Tao, Guoyu PhD; Irwin, Kathleen L. MD, MPH
ACQUISITION OF HUMAN IMMUNODEFICIENCY virus (HIV) and many sexually transmitted diseases (STDs), notably syphilis and gonorrhea, are strongly associated with high-risk sexual behaviors (HRSB) in men and women.1,2 Concurrent infection with HIV and STD is strongly associated with HRSB, such as exchanging sex for money or drugs, having multiple sex partners, being bisexual, having HIV- or STD-infected partners, or being sexually abused.3,4 Health care providers play a critical role in HIV and STD prevention, screening, and care. They can provide sexual risk assessment, counsel patients at risk about safe sexual behaviors, screen for asymptomatic HIV or STD infection, diagnose and treat infected persons, and initiate management of sex partners of infected patients.3 Since the 1990s, the Centers for Disease Control and Prevention, the United States Preventive Services Task Force (USPSTF), and several clinical organizations have recommended HIV and STD risk assessment and screening for persons reporting HRSB.3–8 USPSTF specifically recommends that men be screened for HIV and syphilis and women be screened for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) as a high proportion of infected patients lack symptoms of these infections.5 Early detection and treatment are more successful, avert serious and costly sequelae, and prevent future transmission to sex partners.
A national survey of public health clinics in 1995 found that almost all reported: (a) routinely assessing new patients’ sexual, contraceptive, and STD history; (b) routinely offering testing for syphilis, CT, and NG; (c) providing STD treatment; and (d) providing education and counseling regarding risk factors for HIV and STDs.9 Several studies have shown that patients with HRSB were significantly more likely to receive sexual risk assessment and screening for HIV and STDs in public STD clinics than in other types of public clinics.10–12 Sexual risk assessment and screening appear to differ in private sector settings not dedicated to STD care, the setting where most STDs are now diagnosed in the United States.2,13 For example, 2 national surveys showed that only about one-quarter of US adults reported being asked about STDs during routine checkups, and only 43% of female adolescents and 26% of male adolescents reported having discussed HIV, STDs, or pregnancy prevention at their last preventive health care visit.14,15 In addition, a recent national survey of primary care physicians showed that less than one-third of physicians routinely screened men or women for HIV, syphilis, CT, and NG. These physicians were less likely to report screening male patients for these infections (13%–24%) than nonpregnant female patients (20%–35%). Obstetrician/gynecologists reported the highest screening rates for pregnant women; approximately 78% to 85% routinely were screened for one of these infections.16
To date, no study has examined HIV and STD testing practices during routine general medical examinations (RGME) or gynecological examinations (GYNE) for commercially insured patients who report HRSB. Therefore, we analyzed existing medical claims data with 2 objectives: (a) to compare proportions of patients diagnosed with and tested for HIV, syphilis, CT, or NG during RGME or GYNE of patients with claims for HRSB (high-risk group) with patients without a claim for HRSB (the comparison group), stratified by patient sex and type of examinations; and (b) to determine whether patients with claims for HRSB who did not receive HIV or STD testing at RGME or GYNE received HIV or STD testing services at other visits shortly before or after these examinations.
Materials and Methods
We analyzed data from the 2000 to 2003 MarketScan databases (The MEDSTAT Group, Ann Arbor, MI, www.medstat.com). The databases include claims of enrollees in more than 100 health plans that serve the employees and their dependents of approximately 50 large nongovernmental employers. The database includes all inpatient and outpatient claims for about 5 million persons from all US states but largely represents persons from 13 states in different regions of the United States. Most of these 5 million persons were enrolled in one of the following types of commercial health plans: health maintenance organizations, preferred provider organizations, fee for service arrangements, and point of service plans. Variables in the databases included patients’ demographic characteristics and type of health plan, provider information, and the dates that medical services were provided and associated diagnostic and procedural codes.
Identifying RGME, GYNE, and HRSB
We used the International Classification of Disease (ICD-9), Ninth Revision, Clinical Modification code V70.0 (RGME at a health care facility) for male and female patients and V72.3 for female patients (GYNE) to identify RGME and GYNE in the outpatient claims data, respectively. We used ICD-9 code V69.2 (HRSB) to classify patients reporting HRSB at outpatient visits. In general, V-codes in the ICD-9 code system are used to note supplementary factors that might influence health status or contact with health services.
