CELUM, CONNIE L. MD, MPH*†; BOLAN, GAIL MD‡; KRONE, MELISSA MS*; CODE, KAREN MHA*; LEONE, PETER MD§∥; SPAULDING, CORA MD§; HENRY, KEITH MD¶; CLARKE, PEGGY MPH#; SMITH, MARK MD, MBA**††; HOOK, EDWARD W. III MD‡‡
In most cities and many smaller communities, local health departments operate dedicated clinics for provision of specialized sexually transmitted diseases (STD) care. The services provided by STD clinics often include diagnostic testing, provision of therapy, partner management interventions to control the spread of STDs, human immunodeficiency virus (HIV) and STD screening, and risk reduction counseling.1,2 Nationwide public STD clinics see a disproportionate amount of reported national bacterial STD morbidity. In 1994, 69% of early syphilis, 58% of gonorrhea, and 33% of chlamydial infections were reported to the Centers for Disease Control and Prevention by STD clinics.3
Despite the fact that STD clinics are present in most cities and see a major share of reportable national STD morbidity, little is known about their clientele and why they attend STD clinics rather than other health care settings.2 As managed care organizations provide a growing proportion of health care and are being considered as cost‐effective systems for Medicaid recipients, the role of public STD clinics must be examined. Critical pieces of information germane to this debate include the demographic profile of STD clients, their income and insurance status, the reasons they choose to seek care at public STD clinics, their use of other non‐STD health care services, and their preferences for sources of STD care under an evolving system of health care. To begin to address these issues, we conducted a survey of nearly 2,500 clients seeking services at five public STD clinics in geographically diverse parts of the United States to describe the profile of patients who attend public STD clinics and why they do so.
Between April and September 1995, a standardized questionnaire was administered to clients attending five urban public health STD clinics in Birmingham, AL; Raleigh, NC; St. Paul, MN; San Francisco, CA; and Seattle, WA. Participating clinics were chosen on the basis of relatively high client volumes and to sample a geographically and demographically diverse group of clients. The five cities also have variable rates of managed care penetration, ranging from approximately 20% in Birmingham to 60% in Minneapolis‐St. Paul. Enrollment goals for each site were 250 men and 250 women, requiring oversampling of women because these STD clinics see approximately a 2:1 ratio of men to women. A convenience‐based sampling method of approaching consecutive clients during the study period was used to recruit patients presenting for new problem visits or for general STD screening. Exclusion criteria included visits for follow‐up, HIV counseling and testing only without STD screening, test results, and research projects.
In a private setting in the clinic, a designated study interviewer recruited subjects from patients in the STD clinic after registration and before being seen by a clinician and determination of fees, if any, for the clinic visit. The survey was designed to ascertain the following self‐reported characteristics of participants: income; education; insurance and third‐party payer coverage (e.g., Medicaid); employment status; reason for that day's STD clinic visit; and preferences for source of future STD care. Women were asked about prenatal care utilization during their last pregnancy. Non‐STD related general medical care utilization during the prior 3 years was ascertained and categorized as primary care source (i.e., private physician's office, community clinic, managed care organization, family planning clinic) or urgent care (i.e., emergency room or urgent care clinic). After all test results were available, each subjects' chart was reviewed to determine clinical diagnoses and laboratory test results.
The voluntary nature of the study was stressed, informed consent was obtained, and subjects were assured that information provided about income or medical insurance would not be used in the determination of STD charges or STD services provided by the clinic. The study was approved by the human subjects committees for each of the five sites.
Survey data were entered into Epi‐Info 6.0 (Centers for Disease Control and Prevention, Atlanta, GA). Cross‐tabulations and descriptive statistics were calculated using chi‐square tests for categorical variables, and Students' t tests and nonparametric tests (e.g., Mann‐Whitney) for continuous variables using SAS (Statistical Analysis Software, Carey, NC). Because the responses to reasons for choosing to attend the STD clinic were not rank‐ordered by clients and the three most important reasons were recorded, all responses were analyzed as separate, dependent variables. To analyze reasons for choosing to attend the STD clinic for that visit and predictors of preferring the STD clinic for source of future care, multivariate analyses (stepwise logistic regression) were performed using EGRET (Epidemiological Graphics, Estimation, and Testing Package, Seattle, WA). The independent variables entered in the multivariate model included demographics, income and insurance status, prior attendance at the STD clinic, use of non‐STD health care in the past 3 years, reasons for the STD clinic visit, and STD morbidity at that clinic visit.
A total of 2,490 clients were surveyed at the participating STD clinics: 506 from Seattle, WA; 500 from St. Paul, MN; 499 from Birmingham, AL; 500 from Raleigh/Wake County, NC; and 485 from San Francisco, CA. Of the 15,633 clients of new problem visits at the participating STD clinics during the study period, 15% participated in the study. The study sample was similar to the entire clinic population in terms of demographic characteristics and the STD morbidity with the exception that the study respondents were younger (51% <25 years of age compared with 38% of all clients with new problem visits during the study period) and had a higher proportion of women (50% of sample vs. 40% of all clients seen, data not shown). The refusal rate was low across all five clinics; characteristics of those who declined to participate in the study are not available.
