INTERRUPTING THE SPREAD OF SEXUALLY transmitted diseases (STDs) and preventing reinfection requires treatment of exposed partners. Traditional methods of partner management (PM) include patient referral, whereby healthcare providers (HCPs) instruct patients to tell sex partners about possible exposure to infection and the need for evaluation, and provider referral, in which HCPs or their designees contact patients’ sex partners directly. Provider referral is frequently used1 2 1 3–6 4,7–13
Recent randomized, controlled trials have examined alternative PM approaches, deemed “expedited partner therapies,” which attempt to interrupt the spread of disease by treating sex partners without a medical evaluation or counseling session. A commonly used expedited strategy is patient-delivered partner treatment (PDPT), which involves dispensing medication, or a prescription for medication, to patients infected with an STD for delivery to sex partner(s). Recent PDPT randomized, controlled trials have demonstrated that, compared with traditional PM approaches, PDPT reduced rates of persistent and recurrent gonorrhea and chlamydia infection in the index patient14–16 15
PDPT is used, although not commonly, in the European Union and in Australia.17–19 20,21 22–25 26
Although PDPT is a potentially useful strategy, it could reduce the probability of in-person evaluation for sex partners, and concerns exist that HCPs who use PDPT might be less likely to use other PM strategies with their patients. Fewer in-person evaluations might lead to missed opportunities to educate and counsel patients, diagnose concurrent STDs, and identify upper genital tract disease among women. There are few data with which to judge the extent to which these considerations should temper recommendations related to PDPT; however, such concerns have influenced recommendations that PDPT be practiced in addition to other strategies and not as a replacement for other PM strategies.27,28
Materials and Methods
Using the American Medical Association Physician Masterfile for physicians (MD/DO) and a proprietary database containing licensure information from the New York State medical boards for nurse practitioners (NPs) and physician assistants (PAs), we identified HCPs listed as either living or practicing in NYC. During November 2004 through January 2005, a total of 2000 HCPs were randomly selected, and surveys were mailed to 1600 MD/DOs, 200 NPs, and 200 PAs. On receipt of completed surveys, respondents were sent $15 bookstore gift certificates. This survey was approved by Institutional Review Boards at both NYC DOHMH and the Centers for Disease Control and Prevention. Characteristics of respondents were compared with nonrespondents to assess the representativeness of the sample that was analyzed. Because we wanted to focus on HCPs who treat patients with STDs, we limited analyses to HCPs who had diagnosed at least one case of chlamydia or gonorrhea during the past year.
To assess the frequency with which NYC HCPs practice patient and provider referral, we included 2 case scenarios on the survey, one describing a patient with likely chlamydia infection and the other a patient with likely gonorrhea infection. HCPs were asked to report the frequency with which they practiced patient or provider referral: rarely, sometimes, usually, or always. To assess PDPT use, HCPs were separately asked, “How often do you give a patient you have diagnosed with chlamydia [gonorrhea] a dose of antibiotic or a prescription for his/her partner(s)?” using a 4-point scale of never, sometimes, usually, or always for response categories. For analyses of patient and provider referral, response categories were dichotomized into frequent use (always/usually) and infrequent use (rarely/sometimes). For analyses of PDPT, groups were dichotomized into ever use (sometimes/usually/always) and never use (never). Results for both chlamydia and gonorrhea were similar for both case scenarios and PDPT responses, so we aggregated results for both diseases. Bivariate analyses were conducted to identify characteristics statistically significantly associated with PDPT use and to examine the relationship between PDPT and other PM strategies. Logistic regression was performed to identify independent predictors of PDPT use. Independent variables that were significant at a 0.10 level in bivariate analysis were added to the multivariate model one at a time and were dropped if they were not significant. Although not significant in stepwise logistic regression, certain variables were retained because they had been significant in previous studies on PDPT (e.g., HPC type [MD/DO, NP, or PA], HCP specialty or number of patients seen per week) or because of a plausible relation with provider behavior (e.g., HCP sex, HCP type).
