Karen W Hoover

Centers for Disease Control and Prevention, Atlanta, Michigan, United States

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Publications (20)73.83 Total impact

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    ABSTRACT: HIV-infected men who have sex with men (MSM) are at increased risk for transmitting and acquiring sexually transmitted diseases (STDs). Guidelines recommend at least annual screening of HIV-infected MSM for syphilis and for chlamydia and gonorrhea at exposed anatomical sites, to protect their health and their sexual partners' health. Despite these guidelines, STD screening has been suboptimal, with very low nongenital chlamydia and gonorrhea testing rates. Our objective was to better understand barriers encountered by HIV care providers in adhering to STD screening guidelines for HIV-infected MSM. We conducted 40 individual semistructured interviews with health care providers (physicians, midlevel providers, nurses, and health educators) of HIV-infected MSM at 8 large HIV clinics in 6 US cities. Providers were asked about their STD screening practices and barriers to conducting sexual risk assessments of their patients. Emerging themes were identified by qualitative data analysis. Although most health care providers reported routine syphilis screening, screening for chlamydia and gonorrhea at exposed anatomical sites was less frequent. Obstacles that prevented routine chlamydia and gonorrhea screening included time constraints, difficulty obtaining a sexual history, language and cultural barriers, and patient confidentiality concerns. Providers reported many obstacles to routine chlamydia and gonorrhea screening. Interventions are needed to help to mitigate barriers to STD screening, such as structural and patient-directed health services models that might facilitate increased testing coverage of these important preventive services.
    Sexually transmitted diseases 02/2014; 41(2):137-42. · 2.58 Impact Factor
  • Guoyu Tao, Karen W Hoover
    Sexual Health 06/2013; · 1.65 Impact Factor
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    ABSTRACT: Background. Chlamydia is prevalent among young persons in the United States. Infected persons have a high prevalence of infection several months later, most likely from reinfection. Retesting of all men and women with a positive test is recommended 3 months after treatment. A test-of-cure is recommended for pregnant women 3-4 weeks after treatment.Methods. We analyzed 2008-2010 chlamydia testing data from a large US laboratory to estimate test positivity by patient demographic characteristics and diagnoses, and patterns of repeat testing of men and nonpregnant women with a positive test and tests-of-cures of pregnant women with a positive test.Results. During the study period, 7.0% of 0.40 million tests performed in men and 4.0% of 2.92 million tests performed in women were positive. Among young women, positivity rates were highest among those aged 15-19 years, ranging from 8.5% to 10.0%. Retesting rates of persons with a positive test were suboptimal, with 22.3% of men and 38.0% of nonpregnant women retested. Although 60.1% of pregnant women with a positive test were retested, only 22.0% received a test-of-cure within the 4-week recommended time frame. Repeat tests were positive in 15.9% of men, 14.2% of nonpregnant women, and 15.4% of pregnant women.Conclusions. Analyses of laboratory testing data provided important insights into chlamydia testing, retesting, and positivity among a diverse US population of men and women. Too few persons were retested as recommended, and interventions are needed to increase both healthcare provider and patient adherence to recommendations for retesting men and women with positive tests.
    Clinical Infectious Diseases 10/2012; · 9.37 Impact Factor
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    ABSTRACT: Using the 2006-2008 National Survey of Family Growth, we estimated a 37.9% annual chlamydia testing rate for sexually active US women aged 15 to 25 years, defined as having ≥ 1 sex partner in the past year. Our results highlight the need for increased testing among sexually active young women.
    Sexually transmitted diseases 08/2012; 39(8):605-7. · 2.58 Impact Factor
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    ABSTRACT: To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.
