臨床實務介入可增加青少女的披衣菌篩檢


  June 1, 2009 — 根據發表於6月小兒及青少年醫學檔案期刊的隨機控制試驗結果,一種臨床實務介入(CPI)顯著改善部份青春期少女接受急症照護時的披衣菌篩檢。
  
  加州大學舊金山分校的Kathleen P. Tebb博士等人寫道,未加治療的CT[砂眼披衣菌]感染會導致骨盆發炎疾病、子宮外孕以及不孕。因為這些感染多數沒有症狀,例行性篩檢是唯一可偵測多數CT案例的方法。儘管建議所有有性行為的青少年與26歲以下青年每年至少進行一次CT篩檢,但是篩檢率相當低。
  
  研究目標是設計與評估某介入方式於有性經驗的青少女接受急症照護時能否增加砂眼披衣菌篩檢。
  
  北加州的大型健康維護組織(HMO)中,有10間小兒科診所提供14至18歲少女急症照護服務,隨機分派為介入組(5間診所)或控制組(5間診所)。介入方式包括每月與提供者團隊會面一次,且診所員工開會重新設計他們診所的方式,以改善急症照護時的披衣菌篩檢目標。控制組的診所接受有關披衣菌篩檢的資料。
  
  從2005年4月至2006年9月,研究者估計每一診所有性行為青少女的批衣菌篩檢率,此為研究主要終點。
  
  相較於控制組,介入組急症照護時的披衣菌篩檢率隨著時間顯著增加(相似比,χ2 (1) = 18.7;P < .001)。介入組的少女披衣菌篩檢比率,從開始時到第5次介入時增加達15.93%,而對照組診所的篩檢比率僅增加2.13%。
  
  研究作者寫道,此介入方式顯著改善青少女在急症照護時的CT篩檢比率。儘管此方法成功,但急症照護時的CT篩檢仍有明顯障礙。相當需要可提供有關CT、其他性行為傳染與懷孕基本資訊的創新策略,因為許多青少年在過去一年間從未接受預防照護。
  
  研究限制包括缺乏大型HMO體系之外的一般性。此外,較少診所完全採用所有的介入手段,有一間診所因為嚴重的勞資問題而停止了介入計畫。
  
  研究作者寫道,為了呈現青少年與青年人的CT流行程度,需將注意力集中在急症照護的諸多青少年與青年,特別是那些有CT高風險者,與健康照護系統銜接。針對這類族群的介入方式是有挑戰性的,只有和CT篩檢過程有關的諸多步驟可以成功支持員工和病患本身。探究可隨著時間發揮效果的介入方式也是重要的,特別是這類族群的急症照護時。
  
  麻州大學醫學院的Diane Blake醫師在編輯評論中表示,確保持續評估在非臨床對象中的披衣菌篩檢,證明新篩檢對象獲得一樣的成功。Blake醫師寫道,青少年接受篩檢機會的可能性越高,篩檢選項的漏洞就越少,有性行為之青少年的披衣菌篩檢比率有可能達到100%。這是一個極高的目標,但是值得推動。Tebb博士等人的研究讓我們更靠近這個目標。
  
  疾病控制與預防中心健康照護研究與品質小組以及Kaiser Garfield紀念基金會支持本研究。研究作者之一有部份接受母嬰健康局的資助。其他研究作者宣告沒有相關財務關係。
  
  Blake醫師之前接受GenProbe公司資助進行披衣菌篩檢成本效益分析,接受約翰霍普金斯醫學院的顧問費用。
  

Clinical Practice Intervention May Increase Chlamydia Screening in Teen Girls

By Laurie Barclay, MD
Medscape Medical News

June 1, 2009 — A clinical practice intervention (CPI) significantly improved the proportion of adolescent girls screened for chlamydia during urgent care, according to the results of a randomized controlled trial reported in the June issue of Archives of Pediatrics & Adolescent Medicine.

"Untreated CT [Chlamydia trachomatis] infections can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility," write Kathleen P. Tebb, PhD, from University of California-San Francisco, and colleagues. "Since most of these infections have no symptoms, routine screening is the only way to detect the majority of CT cases. Despite recommendations for at least annual screening for CT among all sexually active adolescents and young adults younger than 26 years, screening rates remain low."

The goal of this study was to design and assess an intervention to increase screening for Chlamydia trachomatis in sexually active adolescent girls seen during pediatric urgent care.

At a large health maintenance organization (HMO) in northern California, 10 pediatric clinics offering urgent care services to adolescent girls aged 14 to 18 years were randomly assigned to an intervention group (5 clinics) or to a control group (5 clinics). The intervention consisted of a monthly meeting in which a team of providers and clinic staff met to redesign their clinic system with the goal of improving chlamydia screening during urgent care. Clinics in the control group received an informational lecture on chlamydia screening.

From April 2005 to September 2006, the investigators estimated the clinic-specific proportions of sexually active girls screened for chlamydia, which was the main endpoint of the study.

Compared with the control group, the intervention group had significantly greater change with time in clinic-specific chlamydia screening rates in urgent care (likelihood ratio, χ2 (1) = 18.7; P < .001). The proportion of girls screened for chlamydia increased by 15.93% in the intervention group from baseline to the fifth intervention period, whereas it decreased by 2.13% in the comparison clinics.

"The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care," the study authors write. "Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year."

Limitations of this study include possible lack of generalizability beyond large HMO systems. In addition, few clinics fully adopted all of the intervention components, and significant labor and management issues prevented 1 clinic from implementing the intervention as it was intended.

"To address the CT epidemic among our adolescent and young adult populations, attention needs to be given to the urgent care setting, the setting in which many adolescents and young adults, especially those at high risk for CT, interface with the health care system," the study authors write. "Targeting interventions for this setting is challenging and will only be effective to the extent that as many of the steps involved in the CT screening process can be redirected to other support staff and the patients themselves. It will be important to also investigate the extent to which intervention effects can be sustained over time, especially in urgent care given the constraints in this setting."

In an accompanying editorial, Diane Blake, from University of Massachusetts Medical School in Worcester, recommends assuring ongoing access to chlamydia screening in nonclinical settings with proven success as well as further exploration of novel settings for screening.

"The more possibilities there are for an adolescent to 'bump into' a screening opportunity, the fewer holes there will be in the patchwork of screening options, which will increase the probability of approaching 100% chlamydia screening of sexually active adolescents," Dr. Blake writes. "This is a lofty goal, but one well worth pursuing. The study by Tebb and colleagues moves us a step closer to this goal."

The Centers for Disease Control and Prevention Agency for Healthcare Research and Quality and the Kaiser Garfield Memorial Fund supported this study. One of the study authors was also supported in part by a grant from the Maternal and Child Health Bureau. The other study authors have disclosed no relevant financial relationships.

Dr. Blake previously conducted a chlamydia-screening cost-effectiveness analysis funded by a grant from GenProbe, Inc, and was paid as a consultant by Johns Hopkins School of Medicine.

Arch Pediatr Adolesc Med. 2009;163:559-564, 585-586.

    
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