Results
The overall study response rate was 42% (695 HCPs responded to 1647 successfully delivered surveys). The response rate differed significantly by provider type, with a greater percentage of NPs and PAs responding than physicians (59% NPs, 55% PAs, 38% MD/DOs; P <0.0001). Compared with nonresponders, responders were, on average, 1 year older (P <0.05), more likely to be female (P <0.05), and more likely to be an NP or PA than an MD/DO. Providers representing certain specialty groups were more likely to complete and return the survey than others; 50% of obstetrician/gynecologists and 42% of pediatricians sampled responded to the survey compared with 35% of internal medicine HCPs.
Of 622 respondents who reported providing patient care in NYC, 410 (65.9%) reported having diagnosed a case of chlamydia or gonorrhea during the previous year, and all analyses of PM strategies were limited to this group. Among these HCPs, 93.6% (368 of 393) reported frequent use of patient referral; only 20% (80 of 401) reported frequent use of provider referral. Table 1 presents PDPT use by response category separately for chlamydia and gonorrhea and overall for either pathogen. Overall, 49.2% (196 of 398) of HCPs reported ever using PDPT, and 27.1% (108 of 398) reported using this strategy frequently (defined as always or usually) for either chlamydia or gonorrhea. Of providers that reported diagnosing more than 10 cases of chlamydia in the past year, 41.9% reported having ever used PDPT; of those who had diagnosed more than 10 cases of gonorrhea, 34.7% reported having ever used PDPT.
TABLE 1: Provider Use of Patient-Delivered Partner Treatment for Chlamydia and Gonorrhea Among Providers Reporting Diagnosing Chlamydia/Gonorrhea in the Past Year
Frequent use of patient referral did not differ significantly by HCP type (MD/DO, PA, or NP), HCP sex, practice setting, or duration in practice. Frequent use of patient referral did differ significantly by HCP specialty (P <0.05); however, there was no difference between specialties when the analysis was limited to physicians. Frequent use of provider referral also did not differ by provider type (MD/DO, PA, or NP) but did differ significantly by practice setting (P <0.05) and HCP specialty (P <0.01), with HCPs specializing in emergency medicine or working in emergency department/urgent care settings being less likely to conduct provider referral than those specializing in internal medicine or pediatrics or working in inpatient settings.
When examining the association between use of PDPT and other PM strategies, we determined that use of patient referral was high regardless of whether the HCP reported use of PDPT (93.1% among those who ever used PDPT and 93.8% among those who never used PDPT). In contrast, use of provider referral differed significantly by whether the HCP had ever used PDPT. HCPs who reported having ever used PDPT were 2 times more likely to report frequent provider referral than those who had never used PDPT (26.7% vs. 12.6%; P <0.001). Correspondingly, among HCPs who reported frequent provider referral, 67.5% reported having ever used PDPT.
Table 2 presents a multivariate model of predictors of PDPT use. HCP practice setting, HCP specialty, duration of practice, HCP race/ethnicity, and report of frequent provider referral practice were each independently associated with PDPT in multivariate analysis. HCP report of frequent provider referral was one of the strongest independent predictors of PDPT use (odds ratio [OR] = 2.4; P = 0.005). HCPs who practiced in emergency department/urgent care settings were much less likely than those practicing in either inpatient or ambulatory care settings to use PDPT (OR = 0.1; P = 0.03). Additional significant HCP related predictors of PDPT use included having a specialty of obstetrics/gynecology (OR = 1.9; P <0.05), having completed medical or graduate school within the previous 10 years (OR = 1.8; P = 0.01), and being of Hispanic race/ethnicity (OR = 2.6; P = 0.04). Exploration of relationships between covariates showed that there was a significant relationship between HCP sex and HCP specialty (P <0.0001), with females representing a higher proportion of obstetrician/gynecologists, family practice, pediatrics, and males representing a higher proportion of emergency medicine and internal medicine specialties. An interaction term for sex and specialty was added to the multivariate model and found to be nonsignificant and therefore was not included in the final model. In addition, as might be expected, there was also a significant relationship between specialty type and practice setting (P <0.0001). Because both were significantly related to PDPT, they were both kept in the final multivariate model. HCP type (MD/DO, NP, PA) was also kept in the final model because of a plausible relationship with PDPT.