Demographic Characteristics, Income, and Insurance Status of Study Population
Overall, survey respondents were young (51% were under 25 years of age), nonwhite (64% were of minority race or ethnicity), and heterosexual (91%), and 55% had a high school education or less. As anticipated, there were significant site‐to‐site differences in demographic characteristics of the clients surveyed (Table 1); e.g., in Birmingham, 72% of clients surveyed were <25 years of age compared with 30% of the San Francisco clients. Birmingham and Raleigh had the highest proportion of African‐American study participants, whereas at the other three sites, 45% to 55% of participants were white. Across all five sites, 17% of clients over 18 years of age had not completed high school. San Francisco and Seattle had the highest reported proportion of homosexual and bisexual men and women.
The study population reported low household incomes; 43% reported incomes of 0 to $10,000 per year, and 24% reported incomes of $10,000 to $20,000. Twelve percent of clients interviewed refused to answer the question about income (Table 1). In the cities with the highest cost of living (Seattle and San Francisco), the majority of subjects reported incomes of less than $10,000 and approximately half were unemployed.
Insurance Status of the Study Population. Across the five sites, 58% of clients surveyed were uninsured, 27% had private insurance (either employer‐based, self‐paid, or through coverage on parents' policy), and 14% had Medicaid coverage(Table 2). Of respondents who reported full‐time employment across the five sites, 51% reported no insurance coverage; however, there was no association between unemployment and lack of insurance after adjusting for site. Among the STD clients with health insurance, 33% indicated that they would not use it to pay for that STD clinic visit, stating that they did not want their insurance company to know that they had been treated for STD services (37%) or had a co‐pay‐ment or an unmet deductible (22%), did not want their parents to know they attended a STD clinic(10%), were uncertain about their coverage for STD services (7%), or wanted to avoid the inconvenience of billing their insurance (3%).
Prior Use of Other Non‐STD Care Among Subjects Previously Seen at This STD Clinic
Over half (53%) of respondents had previously attended that STD clinic (Table 2). Despite the high proportion of uninsured clients, 81% had received non‐STD health care services in the prior 3 years: 46% for routine check‐ups, 44% for acute problems, and 9% for chronic problems (Table 2). Over 85% of clients who had used medical care in the prior 3 years went to a primary care setting (managed care organizations, private physician, or community or family planning clinics), and 84% of the pregnant female clients had received prenatal care during their last pregnancy.
Reasons for Choosing the STD Clinic for Source of Care
On the day that they were surveyed, subjects were asked to identify the major reasons for having attended the STD clinic. Multiple reasons were allowed, and the reasons were not rank‐ordered. Symptoms of an STD were cited by 63%, followed by contact to an STD (18%) and STD screening (17%)(Table 3).
Participants were asked to identify up to three reasons for choosing to attend the STD clinic on the day of the interview (Table 3). The most common reasons included the availability of walk‐in services or same‐day appointments (68%), lower cost of care (59%), privacy or confidentiality concerns(43%), convenience of the STD clinic's location (40%), and expert care (34%). In multivariate analysis, with preference for walk‐in services as the dependent variable, symptoms of a possible STD was the only significant independent variable (odds ratio[OR] 1.2; 95% confidence interval [CI] = 1.0, 1.4), after adjusting for site.
Preferences for Future STD Services
To address the issue of whether participants would want to receive future care in these clinics if other options were available, they were asked, “If medical care were free, where would you have gone today for STD services?” Across all sites, 68% of patients reported that they would prefer to receive future care from the STD clinic (Table 3). In multivariate analysis, independent predictors of preferring the STD clinic for future care were as follows: having previously been seen at the STD clinic, private insurance or Medicaid coverage, and lack of use of primary care services in the prior 3 years (Table 4).
STD Diagnoses at That Visit: Clinical Diagnoses and Lab‐Confirmed Results
Approximately two thirds of participant's were diagnosed with one or more STDs (data not shown).4 Across the five clinics, the prevalence of disease among those tested varied considerably by site: a diagnosis of gonorrhea was made in 9% to 34% of men and 4% to 17% of women surveyed, and chlamydia prevalence ranged between 4% to 18% among women screened. Additionally, nongonococcal urethritis (NGU) was diagnosed in 16% to 31% of men, and cervicitis in 2% to 14% of women. Vaginitis was also highly prevalent with 4% to 22% of women diagnosed with bacterial vaginosis and 6% to 15% with trichomoniasis. Syphilis was relatively uncommon at all five STD clinics, with<1% to 7.7% reactive serologies among those tested, reflecting recent national declines in syphilis. The proportion of clients who were diagnosed as HIV positive at that visit was low (1%) but does not reflect HIV prevalence among these clients because HIV testing was performed in only 16% of the survey participants and many may have already known their HIV serostatus from prior testing. Only 34% of clients in the study population had no evidence of a sexually transmitted disease.
