Transcript Implementation of EPT at DMHC

Evolving STI Clinic Practice
Cornelis A. Rietmeijer, MD, PhD
Denver Public Health Department
and
Colorado School of Public Health
University of Colorado Denver
This Talk Is…
• …not about diagnostics and treatment
• …but rather about program operations,
innovations, and evaluation in the STI
clinical setting
2
Denver Metro Health Clinic
• Largest STI clinic and HIV testing facility
•
in U.S. Rocky Mountain region
Provides:
– Comprehensive STI diagnostic and
treatment services
– Confidential and anonymous testing in the
HIV counseling and testing site integrated
in the clinic
3
Denver Metro Health clinic
2008 Clinic Stats
• 18,000 visits
• 1,874 Ct cases
(9.5% of all visits)
• Men: 9/9%
• Women: 8.9%
•
700 GC cases
(3.5% of all visits)
• Men: 4.3%
• Women: 2.4%
•
120 new HIV infections
4
Electronic Medical
Record (EMR)
The Backbone Of STI Practice
Innovation and Evaluation
HealthDoc
• Electronic medical record system
•
developed specifically for the Denver
Metro Health Clinic
Implemented in March 2005 to replace an
outdate medical record system that was
based on scannable forms and had been
in existence since 1988
6
HealthDoc
• Built from a public health perspective
– Not focused on billing
– Serves patient management and public health
functions
• Fully integrated medical record, including
•
laboratory ordering and results, diagnosis, and
treatment information
Allows automatic reporting to state health
department for reportable infections
7
HealthDoc
• Combines
– a registration system
– an electronic form document system
– a rules engine to ensure accurate and
appropriately coded information
– a web portal interface
– an interface with the Denver Health patient
registration system (Siemens Invision)
– an interface with the Sunquest laboratory
system
– multiple inbound/outbound interfaces with the
Colorado State Health Department.
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9
Stockholm, September 3 1967: 5:00 AM
Transfer to Electronic Medical Record System
10
Denver, March 14 2005, 8:00 AM
HealthDoc: Advantages
• All STI services in one system
– DMHC
– Jail services
– Title X Family Planning
– HIV counseling and testing
– Outreach testing
• Bath House HIV/STI testing program
• Non-clinical chlamydia/gonorrhea NAAT testing
– Special testing events
11
HealthDoc: Advantages
•
Data Exchange
– (partially) integrated with lab database
– Electronic transfer of data between DMHC and state
health department
• HIV counseling and testing data
• HIV (WB and NAAT) results
• RPR/TPPA results
– Automatic reporting of reportable infections
– Easy abstraction, transfer, and analysis of data for
• Surveillance and Epidemiology
• Program evaluation and research
12
HealthDoc: Advantages
•
Relatively flexible
– Many changes and updates can be performed inhouse at low cost
•
Data quality
•
Cost-effective
•
– Internal error checking system
– Has reduced clerical data input and associated risk
for errors
Easily accommodates innovations
– Online results
– Automatic text messaging
– Expedited partner therapy (EPT)
13
HealthDoc: Disadvantages
• Steep learning curve, especially among
•
staff not accustomed to electronic
interfaces and data entry
Potentially distracting from provider-patient
interaction
14
Providing STD Test Results
Online
Results Online
•
How it works:
– Program started June 2008 as an alternative to inperson and telephone results
– Results available online after 5 days
– Originally, patients opted in and had to create their
own (strong) password (opt-in)
– Since December 2008, patients are given a login
code and a predetermined password (opt-out)
– Patients are given instructions in case of positive
results
– Access of online results automatically registered in
patient medical record
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DMHC Online Results Evaluation: 12/07 – 04/09
80
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40
30
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% of patients receiving results via the telephone
% of patients receiving results online
20
Ling et al. Sex Transm Dis 2009; In Press.
Providing Test Results Online
Lessons Learned
• Proportion of patients receiving results
online
– Opt-in Phase: 25%
– Opt-out Phase: 50%
• No net increase or decrease of patients
•
receiving results
Substantial savings in clerical time spent
on answering phone calls
21
Ling et al. Sex Transm Dis 2009; In Press.
Cell Phone & Text Messaging Use
Among STD Clinic Patients
Clinic Survey Results
Do you use a cell phone?
84.7%
Do you use text messaging on your
cell phone?
90.2%
Is it OK to contact you via text message?
93.5%
22
Richardson et al. ISSTDR, 2007
Text Messaging Projects
Denver Metro Health Clinic
• Project 1
Send text message to those testing
positive for gonorrhea or chlamydia to call
the clinic to receive their results (if they
haven’t called back after 7 days)
23
Proportion not receiving results
Historical controls
Text message intervention
Compared to historical controls, during the text
messaging period, patients received their test results
an average of 3.5 days earlier.
Days Since Test
24
Text Messaging Projects
Denver Metro Health Clinic
• Project 2
Send text message to those treated for
gonorrhea or chlamydia to return to the
clinic for re-testing after 3 months
25
Expedited Partner Therapy
The DMHC Experience
Expedited Partner Therapy
• Approach whereby partners are treated
without an intervening clinical assessment
– Patients delivering medications to partners
– Patients delivering prescriptions to partners
– Field treatment by DIS or outreach workers (with or
without testing)
27
EPT Studies
•
Schillinger et al. Sex Transm Dis 2003;30:49-56
– 20% reduction in CT re-infection of 20% among
women (P = 0.102)
•
Golden et al. New Engl J Med 2005;352:676-85
– 73% reduction in GC re-infection among men and
women (P < 0.01)
– 17% reduction in CT re-infection (P = 0.17)
•
Kissinger et al. Clin Infect Dis 2005; 41:623-9
– 46% reduction in GC and/or CT infection among men
with urethritis (P<0.001)
28
CDC Recommendations
• “….patient delivered therapy (i.e., via
•
•
medications or prescriptions) can prevent
re-infection of index case and has been