    American Journal of Public Health 06/2012; 102(8):e26-9. · 3.93 Impact Factor
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    ABSTRACT: HIV-infected men who have sex with men (MSM) are at increased risk of viral hepatitis because of similar behavioral risk factors for acquisition of these infections. Our objective was to estimate adherence to HIV management guidelines that recommend screening HIV-infected persons for hepatitis A, B, and C infection, and vaccinating for hepatitis A and B if susceptible. We evaluated hepatitis prevention services received by a random sample of HIV-infected MSM in 8 HIV clinics in 6 US cities. We abstracted medical records of all visits made by the patients to the clinic during the period from 2004 to 2007, to estimate hepatitis screening and vaccination rates overall and by clinic site. Medical records of 1329 patients who had 14,831 visits from 2004 to 2006 were abstracted. Screening rates for hepatitis A, B, and C were 47%, 52%, and 54%, respectively. Among patients who were screened and found to be susceptible, 29% were vaccinated for hepatitis A and 25% for hepatitis B. The percentage of patients screened and vaccinated varied significantly by clinic. Awareness of hepatitis susceptibility and hepatitis coinfection status in HIV-infected patients is essential for optimal clinical management. Despite recommendations for hepatitis screening and vaccination of HIV-infected MSM, rates were suboptimal at all clinic sites. These low rates highlight the importance of routine review of adherence to recommended clinical services. Such reviews can prompt the development and implementation of simple and sustainable interventions to improve the quality of care.
    Sexually transmitted diseases 05/2012; 39(5):349-53. · 2.58 Impact Factor
  • Guoyu Tao, Karen W Hoover, Charlotte K Kent
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    ABSTRACT: Annual chlamydia screening for sexually active women aged ≤25 years is recommended, and chlamydia testing rates have continuously increased. However, several studies have shown that many providers screen all women of reproductive age in public settings. To examine chlamydia testing patterns in private settings for women and young women aged 15-44 years (hereafter referred to as women). A large commercial claims database was used to estimate the chlamydia testing rate for women aged 15-44 years who had reproductive health services in 2008. Such services and tests were identified using diagnostic and procedural codes in 2008. Of 3.2 million women aged 15-44 years who had reproductive health services in 2008, 19.2% had at least a claim for a sexually transmitted disease (STD), 29.3% for pregnancy, and 81.2% for a gynecologic exam. Of those 3.2 million, 22.3% had chlamydia testing: 34.2% aged 15-25 years vs 18.3% aged 26-44 years. Of the 0.7 million who were tested, 65% were aged 26-44 years, and the reason for the healthcare visit in which their first chlamydia test was performed was an STD for 22.7% and pregnancy for 33.5%. In this population of insured women, young women are undertested and older women are overtested for chlamydia. Efforts to improve screening practices should be evaluated.
    American journal of preventive medicine 04/2012; 42(4):337-41. · 4.24 Impact Factor
  • Source
    Karen W Hoover, Justin D Radolf
    The Journal of Infectious Diseases 09/2011; 204(9):1295-6. · 5.85 Impact Factor
  • Obstetrics and Gynecology 03/2011; 117(3):729; author reply 729-30. · 4.80 Impact Factor
  • Kwame Owusu-Edusei, Karen W Hoover, Guoyu Tao
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    ABSTRACT: No study has directly estimated the direct outpatient medical cost of care for primary and secondary (P&S) syphilis among the employer-sponsored commercially insured population in the United States. We used international classification of diseases, ninth revision (ICD-9) codes to identify outpatient claims for persons diagnosed with P&S syphilis for 2003 through 2007 from the MarketScan database. Diagnostic test costs were also analyzed using current procedural terminology codes for syphilis tests. We used healthcare common procedure coding system (HCPCS) codes to identify and analyze parenteral treatment costs for those diagnosed with P&S syphilis. Potential oral drug regimen was also investigated for those diagnosed using national drug codes. All costs were adjusted to 2007 US dollars. Overall costs estimates were categorized into males and females. The overall average cost per episode of P&S syphilis on an outpatient basis was $194. Further analyses indicated that the estimated average cost per case of P&S syphilis diagnosed and treated parenterally on an outpatient basis was $229. We did not find any significant difference between the total average costs for males and females. However, the cost per parenteral treatment was significantly higher (P<0.05) for males ($54) than those for females ($39). The estimate reported in this study represents a lower-bound estimate because it was based on direct medical cost only and does not include other associated costs such as pain and suffering nor lost productivity.
