Perspectives on Expedited Partner Therapy for Chlamydia
Perspectives on Expedited Partner Therapy for Chlamydia
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).
Findings are organised around perspectives on EPT; knowledge and practices; perceived benefits of EPT; harms and legal barriers; and facilitators for EPT use.
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).
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)
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)
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)
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.
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.
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).
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.
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