associated with a higher likelihood of
partner notification, compared with
unassisted patient referral of partners”
EPT recommendations are limited to GC
and CT contacts only
EPT is not recommended for MSM
29
CDC 2006 STD Treatment Guidelines
EPT in the STD Clinical Setting
Questions
• How to implement EPT in a busy STD
•
clinic?
What are the EPT acceptance rates
among patients eligible for EPT?
– Currently no published benchmarks
• What are the reasons eligible patients
decline EPT?
30
History of EPT at DMHC
• 11/2006 – 3/2007
–Demonstration Project
• 3/2007 – 8/2007
–Review by pharmacy board
• 9/2007 – Current
–Standard of care
31
Partner Pack
Chlamydia
32
Implementation of EPT at DMHC
• Provider training
• Changes to the electronic medical
record
–Treatment information includes EPT
–Partner services questions include EPT
and reasons why declined
• Chart review and provider feedback
33
34
35
EPT at DMHC
2007 - 2009
%
•
•
50
45
EPT Acceptance
40
35
•
30
25
20
•
15
10
5
0
2007
2008
2009
2,159 eligible patients
438 (21%) accepted
EPT
Median # partner
packs: 1 Range: 1-3
No demographic or risk
differences between
those who did or did
not accept EPT
36
EPT Provider Rate - 2008
% Accepting EPT
40
35
30
25
Nursing staff 1.7 (1.4 – 2.2) times more likely to dispense EPT than non-nursing staff
20
15
10
5
25
5
17
1
19
16
2
6
9
18
62
24
3
30
111
1
18
4
14
9
1
14
9
90
26
32
3
11
0
Number of Eligible Patients by Provider (N= 28)
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Reasons for Declining EPT
70
%
60
50
40
Ct
GC
30
20
10
0
P. Treated
P. Notified
No Contact
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Express / Fast-Track
Clinic Visits
Express / Fast Track Visits
• Purpose
– To enhance clinic efficiency and patient
satisfaction through a process by which
qualifying patients are offered a testing-only,
no-exam visit
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Express / Fast Track Visits
• Who is eligible?
– Asymptomatic patients regardless of
• Demographics
• Risk or contact status
• Sexual preference
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Express / Fast Track Visits
• How is it done?
– All patients go through triage after registration
– Triage staff determines eligibility
– Patients can opt for comprehensive visit if
they desire regardless of eligibility for express
visit
– Patients are discouraged to opt for express
visit if symptomatic, but are not denied
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Express / Fast Track Visits
• What is done?
– HIV rapid test (unless opt-out)
– RPR
– CT and GC NAAT
• Males: urine
• Females: self-obtained vaginal swab
– Gonorrhea cultures among at-risk MSM
• Anal swab
• Pharyngeal swab
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44
Shamos et al. Sex Transm Dis 2008;35:336-340.
45
Shamos et al. Sex Transm Dis 2008;35:336-340.
Time & Motion Study
• Median visit duration men
– Comprehensive: 85
– Express: 52 minutes
– Reduction: 39%
• Media visit duration women
– Comprehensive: 105
– Express: 46
– Reduction: 56%
46
Shamos et al. Sex Transm Dis 2008;35:336-340.
47
Normalizing HIV Testing
CDC Recommendations
• “All patients seeking treatment for STDs,
including all patients attending STD clinics,
should be screened routinely for HIV
during each visit for a new complaint,
regardless of whether the patient is known
or suspected to have specific behavior
risks for HIV infection.”
49
MMWR 2006 / 55(RR14);1-17
HIV Testing at Denver STD Clinic
Before November 2003
• General consent for all procedures and
•
•
•
testing, except HIV testing, obtained at
registration
HIV testing offered by clinician during
the clinic visit, based on risk
assessment
Blood drawn for syphilis and HIV (if
accepted) testing during the clinic visit
HIV test used: standard EIA
50
HIV Testing at Denver STD Clinic
After November 2003
• November 2003: Rapid HIV testing
(OraQuick) offered
– First as optional alternative to standard EIA
– Routine after July, 2004
• May 2004: Change in testing logistics
• March 2005: Introduction electronic
medical record and switch from opt-in to
opt-out HIV testing
51
HIV Testing at Denver STD Clinic
Change in Testing Logistics
• To avoid adding another 20 minutes to
the visit, prior to clinic encounter:
– Draw RPR blood before clinician sees
patient
– Offer HIV testing routinely by clerical/venipuncture staff
– Use RPR blood draw to collect extra tube
for rapid HIV test
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Evaluation
• Inclusion/Exclusion criteria
– New problem visits
– RPR performed
– Previously known HIV+ excluded
• Main outcome: HIV/RPR ratio
– RPR used as the gold standard of routine
testing
53
Impacts of Rapid Testing
Denver Metro Health Clinic
Percentage of patients who received their positive test results:
Before:
After:
66%
100%
54
HIV/RPR Ratio and HIV Positivity Rate by Period
0.96
1.00
0.92
1.5%
0.86
0.79
HIV(+) Rate
Ratio
(HIV:RPR)
January 2005 - October 2006
0.80
0.8%
0.7%
0.6%
0.5%
0.60
0.0%
Period I: Jan 2003 -
Period II: Dec 2003 -
Nov 2003
Period III: Jun 2004 -
May 2004
Mar 2005
Period
Brooks et al. Sex Transm Dis 2009
Period IV: Apr 2005 Oct 2006
HIV:RPR Ratio
HIV+ Rate
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Counseling
No Respect?
Project Respect
Main Results
• Compared to standard education
•
messages, client-centered counseling
resulted in overall STD reduction of 30%
after 6 months and 20% after 12 months
2-session prevention counseling was as
effective as the 4-session enhanced
counseling
57
Kamb et al. JAMA 1998;280:1161
Project Respect
Relative effectiveness was greatest among those
at highest risk for STI
# STI prevented
per 100 persons counseled
– 20 years and younger
– Exchange sex for money or drugs
– STD at baseline
– Lower education (<12th grade)
– Female
– African American
9.1
5.9
5.3
4.3
3.9
3.2
58
Bolu et al. Sex Transm Dis 2004;31:469.
The bad news is…
...that the good news is old
news…
Prevention Counseling
the main Challenge
• How to implement prevention
counseling in the busy practice setting?
– Competing needs
– Resource constraints
– Lack of provider buy-in
– Lack of supervisory buy-in
60
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What Is the Intervention?

