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

Preventive Medicine 43 (2006) 343 – 350 www.elsevier.com/locate/ypmed

A randomized trial of strategies to increase chlamydia screening in young women Delia Scholes a,⁎, Louis Grothaus a , Jennifer McClure a , Robert Reid a,b,c , Paul Fishman a , Cynthia Sisk a , Jeff E. Lindenbaum c , Beverly Green b,c , Jane Grafton a , Robert S. Thompson a,b,c a

Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA b Department of Preventive Care, Group Health Cooperative, Seattle, WA 98101, USA c Group Health Permanente Medical Group, Group Health Cooperative, Seattle, WA 98101, USA Available online 19 June 2006

Abstract 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. © 2006 Elsevier Inc. All rights reserved. Keywords: Randomized controlled trial; Preventive care services; Chlamydia trachomatis; Screening; Clinical practice guideline; Sexually transmitted diseases; Women's health; Adolescents; Family practice; Managed care

Introduction In the United States, genital Chlamydia trachomatis infection is currently the most common bacterial sexually transmitted disease and the nation's leading notifiable condition (Centers for Disease Control and Prevention, 2005; Cates, 1999). Peak incidence occurs in sexually active adolescent and young adult women (Centers for Disease Control and Prevention, 2005), and this often-asymptomatic infection may cause pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain (Cates and Wasserheit, 1991; Westrom and Eschenbach, 1999; Eng and Butler, 1997). Increasing recognition of the public health ⁎ Corresponding author. Fax: +1 206 287 2871. E-mail address: [email protected] (D. Scholes). 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.04.019

impact of this disease, the availability of effective and economical testing and treatment modalities (Centers for Disease Control and Prevention, 2002; Marrazzo et al., 1997; Honey et al., 2002; Coffield et al., 2001), and evidence of the efficacy of early detection in preventing sequelae (Hillis et al., 1995; Scholes et al., 1996) have led to an emphasis on testing of asymptomatic atrisk women (Centers for Disease Control and Prevention, 2002; U.S. Preventive Services Task Force, 2001; Nelson and Helfand, 2001; Farley et al., 2003; American Medical Association, 1997; National Committee for Quality Assurance, 2000). However, chlamydia testing rates remain low (Mangione-Smith et al., 2000; National Committee for Quality Assurance, 2005; Miller et al., 2004). Even in insured populations, only about 32% of women 16–25 receive testing (National Committee for Quality Assurance, 2005).

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Clinical practice guidelines have been key strategies for translating a body of evidence into practice (Wise and Billi, 1995; Bero et al., 1998; Cretin et al., 2001; Grol, 2001a,b; Casalino et al., 2003; Bodenheimer et al., 2002). Group Health Cooperative (GHC), a mixed-model managed care system in Washington and Idaho, has a strong history of development, implementation, and evaluation of evidence-based guidelines (Handley and Stuart, 1994; Thompson et al., 1995) and developed an evidence-based chlamydia screening guideline in 1998. We report the results of a randomized trial to evaluate the effectiveness of two guideline implementation strategies – a multifaceted clinic-based intervention and a chlamydia screening chart prompt reminder – to improve chlamydia testing rates among adolescent and young adult women. Methods Setting This study was conducted in GHC's integrated group practice model, based in western Washington State. Total GHC enrollment was approximately 450,000 in 2000. Study procedures were reviewed and approved by the plan's Institutional Review Board.

Design We employed a two-by-two factorial randomized trial design to evaluate two conceptually-based interventions to increase adherence to the GHC chlamydia screening guideline in usual clinical practice (Fig. 1). One intervention added clinic-based extensions to standard guideline implementation. Thus, all 23 GHC primary care clinics were randomly assigned to either control (standard imple-

mentation; n = 11) or intervention (enhanced implementation; n = 12) conditions, stratifying on clinic size and geographic location. Randomization at the enrollee level was employed to evaluate the effect of a chart prompt encouraging providers to screen for chlamydia per guideline recommendations (Fig. 1). The intervention targeted women aged 14–20 years, the group which, if sexually active, has the highest risk of chlamydial infection. We selected a random sample of eligible enrollees determined to be sexually active per automated criteria (n = 3509) and placed a screening prompt in 50% of the charts. The remaining 50% received no prompt. Selection of this enrolleelevel sample occurred across both intervention and control clinics. The effects of both interventions on rates of Chlamydia testing were evaluated for a 12-month post-implementation interval.