We assumed that each patient had only one outpatient visit per day in the outpatient claims data. A RGME or GYNE was classified as an HRSB-RGME or HRSB-GYNE if the patient had a claim for V70.0 and V69.2 or V72.3 and V69.2, respectively. A RGME or GYNE was classified as a non-HRSB-RGME or non-HRSB-GYNE if the patient had a V70.0 or V72.3 claim, respectively, but no V69.2 claim. If a patient had only one visit classified as either HRSB-RGME or HRSB-GYNE, that visit was included into the high-risk group for data analyses. If a patient had both HRSB-RGME and HRSB-GYNE, more than one HRSB-RGME, or more than one HRSB-GYNE, only the one with the earliest date of HRSB-RGME or HRSB-GYNE for each patient was included into the high-risk group. Similarly, the only one or the one with the earliest date of non-HRSB-RGME or non-HRSB-GYNE was retained in the subset of the non-HRSB-RGME or non-HRSB-GYNE that were subsequently sampled. In addition, non-HRSB-RGME or non-HRSB-GYNE of patients who also had HRSB-RGME or HRSB-GYNE was excluded from this subset.
We used stratified random sampling techniques to select visits from non-HRSB-RGME or non-HRSB-GYNE into the comparison group, using PROC SURVEYSELECT in SAS, version 8.2 (SAS Institute, Cary, NC, 1999). To sample visits for patients with non-HRSB-RGME or non-HRSB-GYNE, we defined strata based on 4 factors available in these claims data that might influence assessment of HRSB or HIV and STD testing: patient sex, type of examination (RGME vs. GYNE), type of provider, and age group of patients. We assumed that services were more similar if they were provided to patients of the same sex, under the same type of examination, and within the same age group who were served by the same type of providers. The type of providers was classified into 5 groups: family medicine, internal medicine, obstetrics-gynecology, unidentified physician specialty, and other providers (such as other specialty physicians, nurse practitioner, or physician assistant). Age was classified into 4 groups based on patients with HRSB-RGME or HRSB-GYNE: 15 to 24, 25 to 34, 35 to 44, and 45 to 54 years. Sample size was based on the number of HRSB-RGME or HRSB-GYNE in each defined stratum.
Next, we randomly sampled non-HRSB-RGME or non-HRSB-GYNE for each defined stratum so that the number of non-HRSB-RGME or non-HRSB-GYNE sampled was the 3 times of the number of HRSB-RGME or HRSB-GYNE in each stratum. This was done to balance the sample sizes between the high-risk group and the comparison group and to account the availability of non-HRSB-RGME or non-HRSB-GYNE.
Measures and Statistical Analyses
We restricted our analysis to patients aged 15 to 54 years for each year during 2000–2003. For each RGME or GYNE, we first determined if a patient was diagnosed or tested for HIV, syphilis, CT, or NG at that visit by using ICD-9 codes and Physicians’ Current Procedural Terminology (CPT) codes. If diagnostic or test claims for HIV, syphilis, CT, or NG had not been identified during that examination (the index visit), and if that examination was also associated with a claim for HRSBs, we then examined whether the patient had a diagnostic or test claim for (a) HIV within 6 months before the index visit; (b) syphilis, CT, or NG within 30 days before the index visit; and (c) HIV, syphilis, CT, or NG within 30 days after the index visit. Numerous ICD-9 and CPT codes were used to identify patients with HIV, syphilis, CT, or NG diagnoses, and any tests to diagnose these infections (Table 1).
We used SUDAAN, statistical software for analyzing complex sample data to estimate the percentages of HIV, syphilis, CT, and NG diagnoses and tests for these infections at the index visit by patients’ HRSB status stratifying by patient sex and type of examination. Bivariate analyses and the χ2 statistic were used to examine the association between HRSB status and the likelihood of testing for HIV and selected STDs, the association between patient sex and the likelihood of testing for HIV and selected STDs during HRSB-RGME, and the association between type of examination and the likelihood of testing for HIV and selected STDs among female patients with HRSB. In all analyses, a statistically significant difference was defined as a 2-tailed probability of <0.05.
A total of 1074 patients aged 15 to 54 with their first HRSB-RGME or HRSB-GYNE were identified: 87 male patients with HRSB-RGME, 116 female patients with HRSB-RGME, and 871 female patients with HRSB-GYNE. Comparison groups that included 261 male patients with their first non-HRSB-RGME, 348 female patients with their first non-HRSB-RGME, and 2613 female patients with their first non-HRSB-GYNE were sampled from approximately 3 million non-HRSB-RGME or non-HRSB-GYNE. Of the 4296 patients in the data analyses, almost none had ICD-9 diagnostic codes for HIV, syphilis, CT, or NG infection during their RGME or GYNE, regardless of their HRSB status (Table 2).
