Bioethics Discussion Blog: AMA Report (6) Expedited Partner Therapy

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Saturday, May 17, 2008

AMA Report (6) Expedited Partner Therapy

What the heck is “expedited partner therapy”?

Do you have any idea what “expedited partner therapy” is all about? It sounds like a kind of cut and dried, straightforward administrative action. But it isn’t!! It is all about the treatment and prevention of sexually transmitted diseases through the use of identified patients with the disease to personally go to their single or various partners and presumably inform them about the patient’s diagnosed condition, to educate them about the necessity to be seen in a medical clinic for medical evaluation and treatment as necessary. However, if the partners are unwilling to go, the patient is to educate them about the nature of the disease, the treatment and the risks involved in taking the treatment. Then, the patient will have been provided with the medication to give to the partner to take. Under this “expedited” medical care, partners of the infected patient will be treated, completely without a professional medical diagnosis based on history, physical and laboratory tests, without direct education by the physician and provided with a medication, as either as prophylaxis or treatment, without a diagnosis and without any formal professional supervision. I have included the conclusion and recommendations of the report below but I would suggest that the visitor go to the link below and read the entire report including further description of the “expedited partner therapy”, the history and rationale and the ethical and legal issues involved.

The subject Report 6 Expedited Partner Therapy is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

CONCLUSION

Expedited partner therapy has been demonstrated to be a clinically effective strategy for the treatment and limitation of spread of a limited number of sexually transmitted infections. As such, physicians should recognize the practice as a valid tool for promoting public health when appropriately indicated. However, EPT in the absence of a traditional patient-physician relationship creates distinct ethical concerns pertaining to informed consent, confidentiality, and patient safety. Physicians should therefore emphasize to patients that medical care within a patient-physician relationship is preferred. Only in circumstances when this is impossible or unlikely should EPT be considered. While it may be ethical to use EPT to minimize the negative health consequences of sexually-transmitted diseases, physicians should make reasonable efforts to refer the partners of their patients to appropriate health care professionals.

RECOMMENDATION

The Council on Ethical and Judicial Affairs recommends that the following be adopted and the remainder of the report be filed:

Expedited Partner Therapy (EPT) is the practice of treating the sex partners of patients with sexually transmitted diseases via patient-delivered partner therapy without the partner receiving a medical evaluation or professional prevention counseling. While this practice is presently recommended by the Centers for Disease Control and Prevention for use in very limited circumstances (for gonorrhea or chlamydial infection in heterosexual men and women), EPT may be recommended for additional applications in the future.

Although EPT has been demonstrated to be effective at reducing the burden of certain diseases, it also has ethical implications. EPT potentially abrogates the standard informed consent process, compromises continuity of care for patients’ partners, encroaches upon the privacy of patients and their partners, increases the possibility of harm by a medical or allergic reaction, leaves other diseases or complications undiagnosed, and may violate state practice laws. The following guidelines are offered for use in establishing whether EPT is appropriate:

(1) Physicians should determine the need for EPT by engaging in open discussions with patients to ascertain their partners’ abilities to access medical services. Only if the physician reasonably believes that a patient’s partner(s) will be unwilling or unable to seek treatment within the context of a traditional patient-physician relationship should the use of EPT be considered.

(2) Prior to initiating EPT, physicians are advised to seek the guidance of public health officials, as well as determine the legal status of EPT in their state.

(3) If the physician chooses to initiate EPT, he or she must provide patients with appropriate instructions regarding EPT and its accompanying medications and answers to any questions that they may have.

(4) Physicians must provide patients with educational material to share with their partners that encourages the partners to consult a physician as a preferred alternative to EPT, and that discloses the risk of potential adverse drug reactions and the possibility of dangerous interactions between the patient-delivered therapy and other medications that the partner may be taking. The partner should also be informed that he or she may be affected by other STDs that may be left untreated by the delivered medicine.

