1. Sexually transmitted disease diagnostic experience among outpatient clinicians in the United States, 2004 Nidhi Jain MD MPH Health Services Research and Evaluation Branch Division of STD Prevention This information is distributed solely for the purposes of pre-dissemination peer review under applicable information quality guidelines. It has not been formally disseminated by the CDC. It does not represent and should not be construed to represent any agency determination or policy.

2. Sexually transmitted diseases in the United States Chlamydia- 929,462 cases reported Gonorrhea- 330,132 cases reported Genital herpes- 269,000 initial visits Genital warts- 316,000 initial visits *STD surveillance report 2004

3. STD burden and costs among youths age 15-24 years* # new casesCosts ($) in 2000 Chlamydia1.5 million248.4 million HSV640,000292.7 million HPV4.6 million2.9 billion HIV15,0003.0 billion * Chesson H, Blandford J, Gift T, Tao G, Irwin K. The Estimated Direct Medical Cost of Sexually Transmitted Diseases Among American Youth, 2000. Perspectives on Sexual and Reproductive Health. 2004: 36(1)

4. STD care in the United States 40-60% of STD cases are treated outside of STD clinics 40-60% of STD cases are treated outside of STD clinics Bacterial STDs are treated in public settings Bacterial STDs are treated in public settings Viral STDs are treated in private settings Viral STDs are treated in private settings Factors influence where STD care is accessed Factors influence where STD care is accessed Sex, ie female patients go to private clinics Sex, ie female patients go to private clinics Race, ie white patients go to private clinics Race, ie white patients go to private clinics Income level, ie higher income go to private clinics Income level, ie higher income go to private clinics Inconvenience, esp. clinic hours Inconvenience, esp. clinic hours Embarrassment and stress Embarrassment and stress

5. Objective Characterize who is providing STD care in the United States from a national survey of clinicians who see adolescents and adult patients who are likely to be sexually active

6. Study Design Stratified sampling design of US providers Random sample taken from national registries (760-828 for each specialty) Physicians Family/General practice (FP) Adolescent medicine (ADOL) Internal medicine (IM) Obstetrics/Gynecology (OB/GYN) Urologists (URO) Dermatologists (DERM) Midlevel providers Physician assistants (PA) Certified nurse midwives (CNM) Nurse practitioners (NP)

7. Survey Methods Self-administered mail surveys May-September 2004 Self-administered mail surveys May-September 2004 Surveys Fed exed to 6,906 randomly selected clinicians Surveys Fed exed to 6,906 randomly selected clinicians Cover letter noted results will inform new clinician training and decision supports tools and patient education materials Cover letter noted results will inform new clinician training and decision supports tools and patient education materials Repeat mailings sent at 3,6,9,and 15 week to encourage response Repeat mailings sent at 3,6,9,and 15 week to encourage response

8. Selected survey topics Demographic characteristics of clinicians Demographic characteristics of clinicians Characteristics of practice and patients Characteristics of practice and patients STD experience STD experience Patient education requests for information to prevent STD and how clinicians provided information Patient education requests for information to prevent STD and how clinicians provided information

9. Data Analysis All analyses in SAS and SUDAAN – weighted to adjust for differences by specialty in sampling and non-response Two-sided probability 0.05 considered significant Chi-square test to compare percentages

10. Results

11. Response rates adjusted for eligibility by specialty and non-response Midlevels % Midlevels % Nurse practitioners 96 Nurse midwives 95 Physician assistants 86 Physicians % OB/GYN 81 Adolescent med 79 Dermatology 80 Urology 78 Family Practice 68 Internal Medicine 59 6906 surveys mailed- 4305 completed Overall response rate after adjusting for deceased, retired, ineligible, or did not have current address respondents = 81%

12. Reported characteristics of respondents (n=4305) Demographic characteristics:% ≥ 50 yrs old 40 Female 41 Practicing > 20 yrs 36 Practice characteristics: Practice in private practice office73 Solo practice 26 Saw ≥ 100 patients per week46 Region: Northeast 21 Midwest 22 South 33 West24 Urban setting80

13. Reported characteristics of respondents (n=4305) Patient characteristics: % Mean % patients who were female65 Mean % patients who were white 68 Female patients 18-50 y/o 39 Male patients 18-50 y/o 31 Patients primary method of payment < 75% patients had private insurance 79 ≥ 75% patients had private insurance21

14. Reported STD diagnostic experience in the past 12 months (n=4305) % clinicians with recent experience* Mean # cases (95% CI) median HSV 9116 (14-17)5 Genital warts 8910 (9-11)2 Chlamydia 8014 (13-16)5 HIV 505 (4-6)0 *defined as having seen ≥ 1 case in the past 12 months

