Perspectives on expedited partner therapy for chlamydia: a survey of health care providers

Abstract

There is a lack of research on health care providers’ use of and perspectives on expedited partner therapy in a state where expedited partner therapy is not prohibited or explicitly allowed. The aim of our study was to understand if and how health care providers use expedited partner therapy, if specific demographic factors and knowledge contribute to increased use of expedited partner therapy, and to describe barriers and facilitators to the use of expedited partner therapy in Pittsburgh, Pennsylvania. A convenience sample of 112 health care providers from diverse disciplines who treat young women at risk for chlamydia completed an online survey. About 11% of health care providers used expedited partner therapy consistently. Those who self-reported that they were knowledgeable about expedited partner therapy were more likely to use expedited partner therapy (73% vs. 49%, p = .009) as were those who said no or were unsure about their institution’s guidelines for expedited partner therapy (35% vs. 22%, p = 0.01) (62% vs. 57%, p = 0.01). The most commonly reported facilitator of expedited partner therapy was having clear legal guidelines (86%). This study finds that in a setting where expedited partner therapy is not expressly permitted, health care providers still use the practice but also experience barriers that limit uptake. Legislation expressly endorsing expedited partner therapy in the state and in medical institutions is needed to increase expedited partner therapy use.

Keywords

Expedited partner therapy providers survey sexually transmitted infection treatment

Introduction

One means to combat chlamydia, the most commonly reported sexually transmitted infection (STI) in the United States,¹ is by using expedited partner therapy (EPT), a strategy that involves empirically treating sexual partners without requiring them to undergo screening or medical examination.² The most common form of EPT is when the patient gives their sexual partner(s) a medication or a prescription to treat the infection.² Additional forms of EPT can include patients’ partners obtaining medication from health clinics or from public health workers at non-clinical sites.² EPT is an effective method in reducing rates of reinfection and increasing the number of sexual partners treated for chlamydia and gonorrhoea.^3–5 In 2006, the Centers for Disease Control and Prevention (CDC) recommended broader use of EPT for patients infected with chlamydia and gonorrhoea. However, new treatment regimens for gonorrhoea make the use of EPT less practical.⁶

Despite this national public health policy recommendation, legal status and policies related to EPT vary from state to state.⁷ EPT is prohibited in four states, potentially allowable in eight states (meaning legislation is unclear or inconsistent), explicitly permitted by legislation or statutory authority in 32 states and in the District of Columbia, and permissible in five states (meaning no statutes or regulations either prohibit or allow EPT).⁷ Research indicates that use of EPT is significantly higher in states where there are regulations or legislation that expressly permit the practice.^8–10 However, even in such states there are numerous barriers for providers including funding and reimbursement, and provider fears about liability.^11,12 Research also suggests that provider demographic factors such as gender and specialty as well as knowledge of EPT impact the use of EPT.^10,13,14

In addition, in a state with unclear legislation, there is a need to understand what health care providers (HCPs) think about the practice of EPT. In Pennsylvania, EPT is considered permissible because there are no specific regulations in place at the state level that prohibit EPT, but there are no regulations or statutes that explicitly allow EPT.^7,15 It seems likely that in a state where there is no clear guidance on EPT, providers will report less EPT use than in states where there are specific statutes or regulations allowing the practice, and that they will also note barriers specific to the lack of clear guidance on whether they can or cannot use EPT. In such states where EPT is not clearly endorsed but is also not illegal, we do not know HCPs’ perspectives on the use of EPT. The aim of our study was to understand if and how HCPs use EPT, if specific demographic factors and knowledge contribute to increased use of EPT, and to describe barriers and facilitators to the use of EPT in Pittsburgh, Pennsylvania.

