Patient-Delivered Partner Therapy for Chlamydial Infections: Attitudes and Practices of California Physicians and Nurse Practitioners

Abstract

Objective: 

The objective of this study was to examine California clinicians’ use of and attitudes toward patient-delivered partner therapy (PDPT) to treat sexual partners of patients infected with chlamydia.

Study Design: 

In 2002, a stratified random sample of primary care physicians and nurse practitioners completed a mailed, self-administered survey. Weighted frequencies were calculated to assess partner management practices, including PDPT, and attitudes toward PDPT. Multivariate models were constructed to determine independent predictors of PDPT use.

Results: 

Of 708 physicians and 895 nurse practitioners, approximately half (47% and 48%, respectively) reported that they use PDPT usually or always. Over 90% agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia. However, providers reported concerns that PDPT may result in incomplete care for the partner, may be dangerous without knowing the partner’s medical or allergy history, is an activity the practice may not get paid for, and may get them sued. Obstetrics/gynecology and family practice physicians were more likely than internal medicine physicians to report routine use of PDPT. Concerns about adverse outcomes of PDPT were associated with less PDPT use.

Conclusions: 

Although the proportion of California healthcare providers routinely using PDPT is comparatively high, further study is warranted to examine the circumstances under which this partner management strategy is used.

In Brief

A survey of California providers found that approximately half routinely use patient-delivered partner therapy for chlamydia. Medical specialty and concerns about adverse outcomes were associated with routine use.

MANAGEMENT OF PARTNERS OF PERSONS with a sexually transmitted disease (STD) is a key component of STD control. Ideally, effective partner management can prevent complications of STDs in partners, avoid further spread of the disease in the community, and reduce reinfection of the index case. Traditional partner management includes provider referral and patient referral, both of which require the partner to attend a clinic for evaluation and treatment. Provider referral involves having the healthcare provider or disease intervention specialist directly contact the partner, whereas patient referral involves having the infected patient inform his or her partner of the need for clinical evaluation.¹ Although provider referral has been shown to be more effective than patient referral in detecting infections among partners, particularly with male STD clinic patients,^2–4 high numbers of chlamydia and gonorrhea cases combined with insufficient resources in health departments result in follow up of only a small proportion of cases.⁵

Expedited partner therapy (EPT), an approach whereby partners are treated without an intervening clinical evaluation, is another partner management strategy. One type of EPT, patient-delivered partner therapy (PDPT), allows the patient to deliver antibiotics or a prescription for antibiotics to his or her sexual partners. This facilitates treatment for partners who are unable or unwilling to seek timely medical care for the infection. Genital chlamydial infection is the most common reportable communicable disease in California⁶ and has a relatively high rate of recurrent infection.⁷ Multiple infections increase the risk of adverse reproductive health outcomes for women.⁸ Perhaps the most important risk associated with recurrent chlamydial infection is reexposure to untreated sexual partners.^7,9 High infection rates combined with inadequate partner treatment make EPT a promising option for managing patients with chlamydial infections.

Previous studies assessing the effectiveness of PDPT for chlamydia and other STDs, including one observational study¹⁰ and 4 randomized trials,^11–14 have generally found PDPT to be equally or more effective compared with traditional methods in reducing reinfection, increasing partner notification and treatment, and decreasing high-risk sexual behavior. In an effort to enable appropriate use of this partner management strategy, the California legislature passed a new law in 2001 allowing healthcare providers to prescribe and/or dispense antibiotic therapy for sexual partners of patients infected with genital chlamydial infection, even if they have not been examined.¹⁵

Little is known about clinical practices in California related to STD partner management, including PDPT. As part of a statewide provider survey on chlamydia care practices,¹⁶ we conducted an analysis of practices and attitudes related to PDPT.

Materials and Methods

This was a cross-sectional, self-administered mailed survey of primary care providers in California, including physicians and nurse practitioners. The physician sample included a stratified random sample selected from the 2001 American Medical Association (AMA) database. The AMA database consists of both member and nonmember licensed physicians. Four hundred physicians were surveyed from each primary care specialty group, including family practice, general practice, internal medicine, obstetrics/gynecology (ob/gyn), and pediatrics. In addition, all 68 registered adolescent providers were surveyed. All 1815 primary care nurse practitioners who were members of the California Coalition of Nurse Practitioners were surveyed. These provider types were sampled because they were thought to provide primary care for most young women in California. Eligibility requirements for participation in the survey included providing primary care to sexually active patients under the age of 30 within the past 3 months and spending more than 10% of time providing clinical care.

