Rationale Chlamydia trachomatis remains the most commonly reported bacterial sexually transmitted infection among U.S. females between the ages of 15 and 24 years.¹ Most infections are asymptomatic and if untreated can cause major reproductive morbidity.² Screening for chlamydia has been shown to be cost-effective³ and is recommended for all sexually active female patients 24 years or younger.⁴ Yet, improvements in screening rates have been small.⁵ We developed a systems-based intervention to identify and screen at-risk sexually active adolescents which, in a randomized control trial, resulted in dramatic increases in screening rates in a large Northern California Health Maintenance Organization (HMO).^6-8

The Chlamydia infection rate in Australia has tripled over the past 10 years, with New South Wales having the second highest rate of infection in Australia.⁹ As a result, an international systematic literature review was conducted to examine chlamydia prevention programs that have published sustainable and significant increases in routine screening within the primary care setting. The review identified 23 full text articles that met the inclusion criteria, 4 review articles were excluded and the remaining 19 were analysed based on their level of impact and then later based on their relevance within an Australian context. This analysis identified articles by Shafer and Tebb ^6-8 as having the potential to be applied in the Hunter New England Local Health District of New South Wales (HNELHD).¹⁰ Efforts to translate this intervention into primary care general practices (GP) took place between March 2012- Dec 2012 with Dr. Tebb consulting on the translation methods and materials. Implementation efforts are scheduled to begin June 2012.

The purpose of this proposal is to support this collaborative international partnership to translate, implement and evaluate our chlamydia screening intervention in the HNELHD setting in order to address this major public health epidemic. General practice is considered an ideal setting for population based chlamydia prevention initiatives given its reach to the youth population; with 80-85% of young women, and around 65% of young men visiting a GP annually.^11,12 GP is also considered an acceptable and feasible setting in which to provide routine and sustainable chlamydia care to young people at the population level.¹³

Plan: to tanslate and evaluate our successful Chlamydia screening intervention into 17 GPs in HNELD region. The aims of the practice-based phase are to develop policies, systems and processes to support routine chlamydia screening for all sexually active 15-24 year old patients, and to establish a quality improvement cycle to continuously improve the proportion of at-risk females 15-14 years of age who are screened for chlamydia. Selection criteria for the 17 GP sites were: one major urban area from each of the three clusters that has the highest youth population (15-24 years); 50% of the GP practices in each of the three urban areas with the highest number of active young patients; capacity, and willingness to take part in the project. The practice sites are as follows: 9 from Greater Taree, 7 from Cessnock and 1 from Muswellbrook. The approach will modify the tool kit and strategy used in the original HMO intervention so it is applicable to this new setting. It will also develop step by step information to support project translation and replication efforts. We will evaluate pre-post differences in the proportion screened adjusting for repeated measures and GP region.

Criteria and Metrics For Success A pre-post-test clinical audit intervention conducted with general practices(GP) across three primary care divisions within the HNELHD in 2008. Suggested that providing chlamydia care to over 70% of young people who frequent the GP setting is achievable, as measured by GP self-report, however the follow-up needs assessment found that less than half of the GPs surveyed continued to routinely offer chlamydia screening to their 15-25 year old sexually active patients.¹⁴ It has been shown that 50-70% of young people aged 15-24 years need to be tested and treated for chlamydia to see reductions in the incidence at the population level.¹⁵ We will use this criteria as the primary metric of success. Statistical analyses will compare pre-post changes in the proportion of adolescents screened for CT across each of the GP practices that implement the intervention. A process evaluation will be conducted to evaluate barriers and facilitators to identifying and screening asymptomatic, sexually active adolescents and young adults for chlamydia.

Cost and Budget Justification: The estimated cost for this proposal is $97,800 to support PI (Dr. Tebb) at 30% effort, Co-Investigator (Dr. Shafer) at 10% effort; Statistician (Dr. Nehaus) at 5%; 2 part-time local data collectors $30K and 1 round trip travel for PI at $3,000 and minimal supplies at $1,000.

Collaborators: Hunter New England Health (HNEH) provides care for approximately 840,000 people and covers a geographical area of over 130,000 square kilometres (including Hunter Region, the New England Region and the Lower Mid North Coast local government areas of Gloucester, Greater Taree City and Great Lakes). The Chlamydia Prevention Quality Improvement project is a collaborative project with the Hunter Rural Division of General Practice

References:

1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2009. Atlanta, GA: Centers for Disease Control and Prevention. Division of STD Prevention National Center for HIV, STD and TB Prevention; 2010.
2. Chesson HW, Pinkerton SD. Sexually transmitted diseases and the increased risk for HIV transmission: implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions. J Acquir Immune Defic Syndr. 2000;24(1):48-56.
3. Hu D, Hook EW III, Goldie SJ. Screening for Chlamydia trachomatis in women 15 to 29 years of age: a cost-effectiveness analysis. Ann Intern Med. 2004;141(7):501-513.
4. US Preventive Services Task Force. Screening for chlamydial infection: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;147(2):128-134.
5. National Committee for Quality Assurance. The State of Health Care Quality: 2010. Washington, DC: National Committee for Quality Assurance; 2010.
6. Shafer MA, Tebb KP, Pantell RH; et al. Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls. JAMA. 2002;288(22):2846-2852.
7. Tebb K. P., Pantell R. H., Wibbelsman C. J., Neuhaus J. M., Tipton A. C., Pecson S. C., Pai-Dhungat M., Ko T. H. & Shafer A. B. (2005) Screening sexually active adolescents for chlamydia trachomatis: What about the boys?, American Journal of Public Health, 95 (10): 1806-10.
8. Tebb K, Wibblesman C, Ko T, Neuhaus J, Shafer MA (2011) Translating and Sustaining a Chlamydial Screening Intervention 4 Years Later. Arch Intern Med, 171(19):1767-1768.
9. Centre for Epidemiology and Research. 2009 Report on Adult Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2010.
10. Guy R.J., Ali H., Liu B., Poznanski S., Ward J., Donovan B., Kaldor J. & Hocking J. (2011) Efficacy of interventions to increase the uptake of chlamydia testing in primary care: a systematic review, BMC Infectious Diseases, 11.
11. Centre for Epidemiology and Research. 2009 Report on Adult Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2010.
12. Kong, F. Y. S., Guy, R. J., Hocking, J. S., Merritt, T., Pirotta, M. Heal, C., Bergeri, I., Donovan, B. and Hellard, M. E. (2011) Medical Journal of Australia; 194(5): 249–252
13. Donovan, B., Bodsworth, N. J., Rohrsheim, R., McNulty, A., and Tapsall, J. W. (2001) Characteristics of homosexually-active men with gonorrhoea during an epidemic in Sydney, Australia. International Journal of STD and AIDS, 12:437-443
14. Chlamydia care in general practice.  Draft report. Hunter New England Population Health. 2010
15. Frileux, S., Sastre, M.T.M, Mullet, E. & Sorum, P.C. (2004) The impact of the preventive medical message on intention to change behaviour, Patient Education & Counselling, 52:79-88