Secondary Logo

Journal Logo

The Real World of STD Prevention

Availability of Sexually Transmitted Infection Screening and Expedited Partner Therapy at Federally Qualified Health Centers in Michigan

Jamison, Cornelius D. MD, MSPH, MS∗,†; Waselewski, Marika MPH; Kuznia, Angela MD, MPH; Richardson, Caroline R. MD∗,†; Mmeje, Okeoma MD, MPH‡,§; Chang, Tammy MD, MPH, MS∗,†,¶

Author Information
Sexually Transmitted Diseases: July 2020 - Volume 47 - Issue 7 - p 437-440
doi: 10.1097/OLQ.0000000000001190

The United States is experiencing record high rates of sexually transmitted infections (STIs). According to the Centers for Disease Control and Prevention (CDC), 1.8 million cases of Chlamydia trachomatis (CT) and over 583,000 cases of Neisseria gonorrhoeae (NG) were reported in 2018—resulting in increases of 19% and 63%, respectively, since 2014.1 In 2017 the state of Michigan ranked 24th highest among both CT and NG rates, per hundred thousand, in the United States.1–3 In addition, many STIs go undiagnosed and untreated, leading to further transmission and reinfections. Untreated STIs can lead to pelvic inflammatory disease, infertility, and increased risk of HIV acquisition.1

Expedited partner therapy (EPT) is a health care practice designed to curb rising rates of CT and NG. Expedited partner therapy allows health care providers to treat the sexual partner(s) of patients diagnosed with CT or NG by providing medications or prescriptions to the patient for distribution to their sexual partner(s) without the need to examine the partner.4 Since endorsement by the CDC in 2006, EPT has been practiced in the United States for several years in different variations.5 Expedited partner therapy has been demonstrated to be safe and effective for treating STIs and preventing recurrence and is legally permissible in 44 states (as of December 2019), including Michigan.6 Despite strong evidence and legislation to support EPT, many health care providers and clinics throughout the United States do not offer EPT.7–9

Federally qualified health centers (FQHCs) are federally funded community health centers providing affordable comprehensive primary care services in medically underserved areas and are key sites for provision of sexual health services.10,11 In 2017, FQHCs served an estimated 27 million people nationally,11 including more than 700,000 people in the state of Michigan.12

Since EPT became legally permissible in Michigan in 2015,7,9 there have been no published data about its implementation or provision by physicians in the state. To better understand STI care and EPT provision in Michigan we designed a “secret shopper.” The secret shopper (or “simulated patient”) study has been recommended by the Department of Health and Human Services to mitigate the limitations of provider and household surveys that are likely to have social desirability and nonresponse biases.13

The objective of this study was to understand the availability of STI screening appointments, wait times for STI screening appointments, and EPT provision at FQHCs in Michigan. We hypothesized that STI screening would be provided by most clinics, with varying wait times, but that EPT provision would be limited.

MATERIALS AND METHODS

Study Design

We developed a standardized script for calls and secret shopper profiles (college male, female, etc.). Secret shopper calls were placed from October 4, 2017, to December 6, 2017. Phone calls were performed Monday through Friday beginning at 8:30 am (or at least 30 minutes after the clinic's posted hours began) until 4:15 pm (or at least 30 minutes prior the clinic's posted hours ended). All eligible clinics were called at least once during the data collection period. If the initial call went to voicemail, the clinic was called again on a different date. After 2 attempts with no answer, these clinics were noted as “unable to obtain data” and were excluded from additional analyzes.

To best mimic a new patient experience, we sampled at the clinic level rather than the provider level. Personally identifiable information about call staff, health care providers, or individual patients at participating FQHCs was not collected. The study was not regulated as human subjects research by the University of Michigan Institutional Review Board.

Clinic Inclusion

The full roster of Michigan FQHCs was developed by reviewing 2 statewide clinic databases. The first was from the Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health System and the second was from the Michigan Primary Care Association.14,15

A total of 174 eligible FQHCs were identified. An FQHC was determined to be eligible if it provided medical (primary care, pediatric, and/or obstetrics/gynecologic) services. Federally qualified health center facilities that only provided dental, behavioral/mental health, or pharmacy were considered ineligible. Clinics categorized as Michigan FQHC Look-Alikes and Indian Health Service providers represented by Michigan Primary Care Association were also ineligible.16

Urbanization and location characteristics of FQHCs were collected using data from the US Department of Agriculture.17 Clinics were classified by their county population and county-level urban influence code.

