Expedited Partner Therapy: Pharmacist Refusal of Legal Prescriptions

Reducing Barriers for Expedited Partner Treatment in Adolescents and Young Adults: A Quality Improvement Initiative

BACKGROUND

Adolescents and young adults (AYAs) face significant barriers to screening, testing, and treatment of sexually transmitted infections (STIs). Expedited partner therapy (EPT) streamlines partner treatment of STIs, but use among adolescents is low. We aimed to increase EPT offering and provision at 2 adolescent medicine clinics (AMCs) and the emergency department (ED) in an urban children's hospital. We addressed barriers at provider, pharmacy, and patient levels. We compared EPT offering and provision for chlamydia ( Chlamydia trachomatis [CT]) and trichomonas ( Trichomonas vaginalis [TV]) infection at baseline and across 2 intervention cycles.

METHODS

Baseline data were collected from July 2019 to March 2020 and our intervention time frame spanned from April 2020 to October 2021. Laboratory codes identified patients with CT or TV infections. Cycle 1 allowed providers to order EPT within a patient's chart. The second cycle targeted education and standardization for STI/EPT notification and counseling. During this cycle, notification of ED patients was centralized to the AMC nurses.

RESULTS

A total of 747 CT and TV cases were identified. In the AMC, EPT offering increased from 77.3% to 87.7% ( P = 0.01). Expedited partner therapy provision increased from 32.3% to 69.9% ( P < 0.001). Expedited partner therapy offering for ED patients increased by 82.3%. Retesting rates remained consistent, with a significant drop in reinfection rates ( P = 0.003) within patients seen in the AMC.

CONCLUSIONS

This quality improvement initiative successfully increased EPT offering and provision among the cases identified. Future cycles may include longer-term follow-up to confirm partner treatment and testing per guidelines.

Expanding expedited partner therapy and HIV prophylaxis in the emergency department

PURPOSE

Sexually transmitted infections (STIs) continue to have a disproportionate impact on individuals belonging to sexual, gender, and racial minorities. Across the nation, many emergency medicine pharmacists (EMPs) possess the skills and knowledge to expand the provision of expedited partner therapy (EPT) for STIs and provide HIV prophylaxis within existing practice frameworks. This report serves as a call to action for expanded provision of EPT and HIV prophylaxis by EMPs and highlights current barriers and solutions to increase pharmacist involvement in these practice areas.

SUMMARY

Emergency medicine pharmacy practice continues to expand to allow for limited prescribing authority through collaborative practice agreements (CPAs). In recent years, CPA restrictions have been changed to facilitate treatment of more patients with less bureaucracy. This report addresses the unique challenges and opportunities for expanding EPT and HIV pre- and postexposure prophylaxis provision by pharmacists in emergency departments (EDs). Furthermore, current strategies and treatments for EPT, such as patient-delivered partner therapy and HIV prophylaxis, are discussed. Pharmacist involvement in STI treatment and HIV prevention is a key strategy to increase access to high-risk populations with high ED utilization and help close current gaps in care.

CONCLUSION

Expanding EMP provision of EPT and HIV prophylaxis may be beneficial to reducing the incidence of STIs and HIV infection in the community. CPAs offer a feasible solution to increase pharmacist involvement in the provision of these treatments. Legislative efforts to expand pharmacist scope of practice can also contribute to increasing access to EPT and HIV prophylaxis. With these efforts, EMPs can play an essential role in the fight against STIs and HIV.

Approach to Managing Sex Partners of People with Sexually Transmitted Infections

Partner management of sexually transmitted infection (STIs) is essential to identify and treat new cases, prevent reinfection in the index case, interrupt chains of transmission, reduce STI-related morbidity, and target STI screening and treatment interventions. The responsibility for partner notification and treatment falls on the health care provider. Approaches to partner management include patient referral, provider referral, contractual referral, and expedited partner therapy (EPT), with EPT and enhanced partner referral outperforming other methods. This article provides an overview of clinical recommendations regarding partner management, with particular emphasis on EPT, and an update on new and emerging evidence in the field.