(5) The treating physician should also make reasonable efforts to refer a patient’s partner(s) to appropriate health care professionals.


What do you think about expedited partner therapy and especially if it is approved for application beyond the current limited diagnoses of gonorrhea or chlamydial infection in heterosexual men and women? Write us about your opinion on this interesting twist of medical care and prevention. ..Maurice.

7 Comments:

At Monday, July 07, 2008 12:42:00 PM, Blogger Maurice Bernstein, M.D. said...

I was recently made aware of an article about state legislation written in New York that may allow such patient directed partner therapy. The article points out the issues of patient privacy and who is legally responsible for complications amongst other issues which can arise from this legislation. You can read the article by going to this New York state newspaper
link
.

Here is a summary of the Bill which as of June 24 2008 passed both houses but may not as yet been signed into law by New York Governor David Patterson. ..Maurice.

BILL NUMBER:A8730C

TITLE OF BILL: An act to amend the public health law, in relation to
expedited partner therapy for persons infected with chlamydia trachoma-
tis; and providing for the repeal of such provisions upon expiration
thereof

PURPOSE OR GENERAL IDEA OF BILL: To allow for expedited treatment for
Chlamydia for the sexual partner or partners of someone having been
diagnosed with the disease.

SUMMARY OF SPECIFIC PROVISIONS: Section one, paragraph one allows a
health care practitioner who diagnoses chlamydia in an individual to
prescribe or dispense antibiotics to that person`s sexual partner or
partners without examining the patient`s partner or partners.

Paragraph two protects health care practitioners who conduct expedited
partner therapy in good faith and in accordance with this legislation
from civil or criminal liability.

Paragraph three requires the Commissioner of Health to promulgate regu-
lations and develop forms for patients and their partners explaining
expedited partner therapy for Chlamydia.

Section two includes a sunset clause where the provisions of this bill
will be repealed on January 1st, 2014.

JUSTIFICATION: Chlamydia is the most commonly reported bacterial
infection in New York City, as well as some other areas of the state.
Chlamydia increases the risk of HI V acquisition and transmission. If
Chlamydia is left untreated in women, it can have serious health conse-
quences, like pelvic inflammatory disease, ectopic pregnancy, and infer-
tility. Currently, the most common approaches to sex partner treatment
of Chlamydia are having the infected patient notify his or her partners
of exposure to the disease, and having the infected patient provide a
list of his or her partners to the health care provider.

However, often the patient`s partners, who may likely be infected, do
not come in for treatment. This endangers their health means they may
infect others.

Expedited treatment of the sexual partners of individuals diagnosed with
Chlamydia is a safe and effective way of controlling the spread of this
sexually-transmitted disease. Chlamydia can be effectively treated with
a single dose of oral antibiotics. The most common oral single dose
treatment for Chlamydia is Azithromycin; it has few side effects and is
widely used by health care providers to treat common infections such as
upper respiratory tract infections.

The CDC recently conducted two advisory consultations to review avail-
able data on the practice of expedited partner treatment for sexually
transmitted diseases. They concluded that expedited partner treatment is

a useful option to facilitate partner management of Chlamydia and
strongly urge individuals, organizations, and local public health offi-
cials to work to eliminate obstacles to using expedited partner treat-
ment.

Expedited partner treatment of sexually-transmitted disease is allowable
by law in California.

This proposal came from the New York City Department of Health and
Mental Hygiene.

PRIOR LEGISLATIVE HISTORY: A.11441-A of 2006, passed Assembly

FISCAL IMPLICATIONS: None

EFFECTIVE DATE: 120 days after it becomes law.

 
At Monday, July 07, 2008 1:08:00 PM, Anonymous Anonymous said...

Wow--it's so practical and common-sense! Doctors are going to hate it!

 
At Wednesday, January 28, 2009 8:15:00 PM, Anonymous Anonymous said...

