WI State Report

RVIPP Meeting

Chicago: February 2-3, 2011

Wisconsin State ReportRVIPP Meeting Chicago: February 2-3, 2011

Timeliness to Treatment Update: STD Treatment Audit in FP PPW STD Treatment Audit in FP non-PPW

New Initiatives & Updates: Rural Prevalence Project Milwaukee School Based Testing Trends

2009-2010 Milwaukee Jail Screening Project Condom Survey EPT

Timeliness to Treatment STD Treatment Audit in PPW

Audit provided an opportunity to examine Quality Assurance measures in FP

Treatment rates for chlamydia and gonorrhea Compare treatment rates generated from Treatment Audit

to treatment rates generated from WEDSS reported morbidity data

Re-testing rates for chlamydia and gonorrhea Included in STD Treatment Audit

STD Treatment Audit in PPW conducted in June 2010 STD Treatment Audit in non-PPW to be rolled March

2011 The results of this first audit effort will provide baseline

measures for standard of care expectations in FP statewide

Timeliness to Treatment STD Treatment Audit: PPW

Summary of Treatment Audit in 25 PPW Clinics Maximum of 25 charts reviewed per clinic: (20 females,

5 males) Positive CT and/or GC test results for males and females

High volume clinics: randomly select maximum of 25 positives from 4th quarter 2009

Medium volume clinics: randomly select maximum of 25 positives from 4th quarter 2009

Low volume clinics: select positives from 2009 up to a maximum of 25 positives

STD Treatment Audit: PPW

Electronic Excel Spreadsheet Each clinic entered data from chart

review electronically Grand total site summary of results

PPW Females Positive for Ct Rx rates Re-test Rates

STD Treatment Audit: PPWTreatment Rate for Females Positive for CT

Overall CT Treatment Rate in Females:431 Females + for CT 367/431 treated (85%) Treated women (n=367):

18% ( 67) patients >=25 26% ( 97) patients <19 55% (203) patients >=19 <25

Days to Treatment (N=367) 98% (359/367) Rx <=30 days; 92% (338/367)% Rx <=14days 83% (359/431) Rx <=30 days; 78% (338/431)% Rx <=14days

Range: 0-133 days Average: 7 days Same day RX: 30% (109) patients > 14 days 8% ( 29) patients > 30 days 2% ( 8) patients

STD Treatment Audit: PPWTreatment Rate for Females Positive for CT

Overall CT Non-treatment Rate in Females:

431 Females + for CT64/431 not treated (15%)Non-treated women (n=64):

17% (11) patients >=25 25% (16) patients <19 58% (37) patients >=19 <25

PPW Audit Rx Rate Compared to WEDSS Reported Morbidity Rx Rate Females Positive for Chlamydia

2009 Data

Data Source 2009

Overall Rx Rate Rx Rate <=14 Days

Rx Rate <=30 Days

Audit PPW (N=431) 85% 78% 83%

WEDSS PPW (N=1576)

75% 72% 75%

WEDSS All FP (N=2594)

78% 76% 78%

STD Treatment Audit: PPWRe-testing Rate among CT Positive Females

2010 PPW Audit Results for Re-testing 42% PPW Females Re-tested (153/367) Positive at Re-test:

12% (19 patients/153)

Days to Re-test Range: 0-329 days Average: 107 days Re-tested <30 days: 13% (20) Re-tested <90 days: 48% (73) Re-tested >=90 days*: 52% (80)

*Recommended time frame

STD Treatment Audit: PPWRe-testing Rate among CT Positive Females

Plan to evaluate rates of re-testing in FP as a quality assurance measure in FP clinics

Plan to include ‘Re-tested?’ field in PPW STD Tx Audit Tool in July 2010

PPW will add a required field for ‘Re-tested?’ to Electronic Medical Record when ready in July 2011

Recommendations to re-test in FP Program Guidelines will include males and females

When have SSC changes from prevalence evaluations finalized, will add these changes and ‘Re-screened?’ field to laboratory request form at SLH

STD Treatment AuditNext Steps

Will improve electronic spreadsheet before rolling out non-PPW Audit based on PPW Audit experience Facilitate consistency in data collection Facilitate analysis

Lots of data to sort through Adherence to SSC GC Rx rates and timeliness Males Demographics (age/race, etc.)