Intervention Conceptual framework The Precede/Proceed planning model, developed by Green and Kreuter (Green and Kreuter, 1991; Gielen and McDonald, 1997), was used to guide development of the multifaceted intervention. The model identifies three categories of factors that impact provider behavior and/or patient health: (1) predisposing factors target provider motivation to change and include knowledge, attitudes, and self-efficacy; (2) enabling factors, such as training and infrastructural support, in the practice, organizational, or community environment facilitate change; and (3) reinforcing factors reward and strengthen behavior change. Table 1 summarizes how the study intervention components fit into the planning model constructs. Core content of the GHC Chlamydia screening guideline The GHC guideline recommends, for non-pregnant sexually active women, annual screening if age b 20 years, screening every other year for ages 21–25, and risk-based screening if age b 25. Additional screening is recommended for women reporting a new sexual partner since their last assessment. The current study evaluated chlamydia testing in women aged 14–25 years, the age group with peak rates (Centers for Disease Control and Prevention, 2005).

Fig. 1. Trial design Group Health Cooperative, Seattle, WA 2001–2002.

D. Scholes et al. / Preventive Medicine 43 (2006) 343–350 Table 1 Study intervention components and relationship to the conceptual model Group Health Cooperative, Seattle, WA 2001–2002 Intervention

Components

Post guideline on internal website (A) Control (Standard implementation) (B) Clinic-specific Opinion leaders (implementers of ‘trainintervention a, b the-trainer’ approach in intervention clinics) Measurement and feedback Newsletter Pap test chlamydia guideline prompts Exam room posters about chlamydia infection Guideline Implementation Team (C) Chart prompt Chart prompt reminders intervention c

Relationship to model P/E

P/E/R R R E E E/R E

P, Predisposing; E, Enabling; R, Reinforcing. a All intervention clinics also received standard guideline implementation. b Clinic-specific intervention components included: Opinion leaders—the teams of 2 per clinic received a 1-day training at the beginning of the implementation phase (didactic, role modeling, active role-playing, and interactive question-andanswer) and a half-day reinforcement/update training 6 months later. Measurement and feedback reports—5 reports sent to intervention clinic providers. Each report summarized data at the provider, clinic, and health plan (GHC) level for the current quarter vs. the same quarter in the prior year. Quarterly Newsletters (n = 3), covered topics related to screening rates at GHC, other HMO's, confidentiality concerns and legal requirements for adolescent enrollees, scripts and scenarios for introducing chlamydia screening during acute care visits, urine-based testing for CT, and GHC guideline content and URL. Pap test chlamydia guideline prompts—neon labels affixed to GHC Pap test kits by intervention clinic medical assistants. Project contacted intervention clinic medical assistant point person quarterly. Exam room posters—posters provided by the project, placed in all intervention clinic exam rooms by clinic medical assistants. Guideline Implementation Team—comprised of delivery system representatives and study staff with goals of (1) facilitating organization-wide implementation (e.g. gaining top management buy-in, promoting plan-wide urine-based testing) and (2) assisting opinion leaders with clinicspecific implementation. This team met bi-monthly to address system- or clinicspecific issues. Team members visited all intervention clinics in the 2 months following initial training to facilitate clinic-specific guideline implementation, and again in the 2 months following the update training. c Chart prompt intervention—a brief, highly visible prompt placed in the front of randomly selected patient charts, stated ‘High Risk Age Group for Chlamydia. Consider Screening,’ and included the guideline web-link. Clinic control group (standard guideline implementation) The standard guideline implementation (see Fig. 1) was to post the chlamydia screening guideline on the GHC intranet, which is available to all GHC providers at their workstations. This was accompanied by notification of a new guideline on the intranet guideline homepage. The posting included a summary of the guideline, the guideline screening algorithm, a summary of supporting evidence, printable patient education materials, frequently-asked questions, links to supporting web pages, and a CME quiz. The availability of urine-based testing was emphasized. The guideline was posted organization-wide on April 1, 2001. Clinic intervention group (enhanced guideline implementation) In addition to the standard guideline implementation, intervention clinic providers received the following intervention components (see Table 1): (1) Peer opinion leader teams, consisting of a provider and nurse or clinic administrator, were recruited in collaboration with the medical and administrative leadership at intervention clinics. Opinion leaders received a 1-day training with follow-up at the clinics. The training, at the beginning of the implementation phase, was designed as a ‘train-the-trainer’ session to equip opinion leaders to actively implement the guideline in their home clinic. Training topics included: content/ rationale of the newly-released guideline, updates on urine-based testing; patient