23-minute video

3 story lines

2 cartoon animations
 Condom variety
and selection
 Instructions for use

Posters in waiting and
exam rooms
63
Story Line – Paul and Jasmine
Things are getting more serious between Paul and Jasmine,
but Paul “slips” and has a sexual encounter with Teresa.
Teresa gets an STD and tells Paul.
Now Paul has to tell Jasmine.
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Overview of Study Design

Population: =~40,000 patients attending 3 STD clinics
from December 2003 – August 2005
 Study design: 2 arm non-randomized controlled trial

Arm assignment: alternating 4-week control &
intervention periods

Data collection: Passive review of clinic data & external
surveillance records to ascertain new STI diagnoses*
* gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV
65
Overall Effect of the Intervention
on Laboratory-Confirmed Infection*
Hazard Ratio (95% CI)
All patients
0.91 (0.84-0.99)
* = 9% reduction in STI incidence
66
Warner et al. PLoS Med. Jun 24 2008;5(6):e135.
Intervention Effect, by Characteristic
Hazard Ratio (95% CI)
STI at index visit
Yes
0.86 (0.75-0.99)
No
0.93 (0.84-1.04)
Males
0.87 (0.78-0.96)
Sex
Females
Sexual orientation
Heterosexual
MSM
Age
<25
>25
1.06 (0.89-1.25)
0.84 (0.71-0.98)
0.90 (0.79-1.03)
1.02 (0.88, 1.17)
0.85 (0.77, 0.95)
67
Warner et al. PLoS Med. Jun 24 2008;5(6):e135.
CDC Diffuses Safe in the City
 To Date:
 ~2,000 kit requests and >1,000 kits distributed
 Close to 50% of clinics are playing the DVD after
3 – 6 months
 An estimated 1 million clinic patients exposed in
past 16 months
68
Safe in the City
 More information:
 SITC page and online kit request form on the
Diffusion of Effective Behavioral Interventions
(DEBI) website:
 www.effectiveinterventions.org
 Safe in the City website:
 www.safeinthecity.org
 STDPreventionOnline:
 www.stdpreventiononline.org
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Acknowledgements
•
Denver Public Health
Department
– Doug Richardson
– Ben Westergaard
– Terri Sapp
– Sarah Ling
– Lesley Brooks
– Christie Mettenbrink
– Theresa Mickiewicz
– Dean McEwen
•
CDC Atlanta
– Mary McFarlane
– Rachel Kachur
– Lee Warner
– Andrew Margolis
– Camilla Harshbarger
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Final Thought
“If you don’t change your
direction, you’re going to end
up where you’re headed”
Chinese Proverb
72
THANKS!!
73
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