Sexually transmitted disease diagnostic experience among outpatient clinicians in the United States,

1
Sexually transmitted disease diagnostic
experience among outpatient clinicians in the
United States, 2004

• Nidhi Jain MD MPH
• Health Services Research and Evaluation Branch
• Division of STD Prevention

This information is distributed solely for the
purposes of pre-dissemination peer review under
applicable information quality guidelines. It has
not been formally disseminated by the CDC. It
does not represent and should not be construed to
represent any agency determination or policy.
2
Sexually transmitted diseases in the United States

• Chlamydia- 929,462 cases reported
• Gonorrhea- 330,132 cases reported
• Genital herpes- 269,000 initial visits
• Genital warts- 316,000 initial visits

STD surveillance report 2004
3
STD burden and costs among youths age 15-24 years

• new cases Costs ()
• in 2000
• Chlamydia 1.5 million 248.4 million
• HSV 640,000 292.7 million
• HPV 4.6 million 2.9 billion
• HIV 15,000 3.0 billion
• Chesson H, Blandford J, Gift T, Tao G, Irwin K.
  The Estimated Direct Medical Cost of Sexually
  Transmitted Diseases Among American Youth, 2000.
  Perspectives on Sexual and Reproductive Health.
  2004 36(1)

4
STD care in the United States

• 40-60 of STD cases are treated outside of STD
  clinics
• Bacterial STDs are treated in public settings
• Viral STDs are treated in private settings
• Factors influence where STD care is accessed
• Sex, ie female patients go to private clinics
• Race, ie white patients go to private clinics
• Income level, ie higher income go to private
  clinics
• Inconvenience, esp. clinic hours
• Embarrassment and stress

5
Objective

• Characterize who is providing STD care in the
  United States from a national survey of
  clinicians who see adolescents and adult patients
  who are likely to be sexually active

6
Study Design

• Stratified sampling design of US providers
• Random sample taken from national registries
  (760-828 for each specialty)
• Physicians
• Family/General practice (FP)
• Adolescent medicine (ADOL)
• Internal medicine (IM)
• Obstetrics/Gynecology (OB/GYN)
• Urologists (URO)
• Dermatologists (DERM)
• Midlevel providers
• Physician assistants (PA)
• Certified nurse midwives (CNM)
• Nurse practitioners (NP)

7
Survey Methods

• Self-administered mail surveys May-September 2004
• Surveys Fed exed to 6,906 randomly selected
  clinicians
• Cover letter noted results will inform new
  clinician training and decision supports tools
  and patient education materials
• Repeat mailings sent at 3,6,9,and 15 week to
  encourage response

8
Selected survey topics

• Demographic characteristics of clinicians
• Characteristics of practice and patients
• STD experience
• Patient education requests for information to
  prevent STD and how clinicians provided
  information

9
Data Analysis

• All analyses in SAS and SUDAAN
• weighted to adjust for differences by specialty
  in sampling and non-response
• Two-sided probability 0.05 considered significant
• Chi-square test to compare percentages

10
Results
11
Response rates adjusted for eligibility by
specialty and non-response

• Physicians
• OB/GYN 81
• Adolescent med 79
• Dermatology 80
• Urology 78
• Family Practice 68
• Internal Medicine 59

• Midlevels
• Nurse practitioners 96
• Nurse midwives 95
• Physician assistants 86

6906 surveys mailed- 4305 completed Overall
response rate after adjusting for deceased,
retired, ineligible, or did not have current
address respondents 81
12
Reported characteristics of respondents (n4305)

• Demographic characteristics
• 50 yrs old 40
• Female 41
• Practicing 20 yrs 36
• Practice characteristics
• Practice in private practice office 73
• Solo practice 26
• Saw 100 patients per week 46
• Region
• Northeast 21
• Midwest 22
• South 33
• West 24
• Urban setting 80

13
Reported characteristics of respondents (n4305)

• Patient characteristics
• Mean patients who were female 65
• Mean patients who were white 68
• Female patients 18-50 y/o 39
• Male patients 18-50 y/o 31
• Patients primary method of payment
• 75 patients had private insurance 21

14
Reported STD diagnostic experience in the past 12
months (n4305)
defined as having seen 1 case in the past 12
months
15
STD diagnostic experience by specialty (median)
16
STD diagnostic experience by specialty (median)
17
STD diagnostic experience by specialty (median)
18
STD diagnostic experience by specialty (median)
19
Patient education requests for information on how
to prevent STDs
20
Patient education requests for information on how
to prevent STDs
21
Patient education requests for information on how
to prevent STDs
22
Reported provider provision of STD prevention
education to patients
23
Reported provider provision of STD prevention
education to patients
24
Reported provider provision of STD prevention
education to patients
25
Reported provider provision of STD prevention
education to patients
26
STD experience based on practice having majority
privately insured patients vs. practice having
majority patients with other insurance
statistically significant with p 27
Requests for STD prevention information based on
practice having majority privately insured
patients vs. practice having majority patients
with other insurance
statistically significant with p 28
Conclusions

• Many US healthcare clinicians practice in private
  practice offices with a majority of patients
  paying with other types of insurance and not
  private insurance
• STD care is being provided by different types of
  clinicians
• Dermatologists and urologists are managing many
  viral STD cases
• Mid-level providers seeing many STD cases

29
Conclusions

• Many patients request information on how to
  prevent STD
• Patients are asking all specialty types of
  clinicians
• Many clinicians are providing information in
  person, but not providing written materials or
  using other staff
• Practices whose reimbursement is primarily from
  private insurances are seeing equal to more STD
  cases and are getting many requests for
  information for STD prevention

30
Strengths and limitations

• Strengths
• Large sample size with high response rate (81)
• Use of stratified sampling design and case
  weights give estimates that are representative of
  specialties surveyed
• Inclusion of midlevel providers in the survey
• Limitations
• Poor response rates from some clinicians, esp.
  family practitioners and internists
• Information bias if reported results are not
  identical to actual practices.
• This analysis is a sub-analysis of a larger
  survey on HPV knowledge, attitudes and practices

31
Recommendations

• Encourage awareness and provision of STD care
  across all specialties in all types of practices
• Further research to understand how patients
  decide to go to certain types of clinicians
  and/or practices for STD care
• Can help target STD prevention interventions to
  certain specialty groups and patient groups
• Ensure proper STD care is being provided
• Use of STD treatment guidelines
• Timely reporting is being done

32
Recommendations

• Collaborate with other organizations
• Update clinical training and clinical decision
  support tools
• Especially for dermatologists, mid-level
  providers
• Ensure reimbursement is adequate for STD care and
  STD prevention education
• Update patient and public education materials

33
Acknowledgements

• CDC, Division of STD Prevention, Atlanta
• Kathleen Irwin, MD, MPH
• Nidhi Jain, MD, MPH
• Rheta Barnes, MSN, MPH
• Maya Sternberg, PhD
• Battelle Centers for Public Health Research and
  Evaluation, Seattle
• Daniel Montaño, PhD
• Danuta Kasprzyk, PhD
• Linda Carlin, PhD
• Crystal Freeman, PhD, MPH
• Jeanine Christian, MA
• Charles Wolters, MS

34
Reported practice re-imbursement by specialty type
35
Reported age group breakdown of patients by
specialty type
36
Survey Eligibility

• Eligibility requirements
• Spend 8 hours per week in outpatient care
• Provide routine health exams
• 20 or more of patients aged 13 to 65 years

Not for specialists (urologists and
dermatologists)
37
Survey Disposition