Methods

Design

From 31 March to 4 May 2014, an online survey was distributed via email to a convenience sample of HCPs from diverse disciplines who were likely to treat adult or adolescent women at risk for chlamydia and provided care in a range of settings, including primary care, community-based, or hospital-based clinics in Pittsburgh, Pennsylvania. The study focused on providers who treat women as current chlamydia screening recommendations do not include men.¹⁶ An email describing the study was distributed to department administrators and chiefs of departments in adolescent medicine, internal medicine (including medicine/pediatrics), family medicine, and obstetrics/gynecology within a large health care system. Eligibility requirements included being a physician, physician trainee (resident or fellow), physician assistant, or nurse practitioner. The survey questionnaire was distributed to approximately 150 internists, 10 adolescent medicine providers, 225 obstetrician/gynecologists, and 30 family medicine providers. Participation was encouraged by HCPs who had previously participated in the formative, qualitative research that helped to inform the survey instrument.¹⁷ No incentives to participate were provided. The survey instrument took providers between 5 and 10 minutes to complete. The University of Pittsburgh Institutional Review Board approved this study.

Measures

The questionnaire was developed using information garnered from a qualitative study in which in-depth interviews were conducted with HCPs from this same region exploring their knowledge, experiences with, and barriers and facilitators regarding the use of EPT. The key themes that emerged from the qualitative interviews were included in the questionnaire. Prior to fielding the survey with the study sample, the questionnaire was reviewed with two experts in STI testing and five public health researchers for content, and was piloted with two HCPs to assess understandability.

Demographic items included gender, specialty, age, years out from training, type of clinical practice, type of care provided (primary care, some primary care, consultative practice only), and number of women patients, aged 15 to 25, seen each week. The survey included items assessing EPT use, knowledge, and barriers and facilitators to the practice. The majority of questions were assessed using a five-point Likert scale (e.g. knowledge, barriers, and facilitators). For example, to assess use of EPT, HCPs were asked when they diagnose a patient with chlamydia, how often they use EPT, with response options on a five-point Likert scale ranging from always to never. The last question on the survey was an open-ended question asking providers to share any additional thoughts they had on EPT.

Analysis

Descriptive statistics were computed for all variables including demographics, knowledge, barriers, and facilitators of EPT use. Bivariate analyses using Chi square, Fisher’s exact, or other non-parametric tests were used to examine associations between demographic factors, knowledge, and the outcome variable, use of EPT (dichotomised as always, usually, half of the time, sometimes vs. never for analysis). A p value of less than 0.05 was determined to be statistically significant. The data were analysed using SPSS version 21. The open-ended responses to the last question on the survey were analysed using a codebook previously developed for the qualitative study on EPT. This analysis was conducted using a thematic analysis approach; themes included knowledge, attitudes, benefits, barriers, and facilitators to EPT use.¹⁸ All responses were coded by two independent coders using a consensus coding approach.

Results

Demographics

A total of 112 HCPs completed the survey, with an overall response rate of 27% (Table 1). The majority of participants were physicians (97%), women (70%), attendings (58%), practiced medicine at an academic practice (65%), and provided primary care (46%). For specialty, the majority were internists (44%) followed by obstetrician/gynecologists (40%), family medicine (9%), and adolescent medicine (6%).

Table 1.

Demographic characteristics of study participants.

Demographics	N = 112 (%)
Age (years)
<30	26 (23.2%)
30–49	60 (53.6.4%)
50+	26 (23.2%)
Gender
Men	34 (30.4%)
Women	78 (69.6%)
Specialty
Adolescent Medicine	7 (6.3%)
Family Medicine	10 (8.9%)
Internal Medicine	49 (43.8%)
Obstetrics/Gynecology	45 (40.2%)
Other	1 (.9%)
Years practicing medicine
In residency training	33 (29.5%)
In fellowship or advanced training	14 (12.5%)
0–5	10 (8.9%)
6–10	11 (9.8%)
11–20	20 (17.9%)
21–30	12 (10.7%)
30+	12 (10.7%)
Practice setting (all that apply)
Private practice	4 (3.6%)
Hospital-based practice	41 (36.6%)
Academic practice	73 (65.2%)
Teaching clinic	37 (33%)
Community-based clinic	14 (12.5%)
Hospital-based clinic	21 (18.8%)
Other	4 (3.6%)
Care provides
Primary care	52 (46.4%)
Some primary care	48 (42.9%)
Consultative practice only	12 (10.7%)
Average number of women patients (ages 15 to 25) see per week
0	13 (11.6%)
1–10	55 (49.1%)
11–20	14 (12.5%)
20+	30 (26.8%)

