Implementation of changing clinical practices: Prenatal syphilis screening in Texas




Terrillion, Ryan
Lemuz, Tiffany
Kinard, Ashlyn
Johnson, Kaeli
Griner, Stacey


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Purpose: Congenital syphilis can cause negative health outcomes including stillbirths, miscarriages, birth defects, and infant death. From 2016-2020, national congenital syphilis rates have increased from 16.2 to 57.3 cases per 100,000 live births. Texas congenital syphilis rates are significantly higher than the national rates and have increased 835% from 2016-2020. Prenatal syphilis screening by providers can avert maternal and neonatal mortality and morbidity, although there are conflicts between national professional organization’s recommended guidelines and individual state screening mandates. State dissemination and clinical integration of updated screening mandates are imperative to reduce the rates of congenital syphilis in Texas. The purpose of this study is to understand the factors influencing implementation of prenatal syphilis screening guidelines into clinical practice.

Methods: Prenatal providers including physicians (MD/DO) and mid-level providers (CNM/NP/PA) in Texas were recruited to participate in an in-depth interview. Recruitment strategies included social media advertising, newsletters of professional organizations, and direct email recruitment. The interview guide was based on constructs from the Consolidated Framework for Implementation Research, an implementation science theory focused on identifying determinants, or factors, that influence translation into practice. Interviews were approximately 45 minutes in length, were conducted via Zoom or phone, were audio recorded and then transcribed by a professional. Data were thematically analyzed with emergent and theory-based codes.

Results: Respondents were certified nurse midwives and physicians (n=9) who discussed implementation of changing clinical practices in the context of the Texas Department of State Health Services (TDSHS) updated mandate for prenatal syphilis screening at delivery in 2019. Participants expressed difficulty with having clear communication and resources from TDSHS about changes, reliance on email updates from professional organizations for new screening recommendations, and both formal and informal colleague dialogues as sources of policy updates. Specific difficulties expressed were the confusing TDSHS website interface, ineffective email communications that are not practice-specific, and lack of data to understand the need for a change in practice for their populations. The interviewees discussed how population and professional ethics affect prenatal screening practices and the ease of changing orders once new policy changes were agreed upon by management stakeholders.

Conclusion: Varied responses from participants regarding the source of TDSHS updated mandates for prenatal syphilis screening indicate that there are no universally effective methods of communication between TDSHS and clinicians to understand, be notified of, and/or implement new mandates in a timely and uniform manner. The clinicians also noted deference to national professional organizations as institutions that they could rely on for clear communication about policy recommendations that highlighted their practice needs while considering TDSHS communications as required for practice rather than a source of clinically relevant state and community health data. Understanding of how clinician perceptions of prenatal syphilis risk for their patient populations would change with relevant local statistics within TDSHS communications would further elucidate roadblocks to integration of state mandates into clinical practice. The development of context specific implementation strategies for providers in Texas can improve prenatal syphilis screening and ultimately reduce the adverse neonatal outcomes.


Research Appreciation Day Award Winner - SaferCare Texas, 2023 Excellence in Patient Safety Research Award - 2nd Place