Secret Shopper Protocol

Secret shoppers used a standardized script and a rotating set of 3 predetermined demographic profiles with different names and ages between 16 and 21 years. The secret shopper's script was piloted and refined after calls to 10 non-FQHC Michigan primary care clinics (Appendix, http://links.lww.com/OLQ/A506). The primary investigator (male) and 1 trained research assistant (female) served as prospective patients requesting new patient appointments. Clinics were called at random by the 2 investigators. All calls to obstetrics and gynecology clinics were completed by the female research assistant. Appointments were not confirmed or were canceled at the end of each call to avoid taking appointment times from actual patients.

Secret shoppers expressed the desire to have STI screening and, if asked, indicated no STI-related symptoms. The secret shoppers requested the first available new patient appointment and confirmed STI screening could be performed during the initial visit. If asked by call center staff (including front desk personnel, clinic schedulers, and other staff responsible for accepting clinic phone calls and scheduling appointments) about provider preferences, they responded that any available health care provider would be acceptable. When asked, secret shoppers stated they did not have insurance. If call center staff requested insurance information prior to scheduling an appointment, the call was ended and the clinic was called backwith the name of a specific insurer, United Healthcare, one of the top insurers for Medicaid in Michigan.

Outcome Assessment

The first outcome was the availability of STI screening for patients. The STI screening availability was noted as “yes” or “no” based on clinic staff response about provision of the service. Availability of STI screening appointments for new patients was also assessed and was considered available if the secret shopper was provided with a specific appointment date and time.

The second outcome was wait time (in “business days”) before a new patient STI screening appointment. Wait times were calculated as the difference in days between the date of the call and date of the appointment; only counting Monday through Friday unless the secret shopper was specifically provided a Saturday appointment option. Federal holidays, including Thanksgiving Day (November 23, 2017), the Friday after Thanksgiving (November 24, 2017), Christmas Day (December 25, 2017), and New Year's Day (January 1, 2018) were not included in wait time days as clinics were assumed to be closed. Wait times were categorized as same day, 1 day, 2 to 5 days, longer than 1 week (between 6 and 30 days), longer than 1 month (more than 30 days), and could not schedule (clinics that would not schedule an appointment).

The third outcome was the provision of EPT. After confirming STI screening availability, secret shoppers explicitly asked about treatment for their partners. A clinic was considered to provide EPT if the call center staff responded to the simulated patient's inquiry with a statement that included the provision of a version of EPT (ie, partner pack, medications, prescription). Only clinics with call center staff that definitively noted not providing EPT were identified as having no EPT provision.

RESULTS

Clinic Inclusion

Secret shoppers were able to collect information from 153 of 174 eligible FQHCs. Of the clinics without information collected, 13 went to voicemail, 3 were transferred to the local county public health department or nearest Planned Parenthood clinic for STI screening, 3 were closed during the study period, and 2 required paperwork before an appointment could be made.

Clinic Characteristics

Of Michigan FQHCs, 66% (101/153) were located in metropolitan areas (i.e., Wayne County, population ~ 1.8 million), and 34% (52/153) were located in nonmetropolitan areas (i.e., Manistee County, population ~ 25,000).17 Federally qualified health centers were geographically dispersed across the state, representing 52 of 83 counties. Data from the included FQHCs and their services provided were summarized by county size (Table 1).18

TABLE 1
TABLE 1:
Services Provided at 153 Michigan FQHCs by County Size

STI Screening Availability

Of the 153 FQHCs included, 96.1% (147 of 153) provided STI screening (Fig. 1). Five of the 6 clinics that did not provide STI screening referred the secret shopper to the local health department or planned parenthood. The STI screening was similarly available across all county sizes with a range of 90% to 98% appointment availability.

Figure 1
Figure 1:
Flow chart of included clinics and information collected. *13 calls went to voicemail; 3 were transferred to the county health department or nearest Planned Parenthood for screening; 3 were closed during the study period; 2 required paperwork. †9 clinics were unable to offer a specific appointment times: 3 were unable to complete scheduling, 3 required paperwork, 2 were not accepting new patients, and 1 transferred to the county health department. ‡28 clinics' call staff were unsure if EPT was provided; 8 clinics referred the secret shopper to other sites for quicker STI screening and EPT; 4 had no information collected.