EPT use in clinical practice

Around half of HCPs reported ever using EPT while only 11% reported always using EPT. More than half of HCPs who used EPT never speak to their patient’s partner on the phone when providing EPT, about a third sometimes speak on the phone, and only a few (13%) reported doing it half of the time, usually, or always. For those who used EPT, the most common method of providing EPT was to write a prescription in the patient’s partner’s name (58.7%). Other methods included doubling their patient’s prescription (23.8%), writing a prescription with no name (3.2%), and other (14.3%) (i.e. give refill to patient, call patient’s partner). Examining use of EPT by specialty, HCPs in adolescent medicine and family medicine were more likely to use EPT than any other specialty (Table 2); however, the sample of these providers is small. Type of care provided, years of providing clinical care, and number of women patients were not associated with EPT use.

Table 2.

Expedited partner therapy (EPT) use and associated factors among health care providers.

Characteristic	Never use EPT (n = 49, 43.8%)	Use EPT (n = 63, 56.2%)	p Value
Age (years)
Less than 30	16 (32.7)	10 (15.9)	0.07
30 to 49	25 (51.0)	35 (55.6)
50 or older	8 (16.3)	18 (28.6)
Women	36 (73.5)	42 (66.7)	0.44
Specialty
Adolescent Medicine	0 (0)	7 (11.1)	<.001
Family Medicine	0 (0)	10 (15.9)
Internal Medicine	20 (40.8)	29 (46.0)
Obstetrics/Gynecology	28 (57.1)	17 (27.0)
Other	1 (2.0)	0 (0)
Years providing clinical care beyond residency
Resident or fellow	22 (44.9)	25 (39.7)	0.19
Less than 10 years	12 (24.5)	9 (14.3)
10 years or more	15 (30.6)	29 (46.0)
Care provides
Primary care	18 (36.7)	34 (54.0)	0.19
Some primary care	25 (51.0)	23 (36.5)
Consultative practice only	6 (12.2)	6 (9.5)
Average no. of women patients (ages 15 to 25) see per week
0	5 (10.2)	8 (12.7)	0.10
1–10	23 (46.9)	32 (50.8)
11–20	3 (6.1)	11 (17.5)
20+ Knowledge	18 (36.7)	12 (19.0)
Knowledgeable about EPT	24 (49.0)	46 (73.0)	0.01
Knowledge of EPT legal status	13 (26.5)	23 (36.5)	0.26
Believe colleagues use EPT	21 (42.9)	39 (61.9)	0.045
Knowledge of institutional guidelines for EPT
Yes	10 (20.4)	2 (3.2)	0.01
No	11 (22.4)	22 (34.9)
Don’t know	28 (57.1)	39 (61.9)

Knowledge of EPT

Almost two-thirds (63%) of HCPs agreed that they were knowledgeable about the practice of EPT. When asked if EPT was permissible but not legally endorsed in the state of Pennsylvania, 61% responded that they did not know the legal status of EPT, 7% responded no, and 32% correctly answered yes to this question.

Those who self-reported that they were knowledgeable of the practice of EPT were more likely to use EPT (73% vs. 49%, p = .009) as were those who believed their colleagues use EPT (62% vs. 43%, p = .045). Knowledge of the legal status of EPT was not associated with EPT use. HCPs who said no or were unsure about their institution’s guidelines for EPT were more likely to use EPT (35% vs. 22%, p = 0.01) (62% vs. 57%, p = 0.01); and those who said yes to knowing their institution’s guidelines were less likely to use EPT (3% vs. 20%, p = 0.01). HCPs who said yes to knowing their institution’s guidelines were given the opportunity to describe the guidelines and nine respondents provided answers; all stated that their institution did not allow the use of EPT.