In December 2001 and March 2002, the questionnaire was mailed to the physician and nurse practitioner samples, respectively. All providers received a coupon for a free course given by the California STD/HIV Prevention Training Center. One half of physicians were randomized to receive a $5 incentive that was mailed along with the questionnaire. Nonrespondents received up to 3 mailings, a fax, and/or a phone call.

Survey Instrument

A 2-page, self-administered survey about STD practices included questions regarding provider demographics (age, gender, and graduation year), specialty type, primary practice setting (private practice, health maintenance organization, public clinic, academic institution, or other), and average volume of young female patients (15–25 years of age) seen per week.

To assess use of PDPT for chlamydia management, providers were given a scenario of a nonpregnant patient with a positive chlamydia test and were asked, “How often do you or your office staff provide prescription or medication for male partners of female patients (patient-delivered partner therapy)?” The same question was asked for female partners of male patients. The response options were provided in a 5-point scale: never, sometimes, half of the time, usually, or always.

Attitudes about PDPT were assessed using a series of statements for which agreement was indicated using a 5-point scale: strongly agree, agree, neutral, disagree, or strongly disagree. Statements included: “Patient-delivered partner therapy for chlamydia: helps me provide better care for my patients with chlamydia; protects my patients from reinfection; is an activity my practice may not get paid for; may be dangerous without knowing the partner’s medical or allergy history; may get me sued; may result in incomplete care for the partner; should only be for male partners of females; or should only be given if partner name is given.”

Statistical Analysis

The main outcome of interest for this study was reporting routine use of PDPT for male or female partners of chlamydia cases. Routine practice was defined as a response of “usually” or “always” to clinical practice questions. Responses to attitude statements were dichotomized (strongly agree and agree vs. other responses) for statistical comparison, with the exception of the 2 favorable statements, for which responses were dichotomized as strongly agree, agree, and neutral versus all other responses.

To generate population estimates, weights were constructed based on the inverse of the sampling fraction of each medical specialty in the AMA database. Weighted estimates were used for all overall physician frequencies, with the exception of the sample description. There was no significant demographic or specialty difference between physician respondents who received the financial incentive and those that did not; therefore, the physician samples were combined for the final analysis. The physician and nurse practitioner samples were not combined because of the difference in sampling strategies. Because measuring differences in practice patterns between these provider types was not an objective of this study, analyses were performed separately for physicians and nurse practitioners.

The data were entered in Epi Info (version 6.04) and analyzed using SAS (version 9.0, SAS Institute, Cary, NC) and STATA Statistical Software (version 7.0; Stata Corp., College Station, TX). For 2 × 2 crosstabulation, Yates corrected chi-squared statistic was used. For crosstabulations with greater than 2 categories of variables, statistical associations were determined using the Pearson chi-squared statistic. Statistical significance was defined as P <0.05. Odds ratio estimates and 95% confidence intervals were used to summarize univariate associations. Variables that were significantly associated with the outcome on univariate analysis at the P <0.05 level were included in a multivariate logistic regression model to estimate adjusted odds ratios and 95% confidence intervals.

Results

Of the 2068 physicians who were mailed surveys, 617 were determined to be ineligible. Of the remaining 1451 physicians, 708 (49%) completed the survey. Of the 1815 nurse practitioners surveyed, 397 were determined to be ineligible, and of the remaining 1418, 895 (63%) completed the survey. Adolescent specialists were more likely to respond compared with other specialties. There were no other significant differences between the demographics of responding physicians and nonresponding physicians (data not shown).

The characteristics of the study group are presented in Table 1. The majority of physicians were male with a mean age of 50 years (range, 28–84 years). Physicians had completed residency an average of 17 years prior (range, 2–58 years), and most worked in private practice. The nurse practitioners were mostly female with a mean age of 47 years (range, 23–77 years). Nurse practitioners had completed training 9 years prior on average (range, 1–31 years), and most worked in private practice or public clinic settings. The majority of physicians and nurse practitioners reported a high volume of young female patients.

