"The Spokane County STD Medical Coalition (STDMC) is a coalition of local health care providers and other partners formed in January 2007 in response to increasing rates of chlamydia and other sexually transmitted diseases (STDs). The Spokane Regional Health District (SRHD) surveyed all Spokane County physicians, physician assistants (PAs), and nurse practitioners (ARNPs) practicing in the five specialties that provide the majority of STD-related care in November of 2005. The purpose of the survey was to evaluate the extent to which providers in Spokane County were screening patients for chlamydia, to identify potential barriers to screening, and to identify strategies for public health intervention. Almost 40% of providers were found to not be screening according to recommended clinical practice guidelines. Survey results were used to identify strategies to improve chlamydia screening rates of Spokane County clinicians; a primary recommendation was to use a peer-to-peer approach to influence the practice of other clinicians in the community. Survey respondents had also been asked to indicate whether or not they would be willing to serve on a local STD expert panel. The response to this question was positive; 48 providers indicated that they would, or potentially would serve in such a capacity.
Providers who had indicated interest in participating on an expert panel were invited to an initial meeting in January 2007—thus forming the current STD Medical Coalition. Initially, the STDMC had a small budget – primarily staff time (.25 FTE, approximately $15,000) and funds for meetings supplies and food ($1,000). Funds were drawn from general fund dollars. The SRHD received grant monies slated by the legislature for purposes of disease control in 2008. The STDMC budget was expanded to its current budget of approximately $20,000-$25,000 which supports salary and benefits of lead staff, STDMC-sponsored trainings, and special projects. The goal of the STD Medical Coalition is to improve reproductive health and reduce sexually transmitted diseases in Spokane County through the following objectives: 1) improving STD-related care in the community by influencing the practice of clinicians, 2) promoting sexual and reproductive health policy to influence clinicians, schools, and billing systems, and 3) providing guidance to SRHD on various public health projects and community outreach efforts to increase uptake of preventive screenings and prevention knowledge.
The Coalition is currently 30 members strong, representing health care organizations from across the community. To date, the STDMC has completed the following activities related to improving STD-related care in the community: developed and disseminated a comprehensive online STD toolkit for clinicians (found at http://stdtoolkit.srhd.org/) that received 1,699 hits since 2008; developed and disseminated 9 STDMC newsletters on 15 different STD-related topics to over 2,000 clinicians; organized a speaker’s bureau and delivered 10 speaking engagements at clinical grand rounds to 136 attendees; and participated in 3 didactic, formal trainings in partnership with the Seattle STD/HIV Prevention Training Center.
Activities related to policy include distribution of a letter promoting compliance with the Healthy Youth Act (HYA) among schools. The HYA requires that schools provide comprehensive sexuality education in compliance with state regulations but schools can still opt out of providing sexuality education altogether; promotion of clinical practice recommendations for routine Chlamydia screening; and promotion and delivery of Expedited Partner Therapy (EPT), a strategy recently approved by the Washington State Board of Medical Quality Assurance and the Washington State Pharmacy Board, and a current focus of University of Washington research efforts. Finally, with regard to the objective of public health outreach, the STDMC has contributed to the development of a comprehensive adolescent"
Chlamydia trachomatis is the most frequently reported communicable disease in Spokane County. Nationwide, the highest rates of chlamydia occur in young women less than age 19 years, the next highest in young women age less than 25 years. In Spokane in 2009, the highest reported incidence is in young people ages 20-24 (1499.3/100,000). Adolescents ages 15-19 have the second highest rates of chlamydia (1238.6/100,000). The reason for the discrepancy between local and national data is not know for sure.
However, access to care may be a factor, and actual incidence may be greater than the data demonstrates due to insufficient testing among minors. Adolescents are generally at higher risk of acquiring an infection due to the greater likelihood of unsafe sexual practices, such as multiple partners and unprotected sex. National Youth Risk Behavior Survey (YRBS) data indicate that almost 50% of adolescents have had sex by age of 18. In addition, adolescent females are more susceptible than older women to infection because of developmental differences in the cell structure of the cervix. Research indicates that one in four sexually active youth are infected with an STD by age 24. Most chlamydia infections are asymptomatic and there are serious potential health consequences to undiagnosed infection.
