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Public Health Detailing as a Strategy to Address Congenital Syphilis
Sonali Kulkarni, MD, MPH
Medical Director, Division of HIV and STD Programs
skulkarni@ph.lacounty.gov
213-351-8264
Los Angeles
CA
90005
Your summary must address all the questions below:
Los Angeles County (LAC) spans over 4,000 square miles and includes 88 cities, 26 health districts, and a mix of urban, suburban and rural areas. With a population of 10.2 million residents, including a large number of immigrants, LAC is among the most ethnically and economically diverse regions in the nation.
Between 2012 and 2018, the number of cases of congenital syphilis in Los Angeles County (LAC) has increased 800% (from 6 cases in 2012 to 54 in 2018), coinciding with a similar rise in annual syphilis cases among women of reproductive age, which increased 430% (from 134 cases in 2012 to 602 in 2018). In 2018, LAC’s Department of Public Health (DPH) adopted aggressive local syphilis screening guidelines for women to improve disease control, including one-time universal screening women of reproductive age, and for pregnant women, re-screening early in the third trimester (between 28-32 weeks) and again at delivery. Despite rising syphilis rates, many health care providers are not fully aware of the extent to which syphilis is affecting their community and what local DPH clinical recommendations exist for syphilis control and congenital syphilis prevention.
Public Health Detailing (PHD) is a promising intervention used by local health departments to effectively communicate with health care providers about new or best practices. Like academic detailing, public health detailing builds on some of the techniques used by medical industry representatives to gain access to health care providers for a brief encounter and tutorial, and to advance key public health messages. In 2018, DPH created a first-of-its-kind syphilis focused campaign to raise awareness of rising congenital syphilis and syphilis cases in women. An accompanying physical “Syphilis in Women Action Kit” was developed with information on syphilis screening, staging and treatment as well as mandatory reporting guidelines, and general STD screening and treatment.[i] The goal of the practice was to enlist a broad network of medical providers across LAC to help combat rising syphilis rates in women and reduce congenital syphilis cases. The objectives were to increase provider awareness of local syphilis trends, increase provider awareness of the new DPH screening guidelines for women, and to increase the proportion of female patients screened for syphilis by these providers.
The PHD campaign, conducted between May and July 2018, focused on two groups of health care providers: 1) Medicaid perinatal medical providers, and 2) health care providers identified through LAC’s STD surveillance database based on their diagnosis of at least one case of syphilis in a woman in the past year. Four trained and experienced detailers served as representatives of the LAC Department of Public Health, completing visits with health care providers 795 times within an eight-week period. Of those visits, 432 were initial visits and 363 were follow-up visits within 8 weeks of the initial visit.
At each visit, the detailer spent five to ten minutes highlighting materials in the Action Kit with the provider and reviewing the key messages regarding syphilis trends and screening guidelines. The detailers also completed an assessment of the providers knowledge of syphilis trends in LAC, their knowledge of syphilis screening guidelines in LAC, and their current syphilis screening practice for women.
Compared to baseline, there was a notable increase in provider self-reported knowledge of recent LAC syphilis trends and screening guidelines at the follow-up visit; most significantly, self-reported use of syphilis screening for their patient population also increased. Of the obstetricians who completed follow-up in this phase, the self-reported use of third trimester screening increased from 23% at baseline to 71% after the detailing visit.
While time- and resource-intensive, this intervention has demonstrated efficacy in increasing provider knowledge and changing clinical practice. PHD is also a practical way to reach health care providers in small group or solo practice, who may not hear about new trends or clinical guideline changes as quickly as their counterparts working in larger groups or hospital-based practices. LAC DPH hopes to use new additional California State STD resources to continue with this campaign to target providers caring for women of child-bearing age in specific vulnerable populations, as they are most affected by the current congenital syphilis crisis. This includes providers who care for people with substance use disorders, people who are criminal justice-involved, and homeless individuals. Detailing kit materials and additional information are available at http://ph.lacounty.gov/dhsp/SyphilisInWomen-ActionKit.htm.
[i]LAC DPH “Syphilis in Women Action Kit.” http://ph.lacounty.gov/dhsp/SyphilisInWomen-ActionKit.htm
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
Congenital syphilis and syphilis cases in women have risen tremendously in Los Angeles County (LAC) since 2012. Congenital syphilis (CS), an infection transmitted from mother to child during pregnancy and/or delivery, is an entirely preventable disease. Untreated syphilis infection in the womb can cause potentially severe consequences for a developing fetus. CS can lead to stillbirth, neonatal death, premature birth, low birth weight, and a range of complications. Fetal infection can occur during any trimester of pregnancy. Treating a pregnant woman who is infected with syphilis also treats her fetus.
