Editorials - October 1, 1999 - American Academy of Family Physicians

Editorials

Thinking About Sexually Transmitted Diseases

GEORGE SCHMID, M.D., M.Sc.
Centers for Disease Control and Prevention
Atlanta, Georgia

In this issue of American Family Physician, the treatment of sexually transmitted diseases (STDs) is concisely reviewed by Woodward and Fisher,¹ who used for reference the "1998 Guidelines for Treatment of Sexually Transmitted Diseases," published in January 1998 by the Centers for Disease Control and Prevention.² The advice of both the review and the guidelines remain sound, and it will be another year before an update of the 1998 guidelines is published. Current therapies for STDs are good; what else about STDs might we consider?

See article in this issue.

It is useful to think about the relationships of reproductive tract infections (RTIs), STDs and sexually transmitted infections (STIs). All infections that occur in the genital tract are RTIs, but not all of them are sexually transmitted (see the accompanying figure). "Infection" means the presence of a microorganism in the body, while "disease" means the presence of an adverse bodily state. Although not all infections result in disease, STIs need to be identified and treated (either by medicine or counseling), because they are capable of ultimately causing disease, either in the person infected or in someone who might be infected by that person.

And, we increasingly realize that the majority of STIs (certainly in women and probably in men) are not accompanied by symptoms or signs. Thus, although persons who acquire an STI are generally prone to accuse their sex partner of knowingly "giving them something," the transmitting partner is often "innocent," because the infection was asymptomatic. To reach these asymptomatically infected persons, we have the following two choices: screening and partner notification.

The distinction between RTIs and STIs has important patient care implications. The term STI (my preference, over STD, and one increasingly being adopted) often has a profound social impact on patients. We can use the term, but we should be careful when we do. For example, candidiasis or bacterial vaginosis, or some cases of pelvic inflammatory disease (those caused, for instance, by the organisms characteristic of bacterial vaginosis), are RTIs but not STIs. Similarly, syndromes for which we have not tested patients for an etiology (for instance, a vaginal discharge) should be cautiously approached when counseling patients.

We should use diagnostic tests whenever possible. Some authorities believe that the use of syndromic management (e.g., not testing a man with urethritis for the causes of urethritis but, rather, simply treating with antimicrobials active against the major causes of urethritis) is acceptable in this country. I strongly disagree. By determining the etiology of a reproductive tract syndrome, we can (1) choose the most appropriate therapy, (2) avoid the use of "polypharmacy" and, thus, avoid excess cost and development of antimicrobial resistance, (3) give appropriate counseling, (4) better manage the patient if prescribed therapy fails and (5) determine the need for appropriate partner notification.

FIGURE 1. The relationship of reproductive tract infections (RTIs), sexually transmitted diseases (STDs) and sexually transmitted infections (STIs), with the size of circles representing the approximate number of each.

No diagnostic test has ideal performance characteristics (i.e., 100 percent sensitivity and specificity). While clinicians understand this, the social implications of STIs again argue for particular caution in the clinician's use of test results for counseling purposes. This is of particular concern in screening when we test patients who do not have symptoms or signs--for instance, testing young persons for chlamydial infection, pregnant women for many STIs, or even using the Papanicolaou smear to screen for infection (in cases in which the presence of an STI, such as Trichomonas vaginalis, might be detected). The lack of 100 percent specificity is particularly an issue because there will always be false-positive tests (and, thus, the concept of predictive values is vital to understand).

The proportion of all positive tests that are false-positive may be quite large if one is testing patient populations with a relatively low prevalence of infection. For example, if one is using a chlamydia test that has a 99 percent specificity (a specificity representative of nonamplification tests) to screen a population with a prevalence of infection of 2 percent (which might be representative of a population of married women), then only two thirds of all positive tests are truly positive. To tell all women with a positive test in this population that they have a chlamydial infection when, in fact, only 67 percent do, is wrong. When appropriate, we should make additional attempts to ensure the diagnosis is accurate--that is, ask the laboratory for the strength of signal (how strongly positive was the test?) or perform additional tests.

Given numerous test options, it is difficult for the clinician to know which test is the right one to use. In fact, there is no universal right test. Ideally, tests would be technically easy, would be inexpensive, would have perfect performance characteristics and would be able to be performed immediately on specimens collected with a minimum of invasiveness, but no test embodies all of these characteristics. Instead, the clinician should consider his or her needs and know the advantages and disadvantages of the test that is chosen, including the performance characteristics. Any test is only as good as the specimen that is tested; the technically best test will perform badly if specimens are poorly collected and handled.

The management of STIs includes not only choosing an antimicrobial agent but also appropriate counseling and partner notification. Many patient's lives have been dramatically altered by misinformation or good information misinterpreted (e.g., women with genital herpes who believe they can never have children, or men and women who believe that a diagnosis of human papillomavirus means never being able to have sex again). The guidelines offer valuable advice in a variety of patient management areas and should be on the desk of every family physician.²Copies of the guidelines may be obtained on the CDC's Web site at http://www.cdc.gov, select CDC Prevention Guidelines; by calling 888-232-3228; or by writing the Office of Communications, CDC, 1600 Clifton Rd., Mailstop EO6, Atlanta, GA 30333.

