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Reporting of Laboratory-Confirmed Chlamydial Infection and Gonorrhea by Providers Affiliated with Three Large Managed Care Organizations --- United States, 1995--1999
Surveillance for sexually transmitted diseases (STDs) depends on health departments receiving reports of positive STD test results from laboratories or of STD cases by clinicians (1). The completeness and timeliness of reporting can affect prompt sex partner notification and outbreak detection. In 1998, approximately 70% of chlamydia cases and 55% of gonorrhea cases were reported by private clinicians, including many affiliated with managed care organizations (MCOs) (2). However, little is known about the completeness and timeliness of MCOs' STD case reporting practices. Three MCOs, three state health departments, and CDC evaluated reporting practices for chlamydial infection and gonorrhea by three large staff or group model* MCOs that used different reporting procedures. The findings indicate that state health departments were notified of 78%--98% of chlamydia cases and of 64%--80% of gonorrhea cases identified in these MCOs; the median interval between specimen collection and state health department receipt of a case report was <19 days. To improve surveillance quality, other MCOs, including network model MCOs, which provide most STD care in the United States, should evaluate surveillance quality and identify interventions for improvement.
This study evaluated the chlamydia and/or gonorrhea reporting practices used during 1995--1999 by clinicians affiliated with three large MCOs: chlamydia and gonorrhea reporting at HealthPartners, a staff model HMO in Minnesota, and at Harvard Vanguard Medical Associates (HVMA), a large group practice in Massachusetts that was a staff model component of Harvard Pilgrim Health Care during the study period; and chlamydia reporting at Kaiser Permanente Foundation Health Plan of Colorado (KPCO), a group model HMO. In Minnesota and Massachusetts, clinicians and laboratories are required to report both chlamydia infection and gonorrhea, while in Colorado, only laboratories are required to report chlamydia infection (3).
Reporting procedures varied by MCO. In the case of HealthPartners, laboratories used a Minnesota Department of Health (MDH) form to report a positive STD test result to a patient's clinician, who was then responsible for contacting the patient, prescribing appropriate medication, noting prescribed treatments on the form, and mailing it to MDH. In the case of HVMA, laboratories transmitted a positive test result electronically to a patient's clinician and a single HVMA infection control specialist, who verified the treatment prescribed (4), mailed the test and treatment report to the Massachusetts Department of Public Health (MDPH), and notified the clinician that the case had been reported to MDPH. In the case of KPCO, laboratories filled out a positive STD test result reporting card provided by the Colorado Department of Public Health and Environment (CDPHE), mailed the card to CDPHE, and delivered the test result to a patient's clinician.
For this evaluation, each MCO created a database of positive tests for chlamydia infection and/or gonorrhea among MCO members. This database included all laboratory-confirmed cases of chlamydia infection and gonorrhea at HealthPartners during January 1997--December 1998 and at HVMA during January 1995--December 1997, and all laboratory-confirmed cases of chlamydia infection at KPCO during January--June 1999. These data were transferred confidentially to the respective state STD programs for case matching to determine whether laboratory-confirmed cases had been reported to state health departments.
Laboratory-confirmed cases of chlamydia infection and gonorrhea were matched to state STD registry databases in Minnesota and Massachusetts by patient name, date of birth, sex, specimen collection date, and disease pathogen, and in Colorado by patient name, date of birth, and date of positive test. Matched cases were defined as those for which all variables matched exactly. A case initially unmatched by these variables was reclassified as matched if the patient's address, phone number, or medical record number matched, and the initial mismatch was attributed to typographic error, transposition of first and last names, or a recent last name change. Completeness of reporting was defined as the proportion of cases in the MCO database classified as matched in the state registry database. Timeliness of reporting was defined for HealthPartners and HVMA as the time between specimen collection and entry of case report into the state registry database. Because CDPHE staffing shortages precluded data entry more than once every 6 months, timeliness was defined for KPCO as the time between the date a positive test was identified in the laboratory and the date of receipt by health department staff.
At HealthPartners (Minnesota), 654 (78%) of 841 chlamydia cases and 204 (80%) of 256 gonorrhea cases were matched. Case reports were entered into MDH's registry within a median of 19 days (mean: 33 days, range: 4--380 days) and a median of 17 days (mean: 30 days, range: 6--159 days) after chlamydia and gonorrhea specimen collection, respectively. At HVMA (Massachusetts), 800 (78%) of 1,032 chlamydia cases and 225 (64%) of 354 gonorrhea cases were matched. Case reports were entered into MDPH's registry within a median of 17 days (mean: 38 days, range: 1--268 days) and a median of 14 days (mean: 14 days, range: 1--189 days) after chlamydia and gonorrhea specimen collection, respectively. At KPCO (Colorado), 226 (98%) of 231 chlamydia cases were matched. Case reports were received by CDPHE within a median of 6 days (mean: 7 days, range: 1--25 days) after the date when a positive test was identified in the laboratory.
