Sexually transmitted disease Sexually transmitted disease diagnostic experience among diagnostic experience among

outpatient clinicians in the United outpatient clinicians in the United States, 2004States, 2004

Nidhi Jain MD MPHNidhi Jain MD MPH

Health Services Research and Evaluation BranchHealth Services Research and Evaluation Branch

Division of STD PreventionDivision of STD Prevention

This information is distributed solely for the purposes of pre-dissemination peer review under 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 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.not represent and should not be construed to represent any agency determination or policy.

Sexually transmitted diseases in the Sexually transmitted diseases in the United StatesUnited States

Chlamydia- 929,462 cases reportedChlamydia- 929,462 cases reported

Gonorrhea- 330,132 cases reportedGonorrhea- 330,132 cases reported

Genital herpes- 269,000 initial visits Genital herpes- 269,000 initial visits

Genital warts- 316,000 initial visitsGenital warts- 316,000 initial visits

*STD surveillance report 2004

STD burden and costs among STD burden and costs among youths age 15-24 years*youths age 15-24 years*

# new cases# new cases Costs ($)Costs ($)in 2000in 2000

ChlamydiaChlamydia 1.5 million1.5 million 248.4 million248.4 millionHSVHSV 640,000640,000 292.7 million292.7 millionHPVHPV 4.6 million4.6 million 2.9 billion2.9 billionHIVHIV 15,00015,000 3.0 billion3.0 billion

**Chesson H, Blandford J, Gift T, Tao G, Irwin K. The Estimated Direct Medical Chesson H, Blandford J, Gift T, Tao G, Irwin K. The Estimated Direct Medical Cost of Sexually Transmitted Diseases Among American Youth, 2000. Cost of Sexually Transmitted Diseases Among American Youth, 2000. Perspectives on Sexual and Reproductive Health. 2004: 36(1)Perspectives on Sexual and Reproductive Health. 2004: 36(1)

STD care in the United StatesSTD care in the United States

40-60% of STD cases are treated outside of 40-60% of STD cases are treated outside of STD clinicsSTD clinics Bacterial STDs are treated in public settingsBacterial STDs are treated in public settings Viral STDs are treated in private settingsViral STDs are treated in private settings

Factors influence where STD care is accessedFactors influence where STD care is accessed Sex, ie female patients go to private clinicsSex, ie female patients go to private clinics Race, ie white patients go to private clinicsRace, ie white patients go to private clinics Income level, ie higher income go to private clinicsIncome level, ie higher income go to private clinics Inconvenience, esp. clinic hoursInconvenience, esp. clinic hours Embarrassment and stressEmbarrassment and stress

ObjectiveObjective

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

Study DesignStudy 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)

Survey MethodsSurvey Methods Self-administered mail surveys May-September 2004Self-administered mail surveys May-September 2004

Surveys Fed exed to 6,906 randomly selected Surveys Fed exed to 6,906 randomly selected cliniciansclinicians

Cover letter noted results will inform new clinician Cover letter noted results will inform new clinician training and decision supports tools and patient training and decision supports tools and patient education materialseducation materials

Repeat mailings sent at 3,6,9,and 15 week to Repeat mailings sent at 3,6,9,and 15 week to encourage responseencourage response

Selected survey topicsSelected survey topics

Demographic characteristics of cliniciansDemographic characteristics of clinicians

Characteristics of practice and patientsCharacteristics of practice and patients

STD experienceSTD experience

Patient education requests for information to Patient education requests for information to prevent STD and how clinicians provided prevent STD and how clinicians provided informationinformation

Data AnalysisData Analysis

All analyses in SAS and SUDAAN – All analyses in SAS and SUDAAN –

weighted to adjust for differences by specialty weighted to adjust for differences by specialty in sampling and non-responsein sampling and non-response

Two-sided probability 0.05 considered Two-sided probability 0.05 considered significantsignificant

Chi-square test to compare percentagesChi-square test to compare percentages

ResultsResults

Response rates adjusted for eligibility by Response rates adjusted for eligibility by specialty and non-responsespecialty and non-response

Midlevels Midlevels % %

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

PhysiciansPhysicians % %

OB/GYNOB/GYN 81 81Adolescent med 79Adolescent med 79DermatologyDermatology 80 80UrologyUrology 78 78Family Practice 68Family Practice 68Internal Medicine 59Internal Medicine 59

