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

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. Midlevels % Nurse practitioners 96 Nurse midwives 95 Physician assistants 86 Physicians % OB/GYN 81 Adolescent med 79 Dermatology 80 Urology 78 Family Practice 68 Internal Medicine 59 Response rates adjusted for eligibility by specialty and non-response 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 (n=4305) 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 (n=4305) 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 79 ≥ 75% patients had private insurance 21

14. Reported STD diagnostic experience in the past 12 months (n=4305) *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 patientswith other insurance *statistically significant with p < 0.05

27. Requests for STD prevention information based on practice having majority privately insured patients vs. practice having majority patientswith other insurance *statistically significant with p < 0.05

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 Battelle and University of Washington, Seattle William Philips, MD, MPH University of Washington, Seattle Laura Koutsky, PhD

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