To address the rising CS crisis, the Centers for Disease Control and Prevention (CDC) has called on health care providers to increase screening for syphilis among pregnant women and provide immediate treatment of women diagnosed with syphilis. In 2018, LAC’s Department of Public Health (DPH) adopted aggressive local syphilis screening guidelines for women to improve disease control and prevent congenital syphilis. Unfortunately, despite rising morbidity and traditional messaging from local, state, and national health care leaders around the importance of syphilis screening, many health care providers were not fully aware of the extent to which syphilis was affecting their community. Importantly, many providers were unaware that LAC DPH had issued the new screening guidelines recommendations.
Health care providers are continuously bombarded with emails, letters, and conference invitations regarding a host of clinical updates and best practices. It is challenging for the local health department to ensure that messages about emerging threats and new best practices are received and acted upon by health care providers in their community. This challenge is especially difficult for larger urban jurisdictions, such as LAC, where there are over 36,000 medical providers. Evidence-based models to influence provider practice, particularly in such a large jurisdiction with so many medical providers, are few.
Public Health Detailing (PHD) is a promising intervention used by local health departments to effectively communicate with health care providers about new or best practices. Like academic detailing, public health detailing builds on some of the techniques used by medical industry representatives to gain access to health care providers for a brief encounter and tutorial, and to advance key public health messages. An in-person interaction between the detailer and the provider allows for more meaningful and two-way communication between providers and the health department which would not have been possible via a standard postal mailing or email message.
New York City Department of Health and Mental Hygiene has a long history of using PHD for a range of clinical campaigns, including colon cancer screening, tobacco cessation, and HIV pre-exposure prophylaxis (PrEP), with demonstrated efficacy.[i] In 2017, LAC DPH’s Division of HIV and STD Programs launched a PrEP PHD closely aligned with that of New York City. In 2018, they created a first-of-its-kind syphilis-focused PHD campaign to raise awareness of rising congenital syphilis and syphilis cases in women. An accompanying “Syphilis in Women Action Kit” was developed with information on syphilis screening, staging and treatment as well as mandatory reporting guidelines, and general STD screening and treatment. LAC’s syphilis PHD campaign was an innovative adoption of the PHD model to a non-HIV STD, as this has not been done by any other health department in the country.
LAC DPH set out to target providers who were most likely to be serving women of reproductive age and pregnant women at elevated risk of syphilis. Given the association between poverty and STD risk in LAC, Medicaid providers were a group identified as being of high priority. In California, the Medicaid system operates the “Comprehensive Perinatal Services Program” (CPSP), which provides a wide range of culturally competent services, including nutrition, psychosocial support, and health education, to pregnant women on Medicaid. These providers are more likely to serve low-income women facing adversity such as mental illness, substance use disorders, and economic and housing insecurity. Fortunately, because the LAC CPSP providers receive technical assistance from the LAC DPH’s Maternal, Child, and Adolescent Health Program (MCAH), the LAC Division HIV and STD Program was able to receive a list of all contracted CPSP providers in LAC. LAC DPH also decided that medical providers who had diagnosed at least one case of syphilis in a female in the previous year would be prioritized for PHD. The logic was that DPH could let those providers know that the one (or few) case(s) of syphilis they had diagnosed in the previous year was not an anomaly, but consistent with larger community trends and indicative that their patient panel may be at risk of syphilis and in need of more aggressive screening.
Four trained and experienced detailers served as representatives of the LAC Department of Public Health, completing visits with health care providers 795 times within an eight-week period. Of those visits, 432 were initial visits and 363 were follow-up visits within eight weeks of the initial visit.
Due to the success of the LAC campaign, the State of California is utilizing LAC’s materials to help other jurisdictions launch their own versions of a congenital syphilis focused PHD campaign. Other state jurisdictions including Louisiana, Nevada and Ohio have requested to use and modify the Syphilis in Women Action Kit and PHD campaign. The Syphilis in Women Action Kit materials can be easily modified for the needs of differing providers and target populations.
[i] Dresser, M. G., Short, L., Wedemeyer, L., Bredow, V. L., Sacks, R., Larson, K., Silver, L. D. (2012). Public Health Detailing of Primary Care Providers: New York City’s Experience, 2003–2010. American Journal of Public Health, 102(S3). doi:10.2105/ajph.2011.300622. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22704430
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
LAC’s Public Health Detailing (PHD) campaign was led by the Division of HIV and STD Programs (DHSP) using special one-time funding from the CDC for congenital syphilis control. The goal of the endeavor was to build a larger network of medical providers in LAC screening and treating their female patients for syphilis in hopes of controlling spread of the disease. LAC DPH’s Maternal, Child, and Adolescent Health Program was a strong collaborator in identifying perinatal providers.