    Sexually transmitted diseases 03/2011; 38(3):175-9. · 2.58 Impact Factor
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    ABSTRACT: National guidelines for the care of human immunodeficiency virus (HIV)-infected persons recommend asymptomatic routine screening for sexually transmitted diseases (STDs). Our objective was to determine whether providers who care for HIV-infected men who have sex with men (MSM) followed these guidelines. We abstracted medical records to evaluate STD screening at 8 large HIV clinics in 6 US cities. We estimated the number of men who had at least one test for syphilis, chlamydia (urethral and/or rectal), or gonorrhea (urethral, rectal, and/or pharyngeal) in 2004, 2005, and 2006. Urethral testing included nucleic acid amplification tests of both urethral swabs and urine. We also calculated the positivity of syphilis, chlamydia, and gonorrhea among screened men. Medical records were abstracted for 1334 HIV-infected MSM who made 14,659 visits from 2004-2006. The annual screening rate for syphilis ranged from 66.0% to 75.8% during 2004-2006. Rectal chlamydia and rectal and pharyngeal gonorrhea annual screening rates ranged from 2.3% to 8.5% despite moderate to high positivity among specimens from asymptomatic patients (3.0%-9.8%) during this period. Annual urethral chlamydia and gonorrhea screening rates were higher than rates for nonurethral sites, but were suboptimal, and ranged from 13.8% to 18.3%. Most asymptomatic HIV-infected MSM were screened for syphilis, indicating good provider adherence to this screening guideline. Low screening rates for gonorrhea and chlamydia, especially at rectal and pharyngeal sites, suggest that substantial barriers exist for complying with these guidelines. The moderate to high prevalence of asymptomatic chlamydial and gonococcal infections underscores the importance of screening. A range of clinical quality improvement interventions are needed to increase screening, including increasing the awareness of nucleic acid amplification tests for nonurethral screening.
    Sexually transmitted diseases 12/2010; 37(12):771-6. · 2.58 Impact Factor
  • Guoyu Tao, Karen W Hoover, Charlotte K Kent
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    ABSTRACT: An American College of Obstetricians and Gynecologists Practice Bulletin published in 2009 recommended that cervical cancer screening should begin at age 21 years and women younger than 30 years should be rescreened every 2 years rather than annually. The purpose of this study is to estimate the effect that decreased frequency of cervical cancer screening would have on chlamydia screening, which is recommended annually for sexually active women aged 25 years or younger. Using an administrative database of medical claims from commercially insured girls and women, we compared annual chlamydia screening rates of sexually active adolescent girls and young women aged 15 to 25 years in 2007 among those who underwent cervical cancer screening and those who were not screened for cervical cancer. We identified 701,193 sexually active adolescent girls and young women aged 15 to 25 years. Chlamydia screening rates were significantly higher among adolescent girls and young women who underwent cervical cancer screening compared with those who did not: 43.6% compared with 9.5% for adolescent girls and young women aged 15 to 20 years and 36.1% compared with 12.2% for women aged 21 to 25 years. Among adolescent girls and young women identified as sexually active in 2007, 90.5% had visits for reproductive health services other than cervical cancer screening that could provide opportunities for chlamydia screening. Although the revised American College of Obstetricians and Gynecologists Practice Bulletin recommending less frequent cervical cancer screening will likely reduce chlamydia screening rates in adolescent girls and young women, health care providers should be aware of other opportunities for chlamydial testing. Options include patient self-collected vaginal swabs and urine specimens collected during visits at which adolescent girls and young women seek other reproductive health or preventive services.
