PUBLIC HEALTH
POLICY IN AMERICA
Our presidential election is only days away. Forty eight
million people in America are uninsured and healthcare costs are rising 2 to 3
times faster than our nation's GDP. Where will America's Healthcare System be
in 5 years? Welcome to ReachMD's monthly series, Focus on Public Health
Policy. This month we explored many questions facing healthcare today.
You are listening to Reach MD XM 157, The Channel for
Medical Professionals. For many years, the treatment of those infected with
sexually transmitted diseases, has included recommendations for including the
notification and treatment of partners. Lately, medical researchers and legal
minds are studying how patient's partners are assessed and treated by the
medical system. They are proposing more effective methods for disease
prevention and control. Welcome to the Clinician's Roundtable, I am Dr.
Kathleen Margolin and joining me from Baltimore, Maryland, is attorney James
Hodge and joining us from Seattle, Washington is Dr. Matthew Golden. Mr. Hodge
is with the Center for Law and Public's Health. Johns Hopkins Bloomberg School
of Public Health and Dr. Golden is an associate professor of medicine at the
University of Washington, School of Medicine. He is also Director of the STD
Control Program for public health in Seattle in King County's in Washington.
DR. MARGOLIN:
Welcome, James Hodge and Dr. Golden.
MR. HODGE AND DR. GOLDEN:
Thank you. Thanks a lot.
DR. MARGOLIN:
Before, we discuss partner and treatment issues, Dr. Golden,
could you please give us some current figures on the incidence of sexually
transmitted diseases in the US.
DR. GOLDEN:
Well, when you say incidence, I think what you say is we
have roughly, I think, it is 3 million cases of chlamydial infection annually
and roughly a million cases of gonorrhea reported in the US annually. So,
about 6% of women in Family Planning Clinics, in my part of the country, are
infected with chlamydial infection, probably a little bit higher nationally and
a substantially smaller proportion of women in Family Planning Clinics would be
infected with gonorrhea.
DR. MARGOLIN:
What is traditional partner management for sexually
transmitted diseases?
DR. GOLDEN:
For the most part, I think what clinicians have done for
gonorrhea and chlamydia, is tell the patient they need to get their partners
treated and that is about where it ends. For syphilis, quite a bit of more tests
have been done.
DR. MARGOLIN:
Can you tell us, what is expedited partner therapy for STDs?
DR. GOLDEN:
Expedite partner's therapy refers to the practice of
treating sex partners without requiring that they first seek a complete medical
evaluation or see a clinician and in most instances, that means giving
patient's medication or a prescription medication to give to their sex
partners.
DR. MARGOLIN:
Mr. Hodge, what are the main legal concerns regarding
expedited partner therapy?
MR. HODGE:
Well, anytime you are talking about the provision of medical
services or pharmaceutical products to some portions of the population, they
obviously raised legal issues, thereabout the way in which those specific
medicines are delivered. With EPT, what you have here is literally the
bypassing of a direct physician contact with a potential patient that being the
partner here, to deliver safe and effective antibiotics to their partner, but
when you bypass that traditional root of dispensing pharmaceutical medications
in the United States, you raise the potential issues of whether that goes
beyond existing medical practice and/or may be implicating that liability
concerns as well.
DR. MARGOLIN:
In the Centers for Disease Control, they evaluated numerous
studies of expedited partner therapy and concluded that is useful. Doctor, can
you tell us more about that research and how much more effective is expedited
partner therapy compared with traditional management?
MR. HODGE:
So, what was done and again here we are talking about
gonorrhea and chlamydia is treatments almost control trials have evaluated the
practice of giving people medications to give to their sex partners for the
most part. What we saw across the 3 trails was that all 3 observed decreases
in reinfection rates for people who are given medications versus those who did
not. That said, the decrease in chlamydia is relatively small. So, you are
talking about decline from about 13% or so to about 10% in that neighborhood.
For gonorrhea, the declines are pretty big, so about 10% to about 3% in terms
of reinfection rates. In terms of getting more partners treated, the impact
tends to be quite a bit bigger. So, probably in the 20-30% more partners
getting treated.
DR. MARGOLIN:
Mr. Hodge, as you mentioned, physicians generally do not
prescribe medicines to individuals without first examining them, but there are
exceptions to that where medications are given to the patient through someone
else and they are not legal complications. Tell us about some of these
situations.
MR. HODGE:
Sure, that is a great question because it is really kind of
highlights what we were trying to do in regards to assess the legal environment
for conducting the EPT nationally, but one of the things we had first noted is,
you know, despite that sort of the general recognition, the doctors are not
well positioned to dispense medications outside a direction physician-patient
relationship or clinical examination. The types of examples that are
prevailing out there in regards to how that happens nationally are really quite
well known. When you are dealing with patients, for example, of limited
debilities, persons with mental disabilities, persons with physical disabilities,
persons who are senior in status or age, it may very well be the case that the
doctors are well positioned to provide those medications to their caretakers
without directly having seen those patient those patients and that’s sometime
that is quite common in regards to how we may feel to expedite the provision of
care there. There are all sorts of ways in which specific types of medications
are dispensed regularly without advanced clinical examination. The flu vaccine
is just a common example of that. Yes, it does impose some risk for some
person, but yet we have routinely dispensed it to the millions of persons
without some sort of advanced clinical determination and even some prescription
medications can be purchased by the partners of persons who would mostly need
the drugs without those partners having any prove in regards to delivery of
those medications to the actual patient and by herself. These types of
examples have underlined a very common theme and that is to protect the
public's health. We do not want to insert various different legal mechanisms
that would actually hamper or in somehow limit the ability of those patients
who needs the medication most, actually getting access to them. This is
especially true or safe and effective medication like the types of antibiotics
that may be used in treating chlamydia or gonorrhea, as Dr. Golden notes them.
