The New York City Research and Improvement Networking Group (NYC RING)

Enhancing Confidential Care and STI Screening for Adolescents in Urban Primary Care (CCAP)

Urban adolescents experience a high burden of sexually transmitted infections (STIs).  We developed a practice-based intervention to increase the proportion of adolescents 12-19 years old in urban primary care offices who are tested for STIs (Neisseria gonorrhea, Chlamydia trachomatis, and HIV) by improving access to confidential services in primary care.

Participating Practices
Montefiore Medical Group sites in Bronx, NY:
Williamsbridge Family Practice
University Avenue Family Practice
Castle Hill Family Practice
Marble Hill Family Practice

Principal Investigator
Diane McKee, MD, MS

Project Timeline
Launch: Oct 2007
Data Collection: May 2008-April 2010

Study Overview
In Phase I, we completed qualitative studies (teen and parent focus groups) to inform the specific content of the intervention.  In Phase II, we implemented a pilot intervention.  Primary care practices were randomly assigned to intervention and control. Intervention consisted of a one-time training for primary care providers and office staff, focused on overcoming barriers to visits for unaccompanied youth, allowing for time alone during visits, assessing sexual activity and STI screening. STI testing data was extracted from our clinical information system.
During the pre-intervention data collection period, 1043 adolescents were seen; 1521 in the post. In our intervention sites, there was essentially no change in testing: overall (11.8 to 12.6%), in males (5 to 6.7%), in females (16.4 to 16.6%) nor in teens 16 years and older (20.3 to 19.9%). Testing decreased slightly (45 to 36.7%) in females with concurrent pregnancy test (used as a surrogate for sexual activity). Our control sites had an increase in testing males (0.7 to 5.1%), and a decrease in females (19.1 to 15.3%). During the 6-month window prior to their pre-intervention clinic visit, 8.4% of all intervention site youth were tested for HIV vs 7.1% at control sites. As with GC testing, there was little difference in pre- and post- HIV testing. In intervention sites, rates of HIV testing for all adolescents increased to 9.8%. Improvements pre- vs post- in our intervention sites included testing males (3.9 to 7%), females (11.4 to 11.8%), and adolescents 16 and older (14.2 to 16.3%). Yet there was a decrease in testing for females with a concurrent pregnancy test (29.4 to 24.7%). Our control sites improved in testing males (1.5 to 4%) and sexually active females (15.2 to 25.8%).
For adolescents attending primary care clinics in the Bronx, our pilot intervention to improve STI testing rates showed no meaningful effect. As compared with clinics that did not receive our intervention, there was no change in STI testing. We hypothesize this is because our intervention was not continuously integrated into the usual delivery of care and involved only a one-time training. Future interventions might focus on health systems level changes, such as EMR prompts, to improve testing rates as well as repeated provider level reinforcement and feedback.

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