The Hidden Epidemic Confronting Sexually Transmitted Diseases (1997) / Chapter Skim
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CURRENT STD-RELATED SERVICES
CURRENT STD-RELATED SERVICES
Pages 175-219
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From page 175... ...
Although the private sector is primarily involved in delivery of clinical services to persons with private health care insurance, this situation is rapidly changing and may have significant implications for the delivery of STD-related services. CLINICAL SERVICES Clinical services for STDs screening, diagnosis and treatment of STDs, patient counseling, and partner notification and treatment are provided primarily in one of three settings: · dedicated public STD clinics, operated by local health departments; 1 1 The committee uses the term "dedicated public STD clinics" to refer to publicly funded clinics whose main purpose is to provide STD-related services.
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From page 176... ...
Health Care Professionals and Prevention Activities There is a broad range of health care professionals involved in STD-related care. Most clinicians who provide STD-related care in public or private settings emphasize diagnosis and treatment and, to a lesser extent, management of sex partners rather than other approaches to STD prevention (Bowman et al., 1992~.
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From page 177... ...
State and local health departments also provide financial support for these clinics and programs and are often given responsibility for operating the clinics under federal policies and guidelines. Persons Served A recent five-center survey of more than 2,500 patients attending dedicated public STD clinics in the United States showed that users of such clinics are generally young (38 percent under 25 years of age)
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From page 178... ...
Services Provided Publicly funded STD-related services are provided both by dedicated public STD clinics and within the context of primary care by community-based programs. Dedicated public STD clinics are located in every state, every major city,
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From page 179... ...
These staff, as discussed later in this chapter, typically emphasize partner notification responsibilities over patient education activities. In dedicated public STD clinics, partner notification activities are primarily focused on patients with syphilis, HIV infection, and, to a highly variable degree, gonorrhea, chlamydial infection, or pelvic inflammatory disease.
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From page 180... ...
Several states mandate counseling of patients, using a prescribed content outline, before to HIV testing; however, there is no method for ensuring that these regulations are followed. Data on the specific types of STD-related services provided by local health departments through public STD clinics are limited.
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From page 181... ...
Fam Plann Perspect 1996;28:261 -6. Effectiveness Dedicated public STD clinics provide services to large numbers of patients at little or no cost to the patient.
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From page 182... ...
, a high proportion of patients attending these clinics stated they would preferentially attend public STD clinics should they need further STD care. The most common reasons cited for preferring to use the public STD clinic were walk-in/same-day appointments, lower costs, privacy or confidentiality concerns, convenient location, and expert care (Figure 5-2~.
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From page 183... ...
Since management positions were often given to
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From page 184... ...
Thus, the total number of federal field assignees for STD prevention will be reduced by nearly half from 1996 through 2000, but remaining assignees will receive further training and new recruits will have more extensive training. Transition from a direct service delivery role to a technical assistance and local capacity-building role for federal assignees is being planned (CDC, DSTDP, 1996~.
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From page 185... ...
Community-Based Clinics Many types of community-based clinics, such as family planning clinics, prenatal clinics, youth and teen clinics, homeless programs, community-based health centers, and school-based clinics, also provide STD-related services. Like dedicated public STD clinics, community-based clinics that treat STDs tend to be high-volume clinics that provide services at relatively little or no cost to the patient.
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From page 186... ...
More recently, publicly funded family planning clinics have become the focus of a national initiative on preventing chlamydial infection coordinated by the CDC. Unlike dedicated public STD clinics that provide services to a disproportionate number of men, most persons who use community-based clinics are women and children.
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From page 187... ...
Most cases of STDs are diagnosed by private sector health care professionals (Berg, 1990~. However, very little is known about the volume, extent, disease prevalence, or spectrum of STDs encountered in private sector settings compared to either dedicated public STD clinics or communitybased clinics.
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From page 188... ...
and practice guidelines for STD clinics (CDC, 1991) , there are no generally accepted clinical practice guidelines or standards for STD screening and risk assessment.
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From page 189... ...
Point-of-service plans allow services from network providers at the usual copayment, but also permit 3The committee uses the term ``managed care organization to refer to health plans that are prepaid for the defined benefits of the plan that is, health plans that provide, or arrange and pay for, all covered health services needed by the enrollee, in return for a specified premium plus any allowed copayments. This definition best describes health maintenance organizations (HMOs)
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From page 190... ...