    Obstetrics and Gynecology 12/2010; 116(6):1319-23. · 4.80 Impact Factor
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    ABSTRACT: We examined utilization patterns of adolescents and young women as they seek general and reproductive health services in physician offices and hospital outpatient clinics. We analyzed physician office visits in the 2003-2006 National Ambulatory Medical Care Surveys, and hospital outpatient clinic visits in the National Hospital Ambulatory Medical Care Surveys, to examine utilization patterns of females aged 9-26 years by 2-year age intervals and other characteristics such as physician specialty or clinic type. The number of visits to primary care physician offices increased with age, from 4.9 million for ages 9-10 years to 9.0 million for ages 25-26 years. The proportion of visits made to obstetrician-gynecologists and family practitioners increased with age, and by ages 15-16 years fewer than half of all visits to primary care providers were made to pediatricians. The proportion of visits to family practitioners increased from 25% at ages 9-10 years to 30% at ages 25-26 years. By ages 17-18 years, a larger proportion of visits were made to obstetrician-gynecologists (33% of 7.0 million visits) and to family practitioners (34%) than to pediatricians (23%). The proportion of visits for reproductive health services peaked at 53% of 7.5 million physician visits at ages 20-21 years. Similar utilization patterns were observed for the 11.0 million hospital outpatient visits to primary care providers. Because adolescents and young women most commonly utilize healthcare services provided by obstetrician-gynecologists and family practitioners, these specialties should be priority targets for interventions to improve the quality and availability of reproductive health services.
    Journal of Adolescent Health 04/2010; 46(4):324-30. · 2.97 Impact Factor
  • Karen W Hoover, Guoyu Tao, Charlotte K Kent
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    ABSTRACT: To estimate trends in the rates of diagnosis and treatment of ectopic pregnancy in the United States. We analyzed data from a large administrative claims database of more than 200 U.S. commercial health plans, and estimated time trends in the rate and incidence of ectopic pregnancy among girls and women aged 15-44 years by 5-year age groups and by region from 2002 to 2007. We also estimated time trends in the proportion of cases that were treated surgically, either by laparoscopy or laparotomy, or medically with methotrexate. We identified 11,989 ectopic pregnancies during the period from 2002 to 2007. The overall rate of ectopic pregnancy among pregnant girls and women aged 15-44 years during the 6-year study period was 0.64%. We did not observe a trend in the rate of ectopic pregnancy by 5-year age group or by geographic region. The ectopic pregnancy rate increased with age; it was 0.3% among girls and women aged 15-19 years and 1.0% among women aged 35-44 years. Methotrexate treatment increased from 11.1% in 2002 to 35.1% in 2007 (P<.001); the methotrexate failure rate was 14.7% over the 6-year study period. Surgical management with laparotomy decreased over the study period from 40.0% to 33.1% (P<.001). We did not find an increasing or decreasing trend in the rate of ectopic pregnancy among U.S. commercially insured women from 2002 to 2007. The use of administrative claims data are likely the most feasible method for estimating the rate and monitoring trends of ectopic pregnancy in the United States.
    Obstetrics and Gynecology 03/2010; 115(3):495-502. · 4.80 Impact Factor
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    ABSTRACT: To estimate chlamydia screening rates of young sexually active Medicaid-insured women by race and ethnicity and age from 2002 to 2005. Using Medicaid child claims data from the MarketScan database, we estimated the proportion of sexually active women aged 15 to 21 years screened for chlamydia by race and ethnicity and by age group (15-16, 17-18, and 19-21 years) using codes for medical diagnostic and procedural claims. Overall, chlamydia screening increased from 34% in 2002 to 44% in 2005. In all years, black women had significantly higher screening rates compared with white women (e.g., 51% vs. 39% in 2005). When stratified by age, black women were still significantly more likely to be screened for chlamydia than white women. Although it is encouraging that screening has increased over time and that black women were more likely to be screened than white women, rates remain suboptimal for all women. Effective and targeted interventions are needed to improve chlamydia screening of young women. As interventions to increase screening are developed and implemented, the estimation method described in this article can be used to track chlamydia screening trends in racial and ethnic populations over time.
