2002 National STD Conference - Abstracts Referenced in CHALLENGES IN STD PREVENTION

Abstract 69: "Characteristics of Patients Infected with Ciprofloxacin-Resistant Neisseria gonorrhoeae in the Continental United States, 1994–2000"

S Conner, S Wang
Centers for Disease Control and Prevention, Atlanta, GA

Background: Ciprofloxacin is a widely used, inexpensive treatment for Neisseria gonorrhoeae (GC), but ciprofloxacin-resistant (CipR) GC is becoming more common.

Objectives: To describe characteristics of male patients with CipR GC in the continental United States (U.S.).

Methods: CipR GC isolates in the continental U.S. were identified from 1991-2000 through the Gonococcal Isolate Surveillance Project (GISP), the national sentinel surveillance system monitoring GC. Clinical and demographic data from these male patients with CipR GC were examined.

Results: Forty-one GC isolates from GISP (1991-2000) were identified as CipR within the continental U.S. The first resistant isolate appeared in 1994, followed by a substantial increase in CipR isolates in 1999. These patients with CipR were concentrated within four areas on the west coast: Seattle, WA (24%, 10/41); Orange County, CA (17%, 7/41); San Diego, CA (12%, 5/41); and San Francisco, CA (12%, 5/41). Twenty percent (8/40) were Asian. For those patients with additional data, 84% (33/39) were heterosexual. Forty-five percent (10/22) had taken antibiotics within the previous 30 days. Four of seven patients had sex work exposure within the previous 30 days. Either patients or their sex partners were likely to have had foreign exposure, defined as travel to or residence in a foreign country within the previous 30 days [patients or sex partners combined, (50%, 11/22)].

Conclusions: Foreign exposure or geographic residence on the west coast appeared to be an important characteristic of patients with CipR GC.

Implications for Programs/ Policy: Travel history should be routinely obtained in patients with GC as it may help guide selection of appropriate GC treatment.

Implications for Research: More data on patients with CipR GC are needed in order to better characterize the risk factors for acquisition and spread of CipR GC.

Measurable Learning Objectives: By the end of this session, participants will be able to describe characteristics of some male patients with CipR GC and discuss the implications of antimicrobial resistance on GC treatment.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 240: "Leading Barriers to STD Care in Two Managed Care Organizations: Final Results of a Survey of Primary Care Clinicians"

K Irwin¹, L Anderson¹, M Stiffman², D Magid³, T DeFor², AL Crain²

¹Centers for Disease Control and Prevention, Atlanta, GA; ²HealthPartners, Minneapolis, MN; ³Kaiser Colorado, Denver, CO

Background: Although > 80% of privately insured adults receive STD care in managed care organizations (MCOs), barriers to optimal STD care in MCOs are poorly understood.

Objective: To identify barriers to STD care at two large MCOs.

Methods: During 1999–2000, we mailed a survey to 1,000 randomly-selected physicians, advance-practice nurses, and physician's assistants who practiced internal, family, emergency, or adolescent medicine or obstetrics/gynecology at Kaiser in Colorado and HealthPartners in Minnesota: 500 at Kaiser's staff-model MCO, 250 at HealthPartners' staff-model MCO, and 250 at HealthPartners' network-model MCO. The survey addressed demographic characteristics, STD experience, and perceived barriers to STD care.

Results: Of the 906 clinicians still practicing, 82% responded. Most respondents were physicians (74%), practiced ambulatory care (87%), and had practiced >10 years. Twenty-seven percent had diagnosed > 6 chlamydia cases in the past year. From 20%–45% of clinicians rated eight issues as "problematic" or "highly problematic": limited staff to manage sex partners; managing high-risk patients; finding time for sexual histories; lack of MCO policies about notifying and treating sex partners; finding time to address STDs; limited staff to counsel patients; and the belief that infected patients do not practice safe sex during treatment or notify their partners. Clinicians with more STD experience were less likely to report these problems than less experienced clinicians.

Conclusion: These MCO clinicians consider risk assessment, managing high-risk patients, counseling, patient adherence to treatment advice, and partner services as major barriers to STD care. Many problems concern limited time or staffing.

Implications for Programs/Policy: Interventions to improve STD care in MCOs should focus on these barriers and address resource constraints.

Implications for Research: Interventions to overcome the barriers identified in these staff-model or mixed-model MCOs should be tested. Research on barriers to STD care in the > 90% of MCOs that are exclusively network models is needed.