Barriers and facilitators to EPT use

HCPs answered questions about the extent to which they were concerned with eight barriers and nine facilitators of EPT use (Table 3). The most commonly reported barriers included concerns about safety of their patient with regard to partner notification of infection with an STI (48%), not being able to treat all partners of their patient (43%), and intimate partner violence (42%). The most commonly reported facilitators to the use of EPT were having clear legal guidelines about EPT (86%), including EPT in treatment protocols (83%), and having clear institutional guidelines about EPT (82%).

Table 3.

Barriers and facilitators of expedited partner therapy (EPT) use.

	N (%)
Barriers^a
The safety of my patient with regards to partner notification of infection with a sexually transmitted disease	54 (48.2)
Not being able to treat all partners of my patient	48 (42.9)
Treating a patient who is not my own	47 (42.0)
Intimate partner violence	47 (42.0)
The safety of my patient with regards to provision of medication or a prescription to their partner(s) for treatment of chlamydia	45 (40.2) 44 (39.3)
Liability	37 (33.0)
Azithromycin causing allergic reactions	35 (31.3)
Facilitators^b
Clear legal guidelines about EPT	96 (85.7)
Inclusion of EPT in treatment protocol	93 (83.0)
Clear institutional guidelines about EPT	92 (82.1)
Consensus in my group about the use of EPT	90 (80.4)
Training about how to provide EPT	84 (75.0)
Training about how to discuss partner notification of STIs with my patients	77 (68.8)
Training about how to talk to my patients infected with STIs about intimate partner violence	75 (67.0)
Knowing my colleagues use EPT	71 (63.4)
Being able to talk to my patient’s partner(s) on the phone	60 (53.6)

Reported being very concerned or concerned.

Reported strongly agree or agree to the statement.

The last question on the survey was open-ended, asking providers to share any additional thoughts on EPT. Seventeen individuals responded, with most of the responses having to do with facilitators of and barriers to the practice of EPT, such as:

‘I just learned last week that EPT was allowed in Pennsylvania. Prior to that we were told we could not order meds for our patients’ partners. That is why I have never done this here (but frequently did in Texas). I would like to know the state laws/guidelines as to which STIs we can treat the partner and have the blessing of the employer also.’

‘I trained in a state where EPT was illegal, but when I moved to PA I learned that it was legal here so I started providing it. However I was recently told that it is “not exactly” legal, and so have stopped providing. Clear information of the legality of this would really help!’

‘Thanks for doing this work! We need a clear directive as EPT is officially allowable in PA but we were told not to do it by [name of medical center] several years ago with no interval updates, so it is unclear.’

These responses illuminate provider concerns about whether or not they are permitted to utilise EPT. The legality of the practice at both the state and institutional levels seems unclear to providers.

Discussion

In this survey of 112 HCPs, we found that in a state where EPT is permissible, only about a tenth of providers reported using EPT consistently. We also identified specific factors that contribute to increased use of EPT and described barriers and facilitators to the use of this practice.

Close to half of HCPs reported never using EPT and only 11% always used EPT. These results of EPT use are similar to a national survey about EPT usage conducted more than 10 years ago.¹⁹ However, research conducted in California, a state where EPT has been explicitly permitted since 2001, found that EPT is routinely used by nearly 80% of family planning providers.^13,14 Providers surveyed in our study also had low levels of knowledge of the legal status of EPT in Pennsylvania. Notably, however, knowledge of the legal status of EPT was not found to be associated with the use of EPT in this study. Based on our findings about provider perspectives on facilitators of EPT, it seems likely that clarity in both clinic-level and state-level policies around EPT are likely to be critical to increase usage.