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confidentiality; risk reduction counseling/sexual history-taking skills; and partner treatment strategies. A Guideline Implementation Team of delivery system representatives, study team members, and outside experts delivered the content via lecture and interactive sessions. Opinion leaders received locum tenens coverage. Following the training, Guideline Implementation Team members went to each intervention clinic to assist opinion leaders with clinic-specific implementation. (2) Intervention primary care providers also received computer-generated quarterly measurement and feedback reports on the proportion of their 14- to 25year-old enrollees screened pre- and post-guideline implementation (sent for three quarters). These reports were designed to eventually be part of the standard Practitioner Activity Reports, which summarize quality of care across numerous health conditions. A quarterly newsletter was developed and covered topics related to chlamydia screening of young at-risk women, including gaps in chlamydia testing during Pap test visits, scripts/scenarios for introducing chlamydia screening during non-preventive care visits, and Health Plan Employer Data and Information System (HEDIS) chlamydia testing rates for GHC. The URL for the guideline was highlighted in all 3 newsletters. Periodic reminder e-mails maintained contact and updated/reinforced opinion leader teams. (3) Brightly-colored cytology screening reminder labels with a summary of the guideline were affixed to all Pap test kits by clinic staff. Clinic staff also posted exam room posters recommending chlamydia testing to facilitate dialogue with patients about screening. Role-playing using the posters was part of the training. Chart-prompt intervention The chart prompt intervention, targeting sexually active women ages 14–20, consisted of a highly visible prompt placed in the front of randomly selected patient charts. The prompts stated: ‘High Risk Age Group for Chlamydia. Consider Screening,’ with the guideline web-link. This intervention inexpensively replicated a reminder function that could be programmed into an automated appointment system or electronic medical record. Delivery of the intervention Prior to implementation, the program rationale and implementation strategies were presented to and received support from top GHC leadership and quality assurance committees. The GHC laboratory also made nucleic acid amplification testing of urine samples available throughout the delivery system. A Guideline Implementation Team from the delivery system was recruited to support intervention development and implementation. This team included delivery system administrators, the guideline provider ‘owners’ (two GHC clinicians with ongoing responsibility for the guideline's clinical content), a representative from the central lab, and others. Project activities occurred over three time periods: (1) During the baseline period (4/1/00–3/31/01), providers were surveyed for their knowledge, attitudes and behaviors regarding chlamydia infection and testing; opinion leader teams were identified and trained; intervention materials were developed. (2) In the implementation period (4/1/01–7/31/01), the guideline was posted (standard guideline implementation); clinic-based intervention activities occurred; chart prompts were placed. (3) The intervention effects on chlamydia testing rates were assessed during the 12-month follow-up period (8/1/01–7/31/02).