TABLE 1: Characteristics of the California Primary Care Providers Included in the Survey

Partner Management Practices

The majority of physicians and nurse practitioners reported practicing some form of partner management for their chlamydia-infected patients. Nearly all physicians and nurse practitioners reported routinely telling patients to inform their partner(s) of chlamydial infection (Table 2). Among providers reporting routine PDPT use, there was greater than 90% concordance between use for male and female partners. The majority of providers reported using PDPT at least once and nearly 50% reported routine use of PDPT for either male or female partners. Among physicians, 23% reported never using PDPT, 23% sometimes, 7% half the time, 24% usually, and 23% always. The distribution was similar for nurse practitioners: 25% reported never using PDPT, 23% sometimes, 4% half the time, 19% usually, and 29% always. Other partner management strategies such as asking the health department to inform the partner were less common.

TABLE 2: California Primary Care Providers’ Usual Partner Management Practices for Nonpregnant Chlamydia-Infected Patients (% usually/always)

Attitudes Related to Patient-Delivered Partner Therapy

Providers indicated favorable attitudes as well as concerns related to PDPT (Table 3). Over 90% of physicians and nurse practitioners agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia. Statements of concern with the largest proportion of physician and nurse practitioner agreement included concern that PDPT may result in incomplete care for the partner, concern that PDPT is dangerous without knowing the partner’s medical or allergy history, concern that PDPT is an activity the practice may not get paid for, and fear of being sued.

TABLE 3: California Primary Care Providers’ Agreement With Statements Regarding Patient-Delivered Partner Therapy for Chlamydia

Predictors of Patient-Delivered Partner Therapy

On univariate analysis, demographics significantly associated with routine use of PDPT for either male or female partners included ob/gyn, adolescent medicine, family practice, and general practitioner specialties as compared with internal medicine, younger age for nurse practitioners, and high female patient volume for both physicians and nurse practitioners. Several attitudes were associated with routine use of PDPT on univariate analysis. For both physicians and nurse practitioners, agreement with any of the following statement was significantly associated with not routinely using PDPT: concern about incomplete care, not knowing medical or allergy history, and getting sued. For physicians, agreement with the statement that PDPT should be given only to male partners of females was significantly associated with reporting routine use of PDPT. For nurse practitioners, agreement with the statement that PDPT helps protect patients from reinfection was significantly associated with reporting routine use of PDPT. Although concern that PDPT is an activity the practice may not get paid for was common among both nurse practitioners and physicians, it was not significantly associated with reported PDPT use.

Factors that were found to be significant predictors of PDPT on univariate analysis were included in separate multivariate models for physicians and nurse practitioners. For physicians, obstetrics/gynecology and family practice specialties were independent predictors of routine use of PDPT (Table 4). After adjusting for medical specialty and patient volume, concern that PDPT is dangerous without knowing the medical or allergy history of the partner was independently associated with not routinely using PDPT and agreement that PDPT should only be for male partners of females was associated with routine PDPT use. For nurse practitioners, after adjustment for age and patient volume, agreement with 3 concerns about PDPT remained significant predictors of not routinely using PDPT, and agreement that PDPT protects patients from reinfection remained a significant predictor of routinely using PDPT (Table 5).

TABLE 4: Factors Independently Associated With California Primary Care Physicians’ Routine Use of Patient-Delivered Partner Therapy for Chlamydia (n = 708)

TABLE 5: Factors Independently Associated With California Nurse Practitioners’ Routine Use of Patient-Delivered Partner Therapy for Chlamydia (n = 895)

Discussion

This study determined the frequency of various partner management practices, including PDPT, and identified important attitudes and concerns related to PDPT among primary care providers in California. In particular, we found that nearly half of providers reported that they use PDPT usually or always to treat sexual partners of patients infected with chlamydia. Although the majority agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia, providers also reported concerns that PDPT may result in incomplete care for the partner, may be dangerous without knowing the partner’s medical or allergy history, is an activity the practice may not get paid for, and may get them sued. In the wake of the passage of legislation allowing PDPT in California, establishing the frequency of PDPT use and identifying potential barriers to its use are first steps in monitoring the effect of the legislation and evaluating appropriateness of use.

