Sexually Transmitted Diseases:
Providers' Perceived Barriers to Sexually Transmitted Disease Care in 2 Large Health Maintenance Organizations
Mark, Hayley RN, PhD*; Irwin, Kathleen MD, MPH†; Sternberg, Maya PhD†; Anderson, Lynda PhD†; Magid, David MD, MPH‡§∥; Stiffman, Michael MD, MPH¶
From the *Department of Community and Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland; †Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, Georgia; ‡Clinical Research Unit, Colorado Permanente Medical Group; §Department of Preventive Medicine and Biometrics, and ∥Division of Emergency Medicine, University of Colorado Health Sciences Center, Denver, Colorado; and ¶HealthPartners Research Foundation, Minneapolis, Minnesota.
Supported by the Centers for Disease Control and Prevention through a task order contract with the Alliance for Community Health Plans 0953-026. This work was also supported under a cooperative agreement from the Centers for Disease Control and Prevention through the Association of Teachers of Preventive Medicine.
Correspondence: Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD 21205. E-mail: firstname.lastname@example.org.
Dr Irwin is currently at the World Health Organization, Geneva, Switzerland.
Received for publication May 22, 2006, and accepted September 6, 2007.
Goal: To identify providers' perceived barriers to sexually transmitted disease (STD) care in 2 health plans and plan-, clinician-, and patient-level factors that were associated with these barriers in order to inform quality improvement interventions.
Study Design: Surveys were mailed to a stratified sample of 1000 physicians, physician assistants, and nurse practitioners at 2 large health plans in 1999–2000. Of the 743 (82%) providers who received questionnaires and responded, data were analyzed from 699 with complete specialty information.
Results: Ninety-five percent of providers identified at least 1 barrier to STD care. The most commonly cited barriers in both plans related to insufficient time and staff to address STDs, to counsel patients or manage sex partners, to keep current with managing high-risk patients, and to monitor patient adherence to recommendations to abstain from sex or use condoms during treatment. Nurse practitioners and specialists in obstetrics and gynecology were more likely to cite these barriers. Providers in staff models were more likely to cite the most common patient-level barriers. Few cited barriers related to diagnostic and treatment services.
Conclusions: Interventions in health plans are necessary to address constraints related to time and staff performing STD related care, keeping current with managing high-risk patients, and supporting patient adherence to provider recommendations.
MORE THAN 15 MILLION NEW CASES of sexually transmitted disease (STD) occur each year in the United States,1 resulting in an estimated $17 billion annually in direct medical costs.2 The consequences of STDs are significant and include pelvic inflammatory disease, infertility, pregnancy complications, anogenital neoplasia, and increased susceptibility to HIV infection.3
Provider adherence to recommended practices for STD care is essential to preventing adverse outcomes associated with STD and preventing STD transmission in communities. However, most providers do not fully adhere to these recommendations.3,4 For example, surveys of physicians and patients and medical record reviews in managed care and other practice settings indicate that providers screen a smaller proportion of eligible women for STD than is recommended by national clinical practice guidelines for women.5–18 The extent to which providers provide sexual risk assessment, prevention counseling, patient education, and sex partner services also contrasts with recommendations.19–33
Several factors may influence provider adherence to practices recommended in national STD service guidelines. Recent studies on STD-related attitudes and behavior among health plan providers have found an association between certain provider, health plan, and patient characteristics and STD service delivery.14,15,23,30–34 For example, several provider characteristics are associated with more consistent delivery of STD prevention and control services: having received more recent professional clinical training, feeling well trained in adolescent sexual risk assessment, and holding the belief that routine STD screening can be cost effective. Other clinician characteristics associated with STD service delivery include acknowledging that treatment of STDs is an organizational priority and serving a high proportion of female patients.