Outcome The primary outcome measure was the rate of appropriate testing for chlamydia in women enrollees ages 14–25 years during follow-up. This was defined as the percent of age-eligible women who were tested for cervical chlamydial infection during follow-up among those classified as sexually active. Data for the numerator (number of women tested) and the denominator (sexually active women) were derived from the health plan's administrative databases, including the laboratory, pharmacy, ambulatory care, hospitalization, and enrollment files (Saunders et al., 2000). GHC's laboratory datafile was used to identify women tested for chlamydia during follow-up. Sexual activity was determined using the HEDIS chlamydia screening measure administrative database indices (National Committee for Quality Assurance, 2000; Mangione-Smith et al., 2000), extended to include the prior as well as concurrent year. Secondary outcomes of interest were the percent of women tested in age groups 14–20 and 21–25, and the percent of women tested who made preventive care visits during follow-up. In the latter instance, we hypothesized that

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preventive visits would facilitate testing, since these visits allow more time and more naturally include discussion of STD prevention and screening.

Table 2 Patient and provider baseline characteristics a Group Health Cooperative, Seattle, WA 2001–2002

Analyses Clinic-level intervention effects Because clinic-level randomization was employed, the main analyses compared testing rates among age-eligible sexually active enrollees in control and intervention clinics using a logistic regression model with generalized estimating equations (GEE) (Mancl and DeRouen, 2001). This model derives the same rates and odds ratios as the usual logistic regression analysis, but corrects P values and confidence intervals for within-clinic correlations. Intervention effects were evaluated overall and separately for age and preventive care subgroups. Chart prompt intervention effects To evaluate chart prompt effects on screening rates, chi-square tests and logistic regression models were used to compare chlamydia testing rates in the chart prompt intervention versus no prompt enrollee groups. As above, effects in the subset of preventive care visits were assessed separately. To evaluate whether any chart prompt intervention effect differed between control and intervention clinics, we tested for interaction between the cliniclevel and chart prompt interventions. Since this interaction was not significant, the results for the two interventions are reported separately.

Results The baseline characteristics of 14- to 25-year-old enrollees and their providers are summarized in Table 2. Mean enrollee age was 17.3 years. An estimated 50.5% had been sexually active in the 2 years before implementation, about one third were tested for chlamydia during the baseline period, and about 85% made ≥1 outpatient visit. Among the primary care providers, baseline mean age was 49.5, over one third were female, and approximately three quarters were family practitioners (Table 2). The mean number of target-age women enrolled in providers' panels was about 80. Baseline control and intervention arms were similar for both enrollees and providers (Table 2). Crude and adjusted odds ratios for clinic-level effects during follow-up are summarized in Table 3. Approximately 59% of target-age enrollees were classified as sexually active, with little between-group difference. Overall, the effect of the provider-level intervention on chlamydia testing rates was relatively small (42.0% of intervention clinic enrollees tested vs. 40.1% at control clinics) and not statistically significant (odds ratio (OR) = 1.08, 95% confidence interval (CI) 0.92–1.26, P = 0.31) (Table 3). Testing rates in the two age subgroups (14–20 and 21–25) also did not differ significantly by intervention status. However, a significant intervention effect was noted in the subgroup of women who made preventive care visits: testing rates among women receiving a Pap test during follow-up were higher at intervention clinics (74.6%) than at control clinics (70.4%) (OR = 1.23, 95% CI 1.01–1.51, P = 0.04) (Table 3); results were similar for women who made a physical exam visit: 64.0% vs. 59.7% for intervention vs. control clinics (OR = 1.22, 95% CI 1.06–1.42, P = 0.009). Of the women who received testing, 4.85% (116/ 2394) vs. 4.08% (95/2327) tested positive in control vs. intervention clinics (P = 0.21). The chart prompt intervention effect was not statistically significant (OR 1.08, 95% CI 0.94–1.23, P = 0.27) (Table 4). In

Patient characteristics Total number of females Age 14–25 Age 14–20(%) 21–25(%) Mean (years) Sexually active in 12-month baseline period or in 12 months preceding baseline (%) Tested for Chlamydia in 12-month baseline period c (%) Utilization in 12-month baseline period (all women): No utilization of any type (%) 1 or more outpatient visits (%) Total number outpatient visits (mean) Pap (% with any) Physical exam/preventive visit (% with any) 12-month continuity of care index d Provider characteristics Number of providers Age (%) b 35 35–50 50–65 65 or over Mean age Gender (% female) Specialty (%) Family practice Internal medicine Pediatrics Nurse practitioner Physician assistant Other Years at GHC (mean) Mean no. of patients in practice, females age 14–25