6906 surveys mailed- 4305 completedOverall response rate after adjusting for deceased, retired, ineligible, or did not have current address respondents = 81%

Reported characteristics of Reported characteristics of respondents (n=4305)respondents (n=4305)

Demographic characteristics:Demographic characteristics: %%≥≥ 50 yrs old50 yrs old 4040FemaleFemale 41 41 Practicing > 20 yrsPracticing > 20 yrs 3636

Practice characteristics:Practice characteristics:Practice in private practice officePractice in private practice office 7373Solo practice Solo practice 2626Saw Saw ≥ 100 patients per week≥ 100 patients per week 4646

Region:Region:NortheastNortheast 2121MidwestMidwest 2222SouthSouth 3333WestWest 2424Urban settingUrban setting 8080

Reported characteristics of Reported characteristics of respondents (n=4305)respondents (n=4305)

Patient characteristics:Patient characteristics: %%

Mean % patients who were femaleMean % patients who were female 6565Mean % patients who were white Mean % patients who were white 6868Female patients 18-50 y/oFemale patients 18-50 y/o 3939Male patients 18-50 y/oMale patients 18-50 y/o 31 31

Patients primary method of paymentPatients primary method of payment

< 75% patients had private insurance < 75% patients had private insurance 7979≥ ≥ 75% patients had private insurance75% patients had private insurance 2121

Reported STD diagnostic experience in the past 12 months (n=4305)

% clinicians with recent experience*

Mean # cases (95% CI)

median

HSV 91 16 (14-17) 5

Genital warts 89 10 (9-11) 2

Chlamydia 80 14 (13-16) 5

HIV 50 5 (4-6) 0

*defined as having seen ≥ 1 case in the past 12 months

STD diagnostic experience by specialty (median)STD diagnostic experience by specialty (median)

HSVHSV Genital wartsGenital warts ChlamydiaChlamydia HIVHIV

Family PhysicianFamily Physician 55 22 55 11Internal MedicineInternal Medicine 44 00 22 11Adolescent medicineAdolescent medicine 22 11 55 00OB/GYNOB/GYN 1515 1212 1010 00Nurse Mid-wivesNurse Mid-wives 1010 1010 1515 00DermatologyDermatology 1010 1010 00 22UrologyUrology 44 44 22 11Nurse PractitionersNurse Practitioners 88 33 1010 11Physician AssistantsPhysician Assistants 66 22 66 11TotalTotal 55 22 55 00

STD diagnostic experience by specialty (median)STD diagnostic experience by specialty (median)

HSVHSV Genital wartsGenital warts ChlamydiaChlamydia HIVHIV

Family PhysicianFamily Physician 55 22 55 11Internal MedicineInternal Medicine 44 00 22 11Adolescent medicineAdolescent medicine 22 11 55 00OB/GYNOB/GYN 1515 1212 1010 00Nurse Mid-wivesNurse Mid-wives 1010 1010 1515 00DermatologyDermatology 1010 1010 00 22UrologyUrology 44 44 22 11Nurse PractitionersNurse Practitioners 88 33 1010 11Physician AssistantsPhysician Assistants 66 22 66 11TotalTotal 55 22 55 00

STD diagnostic experience by specialty (median)STD diagnostic experience by specialty (median)

HSVHSV Genital wartsGenital warts ChlamydiaChlamydia HIVHIV

Family PhysicianFamily Physician 55 22 55 11Internal MedicineInternal Medicine 44 00 22 11Adolescent medicineAdolescent medicine 22 11 55 00OB/GYNOB/GYN 1515 1212 1010 00Nurse Mid-wivesNurse Mid-wives 1010 1010 1515 00DermatologyDermatology 1010 1010 00 22UrologyUrology 44 44 22 11Nurse PractitionersNurse Practitioners 88 33 1010 11Physician AssistantsPhysician Assistants 66 22 66 11TotalTotal 55 22 55 00

STD diagnostic experience by specialty (median)STD diagnostic experience by specialty (median)