Appointment Wait Times

Secret shoppers were able to schedule appointments at 138 of the 147 FQHCs that provided STI screening (Fig. 2). Nine clinics could not schedule appointments for the secret shopper due to appointment dates further out than the scheduling system allowed, paperwork requirements for scheduling, and 1 clinic transferring the secret shopper to the county's public health department for an appointment. The average wait time was 7.9 ± 11.5 days. Wait times were similar across metropolitan and nonmetropolitan counties at 8.4 ± 12.6 days and 6.8 ± 8.9 days, respectively.

Figure 2
Figure 2:
STI screening appointment wait times at 147 FQHCs in Michigan.

EPT Availability

Of clinics providing STI screening, 10.2% (15 of 147) noted EPT provision in the case of a positive CT or NG result. These 15 clinics were located in 13 counties; 60% metropolitan and 40% nonmetropolitan. The majority of FQHCs (92/147, 62.6%) did not offer EPT. Information on EPT was unavailable for 40 (27.2%) of the clinics that provided STI screening; 28 call center staff were unsure if they provided EPT or did not know about EPT, 8 recommended the patient go to a different clinic for quicker screening and EPT, and information was unavailable from 4 clinics (Fig. 1).

DISCUSSION

This study assesses STI screening availability and EPT provision at FQHCs in the state of Michigan. Federally qualified health centers serve the state's most vulnerable patients whom are disproportionately affected by STIs.12,19 The majority (96.1%) of Michigan FQHCs provided STI screening, with little variation in the availability of screening between counties of different sizes (range, 90–98%). A majority (59.9%) of secret shoppers were scheduled for a screening appointment within 1 week. However, only 10.2% (15/147) of FQHCs providing STI screening confirmed availability of EPT.

Across the United States, there are concerns surrounding primary care appointment scheduling delays. In a recent survey of large US metropolitan areas, the average wait time for a family medicine provider was almost 30 days.20 Although this study revealed more accessibility at Michigan FQHCs (average wait time of 7.9 days) this may still not be soon enough. Delayed STI care results in increased risk of transmission to others, of additional infections, and STI consequences.21

Low EPT provision may also contribute to high STI rates in Michigan. Limited EPT availability in Michigan is consistent with a survey in Pennsylvania, which showed that although 56% of the clinicians reported ever using EPT, only 11% reported consistent use.8 In contrast, a survey among FQHCs in New York City found that more than half of the clinics had a written policy permitting EPT and 80% of sites provided EPT.22 Although national guidelines for EPT provision are available from the CDC, individual state regulations and procedures may differ, resulting in varied use of EPT.7 These variations also suggest that more research is needed to understand motivators and barriers to EPT provision, both in Michigan and across the country. Lack of knowledge, negative attitudes, and nuanced regulations have previously been noted as possible contributors to the low provision of EPT.23

This study is not without limitations. First, this evaluation of STI screening appointment availability and wait times was limited to availability for new patients and did not examine accessibility for established patients. Next, although Michigan is a large state, a single-state sample may not be generalizable to other states or a national population. Third, this study only assessed FQHCs, however EPT provision rates may differ in other clinical settings. Finally, information obtained from call center staff via secret shopper design may not reflect the true availability of EPT from providers in Michigan FQHCs.

The STI screening and treatment access are of great importance to Michigan's underserved and vulnerable patient populations. Although this study demonstrated availability of STI screening appointments, there was a large void in the provision of EPT across Michigan's FQHCs. Ensuring availability of STI screening and treatment at a wide range of health care settings is key to combating rising rates of STIs. Future research is needed to understand barriers which contribute to low EPT provision in Michigan and across the United States.