Health Plan, are publicly owned and operated by local health departments. In 1994, approximately 31 percent of persons enrolled in managed care organizations were in predominantly staff- or group-model organizations, and 69 percent were in network or independent practice association plans (GHAA, 1995~.
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From page 191... ...
The push by states to enroll Medicaid recipients into managed care plans in order to contain costs raises several concerns regarding the design and implementation of these new programs and the accountability of the new managed care plans for quality (Fisher, 1994~. Effect of Managed Care on STD Prevention There are both opportunities and concerns associated with increased involvement of managed care organizations in the delivery of preventive and public health services (CDC, 1995b)
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From page 192... ...
In general, staff- and group-model managed care organizations are likely to be more effective in STD prevention than health plans that have less infrastructure. Given the limited experience of most managed care organizations in public health activities, however, even some of the best organized managed care organi 5This performance measurement tool, developed by the National committee for Quality Assurance, is utilized primarily by employers and other purchasers of health care to compare and evaluate large managed care organizations.
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From page 193... ...
For example, health plans may refer persons in need of STDrelated services to public STD clinics to avoid assuming the costs of their care. · Persons with STDs may prefer to receive care at public STD clinics and may not feel comfortable receiving care through a managed care organization for a variety of reasons.
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From page 194... ...
of these organizations attempted to define high-risk groups for STDs, and approximately half reported STD prevention or clinical activities that specifically targeted adolescents. Only 26 percent of managed care organizations reported that they provided STD-related services to persons outside their plan, and just 17 percent had a specific individual in charge of STD-related activities.
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From page 195... ...
This initiative also seeks to coordinate clinical preventive services for adolescents in managed care settings with community STD prevention activities and to coordinate all categorical state STD-related programs. Other components of this initiative include a media campaign targeted towards teenagers; development of screening, counseling, and education interventions: school-based programs; and training programs for health care provid ers.
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From page 196... ...
Viral STDs, such as herpes simplex virus type 2 infections, are generally not well identified through this system. In general, initial case reports generated by laboratories or providers are submitted to local public health departments and are, in turn, reported to state public health authorities.
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From page 197... ...
Numerous studies have indicated that reporting from public clinics, such as public STD clinics, is more complete than reporting from private providers (Anderson et al., 19941. Reported data actually may underrepresent true STD incidence by 50 percent or more because many cases diagnosed by private providers are not reported.
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From page 198... ...
In some STD programs, so little effort is being made to identify gonorrhea or chlamydial infections identified outside publicly funded STD clinics that reports sent to the local health departments from non-STD clinic providers are discarded, and little effort is made to identify broader, community-based morbidity trends. As discussed in Chapter 4, partner notification and follow-up of positive laboratory results for syphilis are labor intensive and result in a heavy emphasis on STD program indicators rather than on true population-based measures of program effectiveness.
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From page 199... ...
Although limited in scope, these registries provide useful information on treatment of STDs. Health Behavior Surveys A crucial but underdeveloped tool for directing and targeting STD prevention programs is the behavioral health survey.
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From page 200... ...
Measuring and Evaluating Program Effectiveness Data regarding federally supported projects collected by the CDC through state and local health departments consist primarily of output indicators that relate to laboratory reporting, community screening, case investigation, preventive and other clinical services, and gonorrhea, chlamydia, and HIV case detection. Other federal agencies, such as the Health Resources and Services Administration and the Health Care Financing Administration, collect information primarily related to the provision of direct health care services they support.
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From page 201... ...
Left untreated, Chlamydia can cause pelvic inflammatory disease, infertility, ectopic pregnancy (where the egg is implanted in the fallopian tube instead of in the womb) , and chronic pelvic pain.
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From page 202... ...
preventing and containing chlamydial infection and chlamydia-related sequelae such as pelvic inflammatory disease; and (4) preventing HIV infection through public STD clinics (Alan Friedlob, CDC, Division of STD Prevention, personal communication, February 1996~.
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From page 203... ...
Local Data Analysis Capacity The Division of STD Prevention at the CDC currently provides technical assistance to state and local programs implementing the division's management information software, "STD* MIS." Rather than technical assistance related to initiating or implementing information systems, it has been suggested that technical assistance is needed to develop local data analysis capacity so that data can be used to improve the effectiveness and efficiency of local STD programs (Alan Friedlob, CDC, Division of STD Prevention, personal communication, February 1996~.
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From page 204... ...
