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Evaluation of Sexually Transmitted Disease Control Practices for Male Patients With Urethritis at a Large Group Practice Affiliated With a Managed Care Organization --- Massachusetts, 1995--1997

Effective management for sexually transmitted diseases (STDs) depends on appropriate testing, treatment, partner management, and complete and timely reporting of positive STD tests (1). Testing can ensure appropriate treatment of initial or recurrent infections and identification of drug-resistant pathogens, appropriate treatment can reduce risk for complications and development of drug resistance, and complete and timely reporting of positive test results by laboratories and STD cases by health-care providers to health departments can facilitate rapid sex partner notification and outbreak detection. By 1998, private providers, including those affiliated with commercial or Medicaid managed care organizations (MCOs) (2,3) were caring for approximately 70% of persons with chlamydia and 55% of persons with gonorrhea. To assess the quality of STD care at a MCO-affiliated multisite facility, the testing, treatment, and reporting practices of gonorrhea- and chlamydia-associated urethritis in male patients were evaluated. This report summarizes the evaluation, which indicated that the providers tested most men with urethritis symptoms, prescribed CDC-recommended therapy to all patients, and reported most laboratory-confirmed chlamydia and gonorrhea cases of urethritis to the state health department. Several interventions introduced at this large group practice may have encouraged these favorable STD practices.

Harvard Vanguard Medical Associates (HVMA), Massachusetts Department of Public Health (MDPH), and CDC evaluated a HVMA staff model component of Harvard Pilgrim Health Care during 1995--1997, when most staff in this multispecialty practice tested urethral specimens for chlamydia using enzyme immunoassays and for gonorrhea using culture. The MCO's formulary covered the CDC-recommended drugs for gonorrhea- and chlamydia-associated urethritis, including more expensive single-dose treatments (4). Each week day, HVMA-affiliated laboratories electronically transmitted positive test results to the patient's physician and the HVMA infection control (IC) practitioner responsible for case reporting; treatments were listed on the test result notice (4). By reviewing the electronic pharmacy file and the electronic and paper medical records, the IC practitioner determined whether treatment was prescribed or dispensed within 10 days after the test was ordered. A copy of the case report then was mailed to MDPH and the patient's physician. The physician's copy included CDC-recommended treatments to encourage appropriate future treatment decisions.

To evaluate testing and treatment practices during visits for symptomatic urethritis in men, 2247 medical records were identified in which diagnoses assigned during the visit included urethritis, nonspecific urethritis, urethral discharge, dysuria, or urethritis/ chlamydia (5). Of the 2247 cases, 1988 (88%) were coded as urethritis and/or nonspecific urethritis. Testing and treatment information was abstracted from a random sample of 196 records. The interval between specimen collection and prescribing or dispensing a medication was determined by a review of medical records, HVMA's case database, and MDPH's surveillance database.

To evaluate completeness and timeliness of reporting to MDPH, a database was compiled of 393 cases of laboratory-confirmed gonorrhea and chlamydia infections diagnosed in men during 1995--1997. This database also included 31 symptomatic urethritis cases with positive chlamydia or gonorrhea tests that were included in the medical record review. The 393 case reports were matched with MDPH surveillance data by name, date of birth, sex, specimen collection date, and disease type. Completeness of reporting was defined as the proportion of HVMA cases in the MDPH database. Time-liness of reporting was defined as the interval between specimen collection and entry of the laboratory report into MDPH's database.

Among the 196 cases of symptomatic urethritis sampled, 181 (92%) were tested for chlamydia infection, 163 (83%) for gonorrhea infection, or 161 (82%) for both infections. Sixteen (9%) specimens tested for chlamydia were positive. Fifteen (9%) tested for gonorrhea were positive. No specimen tested positive for both infections. All men with gonorrhea and 88% with chlamydia were prescribed CDC-recommended antibiotics when they initially presented with symptoms (before test results were available); the remaining men were prescribed treatment within 5 days of initial presentation. Among urethritis-associated cases, 11 (69%) of 16 positive for chlamydia and 14 (93%) of 15 positive for gonorrhea were matched with the MDPH database. Among the 393 cases positive for chlamydia or gonorrhea, 158 (78%) of 202 chlamydia cases and 156 (82%) of 191 gonorrhea cases in the HVMA database were matched with the MDPH database. Reports were entered into MDPH's database within a median of 16 days (range: 1--268 days) after specimen collection.

Reported by: S Ratelle, MD, Y Tang, MD, M Whelan, MA, P Etkind, DrPH, Massachusetts Dept of Public Health. D Yokoe, MD, Channing Laboratory, Brigham and Women's Hospital, Boston; R Platt, MD, Harvard Medical School, Harvard Vanguard Medical Associates, Boston; R Blair, MD, L Martino, Harvard Vanguard Medical Associates, Wellesley, Massachusetts. Div of STD Prevention, National Center for HIV, STD, and TB Prevention; and EIS officers, CDC.