Impact of an Electronic Medical Record Best Practice Alert on Expedited Partner Therapy for Chlamydia Infection and Reinfection

Background

Atrius Health implemented a best practice alert (BPA) to encourage clinicians to provide expedited partner therapy (EPT) in October 2014. We assessed (1) the impact of the BPA on EPT provision and chlamydial reinfection and (2) the impact of EPT on testing for chlamydia reinfection and reinfection rates.

Methods

We included patients ≥15 years with ≥1 positive chlamydia test between January 2013 and March 2019. Tests-of-reinfection were defined as chlamydia tests 28–120 days after initial infection, and corresponding positive results were considered evidence of reinfection. We used interrupted time series analyses to identify changes in (1) frequency of EPT, (2) tests-of-reinfection, and (3) reinfections after the BPA was released. Log-binomial regression models, with generalized estimating equation methods, assessed associations between (1) EPT and tests-of-reinfection and (2) EPT and reinfection.

Results

Among 7267 chlamydia infections, EPT was given to 1475 (20%) patients. Expedited partner therapy frequency increased from 15% to 22% of infections between January 2013 and September 2014 (β = 0.003, P = .03). After the BPA was released, EPT frequency declined to 19% of infections by March 2019 (β = −0.004, P = .008). On average, 35% of chlamydia infections received a test-of-reinfection and 7% were reinfected; there were no significant changes in these percentages after BPA implementation. Patients given EPT were more likely to receive tests-of-reinfection (prevalence ratio [PR] 1.09; 95% confidence interval [CI], 1.01–1.16) but without change in reinfections (PR 0.88; 95% CI, 0.66–1.17).

Conclusions

Best practice alerts in electronic medical record systems may not be effective at increasing EPT prescribing and decreasing chlamydial reinfection. However, patients given EPT were more likely to receive a test of chlamydia reinfection.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Do Prescriptions for Expedited Partner Therapy for Chlamydia Get Filled? Findings From a Multi-Jurisdictional Evaluation, United States, 2017-2019

BACKGROUND

Expedited partner therapy (EPT) is commonly provided by prescription; however, the efficacy of this modality is unknown. We examined whether EPT prescriptions are filled when the cost barrier is removed.

METHODS

To track EPT prescription fill rates, we used single-use pharmacy vouchers that covered the cost of azithromycin, 1 g (chlamydia treatment). We recruited clinical sites to distribute vouchers to patients with chlamydia who would receive an EPT prescription under clinic policies. When distributing vouchers, sites recorded and retained: voucher unique identifier, sex and age of index patient, distribution date, and whether partner name was written on the EPT prescription. Pharmacists receiving vouchers entered the identifier, sex and age of presenting person, and redemption date into a standard pharmacy claim transmission system. Data for redeemed vouchers were retrieved from an industry portal and linked with data retained at clinical sites.

RESULTS

Thirty-two clinical sites distributed 931 vouchers during September 2017 to January 2019; 382 (41%) were redeemed. Vouchers distributed to patients 18 years or younger (49 [30%] of 163) were less likely to be redeemed compared with those distributed to patients older than 18 years (322 [44%] of 736; P = 0.001). Just over half of vouchers were redeemed the same day (196 [56%] of 352) and 1 mile or less from the clinical site (188 [54%] of 349). After excluding an outlier site, vouchers accompanied by EPT prescriptions including a partner name (15 [56%] of 27) were more likely to be redeemed than those lacking a name (83 [34%] of 244; P = 0.03).

CONCLUSIONS

Less than half of EPT prescriptions were filled, even when medication was free. Whenever possible, EPT should be provided as drug-in-hand.

