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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)
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
0
200
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600
800
1000
1200
1400
1600
1800
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
0
200
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
0
500
1000
1500
2000
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
0
100
200
300
400
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