TABLE 2: Multivariate Analysis: Predictors of Use of Patient-Delivered Partner Treatment (PDPT) for Chlamydia or Gonorrhea
Discussion
Similar to findings from national and other local provider surveys, the majority (93.6%) of HCPs in our sample reported using patient referral strategies.23–25 25,29 22–24 22–24,29 Chlamydia trachomatis at least half of the time,22 C. trachomatis or Neisseria gonorrhoeae ,24 23
Our findings highlight the associations among different uses of multiple PM strategies, including PDPT, and suggest that NYC providers are using PDPT as well as patient or provider referral strategies. In fact, the positive association between PDPT use and frequent provider referral suggests that HCPs who practice PDPT might be more cognizant than other providers of the importance of PM in interrupting the cycle of reinfection and disease transmission.
Our multivariate results indicate that HCPs’ number of years in practice, specialty type, and practice setting can influence whether an HCP chooses to use PDPT. HCPs that had completed their medical training more recently were more likely to provide PDPT. This may be because of improved medical education surrounding sexual health and increased awareness of the importance of partner management for STDs. Because obstetrician/gynecologists have a female patient population and thus may face significant challenges in providing care to male partners of their patients, they may be more likely than other HCPs to dispense PDPT to their patients, thus treating male partners and preventing reinfection among their patients. HCPs practicing in emergency departments or urgent care settings may be reluctant to use PDPT because a chlamydia or gonorrhea diagnosis would likely not be laboratory-confirmed before dispensing PDPT. Previous research has demonstrated that urban emergency departments have a high prevalence of chlamydia and gonorrhea,30,31 30,31
This study has several limitations. PM questions were asked in the context of a larger survey on STD diagnosis, treatment, and management; therefore, questions that focused specifically on the practice of PDPT were limited in number; we were unable to assess reasons why HCPs do or do not use PDPT, and we did not ask PDPT questions specific to the sex of the index patient. Because this was a cross-sectional survey, we are only able to comment on the frequency of HCP practices and could not directly measure whether one PM strategy detracted from another. We were also unable to estimate the proportion of persons who were given medication to give to their partners with this survey because we did not assess the exact number of STDs diagnosed or the number of cases for which PDPT was used. This should be further examined in future research. In addition to these limitations, our response rates, particularly among physicians, were not high (overall, 42%), which might have affected the generalizability of our findings. It is possible that our low overall response rate and the relatively high percentage of responses from obstetrician/gynecologists could have contributed to our finding that 28% of providers reported using PDPT frequently given that obstetrician/gynecologists were more likely than other specialists to use PDPT. It is also possible that there could have been response bias, whereby providers who chose to respond to the survey may be those more likely to use PDPT. In addition, providers may not have given accurate reports of the frequency with which they use PDPT; however, it is difficult to anticipate the direction of any bias resulting from this. Despite such limitations, the strengths of this study lie in our assessment of different PM practices, inclusion of both physicians and midlevel providers, and demonstration that no difference in PDPT use exists among these groups. Additionally, this study was the first to investigate the relation between use of PDPT and other PM strategies.
Future investigation should examine how HCPs make decisions regarding different PM strategies and barriers to PDPT use. Formal or informal criteria used by HCPs to determine whether they should use PDPT might have direct bearing on its real-world effectiveness and on missed opportunities for prevention. Information is lacking on how HCPs apply PM strategies with individual patients, including whether PDPT is used in combination with, or as a substitute for, provider referral. The impact of missed opportunities for in-person clinical evaluation and counseling (e.g., undiagnosed concurrent STDs or pelvic inflammatory disease) should also be evaluated.
Our findings indicate that NYC HCPs are using strategies beyond patient referral to assure treatment of their patients’ sex partners and that these include both PDPT and provider referral. Currently, NY State law and regulations preclude provider prescription of medication to any individual not under the prescribing physician’s care. As legislatures and licensing bodies consider policies surrounding PDPT, they should take into consideration the limited efficacy of existing PM strategies, the frequency with which HCPs use PDPT, and whether PDPT is used in conjunction with other PM strategies. Development of specific criteria for PDPT use could help to maximize potential benefits and minimize any risks to patients or their partners. PDPT appears to be widely practiced among NYC HCPs diagnosing chlamydia and gonorrhea and may be an important means of reducing reinfection and preventing the spread of chlamydia and gonorrhea in NYC.
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