data. Changes were statistically significant when comparing baseline and end point data. Although statistical significance was not sustained when comparing baseline and postcollaborative data, the initiative produced clinically relevant results when considering the amount of resources dedicated by participating clinics (on average, between 10 and 20 hours of staff time per month, depending on the number of clinic staff involved on a routine basis).
Overall, 29 (78%) of the 37 clinics increased their screening rates; this was consistently at least 75% of clinics in each collaborative. The few clinics that saw a decrease in screening rates experienced significant staff turnover or served small-enough client numbers that screening rates were highly sensitive to fluctuations in screening.
Participating clinics were most successful in implementing normalizing and opt-out language to explain chlamydia screening and in reducing missed opportunities for screening by incorporating screening into all visit types and otherwise routinizing screening as part of clinical care. Although all clinics offered urine and provider-collected specimen collection, self-collected vaginal swabs were more difficult to implement. This was sometimes due to an established workflow that reduced pressure to change (e.g., a urine sample is collected for all clients at the beginning of the visit) and, in some cases, due to perceived lack of willingness of patients to self-collect. Cost was not identified as a barrier by the participating clinics, so it was not a focus for improvement.
Sharing challenges and strategies with peer organizations, developing internal capacity for improvement, and focusing on data were identified as facilitating factors. Clinics encountered challenges related to obtaining data, buy-in, and staff capacity and staff turnover.
Limitations
The generalizability of our findings is limited in a few ways. First, the clinics that volunteered to participate in the collaboratives self-selected and were therefore highly motivated and committed to improvement and not representative of all settings.
Second, there are several limitations of the monthly chlamydia screening measure we collected from clinics. We expect that the screening data reported to us were lower than actual screening rates for a few reasons. Clients who received screening elsewhere would be documented as not screened in our measure, even though the client was up-to-date on screening. Similarly, clients who were screened by the clinic in a prior month within the past year would also be documented as not screened during the month of their second visit, even though they were not yet due for screening (with the exception of the NYSDOH learning collaborative clinics who were able to deduplicate clients to address for this limitation). The delay between submission and confirmation of laboratory results meant that some clients were documented as not screened even when they had in fact received a test. Also, our measure did not exclude clients who are not sexually active from the denominator. However, we determined that these limitations were acceptable to obtain an easy-to-produce measure for monitoring quality improvement efforts.
Third, although we used largely similar approaches across the 3 collaboratives, they also varied slightly based on lessons learned and characteristics of the cohorts. For instance, we only began collecting postcollaborative data after the PPFA learning collaborative ended and also amended the final assessment to clarify some questions. We described variations to our approach throughout this article.
Finally, a majority of the participating agencies received state or federal funding that covered the cost of chlamydia tests when not covered by insurance. Replication in settings without public funding might be more challenging because cost will be a barrier.
Public Health Implications
Drawing on our results, we encourage others to bring providers together in a collaborative learning environment to work on increasing chlamydia screening. Practitioners can draw on the lessons learned about key facilitators and barriers and promote improvement strategies that clinics identified as most successful: adopting normalizing and opt-out language and reducing missed opportunities for screening. Practitioners can adapt the structured learning collaborative materials produced with OPA funding, which are in the public domain (available on fpntc.org).
There is still much more to be learned about successful strategies for increasing chlamydia screening. Future research should explore the impact of strategies such as incentives for health plans to focus on the chlamydia screening Healthcare Effectiveness Data and Information Set measure as well as reimbursement for alternative ways to engage clients into care such as telemedicine, express-clinics, and mail-in test kits.
Increasing chlamydia screening among young, sexually active women is an essential step to manage the STD epidemic currently facing the United States. Screening is an effective strategy for identifying asymptomatic disease, thereby reducing the spread of disease, preventing devastating sequelae, and reducing health disparities. Our results demonstrate that a learning collaborative can be a successful strategy for increasing screening.
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