Reported by: M Stiffman, MD, HealthPartners, Minneapolis; P Carr, PhD, Minnesota Dept of Health. D Yokoe, MD, Channing Laboratory, Brigham and Women's Hospital; R Platt, MD, Harvard Medical School, Harvard Vanguard Medical Associates, Harvard Pilgrim Health Care, Boston; R Blair, MD, L Martino, Harvard Pilgrim Health Care, Wellesley; Y Tang, MD, S Ratelle MD, M Whelan, P Etkind, PhD, Massachusetts Dept of Public Health. D Magid, MD, E Lyons, MS, Colorado Permanente Clinical Research Unit, Denver; C Loftin, PhD, N Freeman, L Cordova, P Whitt, Colorado Dept of Public Health and Environment. G Tao, PhD, KL Irwin, MD, Div of STD Prevention, National Center for HIV, STD and TB Prevention, CDC.
Several system-level factors might have contributed to the fairly high completeness of STD reporting at these MCOs: 1) a single, centralized reporting system handling reports from all MCO-affiliated laboratories; 2) MCOs' established relations with state STD programs; and 3) MCO Web site and newsletter communication to clinicians about trends in STD morbidity among members of two MCOs. The first two features are typical of staff or group model MCOs but rare in other MCO models (e.g., network model HMOs) that dominate the MCO market (5).
A higher proportion of chlamydia cases was reported by these three large staff or group model MCOs than by private clinicians in North Carolina (55%), the only state for which an evaluation of STD reporting in private health care settings has been published (6). However, the lower completeness of reporting found in that study might reflect chlamydia infection having become a reportable disease in North Carolina 5 years earlier. The average completeness of reporting at HealthPartners and HVMA for gonorrhea was similar to that in the North Carolina study (72%).
Although completeness of reporting was fairly high in these three MCOs, the median interval between test specimen collection or processing and receipt or entry of the report by the state health department ranged from 6--19 days. Delayed reporting might slow initiation of services for sex partners and detection of outbreaks, which might reduce the effectiveness of STD control measures (7). Such delays might be associated with the time taken to transfer specimens to laboratories, process specimens in the laboratories, verify treatment, and transmit reports to state health department using regular mail. Delays also might be associated with the time elapsed from the date of receipt to the date of manual entering or scanning of cases at health departments. In addition, manual entering and scanning of data at state health departments might result in mismatches in case information between MCO databases and state STD registry databases. To improve the completeness and timeliness of STD reporting, MCOs might consider collaborating with state health departments to use confidential electronic data transfer systems (8) to transfer STD test results to state health departments. MCOs might find implementing an electronic data transfer system for laboratory-based reporting from a small number of laboratories easier than for provider-based reporting from hundreds of affiliated providers. CDC, with the collaboration of state and local health departments, is implementing a National Electronic Disease Surveillance System (NEDSS) to better manage and enhance current surveillance systems and enable the public health community to respond more quickly to public health threats (9). When implemented, NEDSS will help state health departments receive electronic data.
The findings in this report are subject to at least three limitations. First, the completeness of reporting might have been underestimated slightly because some reports---those with suspected typographic errors in name, date, or disease type and those that were lost during mailing---could not be fully verified. Second, reporting of information that might improve matching (e.g., medical record number, address, or phone number) is not mandated by the three states evaluated and is commonly omitted from reports. Finally, the STD reporting practices in these three staff and group model MCOs might not be representative of other MCOs, especially network models that lack central laboratories, central electronic data transfer capacity, dedicated reporting staff, and regular communication to clinicians about STD rates of the MCO members. However, some features common to staff or group model MCOs that might facilitate STD reporting are readily introduced by other MCO models (e.g., Web site communication to clinicians about STD rates of MCO members).
MCOs that have centralized facilities, staffs, data systems, policies, and the capacity to reach large numbers of patients and clinicians are well positioned to make system-level interventions that will promote more complete and timely STD reporting.
* Physicians in a staff model HMO practice as salaried employees. Physicians in a group model HMO are members of a group that receives a monthly fee for every enrolled patient.
Physicians in a network model HMO might be members of one group or two or more groups that contract to provide services for a monthly fee.
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