Trends in Clinic Visits and Diagnosed C. trachomatis and N. gonorrhoeae Infections

Following the Introduction of a Co-Pay in an STD Clinic

C. RietmeijerL. Lloyd

G. Alfonsi

Denver Public Health DepartmentDenver, Colorado

Presented at the 2004 National STD Prevention ConferenceMarch 8, 2004

Philadelphia, PA

Background

• Offering of clinical (diagnostic and treatment) services has historically been a key strategy for STD control and prevention

• To maximize the impact of this strategy, STD clinical services have traditionally been offered at no or low cost to the patient

Background - 2

• To offset decreases in public funding, fee for services, usually in the form of co-payments, may be initiated or increased

• However, little is known about the effects of such (co-)payments on access to and utilization of services and the ability of STD control programs to diagnose and treat STDs

Background - 3

• The Denver Metro Health Clinic (DMHC) is the largest STD clinic in the Rocky Mountain region

• Due to budget shortfalls, DMHC was forced to introduce co-payments to its clients in December, 2002

DMHC Co-Payment Structure

• $15– Residents of Denver, Adams, Arapahoe, or Douglas

County presenting with a new problem

• $65– Residents of other counties presenting with a new

problem

• None– Patients with a known positive test for STDs with

documentation of positive results– Contacts of patients with known STDs with

documentation of contacts status– Follow-up visits– HIV testing only ($10.00 optional)

DMHC Co-Pay Statistics2003

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1000

2000

3000

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6000

7000

8000

9000

No Pay

$15

$10

$65

LWBS

Objective

• To evaluate trends in patient visits and diagnosed CT and GC infections prior to and after the introduction of the co-pay at DMHC

Methods - 1

• Retrospective analysis of the computerized DMHC medical record database

• Comparing first three quarters of 2002 (prior to initiation of co-pay) to first three quarters of 2003 (after initiation of co-pay)

Methods - 2

• Analysis of data on GC and CT cases reported for the City and County of Denver to the Colorado Department of Public Health and Environment

• Comparison of DMHC-reported GC and CT cases in Denver with cases reported by other providers for the first 3 quarters of 2002 and 2003

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2000

JAN MAR MAY JUL SEP NOV JAN MAR MAY JUL SEP

# VISITS

2002 2003

Start Co-Pay

Denver Metro Health Clinic Visits2002 -2003

Clinic Visits DMHC 2002– 2003 by Quarter

0

500

1000

1500

2000

2500

3000

3500

4000

1st Qtr 2nd Qtr 3rd Qtr

2002

2003

Total visits 2002 through third quarter: 11,382Total visits 2003 through third quarter: 8,132Difference through third quarter: 3,250 = 28.5%

Clinic VisitsDMHC 2002 - 2003

Percent Decline by Gender

0

5

10

15

20

25

30

35

Visits Decline %

Male

Female

%

Percent decline women: 34.0Percent decline men: 25.1

Clinic VisitsDMHC 2002 - 2003

Percent Decline by Age

0

5

10

15

20

25

30

35

40

45

50

Visits Decline %

<20

20 - 29

30 - 39

40 - 49

50+

%

Percent decline age <20: 46.3%

Chlamydia Cases DMHC 2002– 2003 by Quarter

0

100

200

300

400

500

600

1st Qtr 2nd Qtr 3rd Qtr

2002

2003

Total cases 2002 through third quarter: 1519Total cases 2003 through third quarter: 1092Difference through third quarter: 427 cases = 28.1%

Gonorrhea Cases DMHC 2002 – 2003 by Quarter

0

50

100

150

200

250

300

350

1st Qtr 2nd Qtr 3rd Qtr

2002

2003

Total cases 2002 through third quarter: 871Total cases 2003 through third quarter: 539Difference through third quarter: 332 cases = 38.1%

Chlamydia and GonorrheaDMHC 2002 - 2003

Percent Decline by Gender

0

5

10

15

20

25

30

35

40

CT GC

Male

Female

%

Chlamydia and GonorrheaDMHC 2002 – 2003

Percent Decline by Race/Ethnicity

0

5

10

15

20

25

30

35

40

45

50

CT GC

White

Black

Hispanic

Other

%

Chlamydia and GonorrheaDMHC 2002 – 2003

Percent Decline by Age Group

0

5

10

15

20

25

30

35

40

45

50

CT GC

< 20

20 - 29

30 - 39

40 - 49

50+

%

• Among those < 25 years:–Total visits were down by 38%

–CT cases were down by 38.2%

–GC cases were down by 33.8%

• This age group accounted for:–85.6% of fewer diagnosed CT infections

–39.6% of fewer diagnosed GC infections

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400

600

800

1000

1200

Visits GC+ Syphilis HIV

2002

2003

Visits and GC Infections Among MSMDMHC 2002 – 2003

Total visits by MSM declined by 229 (21.1%)GC cases among MSM declined by 82 (40.2%)

Chlamydia PrevalenceDMHC 2002 - 2003

By Age

0

5

10

15

20

25

<20 20 - 29 30 - 39 40 - 49 50+

2002

2003

Through third quarter

%

Gonorrhea PrevalenceDMHC 2002 - 2003

By Age

0

5

10

15

20

25

<20 20 - 29 30 - 39 40 - 49 50+

2002

2003

Through third quarter

%

Chlamydia Reports By ProviderDenver City and County: 2002-2003

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500

1000

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2500

DMHC Other Providers

2002

2003

DMHC: -298 (29.9%)Other Providers: -282 (12.0%)DMHC/Other Providers Ratio: 0.42 (2002); 0.33 (2003)

Gonorrhea Reports By ProviderDenver City and County: 2002-2003

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100

200

300

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500

600

700

DMHC Other Providers

2002

2003

DMHC: -252 (40.2%)Other Providers: -55 (8.2%)DMHC/Other Providers Ratio: 0.94 (2002); 0.61(2003)

Conclusions

• Findings strongly suggest a causal relationship between institution of the co-pay and declining service utilization

• Persons at risk for gonorrhea, women, and persons younger than 25 years appear to be disproportionally impacted by financial barriers

Limitations

• Simple before-after analysis: cannot prove causal relationship

• Patients may have accessed services outside of DMHC

Implications for Program

• Even the institution of a modest co-pay ($15) may result in significant declines in STD clinic service utilization and diagnosed STDs