Sexually transmitted diseases (STDs) are commonly diagnosed and treated by obstetrician-gynecologists. Of the ten most frequently reported diseases in 1995 in the United States, five were STDs,1 with approximately 12 million new cases annually.2 Public awareness and knowledge of STDs is dangerously low, and to date no comprehensive national public education campaign has addressed the issue.3
Methods for reducing disease exposure and transmission requires a multifaceted approach, including partner identification, notification, treatment, and subsequent follow-up.3,4 Several factors limit the ability of partner notification to affect disease control,5 including concurrent drug abuse, multiple sexual partners, and location of the infected woman or partner in a high-crime residency area, making public health contact difficult.5–7 The willingness and ability of health care providers to initiate partner notification is paramount to the success of this approach. For obstetrician-gynecologists, it might be especially difficult because male partners of women with STDs might not be seen as part of their patient panels.
The objectives of the present study were to survey obstetrician-gynecologists in our community to determine their knowledge, attitudes, and practice patterns related to partner notification. We also assessed how many practitioners incorporated state-mandated guidelines into their daily practices for STD diagnosis and treatment.
Materials and Methods
A questionnaire was mailed to community, hospital-employed, and university-based obstetrician-gynecologists within a single health care system located in the Detroit metropolitan area, consisting of four hospitals where obstetrics and gynecology are practiced. A variety of patients are serviced by those institutions, including privately insured, managed-care, and federally funded patients. Physicians surveyed included generalists and subspecialists in maternal-fetal medicine, reproductive endocrinology and infertility, gynecologic oncology, urogynecology, and reproductive genetics. Subjects were asked to return the anonymous questionnaire and a response postcard under separate cover. A second request was sent to nonrespondents based on not receiving the identifying postcard. The study was reviewed and approved by the Wayne State University Investigational Review Board.
The survey consisted of 22 predominately multiple-choice questions, with three requiring a scaled response. The latter questions were not included in the analysis. A copy of the actual survey is available upon request. In addition to demographic questions, the survey was designed to gain information on the knowledge, attitudes, and practice patterns of the obstetric-gynecologic community.
Demographic questions asked about respondents' sex, race, years since completing residency training, practice type, and employment situation. Knowledge-based questions were designed to ascertain whether respondents could identify the required reportable STD conditions by Michigan State Health Code and for which partner notification of STDs was required. Respondents also were asked what the state-preferred method of notifying partners was, along with the duty of the diagnosing laboratory in notifying state public health officials. Participants were asked their attitudes and opinions on the need for informed consent before partner notification, and to speculate on the percentage of their patients' partners who actually sought evaluation and treatment. Practice-pattern-type questions included whether physicians routinely offered partner treatment through their offices, how they confirmed that proper partner follow-up had been done, and whether anyone reported the STD condition to the health department. Physicians were also asked for which STDs they offered screening at a routine annual gynecology visit and if they routinely distributed literature to patients and partners to educate them about STDs. Responses from returned surveys were analyzed by χ2 analysis, with statistical significance defined at (P < .05. Confidence intervals (95% CIs) were calculated for all categoric variables.
Of 222 surveys sent, 108 responses were received, for a rate of 49%. Of the respondents, 36% were private practitioners, 38% were hospital employed, and 23% were university faculty physicians. Demographic variables are given in Table 1.
Knowledge of state regulations for required reportable conditions also varied. Ninety-five percent of respondents (103 of 108) correctly identified syphilis as a required reportable condition (CI 90%, 98%) 85% (92 of 108) identified gonorrhea (CI 77%, 91%), and 75% (81 of 108) correctly identified human immunodeficiency virus (HIV) (CI 67%, 83%). However, only 57% (62 of 108) realized that chlamydia was a required reportable condition (CI 47%, 66%). χ2 tests showed that a statistically significantly higher number of subspecialists recognized chlamydia as a required reportable condition than generalists (P < .014). Forty-one percent of respondents (44 of 108) correctly identified hepatitis B as a required reportable condition (CI 50%, 57%). In Michigan, hepatitis B is a required reportable condition, but it is not specifically categorized as an STD.
Respondents were asked the importance of partner notification for the various STDs as it related to spread of disease. Although most physicians correctly identified the importance of partner notification for several STDs, most respondents (63 of 108, 58%, CI 50%, 67%) could not identify all those conditions. A wide range of responses were identified; 91% of respondents (98 of 108) correctly acknowledged the importance of partner notification for HIV (CI 84%, 95%), 90% (97 of 108) syphilis (CI 83%, 94%), and 86% (93 of 108) for gonorrhea and hepatitis B (CI 32%, 50%). Forty-one percent (44 of 108) correctly identified the need for partner notification in patients with chlamydial infections (CI 38%, 51%). There were no significant trends for gender, race, practice type, or years since residency training.