The clinical sequelae of chlamydia infection includes chronic pelvic pain, pelvic inflammatory disease (PID), ectopic pregnancy, spontaneous abortion, neonatal conjunctivitis and pneumonia, preterm labor and low birth weight, and infertility. Untreated infections often result in long-term consequences to sexual and reproductive health and subsequently contribute to rising health care costs. It is estimated that untreated chlamydia infection and associated sequelae costs the United States more than $2 billion per year. The burden of disease on patients, health care payers, and society is substantial and unnecessary. Addressing rising rates of chlamydia and other STDs and improving the general reproductive health of Spokane County residents by addressing risky sexual behaviors, particularly among adolescents and young adults, became a strategic priority of the SRHD’s Disease Prevention and Response Division.
Agency Community RolesThe role of the Spokane Regional Health District (SRHD) is to serve as primary facilitator of the Coalition. The Coalition is facilitated by a SRHD representative and a clinician representative from the medical community. From its inception, the STDMC has been a collaboration to address a public health issue—the burden of STDs in the community. As the primary facilitator, the SRHD convenes meetings, identifies promising practices to consider for implementation, gauges interest from the STDMC, and works with the group to formulate action plans for implementation of chosen practices and projects.
Costs and ExpendituresThe Spokane County STD Medical Coalition (STDMC) is a coalition of local health care providers and other partners formed in January 2007 in response to increasing rates of chlamydia and other sexually transmitted diseases (STDs). The Spokane Regional Health District (SRHD) surveyed all Spokane County physicians, physician assistants (PAs), and nurse practitioners (ARNPs) practicing in the five specialties that provide the majority of STD-related care in November of 2005. The purpose of the survey was to evaluate the extent to which providers in Spokane County were screening patients for chlamydia, to identify potential barriers to screening, and to identify strategies for public health intervention.
Almost 40% of providers were found to not be screening according to recommended clinical practice guidelines. Survey results were used to identify strategies to improve chlamydia screening rates of Spokane County clinicians; a primary recommendation was to use a peer-to-peer approach to influence the practice of other clinicians in the community. Survey respondents had also been asked to indicate whether or not they would be willing to serve on a local STD expert panel.
The response to this question was positive; 48 providers indicated that they would, or potentially would serve in such a capacity. Providers who had indicated interest in participating on an expert panel were invited to an initial meeting in January 2007—thus forming the current STD Medical Coalition. The goal of the STD Medical Coalition is to improve reproductive health and reduce sexually transmitted diseases in Spokane County through the following objectives: 1) improving STD-related care in the community by influencing the practice of clinicians, 2) promoting sexual and reproductive health policy to influence clinicians, schools, and billing systems, and 3) providing guidance to SRHD on various public health projects and community outreach efforts to increase uptake of preventive screenings and prevention knowledge.
ImplementationTASKS: We conducted a thorough review of the literature to identify factors that contribute to rising STD rates, as well as strategies and activities to control disease in a community. We conducted a further assessment of the healthcare community to fill gaps in data (i.e. chlamydia screening practices of clinicians). We surveyed clinicians and assessed their interest and willingness to participate on a coalition to address the issues identified. Using the information derived from the survey and the literature review, we clarified the purpose and objectives of the coalition and drafted materials to share with prospective participants. We used these materials to share our vision of how these partners might be of assistance, clarifying coalition purpose and scope. Members were provided ample opportunity to give feedback and make changes.
In this way we identified that the three primary objectives of the coalition were to: 1) improve STD-related healthcare, 2) promote policy to support disease control, and 3) provide guidance to public health on community outreach strategies.