LAC DPH set out to target providers who were most likely to be serving women of reproductive age and pregnant women at elevated risk of syphilis. Given the association between poverty and STD risk in LAC, Medicaid providers were a group identified as being of high priority. In California, the Medicaid system operates the “Comprehensive Perinatal Services Program” (CPSP), which provides a wide range of culturally competent services, including nutrition, psychosocial support, and health education, to pregnant women on Medicaid. These providers are more likely to serve low-income women facing adversity such as mental illness, substance use disorders, and economic and housing insecurity. Fortunately, because the CPSP program is managed within the DPH’s Maternal, Child, and Adolescent Health Program (MCAH), the HIV and STD Program was able to receive a list of all contracted CPSP providers in LAC. As a result of their involvement in this project, MCAH staff incorporated the syphilis screening guidelines into their auditing tools; they are therefore able to annually assess how well CPSP providers are doing with syphilis screening and they can share this information with both the provider and LAC DPH colleagues.
The Syphilis in Women Action Kit, which was the physical kit of educational materials for the medical provider to keep, was developed within LAC DPH. However, the design of the cover was borrowed through the generosity of the Pima County (Arizona) Health Department.
For the “Syphilis in Women” PHD campaign, LAC DPH invested $30,000 for the materials, which include well produced and stylized materials. An additional $130,000 was spent on staff time for the four PHD representatives for a one-week training, which was conducted by LAC DPH staff, and eight weeks in the field doing provider visits.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
For the “Syphilis in Women” PHD campaign, LAC DPH included built-in process measure into the intervention. At each initial and follow-up visit, the detailers completed an assessment of the providers knowledge of syphilis trends in LAC, their knowledge of syphilis screening guidelines in LAC, and their current syphilis screening practice for women.
The detailers were able to conduct follow-up visits for 363 of the 432 (84%) providers initially visited. At the initial visit, the detailer obtained key demographic information for the provider and then completed a baseline assessment of the providers knowledge in five key areas: 1) self-reported knowledge of syphilis trends in LAC, 2) self-reported knowledge of syphilis screening guidelines in LAC, 3) self-reported percentage of patient for whom they obtained a sexual history, 4) self-reported percentage of their female patients currently screened for syphilis, and 5) self-reported percentage of pregnant patients currently screened for syphilis early in the third trimester (28-32 weeks). At the follow-up visit, the same tool was utilized to assess for change after the initial educational intervention.
Results were analyzed to assess for change from baseline to follow-up visit in the key areas. Compared to baseline, there was a notable increase in providers self-reporting moderate to high knowledge of recent LAC syphilis trends, with an increase from 46% at baseline to 82% at follow-up visit. At follow-up, 93% of providers reported moderate to high knowledge of syphilis screening guidelines in LAC, up from 52% at baseline. Self-reported adoption of at least one LAC screening recommendation increased from 34% to 78% at the follow-up visit. Most significantly, of the obstetricians who completed follow-up in this phase, the self-reported use of third trimester screening increased from 23% at baseline to 71% after receiving detailing.
DPH also conducted weekly check-in calls with detailers, during which “problematic” provider practices were shared such as providers relying on outdated screening guidelines from the American College of Obstetrics and Gynecology. Additional issues were brought to DPH’s attention such as lack of penicillin access in certain clinics which could be addressed in subsequent one-on-one conversations or meetings between DPH and the providers or clinics. The detailers shared information on the STD clinical consultation “warm line” with all providers, sharing that it is a good resource for questions regarding syphilis screening, diagnosis, and treatment. In the six months following the detailing effort, DPH experienced a doubling of the number of weekly calls to the warm line, which is likely a direct effect of the detailing visit effort.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
While we did not conduct a cost/benefit analysis, we know that developing a new PHD campaign is time and resource intensive. However, in this example, the intervention has demonstrated efficacy in increasing provider knowledge and changing clinical practice. Alternative evidence-based models to influence provider practice, particularly in such a large jurisdiction with so many medical providers, are lacking.
One of the unexpected lessons learned is how well the two-way in-person interaction between the detailer and the provider worked to establish a substantive connection between the LAC DPH and the provider or clinic. Detailers identified critical questions, complaints, or concerns from the providers and shared them with the DPH on a regular basis, serving to inform immediate discussions as well as future collaborations or projects. This invaluable communication and relationship-building between hundreds of providers and the health department would not have been possible via a standard postal mailing or email blast.
One significant sustainable change to local practice is that MCAH staff incorporated the syphilis screening guidelines into their auditing tools; they are therefore able to annually assess how well CPSP providers are doing with syphilis screening and they can share this information with both the provider and LAC DPH colleagues.
DPH hopes to use new additional California State STD resources to continue with this campaign, with the hope of targeting providers caring for women of child-bearing age in vulnerable populations, as they are most affected by the current congenital syphilis crisis. This includes providers who care for women with substance use disorders, who are criminal justice-involved and homeless individuals. Fortunately, due to the success of the LAC campaign, the State of California is utilizing LAC’s materials to help other jurisdictions launch their own versions of a congenital syphilis focused PHD campaign. Other state jurisdictions including Louisiana, Nevada and Ohio have requested to use and modify the Syphilis in Women Action Kit and PHD campaign. The Syphilis in Women Action Kit materials can be easily modified for the needs of differing providers and target populations.