REFERENCES

1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2018. Atlanta: U.S: Department of Health and Human Services, 2019.
2. Michigan Department of Health & Human Services. Chlamydia Cases and Rates by County Michigan Residents, 2008-2012, 2013-2017 and 2018. http://www.mdch.state.mi.us/pha/osr/std/STDRanks.asp?ActiveSTD=C&AreaType=C&ActiveGender=T. Published 2018. Accessed September 23, 2019.
3. Michigan Department of Health & Human Services. Sexually Transmitted Diseases (STDs). https://www.michigan.gov/mdhhs/0,5885,7-339-73970_2944_5320_5332---,00.html. Published 2019. Accessed September 23, 2019.
4. Michigan Department of Health & Human Services; Bureau of Local Health and Administrative Services; Division of Health, Wellness, and Disease Control; Sexually Transmitted Disease (STD) Section. Guidance for Health Care Providers, Expedited Partner Therapy (EPT) For Chlamydia and Gonorrhea. https://www.michigan.gov/documents/mdch/EPT_for_Chlamydia_and_Gonorrhea_-_Guidance_for_Health_Care_Providers_494241_7.pdf. Published 2015. Accessed September 23, 2019.
5. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta: U.S: Department of Health and Human Services, 2006.
6. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676–685.
7. Centers for Disease Control and Prevention. Legal Status of EPT in Michigan. U.S. Department of Health & Human Services. https://www.cdc.gov/std/ept/legal/michigan.htm. Published 2015. Accessed September 23, 2019.
8. Rosenfeld EA, Marx J, Terry MA, et al. Perspectives on expedited partner therapy for chlamydia: A survey of health care providers. Int J STD AIDS 2016; 27:1180–1186.
9. State of MIchigan. Expedited partner therapy. Public Act 368 of 2014. Michigan Compiled Laws Annotated (MCL) 333.5110. In: Effective January 14, 2015.
10. Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care–the growing importance of the community health center. N Engl J Med 2010; 362:2047–2050.
11. Health Resources & Services Administration (HRSA). 2018 National Health Center Data. https://bphc.hrsa.gov/uds/datacenter.aspx. Published 2018. Accessed September 23, 2019.
12. Michigan Primary Care Association (MPCA). Health Centers Deliver Value. https://bphc.hrsa.gov/uds/datacenter.aspx. Published 2017. Accessed September 23, 2019.
13. U.S. Department of Health & Human Services; Office of Inspector General. State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320). Washington DC, 2014.
14. Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems. Federally Qualified Health Centers Provider Directory. https://www.michigan.gov/documents/lara/MI_FQHC_Directory_2-2016_515631_7.pdf. Published 2019. Accessed September 23, 2019.
15. Michigan Primary Care Association (MPCA). Michigan Health Centers and MPCA Members 2017–2018 Directory. https://cdn.ymaws.com/www.mpca.net/resource/resmgr/directory/2017-2018_MPCA_Directory.pdf. Published 2017. Accessed September 23, 2019.
16. Health Resources & Services Administration (HRSA). Tribal & Urban Indian Health Centers. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/tribal-urban-indian/index.html. Published 2018. Accessed September 23, 2019.
17. U.S. Department of Agriculture Economic Research Service. Urban Influence Codes. https://www.ers.usda.gov/data-products/urban-influence-codes/. Published 2019. Accessed September 23, 2019.
18. Michigan Department of Health & Human Services; Division for Vital Records and Health Statistics. Total Population Estimates by County, Michigan, 2017. http://www.mdch.state.mi.us/osr/CHI/POP/MAIN/PO17CO1.htm. Published 2018. Accessed September 23, 2019.
19. Michigan Primary Care Association (MPCA). The Value and Impact of Michigan Primary Care Association. https://cdn.ymaws.com/www.mpca.net/resource/resmgr/publications/2017_MI_Economic_Impact_Anal.pdf. Published 2018. Accessed September 23, 2019.
20. Merritt Hawkins an AMN Healthcare Company. Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates. https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Content/Pdf/mha2017waittimesurveyPDF.pdf. Published 2017. Accessed September 23, 2019.
21. Malek AM, Chang CC, Clark DB, et al. Delay in seeking Care for Sexually Transmitted Diseases in young men and women attending a public STD clinic. Open AIDS J 2013; 7:7–13.
22. Introcaso CE, Rogers ME, Abbott SA, et al. Expedited partner therapy in federally qualified health centers—New York City, 2012. Sex Transm Dis 2013; 40:881–885.
23. Kissinger PJ. The challenges of implementing and evaluating prescription expedited partner treatment. Sex Transm Dis 2017; 44:109–110.

Supplemental Digital Content

Copyright © 2020 American Sexually Transmitted Diseases Association. All rights reserved.