15. STD diagnostic experience by specialty (median) HSV Genital warts ChlamydiaHIV Family Physician 5251 Internal Medicine 4021 Adolescent medicine 2150 OB/GYN1512100 Nurse Mid-wives 1010150 Dermatology101002 Urology4421 Nurse Practitioners 83101 Physician Assistants 6261 Total5250

16. STD diagnostic experience by specialty (median) HSV Genital warts ChlamydiaHIV Family Physician 5251 Internal Medicine 4021 Adolescent medicine 2150 OB/GYN1512100 Nurse Mid-wives 1010150 Dermatology101002 Urology4421 Nurse Practitioners 83101 Physician Assistants 6261 Total5250

17. STD diagnostic experience by specialty (median) HSV Genital warts ChlamydiaHIV Family Physician 5251 Internal Medicine 4021 Adolescent medicine 2150 OB/GYN1512100 Nurse Mid-wives 1010150 Dermatology101002 Urology4421 Nurse Practitioners 83101 Physician Assistants 6261 Total5250

18. STD diagnostic experience by specialty (median) HSV Genital warts ChlamydiaHIV Family Physician 5251 Internal Medicine 4021 Adolescent medicine 2150 OB/GYN1512100 Nurse Mid-wives 1010150 Dermatology101002 Urology4421 Nurse Practitioners 83101 Physician Assistants 6261 Total5250

19. Patient education requests for information on how to prevent STDs Respondents reported that at least some patients had asked for information… %95% CI Family Physician 8581-89 Internal Medicine 7873-83 Adolescent medicine 8784-90 OB/GYN9391-96 Nurse Mid-wives 9391-95 Dermatology7167-75 Urology7774-81 Nurse Practitioners 9088-92 Physician Assistants 8784-90 Total8483-86

20. Patient education requests for information on how to prevent STDs Respondents reported that at least some patients had asked for information… % 95% CI Family Physician 8581-89 Internal Medicine 7873-83 Adolescent medicine 8784-90 OB/GYN9391-96 Nurse Mid-wives 9391-95 Dermatology7167-75 Urology7774-81 Nurse Practitioners 9088-92 Physician Assistants 8784-90 Total8483-86

21. Patient education requests for information on how to prevent STDs Respondents reported that at least some patients had asked for information… % 95% CI Family Physician 8581-89 Internal Medicine 7873-83 Adolescent medicine 8784-90 OB/GYN9391-96 Nurse Mid-wives 9391-95 Dermatology7167-75 Urology7774-81 Nurse Practitioners 9088-92 Physician Assistants 8784-90 Total8483-86

22. Reported provider provision of STD prevention education to patients Not done routinely I do in person Other staff Written materials Family Physician 137549 Internal Medicine 345438 Adolescent medicine 48268 OB/GYN 1464418 Nurse Mid-wives 68139 Nurse Practitioners 77858 Physician Assistants 979210 Total1868410

23. Reported provider provision of STD prevention education to patients Not done routinely I do in person Other staff Written materials Family Physician 137549 Internal Medicine 345438 Adolescent medicine 48268 OB/GYN 1464418 Nurse Mid-wives 68139 Nurse Practitioners 77858 Physician Assistants 979210 Total1868410

24. Reported provider provision of STD prevention education to patients Not done routinely I do in person Other staff Written materials Family Physician 137549 Internal Medicine 345438 Adolescent medicine 48268 OB/GYN 1464418 Nurse Mid-wives 68139 Nurse Practitioners 77858 Physician Assistants 979210 Total1868410

25. Reported provider provision of STD prevention education to patients Not done routinely I do in person Other staff Written materials Family Physician 137549 Internal Medicine 345438 Adolescent medicine 48268 OB/GYN 1464418 Nurse Mid-wives 68139 Nurse Practitioners 77858 Physician Assistants 979210 Total1868410

26. STD experience based on practice having majority privately insured patients vs. practice having majority patients with other insurance Percentage of patients with private insurance Saw ≥ 10 cases in past year of ≥75% <75% Chlamydia3736 Genital herpes 56*41 Genital warts 3626 HIV511 *statistically significant with p < 0.05

27. Requests for STD prevention information based on practice having majority privately insured patients vs. practice having majority patients with other insurance Percentage of patients with private insurance % of providers reporting that ….. ≥75% <75% Some or more patients asked for information on how to prevent STDs 88*83 *statistically significant with p < 0.05

