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Abstract
Objectives Expedited partner therapy (EPT) effectively reduces rates of reinfection with chlamydia and increases the number of partners treated for the infection. Healthcare provider (HCP) provision of EPT is low. The objective of this qualitative study was to understand HCP views and opinions regarding the use of EPT in a state where EPT is permissible but underused.
Methods Using a purposive sampling strategy to include diverse HCPs who treat young women at risk for chlamydia, 23 semistructured, in-depth interviews were conducted between October and December 2013. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT.
Results Many respondents report using EPT and believe the practice is beneficial for their patients. Most providers were unaware of their colleagues’ practices and had limited knowledge regarding institutional policies around EPT. HCPs noted a variety of barriers, such as fear of liability, confusion around the legal status of EPT and not being able to counsel patients’ partners that make routine use of this practice a challenge. Facilitators of EPT include speaking on the phone with patients’ partners and establishing legislation enabling EPT.
Conclusions This is the first study to qualitatively examine HCPs’ perspectives on EPT in the USA. Barriers to EPT, including concerns about counselling patients’ partners and the legal status of EPT, can be overcome. EPT recommendations could include the use of phone calls as part of their guidelines. Changing EPT legislation at the state level in the USA is an important factor to facilitate EPT use.
- CHLAMYDIA INFECTION
- QUALITATIVE RESEARCH
- PARTNER NOTIFICATION
- ATTITUDES
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Introduction
Chlamydia is a bacterial infection spread through sexual contact and is the most commonly reported infectious disease in the USA.1 Left untreated, chlamydia can cause pelvic inflammatory disease, ectopic pregnancy and infertility in women.2 Rates of reinfection are high, with 12–20% of women becoming reinfected with chlamydia within a year of their initial infection.3
Traditionally, healthcare providers (HCPs) encourage patients being treated for STIs to notify their sexual partners to seek treatment or may contact the patient's sexual partners themselves.4 ,5 Research indicates that such approaches do not often result in treatment of partners.4 ,6 Even public health departments that have designated clinical staff to follow-up provide notification for <20% of patients’ sexual partners.7
In 2006, the Centers for Disease Control and Prevention (CDC) suggested the use of expedited partner therapy (EPT) for patients whose partners are infected with chlamydia; this treatment method does not require sexual partners to undergo screening or medical examination.8 The most commonly used form of EPT is patient-delivered partner therapy in which the patient receives a prescription or medication to treat the infection for his/her sexual partner(s).8 Several randomised controlled trials conducted comparing EPT to standard partner notification (by patient or HCP) found that EPT effectively reduces rates of reinfection with chlamydia as well as increases the number of partners treated for the infection.9–13 Studies have also been conducted around the use of EPT for trichomoniasis and gonorrhoea; EPT was not found to be more effective than standard partner management for trichomoniasis and while EPT was effective for gonorrhoea, current treatment regimens for the infection make its use less feasible.8 ,14 As such, EPT is a promising practice for treating individuals for chlamydia and reducing the likelihood of reinfection.8
In the USA, several surveys about providers’ use of and attitudes about EPT indicate that while many HCPs are willing to and do use EPT many barriers have prevented broader implementation of this practice.15–19 These include fears of adverse patient outcomes, incomplete care for patients’ partners, lack of comfort with EPT and reimbursement. Providers also fear liability, such as being sued for medical malpractice for adverse patient outcomes, being sanctioned for treating a patient that they do not have a relationship with or using a practice that is not endorsed by their state medical board. In Pennsylvania, EPT is considered permissible because there are no specific regulations or statutes in place at the state level that prohibit the practice.20 There is, however, no specific legislation authorising the practice of EPT. This qualitative study sought to explore in an in-depth manner HCPs’ experiences and perspectives regarding the benefits, barriers and facilitators to the use of EPT for chlamydia.
Methods
Recruitment and sampling
Using a purposive sampling strategy to include diverse providers (nurse practitioners, physicians and trainees from different disciplines) who treat young women at risk for chlamydia, we distributed an email describing the study to providers in adolescent medicine, internal medicine, family medicine and obstetrics/gynaecology departments within a large healthcare system (providing care in sites including primary care, community-based and hospital-based clinics). Providers were also referred by colleagues to participate. Approximately 100 providers were emailed to participate in the study. The final sample was determined both by content saturation and by fulfilling a sampling matrix that included a range of disciplines and levels of training.
Data collection
Data were collected by means of semistructured, in-depth interviews. All 23 interviews were conducted in person by the primary investigator between October and December 2013 and took approximately 15–40 min to complete. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT. After the interview, providers completed a brief demographic survey, which included questions about sex, age, years practising medicine, profession, specialty and practice setting. Participants were compensated $50 for their time.