Although our findings related to the frequency of provider referral and patient referral were similar to those of a national physician survey conducted in 2000, the proportion of California providers reporting routine use of PDPT in our survey was considerably higher.¹⁷ In the national survey, only 50% of physicians reported they had ever used PDPT for chlamydial infection and only 14% reported usually or always using PDPT.^17,18 Other surveys conducted in Washington, Rhode Island, and Connecticut found rates similar to the national rates,^19,20 whereas, a survey conducted in New York City found that 27% of providers frequently used PDPT.²¹ Subsequent analysis of the national data showed that the rate of PDPT use among California physicians was not significantly different from national rates (Hogben, personal communication, 2005). The difference in findings may be a result of the different timing of administration, particularly in relation to the passage of California legislation allowing PDPT. The national survey was conducted 1 year before the legislative changes, whereas our survey was conducted 1 year after the changes. Media advocacy and provider education may have increased awareness and adoption of PDPT among California providers. Alternatively, differences in wording or context of the question may have affected responses. Although PDPT is a useful management strategy for partners who are unable or unwilling to seek clinical evaluation, we do not yet have information on what proportion of patients’ partners fall into this category; thus, it is unclear what the benchmark should be in terms of appropriate frequency of PDPT use.

The concern among California providers that PDPT may result in incomplete care for the partner is supported by new data on coinfection risk. Two recent studies that investigated concurrent infections in patients and partners attending STD clinics found that for chlamydia index cases, 3% to 6% of partners were infected with gonorrhea and 6% to 11% of partners were infected with trichomonas.^22,23 Because these studies were observational, partners who attended a clinic may have been more likely to be symptomatic as compared with partners who did not attend a clinic, thus overestimating the coinfection rate. Furthermore, there is no guarantee that with other methods of partner management, the partner will receive appropriate testing for concurrent STD/HIV infection. Additional work is needed to document actual adverse outcomes of EPT strategies, including drug allergies, side effects, and interactions; undiagnosed coinfection with other STDs, including HIV; missed counseling opportunities; and inappropriate or incomplete use of medication.

Because of its effectiveness in treating partners and preventing recurrent chlamydia and gonorrhea infections, EPT is a valuable option to facilitate partner management, particularly when partners are unable, unwilling, or unlikely to seek clinical evaluation. Because of the risk of coinfection and advanced infection such as pelvic inflammatory disease in females, it is essential that EPT is accompanied by patient education materials that emphasize the risk of other STDs that may be left untreated by the delivered medication and the importance of seeking clinical evaluation. These informational and counseling messages need to be refined and evaluated for diverse patient populations. Although unnecessary treatment of uninfected partners may occur with EPT, this is no different than the currently recommended epidemiologic treatment of partners presenting to a clinic.²³ To improve medical providers’ use of PDPT, practice guidelines for the state of California have been developed.²⁴ Formal EPT guidelines from the Centers for Disease Control and Prevention (CDC) have also been published (http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf). Interventions at the provider level to promote appropriate use of EPT include distribution of these practice guidelines along with information about the efficacy of EPT, drug safety, and medicolegal issues.

Structural-level barriers to PDPT identified by California providers included reimbursement policies and legal obstacles. Currently, PDPT medication cannot be billed through Medicaid unless the beneficiary (partner) is enrolled; however, several managed care organizations in California pay for PDPT medications. Although clearly legal in California and at least 3 other states, a survey of medical and pharmacy boards found that 88% regarded PDPT as illegal or of uncertain legal status.²⁵ Anecdotal reports indicate that several states are working on legislation to facilitate EPT, and it may be legal in more states in the near future. A recent “Dear Colleague” letter from the CDC endorsing EPT, particularly for heterosexual men and women with chlamydia or gonorrhea, may facilitate expansion of both the legality and reimbursement mechanisms.²⁶ To enable use of this effective partner management strategy, clear policy and program recommendations need to be formulated, federal and state health departments need to work to remove legal barriers, and systems must be implemented for cost-effective delivery of and reimbursement for EPT.

This study has several limitations. Although there were no significant differences in the demographics of respondents and nonrespondents, our response rate of 49% for physicians and 63% of nurse practitioners made findings less generalizable. In addition, for the nurse practitioners, sampling from a professional association for which membership is not a requirement for practice may have introduced bias if certain types of providers are more likely to belong to such organizations. Our study relied on provider self-report of clinical practices, which may over- or underestimate actual provider practice depending on their perception of the pervasiveness and acceptability of the practice.

Future directions for EPT should concentrate on assessing of the circumstances of EPT use, understanding when and why healthcare providers are choosing this method of partner management, and determining what proportion of providers are in compliance with the practice guidelines. Other areas of study should focus on further evaluation of the potential adverse outcomes of EPT and on additional structural and attitudinal barriers to using EPT.