Brief reports
Multicomponent Internet continuing medical education to promote chlamydia screening

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Background

Low Chlamydia trachomatis screening rates create an opportunity to test innovative continuing medical education (CME) programs. Few studies of Internet-based physician learning have been evaluated with objective data on practice patterns.

Design

This randomized controlled trial tested a multicomponent Internet CME (mCME) intervention for increasing chlamydia screening of at-risk women aged 16 to 26 years.

Setting

Eligible physician offices had ≥20 patients at risk for chlamydia as defined by the Health Plan Employer Data and Information Set (HEDIS), had at least one primary care physician (internal medicine, family medicine/general practice, pediatrics) with Internet access, and participated in the study managed care organization. The 191 randomized primary care offices represented 20 states.

Intervention

The intervention, available from February to December 2001, consisted of four case-based learning modules, was tailored in real time to each physician based on theory of behavior change, and included office-level feedback of chlamydia screening rates.

Main outcome measure

HEDIS chlamydia screening rates for the pre-intervention (2000) and post-intervention (2002) periods.

Results

Pre-intervention screening rates for the intervention and comparison offices were 18.9% and 16.2% (p =0.135). Post-intervention screening rates for the intervention and comparison offices were 15.5% and 12.4%, respectively (p =0.044, adjusting for baseline performance).

Conclusions

The substantial decline in chlamydia screening rates observed in the comparison offices was significantly attenuated for the intervention offices. The mCME favorably influenced chlamydia screening by primary care physicians.

Introduction

The gap between routine medical care and best care has generated many studies on implementing best practices.1, 2, 3 Consequently, continuing medical education (CME) activities have been widely disseminated, with U.S. expenditures of >$1.3 billion dollars in 2002.4 However, the ineffectiveness of traditional CME in changing practice5 led the Institute of Medicine to suggest that the current CME system is “broken.”6

With the growing call for more experimental studies of “learning in practice” with clinically relevant outcomes,7 low screening rates for women at risk for Chlamydia trachomatis create a laboratory for testing innovative CME approaches. Despite cost-effective screening tests and treatments8, 9, 10, 11, 12, 13 and considerable attention from professional and regulatory organizations,14, 15 chlamydia screening rates remain unacceptably low.16, 17, 18, 19, 20, 21 For example, the average chlamydia screening rate for at-risk women aged 16 to 25 years reported by commercial managed care plans to the National Committee for Quality Assurance (NCQA) was 25% in 2002 and 30% in 2003.16

Chlamydia is the most commonly reported sexually transmitted disease, with reported rates increasing from 78.5 per 100,000 population to 455.4/100,000 between 1987 and 2002.22 Although most infections in women are asymptomatic,23 the risks of complications, such as pelvic inflammatory disease and ectopic pregnancy, are considerable.24 Therefore, a randomized trial was conducted in 20 states to test a multicomponent CME (mCME) intervention for increasing chlamydia screening for at-risk women in the managed care setting.

Section snippets

Overview

This study was funded by the Agency for Healthcare Research and Quality as part of the Translating Research into Practice (TRIP II) initiative.1 Primary care offices (n =191) participating in the study managed care organization were randomized to an intervention or comparison group (Table 1). Physicians in the intervention group received mCME modules and physicians in the comparison group received flat-text, Internet-based CME modules on women’s health. The main outcome was the

Results

Of all eligible offices (n =978), 325 (33%) were recruited (Figure 1, Phase I). From the recruited offices, 191 (59%) participated. Within participating offices, an average of 1.1 physicians engaged the study Internet site at least once (Table 1). Over the 1-year intervention period, the average physician completed 2.4 of 4 available modules. On average, each module required 12.3 (standard deviation, 9.2) minutes to complete. Office and physician characteristics did not differ significantly by

Discussion

This randomized trial demonstrated that an Internet CME program significantly blunted a decline in chlamydia screening rates observed in comparison offices. Because chlamydia is the most common bacterial STD, small increments in screening rates may detect large numbers of new cases.29 For example, the overall prevalence among females entering the National Job Training Program in 2002 was 10.5%.22 Given that urine screening tests operate with high sensitivity (93% to 99%) and specificity (96% to

Limitations

Additional limitations not mentioned elsewhere warrant discussion. First, this study did not examine changes in chlamydia detection rates, treatment rates, or patient outcomes. However, strong evidence links screening with improved outcomes. Second, recent studies suggest that the HEDIS measure may not be entirely accurate in determining chlamydia risk from administrative data44 or screening status from laboratory data.45 Third, Internet-based CME is more appealing to physicians with greater

Conclusion

This randomized trial of a multicomponent, Internet-based CME intervention found an attenuated decrease in screening rates for offices exposed to the intervention. The demonstrated impact on practice patterns coupled with low intervention intensity increases the potential importance of mCME as a learning method that is easy to disseminate. The appropriateness of mCME for other conditions and settings must be assessed.

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