Analysis
All interviews were audio-recorded, transcribed verbatim, stripped of identifiers and uploaded into Atlas.ti V.6 software. Using a thematic analysis approach,21 an initial codebook was created from reviewing the first five transcripts. The initial codes included a series of a priori codes from the interview questions that included knowledge, attitudes and previous experiences with EPT. More codes were added as additional interviews were reviewed. Content saturation was reached after the 16th interview with no new codes. All transcripts were coded with the finalised codebook by two independent coders who met to review coding and discuss discrepancies. No significant differences emerged in this process of consensus coding.
Results
The majority of the 23 providers interviewed were physicians, women, practising medicine for six or more years and between the ages of 30 and 49 (table 1).
Demographic characteristics of study participants
Findings are organised around perspectives on EPT; knowledge and practices; perceived benefits of EPT; harms and legal barriers; and facilitators for EPT use.
Knowledge and practice of EPT
Providers were informed that EPT is the practice of providing a prescription or medication to patients infected with chlamydia to give to their sexual partner(s), were asked what they knew about EPT, and if relevant, how often they use EPT. Most participants interviewed felt they had some knowledge about the practice of EPT. Several providers across different disciplines noted they did not know a great deal on the subject. Seven HCPs indicated they routinely use EPT, four used it fewer than five times, seven had used EPT in the past and five respondents had never used EPT. Some providers used EPT during their medical training, while others used EPT in the past when they worked in other regions or medical settings. Reasons providers noted for not currently using EPT were being told not to by supervisors and believing they could not use EPT in the region.
Seven of the providers who routinely practised EPT used a variety of methods. Many wrote a prescription for their patient's partner. A few doubled their patient's prescription. Several physicians noted that if the patient's partner was in the room with them they were fine with treating him. Others stated they were more willing to provide EPT if their patient explicitly told them that their partner was uninsured or did not have access to healthcare. A number of providers indicated they preferred to speak to their patient's partner on the phone if they were going to provide treatment.You know in some ways if I can actually have a conversation with the partner on the phone…
And say you know, okay, this is the medicine, have you taken this medicine before, can I tell you about the side effects and, you know, do you have any allergies to any medicines. And if they sort of say no, I mean, then, that's essentially similar to when I would be in a patient visit. (#19, obstetrics/gynaecology)
That was my way of kind of like hearing a voice, of kinda getting a little feel for the tone of voice, everything, asking if they understood what was going on and their role in this. Ask if they understood the antibiotics, do you have allergies…it's like a thirty, sixty, second conversation. (#6, adolescent medicine)
While many HCPs who participated in this study had used EPT, the practice was not something they often discussed with colleagues. In general, providers felt that using EPT was an individual decision made by individual providers. When asked if they knew whether their colleagues practised EPT, responses included, “I don't know, I have to say, what my colleagues do” (#10, adolescent medicine) and “It's not anything that we've ever talked about. So I am not sure” (#17, internal medicine).
Benefits of EPT
All of the HCPs interviewed believed EPT would benefit their patients. Repeat infection with chlamydia was noted as an issue for patients as was the futility of treating their patients without treating their partner(s). Several providers also discussed a need for better ways to treat patients’ partners and felt that the standard practice of sending partners to the health department was a barrier to treatment and EPT made access to treatment easier for partners.I think a faster way to ensure your patient does not get reinfected again, to get their partner treated, which is like most important to us, that our women do not continually get reinfected. So I think it's just kind of a nice, efficient way to at least hopefully get your patient be proactive about her health. (#3, obstetrics/gynaecology)
Harms of EPT
Many providers emphasised the importance of counselling patients and that provision of EPT did not allow them to properly counsel patients’ partners about their infection and sexual health behaviours. The type of relationship the patient had with her partner and a lack of certainty that their patients would be able to actually give their partners the treatment were also concerns.Just having no sense of what they'll do. Will they follow through, will they take it seriously, will they believe their partner? (#23, family medicine)
But then I think it also, probably, if you think about it, especially in our population, probably is a bit of a double edged sword, because then you are putting a lot of the kind of the onus on the patient to be the one to treat her partner. And I think sometimes I mean, obviously it's kind of a, a sensitive topic for partners to discuss. Especially when one is diagnosed with an STD. But I think that there is probably possible domestic violence issues and things like that. So I feel like you would probably have to get a good assessment of that. (#2, obstetrics/gynaecology)
Perceived legal barriers to using EPT
