Patient-delivered partner therapy for chlamydia infections

Attitudes and practices of California physicians and nurse practitioners

Speaker: Laura PackelCo-Authors: Sarah Guerry, Heidi Bauer, Miriam Rhew, Gail Bolan

Sexually Transmitted Disease Control Branch, CA Department of Health Services

2004 National STD Prevention ConferenceMarch 11, 2004

Background

More than 110,000 CT infections were reported in California in 2002.

Repeat CT infection increases risk for adverse health outcomes

Untreated partner is a risk for repeat infection

Allowing patient to deliver antibiotics to sexual partner(s) may facilitate partner treatment and reduce re-infection

Background

New California law allowing patient-delivered partner therapy (PDPT) passed in January of 2001

Implementation of PDPT legislation

California Department of Health Services guidelines for implementation of PDPT

Newsletter articles Provider education and training

Survey Objectives

To examine attitudes and practices around PDPT among clinicians in California

To determine areas for intervention with the goal of increasing appropriate use of PDPT in California

Survey Sample and Design Cross-sectional, self-administered, mailed survey of

primary care providers (medical doctors & nurse practitioners) in California

Medical Doctors (MDs): stratified random sample of MDs in California, 400 per primary care specialty, plus all 68 adolescent medicine providers

Nurse Practitioners (NPs): All 1,815 primary care NP members of California Coalition of Nurse Practitioners

Time frame: Dec 2001-March 2002

Eligibility and Recruitment Eligibility criteria:

• Provide primary care to sexually active patients under the age of 30 in the past 3 months

• Spend more than 10% of time providing clinical care

Exclusion criteria:• Not practicing within California• No valid mailing address• No valid phone number

Recruitment: • 3 mailings• fax and phone follow-up

Analytic Methods Main outcome of interest: reported routinely use of

PDPT to male or female partners of CT cases Routinely use of PDPT=‘usually’ or ‘always’ Overall proportions for physicians weighted by

medical specialty NPs and MDs not combined because of differences

in sampling Pearson chi-squared, logistic regression used for

statistical analysis

Results: Response Rates

MD response rate: • 49%, 708/1456 eligible MDs

NP response rate: • 63%, 895/1418 eligible NPs

MD and NP Respondent Demographics%MD (n=708) %NP (n=895)

Age Group

<45 37% 42%

45-55 32% 45%

>55 31% 14%

Gender

Male 66% 4%

Female 34% 96%

Practice Setting

Private practice/HMO 82% 58%

Public/Academic 18% 42%

Volume of female patients/week

Less than 11 42% 27%

11-20 24% 30%

More than 20 34% 43%

MD Respondents by Medical Specialty (n=708)

Specialty

Family Practice 25%

General Practice 13%

Internal Medicine/Adult 16%

Pediatrics 18%

Obstetrics-gynecology 23%

Adolescent medicine 6%

Chlamydia Partner Management Practices

0 10 20 30 40 50 60 70 80 90 100

Ask patient to contact HD

Ask HD to contact partner

See partner even if not insured

Provide RX for Female Partners

Provide RX for Male Partners

Tell patient to inform partner

Routinely perform (%)

MD*

NP

*weighted

Routine Use of PDPT: Overall MD and NP and by Medical Specialty

48 50

6055 54 52

4337

0

10

20

30

40

50

60

70

80

90

100

NP Overall MD Overall* Ob/Gyn AdolescentMed

GeneralPractice

FamilyPractice

Pediatrics InternalMedicine

% R

ou

tin

e U

se P

DP

T

*Weighted

Barriers to PDPT

Agreement with the following statements: Patient-delivered partner therapy for

chlamydia…• Is an activity my practice may not get paid for• Is dangerous without knowing partner’s

medical/allergy history• May get me sued• May result in incomplete care for the partner• Should only be for male partners of females• Should only be given if partner name is given

Provider Barriers to PDPT

0 20 40 60 80 100

Only for male partners

Partners name must be provided

May get me sued

Practice not paid for

Dangerous without knowing hx

Incomplete care for partner MD*

NP

* weightedStrongly agree/agree (%)

→→

→

→ Significant predictors of PDPT

MD predictors of routine use of PDPT

Specialty Wtd % OR (95% CI) Adjusted OR* (95% CI)

Internal Medicine 37% Referent Referent

Ob/Gyn 60% 2.51(1.50-4.22) 1.82 (1.01-3.27)

Adolescent Med 55% 2.08 (0.98-4.42) 1.36 (0.62-2.98)

Family Practice 52% 1.81 (1.09-3.01) 1.79 (1.04-3.10)

General Practice 54% 1.97 (1.08-3.59) 1.86 (0.97-3.58)

Pediatrics 43% 1.30 (0.74-2.29) 1.22 (0.67-2.24)

Barriers

No allergy history 37.2% 0.44 (0.30-0.64) 0.56 (0.36-0.87)

Incomplete care 41.7% 0.63 (0.43-0.91) 0.83 (0.55-1.26)

Sued for 37.8% 0.47 (0.33-0.65) 0.68 (0.43-1.09)

*Adjusted for volume of female patients per week, MD specialty and barriers

←

←

←

NP predictors of routine use of PDPT

Female pts per week

% OR (95% CI) Adjusted OR* (95% CI)

<11 40.5 Referent Referent

11-20 49.2 1.48 (1.03-2.12) 1.44 (0.98-2.11)

>20 51.3 1.61 (1.15-2.25) 1.38 (0.97-1.98)

Barriers

No allergy history 35.3 0.32 (0.24-0.43) 0.51 (0.37-0.71)

Incomplete care 39.2 0.41 (0.31-0.54) 0.62 (0.46-0.85)

Sued for 27.9 0.31 (0.22-0.43) 0.51 (0.35-0.74)

*Adjusted for volume of female patients per week and barriers

←←←

Conclusions

~ 50% of CA MDs and NPs reported routinely use PDPT in practice

MDs: Significant differences between specialties in routine use of PDPT

For both MDs and NPs: reported concerns about PDPT were predictors of routine use of PDPT

Conclusions: Most Common Barriers

Incomplete care for partner Practice may not be reimbursed Dangerous without knowing partner

medical and/or allergy history

Next Steps

Improve use of PDPT among MDs and NPs in California

Educate around potential barriers to PDPT may help increase routine use

Develop of more specific guidelines around PDPT use

Reimbursement mechanisms CA Partner services evaluation ongoing