Learning Objectives: Participants will be able to identify barriers to STD care that can guide interventions in MCOs.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 241: "Utilization and Quality of STD Services in Managed Care Organizations: A Synthesis of Recent Research"

K Irwin¹, W Lafferty², ER Brown³, N Pourat³, M Stiffman⁴, D Magid⁵, S Ratelle⁶, R Platt⁷, D Yokoe⁷, G Tao¹, L Anderson¹, E Patterson¹, W Kassler⁸

¹CDC, Atlanta, GA; ²University of Washington, Seattle, WA; ³University of California, Los Angeles, CA; ⁴HealthPartners, Minneapolis, MN; ⁵Kaiser Colorado, Denver, CO; ⁶Massachusetts Department of Public Health, Jamaica Plain, MA; ⁷Harvard Medical School, Boston, MA; ⁸New Hampshire Department of Health and Human Services, Concord, NH

Background: Managed care organizations (MCOs) now provide most STD care in the US. However, little is known about the utilization and quality of STD care in MCOs.

Objective: To review the results of CDC-sponsored research on STD care delivered in commercial and Medicaid MCOs from 1997–2001.

Methods: CDC-sponsored intramural and extramural projects addressed the delivery of STD risk assessment, screening, diagnostic testing, treatment, risk reduction counseling, and partner services. Data from medical claims and records, surveys of MCO clinicians and policies, and surveys of the privately insured adults were analyzed.

Results: Only 27% of privately insured adults and 47% of adolescents in three Medicaid MCOs had sexual risk assessment during routine checkups. In three Medicaid MCOs, <28% of sexually active adolescents were screened for chlamydia. In another 31 Medicaid MCOs, only 55% of clinicians reported screening adolescents for chlamydia. Only 50% of pregnant women insured by >100 commercial MCOs were screened for syphilis. In two commercial MCOs, >25% of clinicians reported that finding time or staff for risk assessment, counseling, and partner services was problematic. Among 21 Medicaid MCOs, <60% had policies to notify health departments about partner services. In three commercial staff-model MCOs, >86% of men with symptomatic urethritis were tested and treated with CDC-recommended antibiotics, and >93% of chlamydial infections and genital warts were treated with CDC-recommended treatments.

Conclusion: Substantial improvement in risk assessment, screening, counseling, and partner services is needed in both commercial and Medicaid MCOs. Diagnostic testing and treatment appear adequate in several commercial MCOs.

Implications for Programs/Policy: Interventions to improve STD care should focus on risk assessment, screening, counseling, and partner services.

Implications for Research: More research on actual and perceived barriers to STD care is needed, especially in network-model MCOs that dominate the commercial market and in Medicaid MCOs that serve high risk populations.

Learning Objectives: Participants will be able to identify barriers to STD care that can guide intervention development in MCOs.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 435: "Chlamydia Screening and Test Type Utilization in California Publicly Funded Family Planning Services"

JM Chow¹, M Bradsberry², J Treat³, C Maternowska², P Darney², A Ramirez³, G Bolan¹

¹California Department of Health Services, Sexually Transmitted Disease Control, Berkeley, CA; ²University of California, San Francisco, Department of Obstetrics and Gynecology; ³California Department of Health Services, Office of Family Planning, Sacramento, CA

Background: Since 1998, the Centers for Disease Control have recommended and more recently, the USPS Task Force and HEDIS recommend annual chlamydia (CT) screening for sexually active females less than 25 years of age. Evaluation of adherence to CT screening requires data for services delivered to clients served by family planning providers.

Objective: To describe CT screening coverage and test type utilization among adolescent and young adult female family planning clients.

Methods: Administrative databases from Family PACT (FPACT), the California state-funded family planning program were analyzed. Client and clinician provider data were linked to paid laboratory claims for female clients served in FY 98/99 and 99/00. CT screening coverage was estimated as the proportion ofCT tests that were performed on clients seen. Data were stratified by provider type (public sector versus private) and test type (CPT-4 code).

Results: During FY 99/00, 509,429 female clients were served by 586 public sector/non-profit and 1,301 private practice FPACT providers. Private practice providers tested 53.2% of females eligible for screening (age 15–26) while public sector/non-profit providers tested 68.4% (P<0.0001). However, there was little difference in testing of females older than 26 years by provider type (57.0% private practice versus 59.6% public sector). Seventy-three percent of all CT tests ordered for females age 15–26 by public sector/non-profit providers were amplified DNA tests as compared with 37.0% of CT tests performed by private sector providers.

Conclusions: There is considerable variation in CT screening coverage and test type utilization by family planning provider types with higher screening rates among young women and utilization of more sensitive tests among public sector providers.

Implications for Program/Policy: Claims data analysis is useful to identify targeted interventions among providers to improve program adherence to screening guidelines and appropriate selection of chlamydia tests.

Implications for Research: Further analysis of claims data relating to provider and client characteristics may aid in the interpretation of screening and test utilization patterns.

Measurable Learning Objectives: The participant will be able to: 1) Identify claims data elements that are needed to construct a chlamydia screening coverage measure, and 2) Describe differences in chlamydia screening coverage by client age, test type, and provider type.

Contact Information: Joan M. Chow, 510/540-2493, jchow@dhs.ca.gov