28. Conclusions Many US healthcare clinicians practice in private practice offices with a majority of patients paying with “other” types of insurance and not private insurance Many US healthcare clinicians practice in private practice offices with a majority of patients paying with “other” types of insurance and not private insurance STD care is being provided by different types of clinicians STD care is being provided by different types of clinicians Dermatologists and urologists are managing many viral STD cases Dermatologists and urologists are managing many viral STD cases Mid-level providers seeing many STD cases Mid-level providers seeing many STD cases

29. Conclusions Many patients request information on how to prevent STD Many patients request information on how to prevent STD Patients are asking all specialty types of clinicians Patients are asking all specialty types of clinicians Many clinicians are providing information in person, but not providing written materials or using other staff Many clinicians are providing information in person, but not providing written materials or using other staff Practices whose reimbursement is primarily from private insurances are seeing equal to more STD cases and are getting many requests for information for STD prevention Practices whose reimbursement is primarily from private insurances are seeing equal to more STD cases and are getting many requests for information for STD prevention

30. Strengths and limitations Strengths: Large sample size with high response rate (81%) Large sample size with high response rate (81%) Use of stratified sampling design and case weights give estimates that are representative of specialties surveyed Use of stratified sampling design and case weights give estimates that are representative of specialties surveyed Inclusion of midlevel providers in the survey Inclusion of midlevel providers in the surveyLimitations: Poor response rates from some clinicians, esp. family practitioners and internists Poor response rates from some clinicians, esp. family practitioners and internists Information bias if reported results are not identical to actual practices. Information bias if reported results are not identical to actual practices. This analysis is a sub-analysis of a larger survey on HPV knowledge, attitudes and practices This analysis is a sub-analysis of a larger survey on HPV knowledge, attitudes and practices

31. Recommendations Encourage awareness and provision of STD care across all specialties in all types of practices Encourage awareness and provision of STD care across all specialties in all types of practices Further research to understand how patients decide to go to certain types of clinicians and/or practices for STD care Further research to understand how patients decide to go to certain types of clinicians and/or practices for STD care Can help target STD prevention interventions to certain specialty groups and patient groups Can help target STD prevention interventions to certain specialty groups and patient groups Ensure proper STD care is being provided Ensure proper STD care is being provided Use of STD treatment guidelines Use of STD treatment guidelines Timely reporting is being done Timely reporting is being done

32. Recommendations Collaborate with other organizations: Collaborate with other organizations: Update clinical training and clinical decision support tools Update clinical training and clinical decision support tools Especially for dermatologists, mid-level providers Especially for dermatologists, mid-level providers Ensure reimbursement is adequate for STD care and STD prevention education Ensure reimbursement is adequate for STD care and STD prevention education Update patient and public education materials Update patient and public education materials

33. Acknowledgements CDC, Division of STD Prevention, Atlanta Kathleen Irwin, MD, MPH Nidhi Jain, MD, MPH Rheta Barnes, MSN, MPH Maya Sternberg, PhD Battelle Centers for Public Health Research and Evaluation, Seattle Daniel Montaño, PhD Danuta Kasprzyk, PhD Linda Carlin, PhD Crystal Freeman, PhD, MPH Jeanine Christian, MA Charles Wolters, MS Battelle and University of Washington, Seattle William Philips, MD, MPH University of Washington, Seattle Laura Koutsky, PhD

34. Reported practice re-imbursement by specialty type ≥75% with private ins. <75% with private ins. Family Physician 2476 Internal Medicine 1585 Adolescent medicine 4159 OB/GYN 5248 Nurse Practitioners 1387 Nurse Mid-wives 2773 Physician Assistants 2872 Dermatologists 1981 Urologists 979 Total2568

35. Reported age group breakdown of patients by specialty type Female patients 18-50 y/o Male patients 18-50 y/o Family Physician 4441 Internal Medicine 3331 Adolescent medicine 5452 OB/GYN 69- Nurse Practitioners 5953 Nurse Mid-wives 89- Physician Assistants 5752 Dermatologists 4543 Urologists 2826 Total4839

36. Survey Eligibility Eligibility requirements: Spend ≥ 8 hours per week in outpatient care Spend ≥ 8 hours per week in outpatient care Provide routine health exams* Provide routine health exams* 20% or more of patients aged 13 to 65 years* 20% or more of patients aged 13 to 65 years* * Not for specialists (urologists and dermatologists)

37. Survey Disposition 6906 Surveys mailed 1005 Refused/ No response 881 Ineligible 715 Undeliverable/ Deceased 4305 Completed surveys