Over the course of the first 3 meetings, a list of potential activities/strategies for each of the three objectives was presented to coalition participants as a starting point for discussion. Participants were then invited to discuss these and present alternate or additional activities or strategies, were asked to prioritize activities, and invited to “sign up” to participate on the activities of greatest interest via online surveys using SurveyMonkey. Subsequent meetings and surveys were used to carry out and develop activities further with leadership provided by public health staff and a clinician co-facilitator. We repeated this process for each of the objectives - identifying activities and strategies via review and research of literature and best practice, presenting the information to the coalition for discussion, reviewing progress and prioritizing activities annually, and asking for participants to take on components of activities. We found that this approach helped us demonstrate progress quickly and maintain the interest of busy practicing clinicians, but has also been heavily reliant on staff time and resources
Timeframe: The following describes the general timeline of Coalition activities. February 2007-first meeting covering purpose, objectives, and expectations of the Coalition and introduction of possible projects; Feb to May 2007- conducted online survey to select activities and gauge participant interest for each objective and activity; May 2007- held meeting to begin to prioritize and develop specific activities for the policy and provider outreach objectives (we identified clinician trainings and a STD toolkit for clinician); Sept 2007- continued to work on prioritization of policy issues and continued work to implement clinician outreach strategies (worked on design and content of provider toolkit, assigned clinicians for the materials review process, identified venues for Speakers Bureau presentations); Feb 2008- held meeting and provided first year progress report, continued work on clinician outreach strategies, and initiated discussions related to the third coalition objective of public health outreach (we focused on adolescent sexual health education); April to May 2008- policy letter to parents, educators, school boards in support of comprehensive sex education and rolled out the STD toolkit; May 2008- identified strategies for adolescent health outreach (website, sports physicals testing, school-based health centers); November 2008- worked on adolescent outreach strategies, prioritized activities for 2009, and evaluated the Coalition to date. Each year we review and prioritize activities for the year in the first meeting of the quarter and work on priority activities during the rest of the year. This process is captured in our annual Coalition “Road Maps.”Coalition activities are evaluated biennually.
The STDMC efforts are part of the larger effort of the Communicable Disease Prevention program to address STDs in the community. Thus, it is difficult, if not impossible, to draw specific conclusions regarding the impact of Coalition efforts on population outcomes and some impact outcomes. There are three primary objectives of the STD Medical Coalition to meet the overall goal of improving reproductive health and reducing sexually transmitted diseases in Spokane County. Generally, the efforts of the STDMC are evaluated through use of a logic model, utilizing activity outputs, process, impact and population outcomes. Evaluating the Coalition itself is considered a process outcome. We do this semiannually through a survey sent to all Coalition members. The survey gathers their feedback on meeting times, effectiveness of meetings, collaboration, and on specific Coalition activities. Results of evaluations are shared back with STDMC participants at the year end meeting. The results of Coalition surveys and logic model findings are used to help evaluate Coalition activities and prioritize activities for the next year's Coalition work plan. Additionally, logic model data is evaluated within the Communicable Disease Prevention program in order to assess relative effectiveness of Coalition work against other program activities, and shared across the agency and at Statewide STD Program Manger meetings. Below are specific objectives that are measured, utilizing findings to date drawn from the 2008 and 2009 logic models.
The first objective is to: improve STD-related care in the community by influencing the practice of clinicians. There are four primary activities for the first objective. 1) Conducting educational outreach through passive dissemination of information. Performance Measures: the number of Coalition newsletters distributed, the number of clinicians reached by the newsletter, number of Coalition members writing articles(outputs); surveying newsletter recipients on newsletter satisfaction (process) and impact on knowledge (impact).
Data Collection: developed and distributed 8 STDMC newsletters with input from 4 different coalition members on 14 different STD-related topics. Distributed to over 2,000 clinicians in the community. Evaluation Results: Surveyed newsletter recipients in 2008 to gauge impact but had response from only 30 people. 100% of respondents indicated that they found the information useful.