This study provides the only recent profile of clients attending urban public STD clinics in the United States, with regard to demographic characteristics, insurance status, reasons for attending an STD clinic, STD morbidity, and preferences for source of STD services. The majority of the 2,490 clients surveyed in these five STD clinics were young, minority, poor, and uninsured‐a growing population in continuing need of better access to STD care. Our survey suggests that the majority of clients treated in these clinics are in need of STD services and have significant STD morbidity. Our survey of clients attending public STD clinics corroborates the findings of the recent Guttmacher Institute survey of public health departments providing STD services at public STD and family clinics,2 with respect to the demographics and high STD morbidity of the populations seen at public STD clinics.
Factors leading clients to seek care at the STD clinic included the ready availability of walk‐in services and same‐day appointments, lower costs, confidential services, convenient location, and expert care. The only other survey looking at choice for STD health service was from the Netherlands in which patients who had sought STD services from either an STD clinic, family planning clinic, or their general practitioner reported that unprofessional attitudes and embarrassment were reasons for not seeking STD services from their regular provider.5 A recent survey of adolescents attending a public STD clinic found that perception of barriers to care was an important factor affecting duration before symptomatic adolescents sought STD services.6
Despite overall low insurance and Medicaid coverage, respondents did access health care services; in the 3 years before the survey, a majority (81%) of respondents had received non‐STD related medical care from other sources, mostly in primary care settings. In addition, 84% of women reported having received prenatal care during their last pregnancy. Thus, this population had used other types of health care services, but chose the STD clinics for their STD care. The responses to clients' reasons for seeking services at the STD clinic indicated that delays in getting an appointment, concerns about confidentiality, and the quality of STD care in non‐STD clinic sites may determine why clients preferentially attend public STD clinics. As a growing proportion of the population is covered by such plans, managed care plans need to offer walk‐in visits or referrals to STD clinics as a way to provide timely STD care to their clients with STD symptoms or contact to an STD. Health maintenance organizations (HMOs) and other primary care networks also need to review the quality of their STD care and ensure that their medical protocols include STD patient management guidelines, including the 1997 Centers for Disease Control and Prevention STD Treatment Guidelines. Lastly, they need to design systems to ensure patient confidentiality, such as a separate medical record for HIV and STD screening, if a patient is concerned about disclosing STD risk information to their primary care provider. One indicator of the need for confidential, easily accessible STD services in managed care organizations is out‐of‐plan use of STD services; a survey of 18‐year olds in one large managed care organization in Seattle found that 68% and 40% of sexually active male and female 18‐year‐old members, respectively, had sought STD services outside the HMO in the past 12 months (Scholes D, personal communication, May 1996).
Interestingly, cost of care was the second most common reason cited for seeking care at the STD clinic. A third of insured STD clients reported that they would not use their insurance to pay for the STD clinic visit, primarily to avoid their insurance company knowing of their STD clinic visit, although all five STD clinics ensure confidentiality for billing clients' insurance companies for STD services. These data indicate that insurers should review and, if necessary, modify their billing, reporting, and co‐payment procedures for STD and HIV services, given these significant concerns over confidentiality.
The findings of this survey may not be fully applicable to all public STD clinics since the five STD clinics participating in this survey have forged strong links between their local public health department and academic programs and are known to provide comprehensive and quality services. The fact that 53% of the clients surveyed had previously been to these five STD clinics and 27% were insured may not be representative of clients seen at STD clinics without these academic linkages or local recognition for their quality of care. A second source of bias affecting this study is that since the clients surveyed were attending an STD clinic, they may be more likely to be comfortable in seeking care at an STD clinic over other sites; in fact, approximately half of the clients surveyed had previously been to the STD Clinic. Similar data are needed from persons diagnosed with STDs in the private sector to ascertain their experiences and satisfaction with the care they received. In addition, although the survey included questions about whether and where clients had received non‐STD health care in the past 3 years, it did not ascertain whether they had an established, ongoing relationship with a primary care provider or had previously obtained STD services elsewhere. Lastly, the data on income and insurance status are based on self‐report and may have been underreported because all of the clinics had some form of sliding fee scale. However, clients were counseled that their answers to the survey questions would not influence charges for that day's visit.
The findings of this survey indicate several important aspects of the present and future roles of public STD clinics. STD clinics serve an important public health role in reducing STD transmission, given the high STD morbidity among their clients. STD clinics currently see clients who prefer readily accessible, low cost, confidential, and convenient services by expert providers. It is unlikely that the private sector can completely subsume the role of public STD clinics, especially without universal coverage. Ideally a range of options for STD services should be available in major urban areas, including categorical STD clinics, private providers, and HMOs. Although this study was not designed to assess the availability or adequacy of STD services in the private sector, the results indicate aspects of STD services that are important to high‐risk clients. As is the standard for STD clinics, private providers and managed care programs need to provide easy and rapid access to expert STD diagnosis and treatment for their clients; services should be confidential and must include risk reduction counseling and partner management services. However, even the most basic STD risk assessment is not performed by many primary care physicians.7,8 STD programs will need to work more closely with the private sector in general, and managed care plans in particular, to improve the quality of STD service available, by providing training as well as consultative and referral services. A more integrated health care system that delivers primary care is desirable, but certain traditional core public health functions, including a capacity to provide STD clinical service, will need to be maintained.