Editorial Note:

Most HVMA providers followed the CDC recommendation (4) to test men with symptomatic urethritis for chlamydial and gonococcal infection. The proportion of symptomatic urethritis associated with gonorrhea or chlamydia was consistent with another U.S. study (6); however, the HVMA testing practices were not consistent with earlier reports that MCO-affiliated providers may defer diagnostic testing because of cost constraints (7). HVMA-sponsored STD education for the provider and feedback from patients may have promoted testing at this practice. Introduction of more acceptable urine-based STD tests also may have increased testing rates.

The finding that most providers prescribed CDC-recommended treatments for urethritis (8,9) was not consistent with anecdotal reports that MCO-affiliated providers may defer expensive single-dose treatments that may improve patient adherence because of cost or formulary constraints (7). Interventions at this group practice that may have encouraged use of CDC-recommended treatments stemmed from collaboration with MDPH, which resulted in having these drugs available in the MCO formulary, listing CDC-recommended treatments on positive test reports and case report notices, and MDPH's disseminating CDC STD treatment guidelines to HVMA providers during the study period. Completeness of HVMA case reporting was higher in this study than in others (10). Providers may not report STD cases because of a lack of staff dedicated to reporting, time constraints, an inability to bill for reporting, concerns about confidentiality, and lack of awareness of reporting requirements (1). Interventions at HVMA that may have enhanced reporting completeness include 1) a central reporting system that did not require provider time; 2) electronic transfer of test results to the IC practitioner; 3) use of electronic records to verify prescribed and dispensed prescriptions; 4) HVMA's productive relation with MDPH; 5) Internet and newsletter communications to providers about rates of STDs in MCO members; and 6) a commitment to public health reporting.

The findings in this report are subject to at least four limitations. First, the selected diagnostic codes may not have identified all enrollees with urethritis-related symptoms, and testing and treatment information in medical records may have been incomplete. These factors may have resulted in an underestimate of the proportion of patients tested and prescribed appropriate treatment. Second, the case report matching procedure may have missed inexact matches (e.g., typographic errors). This may have resulted in a minor underestimate of completeness of reporting. Third, this evaluation was intended to provide information about STD control practices in this group practice and was not intended to compare the testing, treatment, and reporting practices before and after HVMA introduced interventions that may have improved performance. Finally, the evaluation did not compare STD control practices in this staff model group practice with other MCO-affiliated practices that lacked centralized laboratories, electronic pharmacy and medical records, and training and other education resources.

Some features of staff model practices, such as centralized local laboratories, may not be available in nonstaff model practices that now dominate the U.S. market. However, other features, such as dissemination of guidelines, may be easily implemented in other settings. Interventions to enhance STD control and surveillance can capitalize on the strengths of MCOs, specifically their coverage of large populations of persons at risk, affiliations with large numbers of health-care providers, and use of centralized data systems, procedures, guidelines, and policies. Comparative evaluations of MCO-affiliated practices that use different methods to promote appropriate testing, treatment, and reporting of STDs are needed to identify the most effective interventions in these settings.

References

  1. Eng TR, Butler WT. The hidden epidemic. Washington, DC: National Academy Press, 1997:33.
  2. CDC. Sexually transmitted disease surveillance, 1998. Atlanta, Georgia: US Department of Health and Human Services, CDC, September 1999:71.
  3. Health Care Financing Administration. Medicaid managed care enrollment report. Baltimore, Maryland: Health Care Financing Administration, 1999. Available at http://www.hcfa.gov/medicaid/trends98.htm. Accessed May 2001.
  4. CDC. 1993 sexually transmitted diseases treatment guidelines. MMWR 1993;42(no. RR-14):49--69.
  5. Ratelle S, Yokoe D, Whelan M, et al. Management of urethritis in HMO members receiving care at multi-specialty group practice in Massachusetts. Sex Transm Dis 2001;28:232--5.
  6. Burstein GR, Zenilman JM. Nongonococcal urethritis: a new paradigm. Clin Infect Dis 1999;28:566--73.
  7. Mauery DR, Wehr E. Notifiable disease reporting by out-of-state laboratories: implications of managed care and options for reform. Washington, DC: Center for Health Policy Research, George Washington University School of Public Health and Human Services, January 1999.
  8. Ciemans EL, Kent CK, Flood J, Klausner JD. Evaluation of chlamydia and gonorrhea screening criteria. Sex Transm Dis 2000;27:165--7.
  9. Eubanks C, Lafferty WE, Kimball AM, MacCormack R, Kassler WJ. Privatization of STD services in Tacoma, Washington: a quality review. Sex Transm Dis 1999;26:537--42.
  10. Smucker DR, Thomas JC. Evidence of thorough reporting of sexually transmitted diseases in a southern rural county. Sex Transm Dis 1995;22:149--54.

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