is the most prevalent reportable bacterial sexually transmitted disease (STD) in the United States.1
The highest rates are consistently among adolescent and young adult females who comprise approximately 50% of the total reported CT case burden.1,2
Racial/ethnic minorities are also disproportionately infected, so that African American females comprise nearly half of all female CT cases in the United States.1
As up to 80% of CT infections are asymptomatic, a key prevention strategy is to screen young women in order to identify and treat infections that, if left untreated, can lead to preventable adverse reproductive health outcomes, such as pelvic inflammatory disease (PID), infertility, and chronic pelvic pain.3,4
National and professional organizations, including the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC), recommend annual CT screening for sexually active women ≤25 years.5,6
Women aged ≥26 years consistently have lower rates of CT prevalence compared to that of younger women, and universal screening would not be cost-effective. Therefore, CDC recommends screening women ≥26 years if they report specific STD risk factors, including multiple partners, new partner, past STD history, or inconsistent condom use.6
Clinician providers adhering to CDC sceening guidelines should, therefore, screen older women at lower rates compared with younger women. Clinician providers serving women in family planning clinic settings are a key group to evaluate for adherence to CT screening guidelines.
The nation's largest publicly funded family planning program is the California Medicaid family planning expansion, Family Planning, Access, Care, and Treatment (Family PACT). Family PACT reimburses on a fee-for-service basis for direct clinical services to clients at or below 200% of the Federal Poverty Level. Public sector Family PACT providers can apply for Title X funding, a federal grant program administered by state health departments or regional agencies. Title X-funded providers are required to adhere to clinical and administrative guidelines as determined by the Federal Office of Population Affairs.7
In an effort to expand access to family planning services, the Family PACT provider network includes a broad range of public sector providers (nonprofit and governmental) funded and not funded by Title X and private sector providers who are not eligible for Title X funding.8
Family PACT program standards for clinical care include adherence to national screening guidelines through routine provider training and data feedback in the form of semiannual provider profiles on quality measures related to family planning and STD care.9
Data feedback regularly informs all clinician providers of relative performance over time and compared with that of their peers. Provider profiles for Family PACT providers since 2006 have included screening rates for both younger and older women in an effort to improve adherence to the full set of CT screening guidelines. The profiles have shown increasing trends or high levels of CT screening for both young and older women by most providers. In 2009, the CT screening rate for young women by Family PACT providers was 71%, far higher than by the Medicaid program in California (54%) and nationwide (56%) as reported in the Healthcare Effectiveness Data and Information Set (HEDIS) quality measures.9,10
Closer examination of provider-specific rates, however, show variation in performance across providers and provider groups.
Similarly, Family PACT provider profile trends in CT screening rates for women aged ≥26 years indicate that there is variation in screening rates, with overall levels that are consistently >50%, indicating potential overtesting.9
High levels of screening among older women may reflect higher levels of sexual risk behaviors among women accessing care, but this has not been systematically explored. There are few data that describe how best practices in screening might vary as a result of clinic or client population characteristics, although variation in CT HEDIS rates by region may reflect differences in urban vs. rural access to reproductive healthcare services and, by extension, the relative size of clinic populations served. Identifying provider characteristics that are associated with adherence to CT screening guidelines may help inform targeted provider-specific interventions for STD care quality improvement.
Provider characteristics, such as clinic structure and receipt of Title X funding, a major source of funding for family planning services for low-income clients, may affect Family PACT provider adherence to clinical guidelines. Title X providers in Family PACT providers receive additional tools and technical assistance for the provision of high-quality healthcare services. Title X grantees are part of a network that coordinates quality of care standards; ongoing monitoring of services is enabled through standardized reporting of client use and clinical and laboratory services.11
Title X follows (1) CDC guidelines for CT screening practices and (2) the performance standards of the Family Planning Councils of America, Inc., which specify annual CT screening of women ≤25 years of age as one of the performance measures.12
Integration of STD prevention strategies is further evidenced by Title X participation in the CDC-funded Infertility Prevention Project effort to increase access to CT screening and to monitor prevalence.2
Title X quality improvement efforts have a potentially large impact within the Family PACT program. Although Title X providers constitute <20% of the Family PACT providers, they serve nearly half of all Family PACT clients and higher proportions of adolescent and young adult clients. Title X providers are located in communities with a high unmet need for reproductive health services and significant racial/ethnic health disparities. However, it is not known to what extent differences in screening rates among Title X clinics and non-Title X clinics may be influenced by clinic size, racial/ethnic composition of client populations served, or location in rural vs. urban areas.
Our study goal was to determine if Title X providers are more likely to adhere to the national and program CT screening guidelines compared to other Family PACT provider groups, after controlling for differences in clinic and client demographic characteristics. Our study aims were to (1) compare age-specific CT screening rates among three main Family PACT provider groups (Title X, non-Title X public, and private), (2) assess if rates for young female clients differed after adjusting for provider-level client sociodemographic confounders, and (3) compare the absolute difference in screening rates for younger vs. older female clients by provider group.