Control clinics b (N = 11)

Intervention clinics b (N = 12)

N = 6810

N = 5881

84.7% 15.3% 17.44 51.5%

86.9% 13.1% 17.33 50.5%

32.4%

33.9%

15.2% 84.6% 3.88 21.5% 28.6%

13.9% 86.1% 4.00 21.2% 28.4%

0.216

0.221

N = 105

N = 99

5.7% 50.5% 42.9% 1.0% 49.0 38.1%

2.0% 53.5% 43.4% 0.0% 49.5 36.4%

75.2% 1.9 14.3 1.0 7.6 0.0 13.9 81.0

75.8% 7.1 11.1 2.0 2.0 1.0 15.5 81.9

a

For enrollees in follow-up cohort who were also enrolled at baseline. Clinics randomized into four strata based on size (‘large’ if >1000 women enrollees 14–25 or ‘small’) and region (Central-East, and South). Average enrollment for control clinics was 17,618 for control clinics and 14,279 for intervention clinics. c Denominator is sexually active women per automated indices of sexual activity. d Based on the Bice-Boxerman continuity of care index (Bice and Boxerman, 1977). b

intervention clinics, women who had chart prompts were somewhat more likely to receive testing than women without prompts, but this difference also was not statistically significant (data not shown). The chart prompt was not more effective among women making preventive care visits during follow-up (data not shown). Discussion Evidence-based guidelines have been heavily utilized for translating research findings into improved clinical services

D. Scholes et al. / Preventive Medicine 43 (2006) 343–350

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Table 3 Clinic-level intervention effects: chlamydia testing rate during follow-up of sexually active women a ages 14–25 years Group Health Cooperative, Seattle, WA 2001–2002 Group

Total N

Control

Intervention

Difference

Odds Ratio (adj OR) b, c

95% CI (adj CI) b, c

P value (adj P value) b, c

Age 14–20 Number sexually active Percent sexually active Percent tested for CTd

7,160 49% 38.5%

3,649 48% 37.5%

3,511 50% 39.6%

2.1%

1.09 (1.02)

0.92, 1.29 (0.89, 1.16)

0.31 (0.82)

Age 21–25 Number sexually active Percent sexually active Percent tested for CT d

4,595 83% 44.9%

2,456 82% 44.0%

2,139 84% 45.9%

1.9%

1.08 (1.10)

0.91, 1.28 (0.95, 1.26)

0.37 (0.22)

All ages (14–25) Number sexually active Percent sexually active Percent tested for CT d

11,755 58% 41.0%

6,105 58% 40.1%

5,650 59% 42.0%

1.9%

1.08 (1.01)

0.92, 1.26 (0.92, 1.12)

0.31 (0.83)

Among all sexually active women with Pap test d Number with Pap 4,934 2,612 Percent with Pap 42.0% 42.8% Percent tested for CT e 72.4% 70.4%

2,322 41.1% 74.6%

4.2%

1.23 (1.23)

1.01, 1.51 (1.05, 1.43)

0.04 (0.02)

Among all sexually active women with physical exam (PE) d Number with PE 4,883 2,552 2,331 Percent with PE 41.6% 41.8% 41.3% Percent tested for CT e 61.9% 59.7% 64.4%

4.7%

1.22 (1.16)

1.06, 1.42 (1.04, 1.30)

0.009 (0.02)

CT, Chlamydia trachomatis; OR, odds ratio; CI, confidence interval. a Per automated indices of sexual activity. b All values obtained from GEE logistic regression, correcting for within-clinic correlations due to randomization by clinic; computed using t statistic with 21 d.f. and bias corrected standard errors (Mancl and DeRouen, 2001). c Adjusted OR, CI, and P value controlled for age (in years) and baseline differences in chlamydia testing rates. d Age groupings for sexually active women receiving Pap tests were 49% ages 14–20, 51% ages 21–25; age groupings for sexually active women with physical exams were 57% ages 14–20, 43% ages 21–25. e Baseline CT testing percentages for Control (C) and Intervention clinics (I) were the following: age sub-groups 14–20: 29.3% (C), 31.8% (I), P = 0.24; 21–25: 38.1% (C), 35.9% (I), P = 0.41; Prevention visit sub-groups Pap test: 40.7% (C), 42.1% (I), P = 0.62; PE: 34.2% (C), 36.3% (I), P = 0.47.