HSVHSV Genital wartsGenital warts ChlamydiaChlamydia HIVHIV

Family PhysicianFamily Physician 55 22 55 11Internal MedicineInternal Medicine 44 00 22 11Adolescent medicineAdolescent medicine 22 11 55 00OB/GYNOB/GYN 1515 1212 1010 00Nurse Mid-wivesNurse Mid-wives 1010 1010 1515 00DermatologyDermatology 1010 1010 00 22UrologyUrology 44 44 22 11Nurse PractitionersNurse Practitioners 88 33 1010 11

Physician AssistantsPhysician Assistants 66 22 66 11TotalTotal 55 22 55 00

Patient education requests for information Patient education requests for information on how to prevent STDson how to prevent STDs

Respondents reported that at least some patients had asked for information…

% 95% CI

Family PhysicianFamily Physician 8585 81-8981-89

Internal MedicineInternal Medicine 7878 73-8373-83

Adolescent medicineAdolescent medicine 8787 84-9084-90

OB/GYNOB/GYN 9393 91-9691-96

Nurse Mid-wivesNurse Mid-wives 9393 91-9591-95

DermatologyDermatology 7171 67-7567-75

UrologyUrology 7777 74-8174-81

Nurse PractitionersNurse Practitioners 9090 88-9288-92

Physician AssistantsPhysician Assistants 8787 84-9084-90

TotalTotal 8484 83-8683-86

Patient education requests for information Patient education requests for information on how to prevent STDson how to prevent STDs

Respondents reported that at least some patients had asked for information…

% 95% CI

Family PhysicianFamily Physician 8585 81-8981-89

Internal MedicineInternal Medicine 7878 73-8373-83

Adolescent medicineAdolescent medicine 8787 84-9084-90

OB/GYNOB/GYN 9393 91-9691-96

Nurse Mid-wivesNurse Mid-wives 9393 91-9591-95

DermatologyDermatology 7171 67-7567-75

UrologyUrology 7777 74-8174-81

Nurse PractitionersNurse Practitioners 9090 88-9288-92

Physician AssistantsPhysician Assistants 8787 84-9084-90

TotalTotal 8484 83-8683-86

Patient education requests for information Patient education requests for information on how to prevent STDson how to prevent STDs

Respondents reported that at least some patients had asked for information…

% 95% CI

Family PhysicianFamily Physician 8585 81-8981-89

Internal MedicineInternal Medicine 7878 73-8373-83

Adolescent medicineAdolescent medicine 8787 84-9084-90

OB/GYNOB/GYN 9393 91-9691-96

Nurse Mid-wivesNurse Mid-wives 9393 91-9591-95

DermatologyDermatology 7171 67-7567-75

UrologyUrology 7777 74-8174-81

Nurse PractitionersNurse Practitioners 9090 88-9288-92

Physician AssistantsPhysician Assistants 8787 84-9084-90

TotalTotal 8484 83-8683-86

Reported provider provision of STD Reported provider provision of STD prevention education to patientsprevention education to patients

Not done Not done routinelyroutinely

I do in I do in personperson

Other Other staffstaff

Written Written materialsmaterials

Family PhysicianFamily Physician 13 75 4 9

Internal MedicineInternal Medicine 34 54 3 8

Adolescent medicineAdolescent medicine 4 82 6 8

OB/GYNOB/GYN 14 64 4 18

Nurse Mid-wivesNurse Mid-wives 6 81 3 9

Nurse PractitionersNurse Practitioners 7 78 5 8

Physician AssistantsPhysician Assistants 9 79 2 10

TotalTotal 1818 6868 44 1010

Reported provider provision of STD Reported provider provision of STD prevention education to patientsprevention education to patients

Not done Not done routinelyroutinely

I do in I do in personperson

Other Other staffstaff

Written Written materialsmaterials

Family PhysicianFamily Physician 13 75 4 9

Internal MedicineInternal Medicine 34 54 3 8

Adolescent medicineAdolescent medicine 4 82 6 8

OB/GYNOB/GYN 14 64 4 18

Nurse Mid-wivesNurse Mid-wives 6 81 3 9

Nurse PractitionersNurse Practitioners 7 78 5 8

Physician AssistantsPhysician Assistants 9 79 2 10

TotalTotal 1818 6868 44 1010

Reported provider provision of STD Reported provider provision of STD prevention education to patientsprevention education to patients