Medical School and Medical Graduate Education Two national committees in the United States have previously expressed concern regarding the adequacy of education in the area of STDs (Kampmeier, 1975; Work Group on Sexually Transmitted Disease, 1979~. In addition, a 19801981 study indicated that medical school instruction regarding STDs was generally inadequate (Stamm et al., 1982~.
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From page 205... ...
Clinical training in dedicated public STD clinics, therefore, remains the exception rather than the rule for medical students in the United States. While infrequent encounters with patients with STDs in other ambulatory settings such as primary care, general medicine, or family medicine clinics (Berg et al., 1984)
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From page 206... ...
Primary care professionals often do not receive special training in STD risk assessment, diagnosis, and treatment. Such training, when it does exist, is often based within dedicated public STD clinics, and is not accessible to primary care professionals.
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From page 207... ...
Since 1979, the CDC has funded 10 to 12 regional STD Prevention Training Centers. These centers have provided instruction composed of didactic lectures and clinicbased experiences to nearly 100,000 nurse practitioners, physician assistants, and physicians working in public health or family planning clinics throughout the United States.
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From page 208... ...
Of that amount, approximately $91.8 million (87 percent) was awarded in grants by the CDC to states and cities for STD prevention activities.6 The National Institute of 6 The remaining amount of the appropriated funds ($13.4 million)
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From page 209... ...
Based on an informal CDC survey of state and local health departments regarding their contributions to STD program funding in 1994, the total state and local contribution to STD-related programs was approximately $125.6 million or approximately 58 percent of combined state, local, and federal funding (CDC, Division of STD Prevention, unpublished data, April 1994~. State and local contributions, as a percentage of combined state, local, and federal funding in the respective area, ranged from 0 percent ($0)
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From page 210... ...
Even if the true public investment in STD prevention and research is several times higher than that estimated by the committee, the public investment would still be extremely low compared to the total costs of STDs in the United States. Categorical Funding Funding for state and local health departments comes from the CDC cooperative agreements and state and local governments.
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From page 211... ...
STDrelated care provided in community-based health facilities, such as family planning clinics and community health centers, receive federal and other support. Local health departments receive reimbursement for services provided by public STD clinics to persons with private insurance only to the extent allowed by law or under written contract.
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From page 212... ...
Association of Teachers of Preventive Medicine (ATPM) Extramural Research and Demonstrations STD Accelerated Prevention Campaign Enhanced Projects Research and Evaluation Issues in Prevention of Infertility Due to STDs STD Accelerated Prevention Campaign: Enhanced Projects for STD Prevention in High-Risk Youth Innovations in Syphilis Prevention in the United States: Reconsidering the Epidemiology and Involving Communities Development and Feasibility Testing of Interventions to Increase Health-Seeking Behaviors in, and Health Care for, Populations at High Risk for Gonorrhea STD APC Enhanced Projects: Jail STD Prevalence Monitoring Total Program Funding 69,954,310 9,798,309 1,700,000 715,390 325,000 4,008,547 2,965,623 648,070 400,000 22,500 1,463,510 1,275,000 1,025,188 1,000,000 750,000 125,000 96,176,447 SOURCE: CDC, Division of STD Prevention.
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From page 213... ...
For example, many states have kept HIV and STD prevention programs completely separate, although most observers acknowledge that it is logical to coordinate programs to prevent HIV infection and other STDs because they share common modes of transmission and risk groups and many common interventions. By measuring accountability in terms of the number of persons who receive a service or educational program, federal categorical funding encourages state and local agencies to keep programs separate.
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From page 214... ...
Although these components are largely publicly sponsored programs, they involve all levels of government and the private sector. Dedicated public STD clinics have been instrumental in public efforts against STDs since they were established several decades ago.
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From page 215... ...
The traditional role of dedicated public STD clinics and some of the functions of public health agencies will likely change given the national trend towards managed care, especially the increasing enrollment of Medicaid beneficiaries into managed care plans. This change in the health care delivery environment is both an opportunity to improve services and a cause for concern that the "safety net" for essential public health services will be eroded.
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From page 216... ...
Atlanta: Centers for Disease Control and Prevention, 1995. CDC, DSTDP (Division of STD Prevention)
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From page 217... ...
Seroconversion in patients attending sexually transmitted disease clinics.
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From page 218... ...
Editorial: family planning, sexually transmitted diseases, and prevention of AIDS divided we fail? Am J Public Health 1996;86:783-4.
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From page 219... ...
A proposal for strengthening medical school training in STD prevention techniques. Public Health Rep 1991;106:196-202.
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