and outcomes. However, guideline development alone is usually insufficient to induce practice change (Wise and Billi, 1995; Grol, 2001a,b; Wolff et al., 1998; Cabana et al., 1999; Solberg, 2000; Grilli et al., 2000) A variety of implementation strategies, including ‘train the trainer’ and opinion leader approaches, measurement and feedback, patient and provider reminders, financial incentives, and clinic level re-design have been shown to help effect practice change (Wise and Billi, 1995; Bero et al., 1998; Cretin et al., 2001; Thompson et al., 1995; Oxman et al., 1995; Hulscher et al.,

2001; Lomas et al., 1991; Walsh and McPhee, 1992; Thomson O'Brien et al., 1999; McCulloch et al., 1998; Berwick, 1998; Grimshaw et al., 2001; Solberg et al., 2000). The current intervention was guided by this body of research. Although the trial did not show a strong effect overall, we did see significant clinic-level intervention effects among women making preventive care visits. In this regard, our results agree with those from two other interventions to improve chlamydia screening. A randomized trial by Shafer et al. assigned managed care plan pediatric clinics to control or to a practice intervention

Table 4 Chart prompt intervention effects: chlamydia testing rates during follow-up of sexually active women a ages 14–20 years Group Health Cooperative, Seattle, WA 2001–2002 Group (Ages 14–20)

Total N

No prompt

Prompt

Difference

Odds Ratio (adj OR) b

95% CI (adj 95% CI) b

P value (adj P value) b

Number sexually active Percent sexually active Number tested for CT Percent tested for CT c

3,509 97.9% 1,463 41.7%

1,732 97.8% 706 40.8%

1,777 98.0% 757 42.6%

1.8%

1.08 (1.03)

0.94, 1.23 (0.89, 1.20)

0.27 (0.66)

CT, Chlamydia trachomatis; OR, odds ratio; CI, confidence interval. a Per automated indices of sexual activity. b Adjusted OR, CI, and P value controlled for age (in years) and baseline differences in chlamydia testing rates. c Baseline CT testing percentages for Control (C) and Intervention clinics (I): 39.9% (C), 45.0% (I), P b 0.01.

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designed to increase testing in adolescent women receiving routine checkups (Shafer et al., 2002). Post-intervention testing was 65% vs. 21% in intervention vs. control clinics. A second study, of a systems-level ob-gyn practice change to improve testing during routine Pap visits, noted significantly increased prevs. post-intervention testing rates (Burstein et al., 2005). However, while sharing similarities, the current study differed from these reports in its focus on primary care clinics and its emphasis on a system-wide program for all at-risk women. A number of factors may have contributed to the intervention's non-significant overall effects. Possibly, the standard guideline posting and some of the wider attention to chlamydia testing (e.g., the USPSTF ‘A’ rating and development/ dissemination of the HEDIS measure) (U.S. Preventive Services Task Force, 2001; Nelson and Helfand, 2001; National Committee for Quality Assurance, 2000) led to increased testing in both groups; overall testing increased 8% during the study period. Also, even with the infrastructural support of an integrated group practice, the strength of the intervention approaches may not have been commensurate with the desired plan-wide reach. Preventive care visits, with their longer duration and focus on screening, were associated with improved testing rates. However, relatively low proportions of at-risk women made preventive care visits (about 40%). Complex communication and high interaction requirements impair delivery of preventive services (Vogt et al., 2004), including STD screening of asymptomatic women (Schuster et al., 1996; Cook et al., 2001). The added challenges of non-preventive visits – less time, added confidentiality concerns, and more provider–patient interaction to introduce screening – likely require more intensive and/or comprehensive strategies. Finally, this and most interventions to date have targeted provider behavior and have been utilization-based, thus limiting opportunities to improve testing through patient activation or outreach to infrequent plan utilizers. Recent work suggests a number of intervention strategies that may extend a screening program's effectiveness. Elements of organizational change (Casalino et al., 2003; Bodenheimer et al., 2002; Stone et al., 2002; Burstein et al., 2005), such as planned prevention visits, separate clinics dedicated to screening activities, and designation of selected prevention responsibilities to non-provider staff, were the most potent in a recent metaanalysis of interventions to increase delivery of several preventive services (Stone et al., 2002). In our study, nonprovider staff delivered some intervention components, but other elements were not accessed. As chlamydia testing is an under-delivered service that is cost-effective, even relative to other preventive services (Coffield et al., 2001; McGlynn et al., 2003), increasing screening opportunities by encouraging more at-risk women to make preventive care visits merits consideration. Also, patient – rather than provider – activation approaches, such as financial incentives (e.g. co-pay reduction/waiving), patient reminders and tailored messages, have been found to be effective (Bodenheimer et al., 2002; Stone et al., 2002). Our finding of an inverse association between continuity of care and chlamydia testing in this cohort (Reid et al., 2005) and reports of out-of-plan care for STD services

