Check STD screening: Room for improvement?
Review the number of patients who came through your examination room today, and count how many were screened for one or more sexually transmitted diseases (STDs). If the answer is "zero," then perhaps it is time to review your practice guidelines.
According to a national survey of U.S. physicians that assessed screening, case reporting, partner management, and clinical practices for syphilis, gonorrhea, chlamydia, and HIV infection, STD screening levels are well below national guidelines for women and virtually nonexistent for men.1 While obstetrician-gynecologists (OB/GYNs) were found to screen women for STDs at a higher rate than physicians in several other specialties, companion research notes that they are more likely to screen pregnant than nonpregnant women, and thus they are missing many opportunities to stem what has been called "the hidden epidemic" of STDs in the United States.2
Why are so many providers failing to screen? There are a number of factors coming into play, says Matthew Hogben, PhD, of the Division of STD Prevention at the Atlanta-based Centers for Disease Control and Prevention (CDC).
Some providers may not be familiar with national screening guidelines, notes Hogben. (Review the highlights of the recently released 2002 Guidelines for the Treatment of Sexually Transmitted Diseases; see the article, "Take your STD skills to the next level with new guidelines," in the STD Quarterly inserted in the August 2002 issue of Contraceptive Technology Update.)
Some physicians report that they are uncomfortable talking about sexual behavior with their patients, observes Hogben. Also, if STD screening is not reimbursable under the patient’s health coverage, such tests may be less likely to be ordered, he notes.
Where is the care?
The physician survey, mailed to a random sample of 7,300 physicians, was conducted by the CDC with the Seattle-based Battelle Centers for Public Health Research and Evaluation. Results indicate that a substantial proportion of STD care is provided outside of dedicated STD clinics. With more people seeking care outside of STD clinic walls, providers who work in community-based practices are "essential links" in STD partner management and public health surveillance, researchers note.1
When looking at all physicians surveyed, fewer than one-third reported routinely screening men or women (regardless of pregnancy status) for STDs. When STDs were diagnosed, many providers failed to report to public health officials: Case reporting was lowest for chlamydia (37%), intermediate for gonorrhea (44%), and higher for syphilis, HIV, and AIDS (53%-57%). And when it came to partner notification, the majority of physicians said they instructed patients to notify their partners or the health department, rather than doing so themselves.
Researchers found that OB/GYNs were more likely to screen women for syphilis, gonorrhea, and chlamydia than other surveyed physicians. Depending on the STD, 23%-55% of OB/GYNs screened nonpregnant patients for STDs, compared to the 19%-31% of other specialists screening nonpregnant women. However, OB/GYNs screened nonpregnant women at significantly lower rates than they screened their pregnant patients. Approximately four-fifths of OB/GYNs screened pregnant women for chlamydia and gonorrhea, and 85.6% screened pregnant women for syphilis.
Such low rates of screening are troublesome, particularly in the case of chlamydia, the most common of all bacterial STDs. The CDC estimates there are 3 million new cases of the STD each year, and many women who become infected do not present with symptoms. In an effort to stem the spread of the disease, the U.S. Preventive Services Task Force in 2001 called for all primary care clinicians to perform chlamydia screening for all sexually active women ages 25 and younger, as well as older women at risk, as part of their regular health care visits. (Review the guidelines in the CTU July 2001 article, "Task force calls for chlamydia screening," p. 81.)
Finances constrain care
Family planning providers are doing their part in delivering STD services to low-income women and teens, according to research published by the New York City-based Alan Guttmacher Institute. Findings indicate that women receiving contraceptive or other related services at family planning clinics are one-third more likely than those receiving such services from private physicians to report that they obtained an STD service.3
However, budget constraints often keep many family planning facilities from offering new STD diagnostic or treatment modalities. New nucleic acid amplification tests offer a noninvasive way to test for chlamydia; however, facilities such as Tapestry Health, an independent family planning agency serving western Massachusetts, are unable to institute their use due to price constraints. (Read about the tests in the STD Quarterly article, "How to stem chlamydia’s silent spread?" inserted in the February 2001 issue of CTU.)
While laboratory costs and pricing are variable due to negotiated rates and test volume, nuceic acid amplification tests can have a two- to three-fold higher per test cost. State subsidies have helped in allowing Tapestry Health to offer one-dose chlamydia treatment to qualified patients; however, self-paying patients are offered the option of the one-dose therapy, or a multi-day treatment, which is less expensive, says Lucy Hartry, director of administrative services.
One way the agency has been able to check out new STD screening and treatment methods is through participation in research trials, says Hartry. However, when it comes to implementing daily use of technologies, funding keeps the facility from moving forward, she notes.
References
1. St. Lawrence JS, Montaño DE, Kasprzyk D, et al. STD screening, testing, case reporting, and clinical and partner notification practices: A national survey of U.S. physicians. Am J Public Health 2002; 92:1,784-1,788.
2. Hogben M, St. Lawrence JS, Kasprzyk D, et al. Sexually transmitted disease screening by United States obstetricians and gynecologists. Obstet Gynecol 2002; 100:801-807.
3. Dailard C. Family planning clinics and STD services. Guttmacher Report on Public Policy 2002; 5:8-11.
Review the number of patients who came through your examination room today, and count how many were screened for one or more sexually transmitted diseases (STDs). If the answer is zero, then perhaps it is time to review your practice guidelines.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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