Shlay, Judith C. MD, MSPH*†; McEwen, Dean MBA*; Bell, Deborah NP*; Maravi, Moises MS*; Rinehart, Deborah PhD‡; Fang, Hai PhD§; Devine, Sharon JD, PhD¶; Mickiewicz, Theresa MSPH*; Dreisbach, Susan PhD¶
Sexually transmitted diseases (STDs) and unintended pregnancy are significant, costly public health concerns.1,2 An estimated 50% of pregnancies in the United States are unintended, and approximately half of these result in therapeutic abortions.3,4 Approximately 19 million people are newly infected with an STD annually in the United States, with almost half aged 15 to 24 years.5–7
In a time of increasingly limited resources, creating efficiencies to simultaneously address 2 overlapping health concerns may reduce costs. Although programs combining family planning services (FPS) and STD care in an STD clinic have been described,8–10 few studies have evaluated direct and indirect consequences or identified clinical barriers and facilitators.10–12 Sexually transmitted disease clinics have been slower than family planning clinics to implement this integrated treatment model, although they reach a population that is often less socially organized and has less access to preventive care.13 and is a methodology promoted by the Centers for Disease Control and Prevention (Program Collaboration and Service Integration) to increase efficiency, reduce redundancy, and avoid missed opportunities for clients being seen for prevention services.14
The 4 objectives of the study were to (1) measure change in enrollment into FPS among STD clients after implementation of an integrated STD/family planning record with electronic eligibility reminder, (2) compare client and staff satisfaction before and after implementation, (3) calculate the additional staff time and clinic costs required to offer FPS to STD clients, and (4) explore incident pregnancy and STD rates before and after implementation among those patients who returned for services.
MATERIALS AND METHODS
This study was conducted at the Denver Metro Health Clinic (DMHC), the Denver Public Health STD clinic, after review and approval by the Colorado Multiple Institutional Review Board. The DMHC provides confidential, free, walk-in diagnosis, treatment, management, and prevention of STDs with 15,000 to 18,000 patient visits per year.
Since 2001, the DMHC has offered initial FPS to clients presenting for STD evaluations through Federal Title X funding. Family planning services provided to eligible women include preconception counseling, pregnancy testing, contraceptive counseling, or provision of a contraceptive method or referral to prenatal care or termination services. Eligible men receive preconception health counseling and pregnancy prevention counseling. All staff receive training and follow protocols on the provision of FPS. Two nurse practitioners were hired and trained to dispense long-acting methods.
Each calendar year, clients presenting for STD clinical services are eligible for initial FPS in addition to receiving STD care. Condoms and all current forms of contraceptives are available free of charge. Emergency contraception is offered to men and women using condoms as their primary birth control method in case of condom errors. Referrals for sterilization are provided when appropriate. After FPS, most clients, with the exception of teens and high-risk continuity clients, are referred to a primary care provider for ongoing reproductive services to maintain clinic capacity for new clients needing STD services.
STD Clinic Process
After clinical triage, patients receive either an express visit (asymptomatic), comprehensive examination (symptomatic), follow-up examination, confidential HIV test, or teen/continuity visit (high-risk women and teens). Female clients requesting emergency contraception or contraception see a nurse or advanced practice nurse regardless of STD symptoms. For express visits, no clinical examination is performed.15 Comprehensive visits include a standardized STD-related physical examination.
Electronic Health Record Integration
In 2008, clinicians provided FPS to clients based on their contraception history, pregnancy status, or request for FPS. No reminder system prompted a clinician that FPS was indicated. Provision of FPS depended on the clinician remembering to consider offering FPS as part of the STD evaluation. A separate electronic family planning clinical encounter form was used to document required Title X information.
On January 1, 2010, a computer program was implemented to classify patients into family planning status categories (not eligible, enrolled, or check eligibility) within the DMHC Electronic Health Record (EHR) system. This program reviews previous visits, sexual preferences (heterosexual/bisexual vs. homosexual), and sterilization status to update family planning enrollment eligibility nightly. Family planning status is displayed on the top of the EHR screen when a client’s information is retrieved. Clinicians can quickly identify whether a person is already enrolled, needs screening, or is not eligible.
Additional integration of the EHR included combining family planning, STD new visit, and follow-up visit forms. Charting was optimized to facilitate data reporting and improve visit flow.