Patients with claims for HRSB were significantly more likely to be tested for HIV, syphilis, CT, and NG than patients without a HRSB claim during RGME or GYNE (Table 2). Of patients with claims for HRSB, male patients were significantly more likely than female patients to be tested for HIV (79.3% vs. 38.8%) and syphilis (39.1% vs. 27.6%) during their HRSB-RGME (Table 2). However, female patients were significantly more likely than male patients to be tested for CT (56.9% vs. 20.7%) or NG (50.9% vs. 20.7%) during their HRSB-RGME. There was no significant difference in proportions of HIV or STD testing when comparing HRSB-RGME and HRSB-GYNE of female patients. Of HRSB-RGME or HRSB-GYNE of female patients, there was no significant association between HIV or STD testing and type of providers; however, women aged 15 to 24 years were significantly more likely to be tested for CT (66.3% vs. 43.2%) and less likely to be tested for HIV (26.2% vs. 40.7%) than women aged 45 to 54 years.
Of patients with claims for HRSBs who lacked diagnostic or testing claims for HIV, syphilis, CT, or NG at their index examinations, a small proportion had diagnoses or tests for HIV at other visits within 6 months before or 30 days after their index examinations (7%–17%). A small proportion also had diagnoses or tests for syphilis (2%–5%), CT (1%–7%), or NG (0%–5%) at other visits within 30 days before or after their index examinations (Table 3).
In these claims databases, only one of approximately 3000 (1074 of 3 millions) RGME or GYNE was associated with the V69.2 code for HRSB, although much higher percentages (11% in women and 13% in men) had reported HRSB on national surveys of the general population.17 This suggests that V69.2 code use is quite underutilized and may typically be used when prevention or discussion of HRSB is the focus of the visit or when a patient is specifically seeking HIV or STD testing. Limited use of this code may also reflect reluctance by patients to report HRSB, reluctance by providers to bill for a sensitive topic like HRSB that may result in stigma or other adverse consequences or a lower prevalence of HRSB in the population represented by this database compared with the general population.
Although a higher proportion of patients with HRSB was tested for HIV or STDs, only 21% to 79% of patients with HSRB-RGME or HSRB-GYNE had claims for HIV, syphilis, CT, or NG testing. Although the most common testing codes were for testing male patients for HIV and syphilis and female patients for CT and NG as recommended by USPSTF, these proportions still fell far short of the USPSTF recommendations. This indicates that there is substantial room for improvement of HIV and STD screening of high-risk patients.
Interventions to increase HIV and STD testing of patients with HRSB in settings that provide care to predominantly commercially insured persons are needed to enhance adherence to current risk assessment and screening guidelines. Several health care purchasers contracting with private health systems have made HIV and STD medical services explicitly covered benefits and have allowed for provider reimbursement for the time needed to provide the service (see www.gwu.edu/sphhs/healthpolicy/chsrp/newsps/ for model health benefit language). Several interventions have been developed to increase HIV and STD screening in commercial health plans. Examples include using rapid and/or noninvasive HIV and STD tests using urine or oral fluid4,18–20; routinely placing STD specimen collection materials next to Pap test collection materials to effectively “bundle” STD and Pap testing21; and use of parent “rooming-in” policies that routinely allow providers to discuss sexual activity and STD screening privately with adolescent patients.22 Several interventions have attempted to facilitate sexual risk assessment for providers. These include standard forms and interactive computer tools for self-administered or rapid clinician-administered sexual histories.23,24 Some health plans have attempted to improve delivery of these services by developing and disseminating print- and Web-based guidelines and protocols.25
Strengths of this analysis included the use of a large database from several US regions and the use of standardized diagnostic and procedural codes. Compared with abstraction of medical records or clinical or patient surveys, claims data involved less expensive and obtrusive data collection from multiple providers and sites of care and allow analysis of relatively rare outcomes, such as HRSB claims. However, this study has several limitations. First, very few visits were coded with V69.2, suggesting that the code identifies only a small subset of patients who engage in HRSBs. Second, like all studies of medical claims, this database may not have captured all services rendered, which may underestimate the proportion of HIV and STD testing during RGME or GYNE. Coding of services rendered may be done by physicians or office staff and different clinics may use these V codes differently; this is a limitation of all claims databases. Further evaluations are needed to identify the extent to which sexual health services that are provided are not coded either unintentionally or intentionally in the claims data. Third, although V69.2 code was used in this study, detailed risk behaviors that patients involved were unknown. Fourth, our data did not allow analysis of referral services for HIV or STD testing to public clinics, or HIV and STD counseling that might have been offered to patients with HRSB, thereby, underestimating actual HIV and STD testing. Finally, because patients in this data set were largely from 13 states in 2000–2003, our results may have limited generalizability to other states, populations, and clinical practices after this period.