I am a gynecologist. I was trained to provide EPT, and have been practicing this way (as have the majority of my colleagues) for a decade. I live in a state where it is considered legally permissible, but not expressly so.

 
At Wednesday, January 28, 2009 8:53:00 PM, Blogger Maurice Bernstein, M.D. said...

To the gynecologist from today: When you write that in your state EPT is "considered" legally permissible, "but not expressly so" is there state law which gives physicians legal protection for any unintended consequences of the practice of EPT? ..Maurice.

 
At Wednesday, August 26, 2009 8:45:00 PM, Anonymous Anonymous said...

Expedited Partner Therapy is nothing more than medical malpractice at its worst. It does more to hide the STD infection rates, than to treat the infections. One infected person can receive unlimited amounts of antibiotics to 'treat' unknown, unseen partners. That in itself should trigger an alarm bell in the CDC, but it does not. That one person may have dozens of sexual partners, who may also have multiple partners, is not of concern to the CDC, nor to other EPT-approving entities. EPT allows clinicians to dispense medications without knowing whether the intended recipients receive or take the medications. EPT allows 'success' to be counted even when successful treatment of unknown, unseen persons is uncertain.

EPT is not an innovative approach to STD treatment. It is laziness on the part of public health clinicians who no longer want to search for the source of the STD infections. EPT is their way out of searching and removing the source through proper treatment.
The data states that EPT can be (and is) successful at reducing STD infection rates, yet at the same time the same data decries the fact that STD rates continue to rise each year. If EPT is as successful as reports claim, STD rates would be declining. How can the data be saying that STD rates are rising, AND declining at the same time?

Expedited Partner Therapy should be determined to be the medical malpractice that it is.

EPT is going to lead to the development of another MRSA-type superbug. Indiscriminate abuse of antibiotics under the directives of EPT will render these antibiotics useless likely in five years or less.

Expedited Partner Therapy needs to be abolished, the data discredited, and allow medical treatment to return as it has been for many years--doctor sees patient, does medical exam, makes proper diagnosis, prescribes treatment.

 
At Wednesday, August 26, 2009 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

I am going to put this issue up on a bioethics listserv and see if I can get a handle on the ethics of this whole business. However one could look at it in this way: the duty for all physicians is to do the best in the way of diagnosis and therapy for ones own patient. If the doctor simply treats the patient for chlamydia and the patient again turns to sex with an established partner, surely if that partner is similarly infected this would just reinfect the doctor's patient. By managing the patient's condition utilizing EPT, wouldn't that be a act toward the best interest of the doctor's patient? One can look at EPT as an act of prophylaxis for the doctor's patient and an ethically beneficent act. ..Maurice.

 
At Thursday, August 27, 2009 9:59:00 PM, Blogger Maurice Bernstein, M.D. said...

I got one response from a physician ethicist who challenged the commentary by Anonymous from 8-26-09.
The challenge was more in the context of the how the visitor should deal with the data that Anonymous said should be "discredited". The ethicist wrote:

Dear person,

In the recent words of Barney Frank, "What planet do you spend most of your time on?"
My favorite piece of your letter is


"Expedited Partner Therapy needs to be abolished, the data discredited, and allow medical treatment to return as it has been for many years--doctor sees patient, does medical exam, makes proper diagnosis, prescribes treatment."


Data is data. One does not discredit it; perhaps one finds a new approach that is better.

It is not hard to imagine you baying at Galileo,

The Sun Centered Solar Systen needs to be abolished, the data discredited, and allow cosmic reflection to return as it has for many years--The Prince of Peter at the center, discerning, diagnosing and dictating.

It is not hard to find the data. http://www.cdc.gov/std/EPT/ is a start.

Critique the data if you will but start with the data and build from there than than beginning with your apriori conviction that heavy things must fall faster than lighter objects.

Your white coat has whine spilled on it.


Any rebuttal from Anonymous of 8-26-09? ..Maurice.

 

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