DR. MARGOLIN:
Mr. Hodge, as you have just mentioned, there are many
presidents of physicians being able to prescribe without direct contact with
the patients under certain circumstances and with regards to doing this for
STDs, you have pointed out that the prescriptions are safe. What is it about
expedited partner therapy that has some physicians concerns regarding
liability?
MR. HODGE:
That’s a great question because if these medications and
antibiotics that we traditionally used to treat these conditions, are so safe,
why will we, you know, in anyway should be concerned about dispensing to the
person that we haven’t seen. Well, doctors particularly know in regards to,
you know, what will be anticipated standards for practice are in their specific
jurisdiction, that no matter how safe a prescription medication may be, there
really are standardized rules to what they may be prescribed. An EPT does not
follow that standardized rule. It literally says you can double dose the
antibiotic for your patient and have that patient delivered to their partner,
you know, the equivalent dose, so that they can jointly treat the STD in this
particular case. That feels wrong, that seems wrongs and it's certainly not
something that we would utilize in other specific types of medications. It
might raise heightened risks. There are a couple of other issues with it as
well. Notably are there in some states, very specific mandates against this
specific practice, something we have study very systematically as it belongs to
the public health, but other medical practitioners along the way may also had
impediments to implementing EPT; for example, pharmacist. They may be under
very strict constraints to not issue or to provide drugs to person, who do not
have an identified prescription for that drug. So, it may be very hard for the
partner to go in and receive a prescription or have the prescription filled by
a pharmacist, who is aware and knows that that partner has not actually
undergone clinical evaluation to verify that they are legitimate user of that
particular drug. These types of impediments coupled with the sheer nature of
doctors concerns about potentially liability of the partner somehow having an
adverse reaction to the antibiotics or other types of conditions related to
that, is what sometimes drives a concern about whether EPT is legal or illegal
in this specific jurisdiction.
DR. MARGOLIN:
Can you clarify a bit more about the involvement of
pharmacist? If the patient presents to a pharmacist with a prescription and
its signed by the physician, where is the dilemma for the pharmacist?
MR. HODGE:
Like you know, EPT is practiced differently in various
jurisdiction and Dr. Golden, he is well positioned, I can assure you, to tell
us how its done at Washington State and other jurisdictions as well, but you
know none other ways, it may be done is to hold. It may be that the patient
who has actually seen the doctor, receives a single prescription and just as
you need 2 times the dosage of the antibiotic because we have instructed you to
provide the second dose to your partner. You know, but he might also say we
are going to give you 2 prescriptions, 1 for you and 1 for your partner and
then the partner has to literally be named in that specific second prescription,
the partner has to come in often and actually fill the prescription. Its one
step removed from what we would probably desire to expedite the receipt of the
drugs here, but in the same case, it may be required by state law. When you
have that circumstance then fill for it. The pharmacist may get a sense that
one party along this exchange has not been adequately evaluated. When a
pharmacist these are double dosage of this specific antibiotic, I may not be
there to question whether the doctor was right or wrong to issue it, but they
are there to try to protect the patient's interest, so they may raise various
concerns as well. This might particularly be true in some smaller locales, not
necessarily large urban there is, but smaller locales where pharmacist and
patient can have a more direct work knowledge of each other and their health
status. Its an impediment to disagree to which it prohibits or limits the
ability of the pharmacist to accurately fill that prescription.
DR. MARGOLIN:
I see, Dr. Golden, in your research, you looked at
traditional partner management and Metropolitan Health Department and found
some interesting numbers when it came to notifying partners of those with STD.
DR. GOLDEN:
Well, I mean, I think there are couple of issues that you
are alluding to. One is that health department mostly don’t provide per our
services for people with gonorrhea and chlamydia and I think that’s an
important thing for the physicians and other providers to realize that overall
fewer than 20% people with gonorrhea and chlamydia are ever going to have
contacts with the health department about their partners. So, basically the
health department in the US are leaving this up to the doctors and the doctors
have been leaving it up to the patients. When we looked at this in a study
where we contacted 150 providers in Seattle, who had recently diagnosed a case
of chlamydia infection. Only 17% of the providers had any idea of whether or
not their patient's partner had been treated. So, really, I think what ended
up happening was the health department left up to the providers and the
providers have left it up to the patients and then there is no followup. So,
its in that context, that I think one has to consider expedited partner
therapy, that we don’t really have a system beyond simply telling the people
you need to get your partner treated to assure that happens.
DR. MARGOLIN:
If you could put into place the expedited partner therapy,
what would you anticipate would be some of the clinical factors or barriers?
DR. GOLDEN:
We have put it into place, so where I live in Seattle, we
are actually doing this state wise in the state of Washington. The health
department is providing the medications for the partner for free for the entire
state. We provided those medications prepackaged with information from the sex
partner and some condoms to meet the state pharmacy board requirements and to
meet the various requirements related to the law. So, where I live and James
who is alluding to this, it is not legal to simple write for 2 doses with the
index patient for the person you originally diagnosed. Every person who is
supposed to receive antimicrobial needs a prescription written for them. It is
permissible for somebody to pick up medications for their sex partner as long
as the medications are provided with information including a drug allergy warning
and so we have sort of arranged for all that information to be prepackaged.
DR. MARGOLIN:
I would like to thank my guest, Dr. Mathew Golden and James
Hodge.
MR. HODGE AND DR. GOLDEN:
Thank you. Thanks.
DR. MARGOLIN:
I am Dr. Kathleen Margolin. You have been listening to a
special segment, Focus On Health Care Policy on ReachMD XM 157, The Channel for
Medical Professionals. Be sure to visit our web site at reachmd.com featuring
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