Definition of Study Variables
Use of FPS among eligible STD clients was defined as receipt of FPS at least once in the calendar year.
Contraceptive use was defined as highly effective method if reported use was sterilization of the patient or partner, long-acting reversible method (i.e., intrauterine devices or subdermal contraceptive implant), or hormonal injection; moderate effective method if reported use was oral contraception, vaginal ring, or hormonal patch; moderate-low effective method if reported use of contraceptive sponge, diaphragm/cap, male condom, or female condom; and low effective method if reported use was spermicide, fertility awareness method, withdrawal, emergency contraception, or other method.16 Reported use of abstinence was examined separately.
Incident pregnancy rate was defined as an interval pregnancy within 12 months of the initial visit, as documented by review of Denver Health and DMHC clinic databases. Pregnancy indicators included a positive pregnancy test result, change in reported parity, or documentation of pregnancy through the International Classification of Diseases, Ninth Revision, Clinical Modification.
Incident STDs determined through review of previously described databases included laboratory-confirmed cases of gonorrhea and/or chlamydia infection identified within 12 months of the initial visit.
Time and Cost Study
To describe the additional cost for providing integrated services, data were collected to describe costs related to staff time, laboratories, and medical supplies. To assess staff time, in July to August, 2010, all staff recorded their position, patient identification number, time spent with patient, and service type activity using a standardized time log. To obtain staff time cost, median salaries including fringe benefits for the respective positions were multiplied by the time logged. Total staff time cost per visit included registration, triage, history, clinical examination, counseling, phlebotomy, and attending physician consultation. Time data were matched to electronic clinical data to determine the type of visit (STD only or integrated). Electronic clinic data provided information on laboratory and medical supply costs associated with each visit. Overhead costs were allocated to each visit according to the time of each visit, accounting for annual operating expenses and administrative costs to support clinical activities.
Client and Staff Satisfaction
Three months before and 6 months after implementation of the electronic eligibility reminder and integrated EHR, 2 convenience samples of DMHC patients (114 and 183, respectively) completed brief surveys in English or Spanish. Staff was instructed to ask all patients receiving FPS and STD care over a 2-week period to complete the survey after their visit and deposit it in a locked drop box adjacent to the waiting room. No incentive was offered. Patients reported type of FPS received, whether services met their needs and were respectful, and their satisfaction.
All clinic staff and attending physicians (n = 16) completed 30-minute semistructured interviews 6 months before and 9 months after the implementation of the electronic eligibility reminder and integrated EHR. Questions elicited attitudes about integrating services, training needs, and suggestions for streamlining clinic flow, integrated visits, and charting.
Descriptive demographic and clinical characteristic statistics for the clinic populations at both periods were generated. Bivariate analyses between the 2 periods were performed using the χ2 test for proportional comparisons and t test for continuous variables. Incident pregnancy and STD rates were calculated for enrolled and nonenrolled clients for both periods and compared using χ2 test. In addition, outcomes were assessed using 2010 data that excluded individuals seen in both periods (13.5%).
Two types of analyses were performed to assess cost. Multivariate analysis was used to identify the additional time and cost for patients receiving integrating FPS. Ordinary least squares (OLS) estimation was performed for the time and cost analyses to examine the extra costs (dollars) of the integrated services compared with an STD-only visit. Variables controlled for included age, sex, race/ethnicity, type of visit (new or follow-up), days since last sex, total number of partners, presence of symptoms, current drug use, current pregnancy, and English language (yes or no). The main explanatory variable was a dummy variable for integrated services and STD-only services. Ordinary least squares estimations for staff time costs, laboratory costs, and medical supplies costs were calculated separately. The estimate of additional costs is a combination of the additional costs obtained by the separate estimations plus overhead costs. Laboratory costs included all STD tests (e.g., chlamydia, gonorrhea, etc.), Papanicolaou test, and pregnancy tests. Medical supply costs incorporated contraceptives including long-acting methods. Because long-acting methods are more expensive than other contraceptive methods and because clinics’ ability to fund these methods is variable, we conducted a sensitivity analysis to examine cost both including and excluding long-acting methods.
Descriptive statistics and χ2 test were used to compare client satisfaction before and after implementation of the integrated EHR after adjusting for the higher proportion of male participants completing the survey in 2010. Coding of staff interviews identified common themes and individual concerns that were reported back to DMHC staff for clarification and verification.
Analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC) and Stata version 11 (Stata Corporation, College Station, TX). All tests were 2 sided. P values less than 0.05 were considered significant.
There were 9695 clients (male, 5842; female, 3853) eligible for FPS in 2008 and 10,021 clients (male, 5852; female, 4169) eligible in 2010. Comparing the 2 periods, automatic identification of FPS eligibility increased FPS enrollment from 51.6% in 2008 (male, 53.3%; female, 49.1%) to 95.3% in 2010 (male, 94.7%; female, 96.2%; P < 0.01).
Demographic and clinical differences were identified among female and male enrollees by year (Table 1). Women enrolled in 2010 were slightly older, were more often married, were nonwhite, were publicly insured, reported a prior STD, and were initially using a more effective contraceptive method or condoms compared with those enrolled in 2008. Men enrolled in 2010 were slightly older, were more often insured, were married, were nonwhite, reported a prior STD and drug use, and were initially using a more effective contraceptive method or condoms compared with those enrolled in 2008. In contrast to 2008 enrollment, in 2010 more asymptomatic women and more symptomatic men were enrolled and FPS occurred more frequently for new visits.
The EHR enhancements developed in 2010 allowed the determination of the effectiveness of contraceptive method provided to the client at the conclusion of the clinic visit. Women enrolled in 2010 received a more effective method (highly effective method: 24.4%–29.9%, P < 0.01; moderate effective method: 14.8%–28.6%, P < 0.01; moderate-low effective method: 33.4%–26.3%, P < 0.01; low effective method: 5.8%%–2.7%, P < 0.01; abstinence: 6.5%–7.7%, P = 0.01).
Among women returning within 12 months (39.6% in 2008 and 37.1% in 2010), pregnancies were lower among enrolled versus nonenrolled women for both 2008 (86/1116 [7.7%] vs. 80/411 [19.5%], P < 0.01) and 2010 (199/1519 [13.1%] vs. 7/27 [25.9%], P = 0.05; Table 2). No difference in incident STDs was seen between enrolled and nonenrolled women returning within 12 months who were tested for gonorrhea (29.2% in 2008; 33.8% in 2010) and/or for chlamydia (29.2% for 2008; 33.7% for 2010). Results were similar for the men (Table 2). In a subanalysis using 2010 data that excluded individuals seen in 2008, results were similar (data not shown).
Per-visit additional staff time for integrating FPS into an STD visit was 4.01 minutes with additional staff cost of US$3.57, after controlling for confounding variables. Additional laboratory costs were US$5.36, additional medical supply costs were US$14.66, and additional overhead costs were US$5.66. Total additional costs were US$29.25 (Table 3). The sensitivity analysis indicated that not providing long-acting contraceptives would decrease additional costs from US$14.66 to US$1.04, with the resulting overall total cost per visit decreasing to US$15.63.
Client and Staff Satisfaction
All staff (clerical, nursing, nurse practitioners, physicians) were valued as being able to provide family planning and STD services concurrently. Staff expressed greater job satisfaction providing integrated care using the electronic eligibility reminder and integrated EHR. They agreed that the electronic eligibility reminder and integrated EHR facilitated seamless care.
Client satisfaction remained high after the introduction of the electronic eligibility reminder and integrated EHR (99.5% before and 99.0% after were satisfied or highly satisfied, P = 0.76), and patients continued to report that these services met their family planning needs (86.0% and 79.6%, respectively; P = 0.26).
In the past decade, the simultaneous rise in health care costs and decline in available resources have generated interest in developing innovative ways to meet public health objectives through leveraging resources, integrating services, and using technology to create efficiencies. This study examines whether implementation of an integrated STD/family planning record with an electronic eligibility reminder can facilitate the integration of FPS into STD care in a public health STD clinic in a way that is acceptable to staff and patients with minimal additional cost. Our results indicate that customizing the EHR to generate an electronic eligibility reminder for FPS and consolidate STD and family planning records can contribute to an increased proportion of high-risk STD clinic patients enrolled in FPS. The introduction of the electronic eligibility reminder was associated with a nearly 2-fold increase in the proportion of eligible male and female STD clients enrolled. The reminder eliminated staff time to determine eligibility and minimized missed opportunities for family planning messages and services to reach clients in this vulnerable population.