Feedback: Due to difficulties assessing usefulness of newsletter and costs, we limited distribution to only those clinicians reporting STDs to the SRHD. 2) Organizing and conducting office-based trainings as part of quality improvement projects with individual clinics. Performance Measurements: number of quality improvement projects conducted and clinicians in attendance (outputs); and evaluating the impact on clinic chlamydia screening rates through data pulls utilizing electronic medical records and office billing systems and/or clinic chart review to determine chlamydia screening rates before and after quality improvement efforts and trainings are completed (impacts).
Data Collection: Conducted one quality improvement project with a participating STDMC member. 23 clinicians in attendance. Assessment of chlamydia screening rates before implementation of QI intervention using billing system query indicated screening compliance at 100%. Manual chart review showed screening rates at only 31%.
Evaluation Results: the QI training was not well received by participating providers in the pilot site. Additionally, electronic data query methodology proved inaccurate. Participation of STDMC was minimal due to time requirements. Feedback: staff concluded that the QI project should target family planning clinics that focus on STDs instead of expending energy promoting the project to family practices. The QI project was repeated with a family planning clinic with much greater success, led entirely by SRHD staff.
Stakeholder commitment: Since its inception in 2007, the STD Medical Coalition has maintained an active registry of local health providers and community partners that has expanded to 37 current members in 2011. The STDMC holds quarterly meetings to address current issues and projects, each meeting boasting between 15-27 members. STDMC’s accomplishments related to improving STD-related care in the community include development and dissemination of a quarterly newsletter, delivery of speaking engagements, participation in policy efforts surrounding the Healthy Youth Act (HYA), and participation on a community advisory board working to establish a school based health center (SBHC) network in Spokane County. Each of the aforementioned activities has involved concentrated and in-depth direction from its members. The consistent attendance and participation over the past four years demonstrates the members’ dedication to fulfilling the peer-to-peer outreach approach to meet the overall goal of improving reproductive health and reducing sexually transmitted diseases in Spokane County.
Spokane Regional Health District (SRHD) as primary facilitator provides strong leadership and engages in active recruitment of new members to encourage continuing levels of enthusiasm with new ideas and work plans. Additionally, biennial STDMC membership surveys are conducted to identify membership satisfaction and interest. Results to date indicate strong commitment to the STDMC mission and vision, including direct support from members to continue collaboration in improving STD-related care within their own practices and throughout the medical community in the event of dissolution. SRHD has incorporated primary facilitation of the STDMC into the job responsibilities of the Disease Prevention and Response Health Program Specialist 2, which has scheduled funding until at least December 2013. Sustainability: Spokane Regional Health District and STDMC members are committed to broad-based involvement and participation of community partners. A strategic goal of the STD Medical Coalition for 2011 is to strengthen partnerships among community entities, including the Inland Academy of Family Physicians and the Spokane County Medical Society. Not only do these partnerships increase the Coalition’s target audience for pertinent and appropriate trainings and speaking engagements, they also provide additional fiscal resources with which to utilize in supporting projects and work plans. Several of the scheduled projects for 2011-2012 and 2012-2013, including geographically targeting neighborhoods with high health disparities to increase access to reproductive services and launching a home-collection STD testing kit program to increase access to STD testing among adolescents and rural populations, require a collaboration of efforts rather than duplication of efforts.
The STDMC plans to form ad-hoc sub-committees to address each project/work plan more holistically and in conjunction with key representatives from apposite community partners. Program staff have worked hard to develop positive relationships with the Department of Health STD program and have subsequently been able to leverage additional resources to support STDMC project work. The SRHD has been the recipient of a small grant to support STDMC projects, and have received additional support in the form of patient education materials and testing/treatment resources through the Infertility Prevention Project. Relationships have also been developed with the Seattle STD/HIV Prevention Training Center (PTC). PTC staff have worked with the SRHD to bring trainings to Spokane and have also assisted with review of the STD online Toolkit. Maintaining these relationships will continue to facilitate access to resources. Additionally, the Health District staff responsible for facilitation of the STDMC actively pursue grant opportunities to support the efforts of the STDMC.