Identification of providers' perceptions of barriers to STD care could lead to identification of additional interventions to improve STD care. Previous studies have investigated actual STD practices among providers and the associated factors, but only a handful have provided information on the barriers to STD care perceived by providers. In addition, although in the last 2 decades managed care has become the norm for healthcare delivery in the United States, no studies have systematically identified barriers in these settings or compared barriers by type of managed care delivery model. We therefore surveyed providers' in 2 types of managed care organizations to identify perceptions of barriers to STD care and clinician characteristics associated with those barriers.
In 1999–2000, surveys were mailed to providers in 2 large, not-for-profit, commercially managed care plans: (a) Kaiser Permanente Foundation Health Plan of Colorado (KP), a staff model plan that provides care to more than 400,000 enrollees in the Denver metropolitan area and (b) Health Partners (HP), which serves enrollees in the Minneapolis/St. Paul metropolitan area in either a staff or network model. For both plans, an eligible provider had to (a) be a physician, advanced practice nurse, or physician assistant and (b) be practicing in 1 of the 5 medical/nursing specialties that commonly diagnose or treat STDs: family medicine, internal medicine, pediatrics, obstetrics/gynecology, and emergency medicine. For providers in the plans' staff models, eligibility criteria were further refined by using administrative data to identify survey participants who had seen over the preceding 2 years at least 1 patient with a positive result or medical claim (regardless of test result) for a chlamydia or gonorrhea test or ICD-9 coded diagnosis for chlamydial infection or gonorrhea. A random sample of 250 of these eligible staff model providers from each plan was surveyed. The balance of the sample consisted of a random sample of 500 providers from the HP network model for whom administrative data on STD diagnosis and treatment experience were not available. HP network providers were oversampled because the number of enrollees served by HP network model providers (400,000) was approximately twice as large as the number of enrollees served by the staff model providers (220,000). Thus, valid inferences for the HP network providers and comparison with staff model providers could be made.
The Centers for Disease Control and Prevention (CDC) sent packets via express mail that contained a cover letter that described the project and informed consent issues, the questionnaire, and a $25 dollar gift check. Two additional mailings of reminder cards or letters were sent to those who did not respond to the first mailing. Staff model providers who had not responded after the third wave were reminded by e-mail (HP) or voice mail (KP). Lack of demographic data for nonrespondent or noneligible providers precluded comparison with respondent characteristics.
All survey procedures were approved by the human subjects' protections procedures of the Kaiser Foundation Research Institute, HP, CDC, and the Federal Office of Management and Budget.
The survey was developed based on a literature review of STD care and theory on health care settings, clinician, and patient factors that influence delivery of clinical preventive services,35 several focus groups of HP providers,36 and input from STD and managed care experts. The survey addressed the following topics using close-ended questions: (a) Chlamydia and genital wart treatment practices, (b) perceived barriers to management of STDs, (c) use of and perceptions about CDC STD treatment guidelines that were available during the survey period, and (d) use of other sources of information for STD clinical decisions. We asked respondents to rate “barriers to optimal management of STDs in your practice” using a list of 18 potential barriers, which included health system-, clinician-, and patient-level issues that might influence delivery of care. We included patient-level issues related to adherence to providers' recommendations about treatment or reducing STD transmission during the treatment period because these are critical elements of STD care and were cited as important challenges in focus groups. Participants rated perceived barriers using a 5-point Likert scale from 1 = “not at all problematic” to 5 = “very problematic.”