Not done Not done routinelyroutinely

I do in I do in personperson

Other Other staffstaff

Written Written materialsmaterials

Family PhysicianFamily Physician 13 75 4 9

Internal MedicineInternal Medicine 34 54 3 8

Adolescent medicineAdolescent medicine 4 82 6 8

OB/GYNOB/GYN 14 64 4 18

Nurse Mid-wivesNurse Mid-wives 6 81 3 9

Nurse PractitionersNurse Practitioners 7 78 5 8

Physician AssistantsPhysician Assistants 9 79 2 10

TotalTotal 1818 6868 44 1010

Reported provider provision of STD Reported provider provision of STD prevention education to patientsprevention education to patients

Not done Not done routinelyroutinely

I do in I do in personperson

Other Other staffstaff

Written Written materialsmaterials

Family PhysicianFamily Physician 13 75 4 9

Internal MedicineInternal Medicine 34 54 3 8

Adolescent medicineAdolescent medicine 4 82 6 8

OB/GYNOB/GYN 14 64 4 18

Nurse Mid-wivesNurse Mid-wives 6 81 3 9

Nurse PractitionersNurse Practitioners 7 78 5 8

Physician AssistantsPhysician Assistants 9 79 2 10

TotalTotal 1818 6868 44 1010

STD experience based on practice having STD experience based on practice having majority privately insured patients vs. practice majority privately insured patients vs. practice having majority patientshaving majority patients with other insurancewith other insurance

Percentage of patients with private Percentage of patients with private insuranceinsurance

Saw Saw ≥ 10 cases in ≥ 10 cases in past year ofpast year of

≥≥75%75% <<75% 75%

ChlamydiaChlamydia 3737 3636

Genital herpesGenital herpes 56*56* 4141

Genital wartsGenital warts 3636 2626

HIVHIV 55 1111

*statistically significant with p < 0.05

Requests for STD prevention information based Requests for STD prevention information based on practice having majority privately insured on practice having majority privately insured patients vs. practice having majority patientspatients vs. practice having majority patients

with other insurancewith other insurance

Percentage of patients with private Percentage of patients with private insuranceinsurance

% of providers % of providers reporting that …..reporting that …..

≥≥75%75% <<75% 75%

Some or more Some or more patients asked for patients asked for information on how to information on how to prevent STDs prevent STDs

88*88* 8383

*statistically significant with p < 0.05

ConclusionsConclusions

Many US healthcare clinicians practice in Many US healthcare clinicians practice in private practice offices with a majority of private practice offices with a majority of patients paying with “other” types of patients paying with “other” types of insurance and not private insuranceinsurance and not private insurance

STD care is being provided by different STD care is being provided by different types of clinicianstypes of clinicians Dermatologists and urologists are managing Dermatologists and urologists are managing

many viral STD casesmany viral STD cases Mid-level providers seeing many STD casesMid-level providers seeing many STD cases

ConclusionsConclusions

Many patients request information on how to Many patients request information on how to prevent STDprevent STD Patients are asking all specialty types of Patients are asking all specialty types of

cliniciansclinicians Many clinicians are providing information in Many clinicians are providing information in

person, but not providing written materials or person, but not providing written materials or using other staffusing other staff

Practices whose reimbursement is primarily Practices whose reimbursement is primarily from private insurances are seeing equal to from private insurances are seeing equal to more STD cases and are getting many more STD cases and are getting many requests for information for STD preventionrequests for information for STD prevention

Strengths and limitationsStrengths and limitations

Strengths:Strengths: Large sample size with high response rate (81%) Large sample size with high response rate (81%) Use of stratified sampling design and case weights Use of stratified sampling design and case weights

give estimates that are representative of specialties give estimates that are representative of specialties surveyed surveyed

Inclusion of midlevel providers in the survey Inclusion of midlevel providers in the survey

Limitations:Limitations: Poor response rates from some clinicians, esp. family Poor response rates from some clinicians, esp. family

practitioners and internistspractitioners and internists Information bias if reported results are not identical to Information bias if reported results are not identical to

actual practices. actual practices. This analysis is a sub-analysis of a larger survey on This analysis is a sub-analysis of a larger survey on