Individual Report Cards for each of 25 clinics

Rural Screening Project: non-PPW FP Clinics

Low Prevalence of CT (<3%) When prevalence is low, how do we

improve our ability to find those chlamydia positives we KNOW are in the haystack of negatives?

Rural Screening Project

4 sites in Northern Wisconsin participated in Universal screening for the months of April and May Objective: to estimate CT prevalence in

rural non-PPW clinic populations Determine if there are risk criteria

outside of the evidence based SSC currently in use in WI FP which add greater sensitivity to the risk assessment for CT and GC infection in men and women attending these clinics

Rural Screening Project

Preliminary Findings Nuances of interviewing patients

important Consider the consistency and how

questions are asked and perceived by the patient

Numbers are small, but prevalence appears to be under 3% threshold

Rural Screening Project‘North of HWY 29’

Four Agencies to be commended for their efforts Oneida Pierce Polk St. Croix

Universal Screening in April-May 2010 included risk assessment for: Current SSC for chlamydia (12 criteria) Non-SSC Reasons for Testing SSC’ (11 criteria

compiled by participating agencies) If no SSC or OC, would you have tested OC?

North of HWY 29

770 total patients (Females and Males) Females

729 total female patients 640 tested; 18 + (2.8%)

Males 41 total male patients 40 tested

12+ (30%) (11/12 met SSC; the one who did not, met OC

28 – 12/28 (43%) of negatives met an SSC 24/40 (60%) would have been tested if not

universally screening

North of HWY 29

SSC met among 18 Positive Females ? 8/18 met SSC (44%) 10/18 did not meet SSC

Off Criteria met among same 18 Positive Females? 16/18 met OC (89%); majority of these

met the >90 day OC 2/18 no OC

BUTTTTT……!!!

BUTTTT…!!!

622/640 (97%) females tested were NEG 344/622 (55%) negative females met

SSC 278/622 (45%) no SSC 514/622 (83%) met OC 108/622 (17%) no OC

Positivity* in 4 Rural Clinics 2009 vs. 2005

Clinic Females 2009 Males Females 2005 Males

Oneida 4.9% (14/286) 23.1% (9/39) 5.8% (21/362) 14.3% (8/56)

Pierce 5.4%(41/761) 13.9% (10/72) 5% (34/680) 20.2% (17/84)

Polk 4.5% (10/221) 33% (5/15) 6.5% (22/338) 28.6% (10/35)

St. Croix 5.5% (24/433) 20.8% (5/24) 6.6% (14/211) 33.3% (7/21)

*Positivity represents selectively screened individuals (not prevalence) Positivity fluctuates over the period of 2005-2009

Rural Screening Project

0

2

4

6

8

10

12

Oneida Pierce Polk St.Croix

2005

2006

2007

2008

2009

Positivity in Females in 4 non-PPW Rural Clinics 2005-2009

%Positive

Preliminary Conclusions:Lessons Learned…

Further multivariate analysis needed…but numbers are very small….

Patients in low prevalence areas may benefit from clinician directed enhancement of discussions with patients to ensure patients are understanding context of questions so their risk for infection is identified more accurately

Preliminary Conclusions:Lessons Learned…

Rural clinician group will summarize their experience and lessons learned regarding more precise interviewing techniques to increase sensitivity of current SSC

How to better define the 90 day time period of risk assessment for patients to improve accuracy of sexual history

Best methods to elicit a thorough and accurate sexual history

Provide Statewide training on these issues through Webinar/WRPHFP meeting

Preliminary Conclusions:Lessons Learned…

Why do we care about digging deeper for positives in low prevalence settings, when we have plenty of them in more urban settings?

Must address clinician trust in SSC as appropriate standard of care for patients in order for them to continue to adhere to using SSC as an accurate screening tool

Fertile ground for further examination? <25 & >= 25 years of age groups in patients meeting the

“Off Criteria” for: “Lifetime never tested females with Hx of multiple partners”

(and <25 years of age) Cap testing in females >=25 years of age unless

symptomatic and/or contact?