Because providers were randomly sampled with unequal probabilities of selection from substrata created by provider specialty and provider type, the probability of selection varied within each health plan model/provider specialty/provider type strata. We therefore applied sample weights based on the inverse of the probability of selection for a given provider in a given health plan model. We conducted descriptive weighted analysis with SUDAAN,37 using a stratified design without replacement with unequal probability of selection across the strata. We first compared clinician characteristics by plan type using Pearson χ2 tests37 in which a two-sided P value of <0.05 was considered statistically significant. We examined the association between the most commonly reported barriers with plan and clinician characteristics because we hypothesized that barriers might differ by these characteristics. We collapsed responses to each barrier question to dichotomous variables in which scores of 4 or 5 were classified as “problematic,” and scores of <4 were classified as “not problematic” and reported weighted proportions. We then examined the association of the most commonly reported barriers with health plan, plan type (staff vs. network), and the following clinician characteristics: gender, provider type (i.e., physician, nurse practitioner, physician assistant), provider specialty (family medicine, emergency medicine, internal medicine, obstetrics and gynecology, pediatrics), cases of chlamydia infection diagnosed or treated in the past year (0 cases, 1–5 cases, or ≥6 cases), and years in clinical practice (>10 years, 6–10 years, or <5 years) using odds ratios derived from logistic regression.37 Odds ratios whose 95% confidence interval did not include 1.0 were considered as statistically significant. Multivariate analysis was deferred due to the lack of a clear, strong pattern of association across health plans observed in the univariate analyses.
The overall response rate was 82% (n = 743). Of the 1000 surveys mailed, 907 were actually received because addresses were current and mailings were not returned unopened. Of these, 743 (82%) responded: 229 (95%) from KP staff model providers, 192 (87%) from HP staff providers, and 322 (72%) from HP network model clinicians. Information regarding the weighting variables of provider specialty or provider type was missing for 44%, yielding 699 respondents for this analysis. The majority of the respondents were physicians (94%), two-thirds were male (68%), and almost three- quarters (70%) were aged 30–49 years (Table 1). Clinical specialties included emergency medicine (3%), family medicine (47%), internal medicine (24%), obstetrics and gynecology (12%), and pediatrics (14%). Several characteristics of respondents, including provider type, gender, age, specialty, and recent experience with STD diagnosis, differed significantly by plan type (Table 1).
Ninety-five percent of the providers surveyed reported at least 1 barrier to STD care. Barriers were identified at the levels of health plan, provider, and patient. The 7 most common barriers, cited by at least 30% of the providers, included 2 plan-level barriers: “no or limited staff to counsel patients” and “no or limited staff to manage the sex partners of patients”; 3 provider-level barriers: “finding time to address STDs during a visit because of other competing health priorities,” “finding time to elicit sexual history, counsel infected patients, or address sex partners,” “keeping up-to-date with managing high risk patients”; and 2 patient-level barriers: “patient adherence to recommendation that they notify sex partners” and “patient adherence to using condoms or abstaining from sex during treatment” (Table 2). With the exception of 1 patient-level barrier, providers in the HP staff plan were the least likely to report the most common barriers.
Factors Associated With the Most Commonly Reported Barriers
Every provider characteristic was significantly associated with at least 1 of the 7 common barriers, but only a few characteristics were associated with several of these barriers (Table 3). Nurse practitioners were more likely than physicians to report many of the 7 most common barriers. Specialists in obstetrics and gynecology were more likely than providers in other specialties to report many of these barriers, with the exception that emergency medicine specialists were more likely to report “lacking time to address STDs during visits because of other competing health priorities.” Providers in the network plans were significantly less likely than providers in the staff plan to report the most common patient-related barriers, i.e., “patient adherence to recommendation that they notify sex partners” and “patient adherence to using condoms or abstaining from sex during treatment.”