HPV knowledge, attitudes and practicesHPV knowledge, attitudes and practices

RecommendationsRecommendations

Encourage awareness and provision of STD care Encourage awareness and provision of STD care across all specialties in all types of practicesacross all specialties in all types of practices

Further research to understand how patients Further research to understand how patients decide to go to certain types of clinicians and/or decide to go to certain types of clinicians and/or practices for STD carepractices for STD care Can help target STD prevention interventions to Can help target STD prevention interventions to

certain specialty groups and patient groupscertain specialty groups and patient groups Ensure proper STD care is being provided Ensure proper STD care is being provided

Use of STD treatment guidelinesUse of STD treatment guidelines Timely reporting is being done Timely reporting is being done

RecommendationsRecommendations

Collaborate with other organizationsCollaborate with other organizations:: Update clinical training and clinical Update clinical training and clinical

decision support toolsdecision support tools Especially for dermatologists, mid-level Especially for dermatologists, mid-level

providersproviders Ensure reimbursement is adequate for Ensure reimbursement is adequate for

STD care and STD prevention educationSTD care and STD prevention education Update patient and public education Update patient and public education

materialsmaterials

AcknowledgementsAcknowledgementsCDC, Division of STD Prevention, AtlantaCDC, Division of STD Prevention, Atlanta

Kathleen Irwin, MD, MPHKathleen Irwin, MD, MPHNidhi Jain, MD, MPHNidhi Jain, MD, MPH

Rheta Barnes, MSN, MPHRheta Barnes, MSN, MPHMaya Sternberg, PhDMaya Sternberg, PhD

Battelle Centers for Public Health Research and Evaluation, SeattleBattelle Centers for Public Health Research and Evaluation, SeattleDaniel Montaño, PhDDaniel Montaño, PhD

Danuta Kasprzyk, PhDDanuta Kasprzyk, PhDLinda Carlin, PhDLinda Carlin, PhD

Crystal Freeman, PhD, MPHCrystal Freeman, PhD, MPHJeanine Christian, MAJeanine Christian, MACharles Wolters, MSCharles Wolters, MS

Battelle and University of Washington, SeattleBattelle and University of Washington, SeattleWilliam Philips, MD, MPHWilliam Philips, MD, MPH

University of Washington, SeattleUniversity of Washington, SeattleLaura Koutsky, PhDLaura Koutsky, PhD

Reported practice re-imbursement by Reported practice re-imbursement by specialty typespecialty type

≥≥75% with 75% with private ins.private ins.

<75% with <75% with private ins.private ins.

Family PhysicianFamily Physician 24 76

Internal MedicineInternal Medicine 15 85

Adolescent medicineAdolescent medicine 41 59

OB/GYNOB/GYN 52 48

Nurse PractitionersNurse Practitioners 13 87

Nurse Mid-wivesNurse Mid-wives 27 73

Physician AssistantsPhysician Assistants 28 72

DermatologistsDermatologists 19 81

UrologistsUrologists 9 79

TotalTotal 2525 6868

Reported age group breakdown of Reported age group breakdown of patients by specialty typepatients by specialty type

Female patients Female patients

18-50 y/o18-50 y/o

Male patients Male patients 18-50 y/o18-50 y/o

Family PhysicianFamily Physician 44 41

Internal MedicineInternal Medicine 33 31

Adolescent medicineAdolescent medicine 54 52

OB/GYNOB/GYN 69 -

Nurse PractitionersNurse Practitioners 59 53

Nurse Mid-wivesNurse Mid-wives 89 -

Physician AssistantsPhysician Assistants 57 52

DermatologistsDermatologists 45 43

UrologistsUrologists 28 26

TotalTotal 4848 3939

Survey EligibilitySurvey Eligibility

Eligibility requirements:Eligibility requirements: Spend Spend ≥≥ 8 hours per week in outpatient 8 hours per week in outpatient

carecare Provide routine health exams*Provide routine health exams* 20% or more of patients aged 13 to 65 20% or more of patients aged 13 to 65

years*years*

* Not for specialists (urologists and dermatologists)

Survey DispositionSurvey Disposition

6906 Surveys mailed

1005 Refused/ No response 881 Ineligible

715 Undeliverable/ Deceased 4305 Completed surveys