Practice patterns also varied markedly among respondents. Few had direct contact with partners of patients. Forty percent (43 of 108) reported notifying the local or state health department to contact patients' partners (CI 31%, 49%), and 46% (50 of 108) relied on patients to notify their partners (CI 37%, 56%). Most respondents (84 of 108, 78%, CI 69%, 85%) were unaware of all required reportable STDs and the state's preferred method of partner notification. In Michigan, the state's preference is for practitioners to give patients' names to the health department authorities who then contact the patients, obtain a list of partners, and contact them individually. Forty-six percent (50 of 108) correctly identified the state's preferred method for partner notification (CI 37%, 56%).
Twenty-five percent (27 of 108) of respondents felt that supplying information on patient contacts was a violation of physician-patient confidentiality (CI 18%, 34%). Follow-up information to insure that patients' partners were treated also varied. Most respondents, 89% (96 of 108), simply asked patients if their partners were treated (CI 82%, 94%). Sixteen percent (17 of 108) assumed that partners were treated (CI 10%, 24%), and only 3% (3 of 108) asked for documentation (CI 1%, 8%). Those numbers exceed 100% because respondents were allowed to choose more than one method.
Respondents were asked about use of literature as educational materials to inform women and their partners about STDs. Eighty-eight percent (86 of 108) gave literature to women (CI 71%, 86%) whereas 68% (73 of 108) gave literature to partners (58%, 76%), mostly through the women. Significantly more female than male practitioners (P < .05) distributed literature to the women and their partners.
Physicians were asked about the responsibility of the diagnosing laboratory in reporting STDs. According to Michigan Department of Health Rule 325.173, “a clinical laboratory shall report laboratory evidence of any infections specified within 3 days of discovered.” Seventy-five percent (81 of 108) of respondents correctly realized that laboratories had an obligation to report diagnosed STDs to state authorities (CI 66%, 82%). That does not exempt practitioners from state reporting requirements; however, only 49% (53 of 108) indicated they reported STDs from their offices (CI 40%, 58%) (18% self [19 of 108; 12%, 26%], 32% by office staff [34 of 108; 36%, 41%]), and 7% not reporting (8 of 108; CI 4%, 14%). The remainder of respondents specified that they relied on laboratories to report the conditions to state officials.
The Institute of Medicine's report, highlighting the hidden epidemic of STDs in society, signifies the importance of knowledge about disease reporting and partner notification by all physicians.3 We did our study because there were no data examining how obstetrician-gynecologists deal with this issue. We found that many obstetrician-gynecologists lack adequate awareness of what conditions are reportable and the correct guidelines for partner notification. Numerous other studies have confirmed the contagious nature of STD infections, and that control must be achieved by concomitant treatment of women and all their sexual contacts.1–9
Several obstacles to partner notification and treatment can be identified specific to obstetrician-gynecologists. Most physicians in this specialty treat only women and might feel inadequately trained to counsel and treat male partners, which disrupts continuity of care because it is unlikely that physician-to-physician contact will be established for the partner. In the era of managed care, women's partners might not have adequate resources for evaluation and treatment. Even if the partner has access to public health clinics, significant delays to treatment might be encountered, and unnecessary diagnostic or therapeutic interventions might be undertaken. Closing the loop through combined educational sessions for both individuals is important but is unlikely because each identifies with a different health care provider.
Obstetrician-gynecologists rely heavily on ancillary personnel, including laboratory staff and public health agencies. Surveyed physicians also rely on women to inform their partners and ensure that proper treatment was received. Anecdotal experiences in our community suggest that laboratory reporting of STDs is not done consistently. Oversight groups lack adequate resources to guarantee compliance, and personnel shortages in public health departments are common, thus potentially compromising the traditional route of tracking STD contacts.
Limitations to our study included a relatively large nonresponse rate (114 of 222), which limited our ability to generalize the results of our study and might contribute to potential biases in interpretation. There also were no control or comparison physician groups, thus we cannot comment on whether our findings were limited to obstetrician-gynecologists or are seen with other health care providers.
Future educational efforts are needed to increase physician awareness of reportable STD conditions and to educate physicians about state regulations for partner notification. Because of the variety of perceptions about reportable conditions and how to notify and treat patients' partners, we suggest that the ACOG possibly develop guidelines for partner notification and treatment.
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2. Centers for Disease Control and Prevention, Division of STD/HIV Prevention. Annual report 1992. U.S. Department of Health and Human Services, Public Health Service. Atlanta, GA: Centers for Disease Control and Prevention, 1993.
3. Institute of Medicine. The hidden epidemic-confronting sexually transmitted diseases. Washington, DC: Institute of Medicine, Division of Health Promotion and Disease Prevention, Committee on Prevention and Control of Sexually Transmitted Diseases, 1997.
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