In this evaluation of staff and network model health plans, many providers cited barriers to STD management, and barriers did not differ appreciably by staff or network model. The most commonly cited barriers related to inadequate time and staff to address STDs, to counsel patients, to elicit a sexual history or address sex partners, and to keep current with managing high-risk patients. Patient adherence to the recommendation that they notify sex partners and use condoms or abstain from sex during treatment was also cited as a barrier to STD care. Fortunately, fewer than 15% of providers reported barriers related to their discomfort with discussing sexual matters and counseling, to diagnosis and treatment challenges related to coverage of chlamydia screening tests or to patient adherence to treatment. Our findings are consistent with previous studies in which providers identified limited time or staff resources to perform risk assessment, counseling, and partner services as key barriers to providing STD care.27,34,38–40 It is possible that providers may prioritize biomedical functions such as diagnostic and treatment services over more psychosocial functions such as patient sexual risk assessment and counseling when their encounter time is limited or when they have greater skill, experience, or efficiency in performing biomedical functions.41
Few clear and consistent patterns emerged that indicated associations between plan type, provider characteristics, and perceived barriers to STD care. Although staff and network models differ in clinician compensation methods that might influence STD service delivery approaches, there was no association between plan type and reported plan- or clinician-level barriers. Providers in the network model were less likely to report patient-level barriers. It is possible that this difference may be related to differences in patient characteristics by plan type, but patient data were not collected to investigate this possibility. Our findings are consistent with a study in California health plans showing that physician compensation methods (i.e., capitation, fee for service, or salary) were not significantly associated with delivery of guideline-concordant STD care.42 The relationship between plan model type and STD care is complex and requires further investigation. Investigations that measure STD service delivery attitudes, reimbursement, and function might provide further insight into these relationships.
We also found that advanced practice nurses and providers who specialize in obstetrics and gynecology were more likely to report several barriers to STD care than other provider types or specialties. Previous research has shown that advanced practice nurses and specialists in obstetrics/gynecology are more likely to provide a wide variety of STD services, including screening for STD.5,29,34 As these providers are frequently charged with STD care and may consider it a practice focus, they may be more familiar with the characteristics of comprehensive STD care (including risk assessment, counseling, management of sex partners, and patient risk reduction strategies during treatment) and may be more cognizant of constraints to delivering these services within their plan, own practice, or patients.
Strengths of this evaluation include the large, random sample, the high response rate, and the ability to examine 3 levels of barriers in both staff and network models. Like all surveys, this one relied on self-reported data and did not link perceptions about barriers with actual STD care delivered or its quality. Regarding reported barriers, providers may have under-reported barriers that they felt would reflect badly on their performance (e.g., lack of comfort discussing sexual matters) and overreported barriers related to their patients or plans. However, the anonymous survey methods should have minimized this bias. To enrich our sample of STD care providers, staff model providers with administrative data evidence for providing recent chlamydia or gonorrhea services were sampled. However, this selectivity may have excluded some providers who were unable to diagnose any patients with chlamydia or gonorrhea due to profound constraints. Finally, the survey was conducted at 2 large, not-for-profit managed care plans with staff and network models and findings cannot be generalized to other health care settings or organizational models.
Despite the limitations discussed, this survey identified several barriers to STD care that merit attention in managed care organizations. Recently, in response to clinician demand to improve the quality and scope of STD care, several diverse interventions have been introduced to reduce barriers to risk assessment, counseling, and partner services found in health plans. For example, health plans that trained providers and increased access to tools, reminders, and feedback have improved providers' knowledge and attitudes about STD risk assessment and prevention counseling.43,44 To facilitate sexual history taking and counseling, plans have implemented simple, rapid, standard risk assessment and education tools, some of which have facilitated risk assessment and enhanced patient-provider communication.45,46 Others have developed patient-administered, computer-based tools to elicit sexual histories and provide counseling messages tailored to particular patients' risks,44 used nonphysician staff to collect risk information,47 or enhanced coverage and reimbursement of risk assessment services.48 To enhance sex partner services, one health maintenance organization added partner management information to the “after-visit summary” given to all patients tested for chlamydia, trained providers about optimal partner services practices, and posted partner services decision support tools and guidelines on the website used by providers.49 A recent randomized trial found that allowing partners of privately insured patients to obtain treatment at commercial pharmacies without visiting a physician resulted in greater partner treatment compared to traditional strategies.50 Other plans have permitted providers to write prescriptions for sex partners not enrolled in the managed care organization and developed methods to seek third party reimbursement for managing uninsured partners.51–54 Health plans that wish to improve STD care should consider how these interventions might be tailored to their unique plan, provider, and patient characteristics.
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