In summary, screening for HIV, syphilis, CT, and NG is part of a critical strategy to detect and treat HIV and STD infections early before serious sequelae arise and to prevent transmission to sex partners. The limited documentation of HRSB in this database of commercially insured persons and the limited HIV and STD testing in patients with HRSB claims underscores the need for interventions to increase HIV and STD risk assessment, screening, and diagnosis to prevent serious and costly sequelae of these infections and ongoing transmission in the community.
1. CDC. HIV/AIDS Surveillance Report, 2003, vol 15. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.
2. CDC. Sexually Transmitted Disease Surveillance, 2003. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.
3. CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep 2002; 51:1–78.
4. CDC. Revised recommendations for HIV screening of pregnant women. MMWR Morb Mortal Wkly Rep 2001; 50:63–85.
5. US Preventive Services Task Force. Screening for Chlamydia infection: Recommendations and rationale. Am J Prev Med 2001; 20:90–94.
6. American College of Obstetricians and Gynecologists. Committee on Adolescent Health Care. Health Care for Adolescents. Washington, DC: The American College of Obstetricians and Gynecologists, 2003: 69–79.
7. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, IL: American Medical Association, 1994.
8. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric health care (RE9939) (pullout). Pediatrics 105 (2000).
9. Landry DJ, Forrest JD. Public health departments providing sexually transmitted disease services. Fam Plann Perspect 1996;28:261–266.
10. Asch SM, Sa’adah MG, Lopez R, et al. Comparing quality of care for sexually transmitted diseases in specialized and general clinics. Public Health Rep 2002; 117:157–163.
11. Kurth AE, Martin DP, Golden MR, et al. A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history. Sex Transm Dis 2004; 31:719–726.
12. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Project RESPECT Study Group. JAMA 1998; 280:1161–1167.
13. Brackbill RM, Sternberg MR, Fishbein M. Where do people go for treatment of sexually transmitted diseases? Fam Plann Perspect 1999; 31:10–15.
14. Burstein GR, Lowry R, Klein JD, et al. Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics 2003; 111:996–1001.
15. Tao G, Irwin KL, Kassler WJ. Missed opportunities to assess sexually transmitted diseases in US adults during routine medical checkups. Am J Prev Med 2000; 18:109–114.
16. St Lawrence JS, Montano DE, Kasprzyk D, et al. STD screening, testing, case reporting, and clinical and partner notification practices: A national survey of US physicians. Am J Public Health 2002; 92:1784–1788.
17. Anderson JE, Chandra A, Mosher W. HIV testing in the United States, 2002. Adv Data 2005; 363:1–32.
18. Mehta SD, Rothman RE, Kelen GD, et al. Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting. Clin Infect Dis 2001; 32:655–659.
19. Bull SS, Jones CA, Granberry-Owens D, et al. Acceptability and feasibility of urine screening for Chlamydia and gonorrhea in community organizations: Perspectives from Denver and St Louis. Am J Public Health 2000; 90:285–286.
20. CDC. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrheae infections, 2002. MMWR Morb Mortal Wkly Rep 2002; 51:1–38.
21. Burstein GR, Snyder MH, Conley D, et al. Chlamydia screening in a health plan before and after a national performance measure introduction. Obstet Gynecol 2005; 106:327–334.
22. Shafer MA, Tebb KP, Pantell RH, et al. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA 2002; 288:2846–2852.
23. Bull SS, Rietmeijer C, Fortenberry JD, et al. Practice patterns for the elicitation of sexual history, education, and counseling among providers of STD services: Results from the gonorrhea community action project (GCAP). Sex Transm Dis 1999; 26:584–589.
24. Boekeloo BO, Schamus LA, Simmens SJ, et al. A STD/HIV prevention trial among adolescents in managed care. Pediatrics 1999; 103:107–115.
25. Mullooly JP, Valanis B, Maher JE, et al. Improving services for sex partner of Chlamydia-infected patients in an HMO. Am J Manag Care 2005; 11:609–618.