Dr. Schmid is Assistant Branch Chief for Science of the Program Development and Support Branch, Division of STD Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Ga.

Address correspondence to George Schmid, M.D., M.Sc., Centers for Disease Control and Prevention, Division of STD Prevention, Mail Stop E-27, 1600 Clifton Rd., N.E., Atlanta, GA 30333.

REFERENCES

Woodward C, Fisher MA. Drug treatment of common STDs: Part 1. Am Fam Physician 1999;60: 1387-94.

Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47(RR-1):1-116.

Care in the Home

GEORGE TALER, M.D.
Hospital Center
Washington, D.C.

Home care has enjoyed a resurgence over the past 10 years. The growth in home care has been fueled by several factors: the growth of managed care and Medicare's Prospective Payment System, which have reduced the length of hospital stays; liberalization of Medicare coverage policies for community-based care; increasing patient preferences to avoid nursing home placement; and demographic shifts resulting in a burgeoning population of patients with chronic illnesses and disabilities. Although home care remains a relatively small part of total health care expenditures, it has been the fastest growing sector of health care throughout the 1990s.

Change brings with it both good and bad. Let us look at the down side first.

See article in this issue.

The failure of the Health Care Finance Administration (HCFA) to anticipate these expenditures contributed substantially to the recent cost overruns for Medicare. Much of the blame can be attributed to a critical gap in the range of services provided in this setting. Despite being legally accountable for ordering and monitoring the services and equipment used in the home, the vast majority of physicians have little experience or interest in home care and have little knowledge of the regulations governing eligibility, indications for continued services or the effectiveness of the medical care plan. The consequence has been a government perception of insufficient supervision and unbridled excess, if not flagrant fraud and abuse.

The federal response to these developments has been jolting. The Balanced Budget Amendment of 1997 authorized HCFA to extend prospective payment to home care agencies and curtailed reimbursement for a wide range of equipment, supplies and therapeutic interventions. According to the National Association for Home Care, approximately 2,000 home care agencies have either disappeared through mergers or closed their doors since July 1998 when prospective payment was implemented. Similar to hospitals' length-of-stay, the average number of visits per episode of care has plummeted among home care providers. In addition, the Office of the Inspector General recently released a fraud alert for physicians that stipulates the conditions under which services in the home can be initiated, delineates responsibilities for documentation and assigns substantial fines for noncompliance with federal regulations.

These are the early "growing pains" of a blossoming health care delivery system--not unlike that of the nursing home industry nearly 30 years ago, but the potential for expansion is far greater. According to the 1992 National Home and Hospice Care Survey conducted by the National Center for Health Statistics, for every one resident in a nursing facility, up to three to four patients of equal debility reside in the community with the assistance of family, friends and the intermittent services of home health care agencies.

Advances in technology and smaller equipment allows diagnostic capabilities equivalent to those available in the office and therapeutic interventions similar to those available on a hospital ward. Life-support technologies, such as ventilators, intravenous infusion devices, dialysis and enteral feedings pumps are no longer rarely encountered on a house call.

Disease management programs have extended the use of acute care protocols into the home, including the use of investigational drugs. Reimbursement for house calls by physicians has increased, and these billing codes are now applicable to home visits by nurse practitioners and physician assistants. Telemedicine is an emerging technology that facilitates frequent monitoring of patients with especially unstable conditions. Therefore, it is conceivable that within the near future, primary care physicians will spend as much as one half of their time overseeing the care of chronically ill and severely disabled patients in their homes--as is the current practice of medicine throughout the rest of the Western world.

In light of these changes, the specialty of family medicine can no longer ignore the education of physicians in the important differences and challenges of providing care in the patient's home. To assume that clinic-based experience is adequate training for home care is as fallacious as was the conceit that hospital care prepares one for the ambulatory setting. More recently, several focused efforts are emerging, slowly and tenuously.

The Hartford Foundation has funded the development of undergraduate curricula on home care in 10 medical schools, but the good news is that 70 of the nation's 123 medical schools submitted applications. Although most of the primary care specialties have defined curricular guidelines for residency training, no practical means exists for recouping the clinical charges for the services provided. Unfortunately, there has been little support for continuing medical education for practicing physicians.

In this issue of American Family Physician, Unwin and Jerant¹ offer a framework for approaching the comprehensive assessment of patients and their supportive environment. The article is a welcome addition to the article by Montauk in a previous issue.² I am heartened to see greater attention paid to this aspect of medicine. Perhaps, in time, we can all look forward to the return of house calls to the mainstream of medicine. After all, it is what I would want for myself and my family.

Dr. Taler is president of the American Academy of Home Care Physicians. He is director of long-term care at Washington Hospital Center, Washington, D.C. Address correspondence to George Taler, M.D., Washington Hospital Center, 110 Irving St., N.W., Washington D.C. 20010.

REFERENCES

Unwin BK, Jerant AF. The home visit. Am Fam Physician 1999;60:1481-8.

Montauk SL. Home health care. Am Fam Physician 1998;58:1608-14.

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