One barrier that providers had a wide range of perceptions about was whether or not EPT was permissible in the state of Pennsylvania. Some knew, some were unsure, others such as the obstetrician/gynaecology residents interviewed were told by their supervisors that EPT was not allowed. The majority of HCPs were unsure or unaware of their clinic's practice or institutional policies around EPT.I mean, yeah, I think unfortunately our education regarding whether it's permissible or not is lacking and I thought it was just like illegal. (#3, obstetrics/gynaecology)
I believe it is legal in Pennsylvania and should be the standard of care here in Pennsylvania. (#4, internal medicine)
I don't think we have a policy regarding it. (#17, internal medicine)
Liability is an issue that was discussed in all but two of the interviews. Not knowing the partner's medical history and allergies were large concerns for liability. Another issue was not being able to follow-up with their patient's partner to ensure that there were no complications or issues. While the majority of providers expressed some fears over being sued or being somehow liable for providing EPT, several HCPs asserted that risk of liability was outweighed by the benefits of the practice.I don't want to, certainly don't want any legal trouble or somebody suing me or a parent coming after me or something. Which could happen. (#9, family medicine)
So safety issue, liability issue, because they are not a patient of ours you know, we as a physician, you are held liable for any script you write, any refill you make, even if it's not your patient. So there is some fear there. I think we live in a fairly litigious society unfortunately. (#13, family medicine)
Kids don't really sue doctors and they particularly don't do it around issues like their chlamydia infections. I think in terms of, and so if my choice were between doing that and not treating someone. You know, I would rather take that risk. (#11, adolescent medicine)
Other barriers
Providers described their anxiety around providing antibiotics and potential side effects or reactions from the medication. Yet when asked specifically about allergies to azithromycin—the medication recommended for chlamydia treatment—the majority of providers agreed that they did not actually have significant worries about that medication.
Four of the obstetricians/gynaecologists raised a barrier unique to their discipline—EPT requires them to treat men who would never be their patients, which is uncomfortable for at least some obstetricians/gynaecologists.
Suggested facilitators of EPT
The HCPs interviewed provided many suggestions to facilitate EPT use. Several HCPs asserted that addressing one or two issues would make using EPT much simpler, specifically clarifying liability, providing education, and creating guidelines and establishing norms regarding EPT. Many HCPs also expressed a desire to know how other providers were incorporating EPT use into their practices.I think the most important thing is to clear up the liability issue. (#10, adolescent medicine)
I think we would have to attack the medical legal barriers. (#21, obstetrics/gynaecology)
I think if there were, there is obviously the Good Samaritan act. So there's the line of you are trying to do good. And if some bad outcome comes from that, that you are sort of ah, you have some immunity. (#13, family medicine)
I think for me, being a more novice clinician, I think having someone who had more experience tell me that they've done it… knowing that there is a track record there and that people that I trust and that I work with do it. (#18, internal medicine)
Or if there was a general consensus on what your partners do or people who also practice that you identify with that are in your, in your institution or your region. Like if there was some kind of consensus about what everyone does. (#22, internal medicine)
One HCP noted that including prompts to use EPT in electronic medical records would be an effective means to promote use. Several providers noted that having antibiotics in the office to give to patients would make the practice of EPT more feasible. One HCP suggested that having posters and checklists about EPT placed in clinics would encourage its use.
Discussion
This qualitative study of HCPs’ perspectives on EPT in one US state found that all participants felt EPT was beneficial but most did not use it. Many HCPs had limited knowledge about the legal status of EPT and some had concerns about its potential harms, including not being able to counsel patients’ partners. Several HCPs preferred to speak to the patient's partner on the phone before prescribing medication.
There are several limitations to this exploratory qualitative study. Findings may not be generalisable to providers from other regions. Nevertheless, they apply to jurisdictions in which there is no specific legislation, either authorising or prohibiting EPT. This study relied on self-selected pool of providers, thus interviews may be biased towards individuals who are particularly favourable towards or especially concerned about EPT. However, our sample of HCPs did provide a wide range of opinions and knowledge about EPT. Another limitation of the study is that our definition of EPT differed from the interventions that tested the effectiveness of EPT as our definition did not include providing condoms and written information about STIs for partners. As such, we did not assess adherence to EPT protocol; with this qualitative study, we probed HCPs to explain how they understood and practised EPT. A strength of this study is the participation of providers from multiple specialties including adolescent medicine, internal medicine, family medicine and obstetrics/gynaecology, from diverse clinical settings.
