Presented by Judy Shlay, MD, MSPH, Associate Director, Denver Public Health, at the 2013 National Chlamydia Coalition meeting

1. Integration of Family Planning
Services into an STD Clinic Setting
National Chlamydia Coalition Meeting
February 21, 2013
J. Shlay, D. McEwen, D. Bell, M. Maravi, D. Rinehart,
H. Fang, S. Devine, T. Mickiewicz, S. Dreisbach

2. Presenter Disclosures
• Presenter: Judith C. Shlay, MD
• No relationships to disclose

3. Why Integrate Family Planning
with STD Care
• Unintended pregnancy has significant individual
and public health consequences
• Similar behaviors lead to both STDs and
unintended pregnancy
• Patients seeking STD services may not have
another source for FP services

4. Our Program
• Offers FP services at least once a year to
eligible males/females presenting for STD
services
• Refers to primary care for
ongoing contraceptive/
reproductive care needs
• Offers continuity services for teens and high-risk
women who require additional support to avoid
unintended pregnancy and STD/HIV

5. Services for Women
• STD screening, testing, and treatment
• Family Planning:
– Preconception counseling
– Pregnancy testing
– Initial contraception (3-months) and/or emergency contraception

6. Services for Women
• Contraception offered at the DMHC:
– Oral contraceptives
– Transdermal patch
– Vaginal ring
– DMPA
– IUDs and progestin-only implant
– Condoms
– Emergency contraception
• Referrals for sterilizations

7. Services for Men
• STD screening, testing, and treatment
• Family Planning:
– Involve men in pregnancy planning and prevention
– Provide accurate information on available methods,
benefits of spacing children, safe pregnancy/delivery
– Preconception counseling
– Contraception: offer condoms, female-directed methods
discussed
• Emergency contraception
• Referrals for vasectomies

8. Objectives
• Measure change in enrollment into FP services
after implementation of an integrated STD/family
planning record with electronic eligibility
reminder
• Compare client and staff satisfaction before and
after implementation
• Calculate the additional staff time and clinic
costs required to offer FP services to STD
clients
• Explore incident pregnancy and STD rates
before and after implementation

9. Methods
• Quasi-experimental comparison of enrollment and
patient/provider satisfaction before (2008) and after
(2010) implementation
• Incident pregnancy and STD 12-months after initial visit
before and after were explored
• Time and cost were calculated to perform integrated
FP/STD services
• Quantitative and qualitative analyses were performed

10. Streamlining Clinic Processes
Registration
Triage
 Identify symptoms
 Interest in FP Services
New Pt Visit STD Follow-up Express Visit FP Visit Only
 Sexual history  STD follow-up  Sexual history  FP only
 STD testing  Physical exam prn  STD screening  NP, RN
 Physical exam  FP, if applicable  FP, if applicable
 FP, if applicable  NP, RN, LPN  LPN, RN, NP
 NP, RN

11. Electronic Medical Record

12. Electronic Medical Record

13. Results of Integration of Services
Pre-Integration of Services Post-Integration of Services
(2008) (2010)
• 9,656 clients were eligible • 10,021clients were
for FP services eligible for FP services
• Males 5,842 and females • Males 5,852 and females
3,853 (40% female) 4,169 (42% female)
• Among those eligible: • Among those eligible:
51.6% received FP 95.3% received FP
services: services:
– Males 53.3% – Males 94.7%
– Females 49.1% – Females 96.2%

14. Effectiveness of Contraceptive
Method Provided to Client
• Receipt of method at conclusion of the clinic visit
(assessed for only 2010):
– highly effective method: 24.4% to 29.9%, p<0.01
– moderate effective method: 14.8% to 28.6%, p<0.01
– moderate-low effective method: 33.4% to 26.3%,
p<0.01
– low effective method: 5.8%% to 2.7%, p<0.01
– abstinence: 6.5% to 7.7%, p=0.01

15. Dual Contraceptive Use
• Dual use assessed 2010 only:
– Effective dual use included LARC/hormonal
method plus condom
– Less effective dual use included any other
method plus condom
• Effective dual method use: 25.2%
• Less effective dual method use: 4.6%
• No dual use: 70.2%

16. Incident Pregnancy
2008* 2010*
N (%) N (%)
Enrolled 86/1116 (7.7) 199/1519 (13.1)
Not-enrolled 80/411 (19.5) 7/27 (25.9)
P-value <0.01 0.05
*Denominator reflects number with follow-up information

17. Incident STDs
2008 2010
N (%) N (%)
Enrolled Not-enrolled P-value* Enrolled Non-enrolled P-value*
Female:
CT 112/657 67/469 (14.3) 0.21 179/1370 (13.1) 3/36 (8.3) 0.61†
(17.0)
GC 29/657 (4.4) 14/468 (3.0) 0.22 32/1375 (2.3) 1/36 (2.8) 0.57†
Male:
CT 97/559 (17.4) 64/376 (17.0) 0.89 138/1042 (13.2) 4/36 (11.1) 1.00†
GC 33/559 (5.9) 23377 (6.1) 0.90 51/1049 (4.9) 1/36 (2.8) 1.00†
*
Chi-square p-value
†
Fisher exact test two sided p-value

18. Time and Cost Study
• Additional time and cost of integrating FP
services into STD visit: 4.01 minutes and $3.57
• Other additional costs:
– Lab: $5.36
– Overhead: $5.66
– Supplies without providing LARC methods:
$1.04
– Supplies including providing LARC methods:
$14.66

19. Time and Cost Study
• Total additional cost:
– $29.25 (with LARC)
– $15.63 (without LARC)

20. Staff Thoughts about
Integrated Services
• All expressed greater job satisfaction providing
integrated care
• All believe integrated FP-STD EMR facilitated
more seamless care and enrollment of more
eligible patients

21. Patient Satisfaction with
Integrated Services
• Survey before and after integrated FP record in EMR
– 101 patients in 2009 who received integrated services
– 168 patients in 2010 who received integrated services
• 99.5% and 99% very satisfied/satisfied (p=0.76) before
and after integrated EMR
• 86.0% and 79.6% reported the services met their family
planning needs (p=0.26)

22. Limitations
• Likely an underestimation of pregnancies and
STDs since some patients never return to the clinic
• Program conducted in a clinical setting; unable to
control for all potential confounders
• Formal cost-benefit analysis not performed

23. Conclusions
• STD clinics serve high-risk men and women,
many of whom use these clinics because they
lack access to reproductive health care services
• Integration of services is feasible, well accepted
by staff/patients and provides two valuable
services to at-risk populations in a single visit
– Focuses on overlapping health care issues and
behavior
• An electronic reminder of eligibility in the EHR
facilitates enrollment in FP services among STD
clinic patients

24. Conclusions
• Integrated program appears to reduce
pregnancy rates and not increase STD rates
• Offering these integrated services in an STD
setting requires minimal additional time and cost
– With first dollar coverage for contraceptive services
(Affordable Care Act) and STD clinics developing
processes to bill for services, the ability to cover these
additional costs should be realized

25. Questions
Additional information:
Judith Shlay, MD, MSPH
jshlay@dhha.org
303-602-3714