Merging the family planning and STD data fields in the EHR enhanced staff capacity to simultaneously address STD and unintended pregnancy prevention with a population that might not otherwise access reproductive health services.11,17 Integrating patient history questions and eliminating redundancy created a seamless, more comprehensive interview and smooth transition into family planning topics. The integrated record facilitated consistent recording of patients’ plans to change behaviors to both reduce STD transmission and prevent unintended pregnancy. This allowed staff to follow-up and reinforce behavior change strategies on subsequent visits. All clinical staff enthusiastically supported the integrated visit, integrated EHR, and electronic eligibility reminder.
Results from the client survey indicated satisfaction with services provided at DMHC both before and after the integrated EHR was introduced. Similarly, most felt that clinic services met their family planning needs both before and after the electronic eligibility reminder was implemented.
Although the study was not designed to follow up all patients seen in the STD clinic over a 12-month period, the EHR provided follow-up incident pregnancy, gonorrhea, and chlamydia data for approximately one third of the population seen in the respective years. These data were examined to explore whether increasing enrollment in an integrated FPS and STD visit would decrease incident pregnancy without increasing incident STDs. Owing to the narrow focus of the STD clinic, many clients do not return to the clinic within a 12-month time frame. In addition, owing to the low socioeconomic status, lack of insurance, and often unstable social environment of the clients, many also do not seek other kinds of health care within the Denver health system.18,19 As such, we were limited in our ability to track the reproductive health outcomes of the patients seen. However, among women returning to the STD or community health clinics, those receiving integrated services had lower pregnancy rates than did women who did not receive integrated care, and incident STDs did not differ by group. Although caution is warranted in drawing conclusions because of the low rates of follow-up, these data suggest that integrating family planning and STD services may reduce unintended pregnancy.
In the spirit of creating an innovative, efficient approach to 2 costly and important public health problems that could be widely implemented, it was important to consider the additional costs of adding FPS to standard STD care in a clinic setting.
The clinic costs can vary depending on the services provided during the visit and the ability of the clinic to generate revenue for these services. Therefore, integration costs were separated to describe additional costs for staff time, laboratories, medical supplies, and overhead enabling other clinics to better estimate their cost to integrate services.
The additional staff cost of providing integrated services compared with STD-only services accounted for a relatively small percentage of total additional cost (12%). Furthermore, only 4 minutes were required of additional staff time per client. Although this additional time could result in a slight reduction in the total clients seen in a given day, the ability to address 2 reproductive health issues concurrently avoids the need to provide separate visits to address each issue, reduces missed opportunities,14,17 and saves public dollars.20
Medical supply costs accounted for half (US$14.66 per patient) of the total additional costs, with most of these costs related to providing long-acting contraception (US$13.62). Almost all the supply costs could be saved if either paid for by the clients or reimbursed through the client’s insurance (US$29.25–US$15.63, 47% reduction). With the enactment of the Affordable Care Act and first dollar coverage for contraceptive services,21,22 the ability of STD clinics to cover these costs should be realized. Currently, a number of STD clinical programs are developing processes to bill for services rendered.23 This source of revenue coupled with categorical funding for STD services and Title X offers the ability to develop sustainable models for this type of integrated service.
The investigation has potential limitations. First, owing to limitations in our EHR system, particularly in 2008, we were unable to determine pregnancy intention status. Second, a formal cost-benefit analysis was beyond the scope of this project. We attempted to compare our integrated program to stand-alone STD and family planning clinics, but few comparable clinics were identified and barriers limited our ability to obtain accounting data. Finally, the study was not designed to follow up all patients seen in the STD clinic over a 12-month period, thus allowing only an exploration as to whether integration of services impacts patient outcomes (i.e., incident pregnancy and STD rates).
Sexually transmitted disease clinics serve at-risk individuals, many of whom use these clinics because they lack access to reproductive health care services. Integrating FPS into STD visits is feasible, is well accepted by staff and patients, and provides 2 valuable services in a single visit using a client-centered approach to overlapping behaviors. An electronic reminder of eligibility in the EHR facilitates enrollment in FPS among STD clinic patients. The provision of these integrated services requires minimal additional time and cost. Additional studies are needed to assess long-term outcomes of this type of integrated services.
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