One notable finding from this survey was that those who reported that they either did not know or that their institution did not have guidelines for EPT were more likely to use EPT than those who answered that they knew their institution’s guidelines. This finding reveals that providers who are aware of their institution’s protocols about EPT (in this case prohibiting use) actually follow these clinic-level policies. Open-ended responses further reflect the importance of clear guidelines about the practice; HCPs not only want to know that EPT is permitted at the state level but want reassurance that their institution also supports the practice. In addition, our study found that those who agreed that they were knowledgeable about the practice of EPT were more likely to use EPT compared to those who were not knowledgeable. Both of these factors are modifiable; efforts can be made to change institutional policies to allow EPT and providers can be taught about the practice of EPT.

Given the established association between intimate partner violence (IPV) and infection with STIs,²⁰ it is troubling that nearly 60% of providers did not have serious concerns about IPV and over 50% did not have concerns about the safety of their patient with regard to partner notification of infection with an STI. Over one-third of women experience IPV in their lifetime and the highest prevalence is among women aged 15 to 24.^21,22 IPV increases the risk for STIs in a number of ways, including sexual coercion, which can involve pressure to have sex, forced condom non-use, threats of violence with condom negotiation, and intentional exposure to an STI by a partner.^21,23–25 The American College of Obstetricians and Gynecologists recommends assessing patients for IPV in clinical settings that offer STI testing and that providers have community resources and patient education cards on IPV and sexual coercion to aid with counselling on safety and harm reduction (including options for anonymous partner notification).^26,27 Current CDC EPT recommendations do not include any information on IPV²; future guidelines on EPT could include information about how to address IPV when providing patients with EPT. In addition, providers may also benefit from education and training around IPV, STIs, and safer partner notification.

Speaking on the phone to patients’ partners when providing EPT is a method that some HCPs already employ and many believe would facilitate EPT use. Of the HCPs who provide EPT, 30% sometimes speak on the phone, around 13% reported doing it half of the time, usually or always, and over 50% of providers believed that speaking on the phone to their patients’ partners when providing EPT would facilitate the use of EPT. As such, the CDC’s EPT recommendations could include the use of phone calls in their EPT guidelines. In fact, speaking on the phone to patients’ partners is being done in the UK. Due to regulations that prohibit provision of medications without medical assessment, EPT is not permitted in the UK; however, a form of EPT called accelerated partner therapy, where patients’ partners are either contacted via phone or consulted at a pharmacy by a pharmacist is allowed and providers are comfortable with this treatment method.^28,29

There are several limitations to this study. The study utilised a convenience sample of providers from within a large health care system in Pittsburgh, PA, and the findings may not be generalisable to other cities or rural regions in the state. However, the findings may apply to other regions in which there is no specific legislation regarding the practice of EPT. Selection and response bias are other limitations of the survey as the response rate was only 27% and the sample size was small. The majority of HCPs who participated were physicians and thus the survey did not capture the perspectives of nurse practitioners and physicians’ assistants. However, this survey did provide important preliminary data and suggests that further research around this issue would be beneficial.

This study finds that in a setting where EPT is not expressly permitted, HCPs still use the practice but also experience barriers that limit uptake. Clear legislation expressly endorsing EPT in the state of Pennsylvania is likely to be one of the most important facilitators for EPT implementation. Findings from this study demonstrate that institutional policies around EPT also impact EPT use. Confusion exists about what can and cannot be done when it comes to the practice of EPT and clarity around the regulations of this practice is needed to increase EPT use. If policy change at the state level occurs, efforts to implement clear clinical guidelines for providers within medical institutions will be needed to ensure that EPT is expressly allowed and facilitated within health care settings.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Disclaimer

The opinions expressed in this work are those of the authors and do not necessarily represent the policies of the funders, institutions, the US Department of Veterans Affairs, or the US government.

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