Milwaukee School Based Clinics Update 2010

Testing in 15 SBC began Jan 2009 Low volume of testing/positivity at first Volume and positivity picking up Tested 23% more students in 2010 Saw nearly 50% increase in CT positivity and 14% increase in GC

positivity Higher-risk kids more comfortable with health center presence? Staff

efforts?

Year # Tested #/% Pos CT #/% Pos GC

2009 276 34/12.3% 10/3.6%

2010 339 62/18.3% 14/4.1%

Milwaukee School Based Clinics Update 2010

Positivity Rates by Gender 2009-2010:Increase in CT both females and malesGC rate in females exceeds GC rate in males in 2010

Year CT % Positive GC % Positive

Female Male Female Male

2009 12.5% 11.9% 2.7% 4.8%

2010 21% 15.6% 5.7% 2.2%

Milwaukee County Jail Screening Project

CDC Funded Pilot Project (~ $25,000) 2010 Determine CT and GC positivity among women <=39 years of

age in Wisconsin jail population Provide testing, treatment and STD education session for first

400 females at time of jail booking for CT and GC

“Opt out” medical consent for testing Urine sample collected at booking for pregnancy test to be

tested for CT and GC If not treated in facility, City Health Department to provide f/u

for notification of results, treatment and f/u of partners

Organizational and personnel difficulties after Medical Director departed

One month of data available for October 2010

Milwaukee County Jail Screening Project Women Booked & Tested for CT and GC During the Month of October 2010

(N= 131)

Chlamydia (26 +)

+/Tests % Gonorrhea (10 +)

+/Tests %

Total 26/130 20% 10/131 7.6%

Black 21/83 25% 7/82 8.5%

White 4/45 8.9% 3/47 6.4%

<18 yrs 4/9 44.0% 3/10 33.0%

18-24 yrs 11/43 25.6% 3/42 7.1%

25-34 yrs 9/40 22.5% 3/40 7.5%

Sex Charges <=30

22/48 45.8% 8/49 16.3%

Sex Charges>30

2/79 2.5% 2/78 2.6%

Total Rx 11/26 42.3% 4/10 40.0%

Rx In:Rx Out:

4/26 15.4% 3/10 30.0%

7/26 26.9% 1/10 10.0%

Condom Survey

Brand sensitivity in FP clinics in Wisconsin Do we provide a variety of desirable

brands and sizes in WI FP clinics? Survey was distributed at the

DPH/WFPRHA meeting in Wausau in September 2010

17 responses

Condom Survey Results

Types & Sizes Good variety and sizes

Suppliers Global Protection Four Seasons Total Access Trojan Access FPHS IBI Synergy, Inc

Condom Survey Results

Female Condoms: Yes; 11/17 Non-latex Condoms: Yes; 16/17 Colored: Yes; 15/17 Flavored: Yes; 12/17 Other Specialty Condoms: Yes;

10/17 Provide Prescription for Condoms:

No; 15/17

Condom Survey Conclusions & Lessons Learned…

Among FP clinics responding: Good variety and specialty condoms available Non-latex available Female condoms less available Most condoms are provided on site

Future Goals: (Goals met in 2011)

Utilize FPOS to cover cost of condoms through prescriptions or FPOS reimbursement for condoms on site

Conduct patient survey (no interest/need)

Desired brands? Use female condoms if available (now more available

through Dual Protection in 2011)

EPT Update

EPT signed into Wisconsin Law May 11, 2010 Became effective May 26, 2010 EPT allowed for one dose therapy for CT, GC, Trichomoniasis

No name prescription allowed if partner name not obtainable, in which case, ‘EPT’ required to be written on prescription

Information sheets for patient/partner required by the new law and on WEB site; provider guidance soon to be on WEB site

Preliminary training for Family Planning Providers provided in July, September and November 2010

Plans for evaluation under development; WEDSS Promotion of EPT and FPOS awareness among clinical providers

and pharmacists (i.e. males added to waiver, condoms covered by waiver, etc)

Partner referral card for use in FP under development emphasizing partner test and treat gold standard; FPOS enrollment and EPT last resort