(Civic et al., 2001) suggest that incorporating within-plan options that offer more anonymity, confidentiality, or economy may improve testing. These and other organization-level screening and outreach strategies may be facilitated by the availability of urine-based chlamydia testing and the increasing use of electronic medical records by many health plans (Marrazzo et al., 1997; Andersen et al., 2002; Casalino et al., 2003; Vogt et al., 2004). Conclusions In the US, delivery of critical preventive services, including chlamydia testing, is far from optimal. Despite dissemination of evidence-based national and local guidelines, chlamydia testing rates are low and this infection continues to be of considerable public health concern. In this randomized trial to increase guideline-recommended chlamydia screening, we noted significantly improved testing rates in women making preventive care visits, but not overall. Recent work suggests that a combination of organization-level change and patient activation strategies may further the translation of relevant research into effective chlamydia screening practices and programs. Acknowledgments We gratefully acknowledge the contributions of Jean Marshall, Peggy Rogers, Hugh Straley, Dorothy Talbott, Frank Marre, Jane Dimer, Eve Adams, Tara Beatty, Jessica Smith and the Group Health Permanente and Group Health Cooperative health professionals, particularly the clinic opinion leaders, in the participating primary care clinics. Financial support was provided by R01 HS10514 from the Agency for Healthcare Research, as part of the Translating Research into Practice (TRIP) initiative; and K07 CA84603 (JBM). References American Medical Association, 1997. Guidelines for Adolescent Preventive Services. American Medical Association, Chicago, IL. Andersen, B., Olesen, F., Moller, J.K., Ostergaard, L., 2002. Population-based strategies for outreach screening of urogenital Chlamydia trachomatis infections: a randomized, controlled trial. J. Infect. Dis. 185, 252–258. Bero, L.A., Grilli, R., Grimshaw, J.M., Harvey, E., Oxman, A.D., Thomson, M.A., 1998. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The cochrane effective practice and organization of care review group. BMJ 317, 465–468. Berwick, D.M., 1998. Developing and testing changes in delivery of care. Ann. Intern. Med. 128, 651–656. Bice, T.W., Boxerman, S.B., 1977. A quantitative measure of continuity of care. Med. Care 15, 347–349. Bodenheimer, T., Wagner, E.H., Grumbach, K., 2002. Improving primary care for patients with chronic illness. JAMA 288, 1775–1779. Burstein, G.R., Snyder, M.H., Conley, D., Newman, D.R., Walsh, C.M., Tao, G., Irwin, K.L., 2005. Chlamydia screening in a health plan before and after a national performance measure introduction. Obstet. Gynecol. 106, 327–334. Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.A., Rubin, H.R., 1999. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282, 1458–1465.

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