Guidance on Expedited Partner Therapy: A Content Analysis of Informational Materials for Providers, Pharmacists, Patients, and Partners

BACKGROUND

The rates of sexually transmitted infections have steadily increased in the United States over the last 5 years. The Centers for Disease Control and Prevention has endorsed the use of expedited partner therapy (EPT) as an evidence-based practice to prevent chlamydial reinfection in index patients and lower barriers to treatment for partners. State health departments release guidance on EPT for providers, but it is unclear if information is available for other key stakeholders, for example, pharmacists, patients, and partners. The primary objective of this study was to conduct a review of state and territory health department websites to ascertain the availability, readability, utility, and content of EPT informational materials.

METHODS

A content analysis of 84 EPT informational materials was conducted using validated tools to measure readability, adherence to design standards, and EPT content inclusion. Results were stratified for each target audience.

RESULTS

Only 64% of states where EPT is allowable had informational materials available. The materials targeted providers (51.2%) and partners (35.7%). Little information targeted pharmacists (7.1%) or index patients (4.8%). The average reading level was 11th grade. Mean design score was 9.57 points of a possible 13 points. Most provider and pharmacist materials did not meet the content criteria; index and partner materials did not thoroughly describe cost of EPT, how to communicate with sex partners about EPT/chlamydia, or how to fill an EPT prescription.

CONCLUSIONS

To better support the uptake of EPT, existing resources for EPT should be improved in their design, readability, content, and availability for all target audiences.

Breakdown in the expedited partner therapy treatment cascade: from reproductive healthcare provider to the pharmacist

BACKGROUND

The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists.

OBJECTIVE

The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment.

STUDY DESIGN

A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata.

RESULTS

We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively.

CONCLUSION

Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.

Partner Notification, Treatment, and Subsequent Condom Use After Pelvic Inflammatory Disease: Implications for Dyadic Intervention With Urban Youth

Research suggests that youth in urban communities often remain in the same sexual relationships after a pelvic inflammatory disease (PID) diagnosis. Utilizing data from the Technology Enhanced Community Health Nursing (TECH-N) study, we explored partner notification, treatment, and condom use after PID diagnosis. Outreach interviews assessed adherence to self-care behaviors, followed by interviews 3 months after diagnosis. Descriptive statistics and multivariable logistic regressions evaluated baseline condom use versus 3 months after diagnosis as it relates to group and relationship status. Ninety-one percent reported partner notification, and of those notified, 90% reported partner treatment. Reports of condom use increased in both groups compared with baseline use. TECH-N participants were more likely to report condom use at last sex at 3 months compared with baseline. Given the open communication with partners about PID and partner-associated effects on condom use, exploring dyadic intervention to promote consistent, condom use after PID for youth in high STI (sexually transmitted infection) prevalence communities is required.

Patient initiated partner treatment for Chlamydia trachomatis infection in the Netherlands: views of patients with and partners notified for Chlamydia

Patient-initiated partner therapy (PIPT) for Chlamydia is not practiced in the Netherlands. We aimed to explore PIPT-willingness in patients infected with Chlamydia and persons notified for Chlamydia (partners) at sexual health clinics (SHCs) and general practitioners’ offices. We performed interviews among 20 heterosexual patients and 21 partners regarding real or hypothetical situations. The interviews were taped, transcribed verbatim and coded using ATLAS.ti7 software for qualitative research. Despite challenges in notifying partners in some cultural groups and some partner types, most patients and partners would cooperate with PIPT. Perceived barriers included unnecessary treatment, risking untreated other sexually transmitted infections and breaking the notification chain. Most patients and partners opted for home-based test-kits before treatment. Partners desired proper packaging of the test and the medication, along with an information insert, a supportive letter from the SHC, information on the internet and the possibility to contact a professional. Although PIPT may support partner notification (PN), many patients and partners prefer a diagnosis before treatment. PIPT with medication or a prescription combined with a home-based test-kit may be the way forward. However, PN seems to be influenced by type of partner and cultural background, requiring differentiated PN and partner therapy methods.