The majority of HCPs interviewed did not use EPT, although no laws in Pennsylvania specifically prohibit its use. This situation generates confusion about the legal status of EPT and concerns about liability for treating patients with whom they do not have a provider–patient relationship. In California, the first state where legislation expressly authorised EPT in 2001, EPT is routinely used by >50% of physicians and nurse practitioners and by >70% of family planning providers.16 A survey conducted in Arizona found that obstetricians/gynaecologists who received information about changes in state statutes about allowing EPT use were more likely to practise EPT.15
Participants spontaneously raised the issue of the potential harms of EPT, which has not been systematically reported in EPT trials to date. HCPs noted harms such as not being able to counsel patients’ partners, patients not giving their partners the medication and the possibility of intimate partner violence. While providers had positive perceptions of the benefits of EPT, they also have a number of concerns for the safety of their patients and their patients’ partners. Every form of partner notification has benefits and the potential for harm; a systematic review of randomised control trials on partner notification strategies, including EPT, found that the majority of trials do not report on or measure such harms.4 Further research on the potential magnitude of such harms should be considered, especially as EPT is disseminated in clinical practices.
Several HCPs interviewed on their own determined that they preferred to speak to patients’ partners on the phone when providing EPT. HCPs sought ways to counsel patients’ partners about sexual behaviours, STIs and establish a provider–patient relationship; speaking to them on the phone was considered the most effective means to do so. Given that speaking on the phone to patients’ partners makes providers more comfortable using EPT, the CDC's EPT recommendations could include the use of phone calls as part of their guidelines. In the UK, EPT is not permitted because patients must be medically assessed by providers before provision of medication.22 However, recently a form of EPT that complies with UK prescribing guidelines, accelerated partner therapy (APT), in which patients’ partners are either contacted via phone or receive consultation from a community pharmacist, has been assessed.22 Research has found that providers are willing to use APT and prefer the phone approach.23
Barriers and facilitators to using EPT centred around fears about being sued for adverse patient outcomes or being somehow liable for treating a patient they do not have a relationship with and the need to clarify the legality of EPT to alleviate those fears. Our findings around barriers and facilitators to EPT were similar to the findings of studies conducted in the UK and Australia. A qualitative study conducted with general practitioners about their views on EPT and partner notification to treat chlamydia in Australia, a country that has no specific legislation about EPT, found that providers had concerns about treating a patient without evaluating their medical history and asserted that clarity around the legality of EPT would facilitate its use.24 A survey in the UK found that 22% of providers had used EPT, around one-third were opposed to the practice, providers felt that speaking on the phone with the partner was important, and the largest barrier to its use was the legality of EPT.25
This qualitative study demonstrates the way in which providers are willing to use EPT and have positive attitudes about the practice in a state where EPT is permissible but not expressly authorised. Barriers to EPT, including concerns about counselling patients’ partners and the legal status of EPT, can be overcome. Our study identified that providers have found ways to provide EPT in a manner they feel comfortable, by speaking to patients’ partner on the phone, enabling them to counsel patients’ partners. Providers desire clarity around the legal status of EPT; Pennsylvania could follow the lead of states such as California, New York and Arizona, and implement legislation that expressly allows EPT.20 Research is needed to examine how provider perspectives differ across states where EPT regulations differ. Further investigation should also quantify the frequency and impact of harms related to the provision of EPT. To make EPT more widely adopted, steps must be taken to ensure providers feel safe using this practice.
Key messages
All participants felt that expedited partner therapy (EPT) would be a beneficial practice and something that would help reduce rates of reinfection with chlamydia for their patients.
Participants noted barriers, including fear of liability and confusion around EPT's legal status, and the harms of not being able to counsel patients’ partners.
A facilitator of EPT involves speaking on the phone with patients’ partners; EPT recommendations could include the use of phone calls as part of their guidelines.
Establishing specific legislation authorising EPT would facilitate its use.
References
Footnotes
Handling editor Jackie A Cassell
Acknowledgements We would like to thank Carmel Shachar, JD MPH, staff attorney at Harvard Law School Center for Health Law and Policy Innovation, for her help in clarifying legal terms.
Contributors ER conceived the study, designed the interview guide, conducted data collection for the whole study, wrote the analysis plan, analysed the data and drafted and revised the paper. JM designed the interview guide, monitored data collection, participated in interpretation of the results and revised the paper. MT designed the interview guide, participated in interpretation of the results and revised the paper. RS designed the interview guide and revised the paper. CP performed data analysis and participated in interpretation of the results. EM conceived the study, designed the interview guide, wrote the analysis plan, monitored data collection, participated in interpretation of the results and revised the paper. ER is the guarantor.
Funding The Myrna Silverman Award and William Green Award from the University of Pittsburgh.
Competing interests None.
Ethics approval The University of Pittsburgh Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.