Office systems intervention to improve diethylstilbestrol screening in managed care

To examine the effectiveness of a comprehensive office systems intervention for improving identification of diethylstilbestrol (DES) exposure, a low-incidence condition with potentially severe consequences.

We developed a comprehensive office systems intervention to facilitate screening and follow-up for women exposed to DES in utero, consisting of a DES toolkit and the clinical and administrative education necessary to use the tools effectively. The intervention was implemented in the internal medicine and obstetrics-gynecology departments at six free-standing health centers in a Boston-area staff-model health maintenance organization. Intervention sites were matched and paired with a comparison group of centers. Intervention effectiveness was assessed through pretest and posttest surveys of clinicians, medical record review of 3900 women, and review of a computerized medical records data base.

There was significantly higher DES awareness and knowledge among clinical staff at intervention sites. Documentation of DES exposure in the medical record ranged from 1.14 to 2.31 times greater at intervention sites than in matched comparison sites, and rates of DES code use in pregnancy were 1.91 to 3.61 times greater.

The office systems intervention improved documentation of DES exposure in a managed care environment. Because this approach was designed to accommodate the limited time allotted for each patient visit, it not only improved DES screening but could also serve as a model for integrating screening for other low-prevalence but potentially serious conditions into routine care.