    Sexually transmitted diseases 08/2009; 36(10):642-6. · 2.58 Impact Factor
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    ABSTRACT: Because high-risk HPV is highly prevalent in the general population, usually transient, and rarely causes clinical symptoms, and because diagnostic and treatment options for HPV in men are lacking, partner notification is not useful for preventing transmission or protecting the health of male partners. We conducted a nationally representative survey of clinicians in 7 specialties that perform cervical cancer screening. Providers were asked whether they recommend that women with an abnormal Pap or positive HPV test inform sex partners of the infection or refer partners to a clinician. A large proportion of providers in all 7 specialties encourage women with either an abnormal Pap or a positive HPV test to tell their sex partners to see a clinician, ranging from 48% to 73% across specialties. Providers who perform reflex HPV testing were more likely to recommend that patients with an ASCUS Pap inform their partners of test results if an HPV test was positive than if it was negative (66%-83% vs. 29%-50%); providers who perform adjunct HPV testing were more likely to recommend that patients with a normal Pap inform their partners if an HPV test was positive than if it was negative (72%-92% vs. 30%-52%). Most providers advise patients with cervical cancer screening tests suggestive of HPV infection to notify their sex partners and to refer them to a clinician. Guidelines are needed for providers to clarify any rationale for clinical evaluation of male partners, including that informing partners has a limited role in the control of HPV transmission or in preventing adverse health outcomes in the male partner.
    Sexually transmitted diseases 02/2009; 36(3):141-6. · 2.58 Impact Factor
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    ABSTRACT: To determine whether patient race, ethnicity, or insurance status was associated with access to cervical cancer screening with liquid-based cytology (LBC) and with human papillomavirus (HPV) DNA testing and with access to on-site colposcopy at the provider's principal practice site. We conducted a nationally representative survey of clinicians in specialties that provide cervical cancer screening. Adjusted odds ratios (OR) were estimated for the associations between race, ethnicity, and insurance status of patients and provider use of LBC, HPV DNA testing, and on-site colposcopy. Providers who cared for >or=20% Hispanic patients were less likely to use LBC (OR 0.60, 95% CI=0.42-0.84). Providers who cared for >or=25% black women (OR 0.71, 95% CI=0.51-0.98) and providers who cared for <75% privately insured patients (OR 0.66, 95% CI=0.46-0.95) were less likely to use HPV DNA testing. Providers who cared for <75% privately insured patients were less likely to have on-site colposcopy (OR 0.57, 95% CI=0.37-0.89), but those who cared for >or=20% Medicaid patients were more likely to have on-site colposcopy (OR 1.86, 95% CI=1.26-2.73). Given the high rates of cervical cancer in minority women, access to cervical cancer screening and diagnostic follow-up must be ensured. It may also be beneficial to ensure affordable access to technologies such HPV DNA testing that increases the sensitivity of disease detection and to on-site colposcopy that facilitates follow-up of abnormal cytology.
    Journal of Lower Genital Tract Disease 01/2009; 13(1):17-27. · 1.21 Impact Factor
  • Karen Hoover, Guoyu Tao, Charlotte Kent
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    ABSTRACT: To estimate demographic characteristics of nonpregnant women who seek health care in hospital outpatient clinics, and the proportion of visits where a chlamydia test was not done in asymptomatic young women at preventive visits and in symptomatic women. We analyzed data from the 2005 National Hospital Ambulatory Medical Care Survey to estimate the number of visits made by nonpregnant women aged 15-25 years and 26-35 years. We estimated the proportion of preventive visits where young women were not screened for chlamydia and the proportion of visits where women with signs or symptoms of chlamydia were not tested. In 2005, 5.2 million visits were made by nonpregnant women aged 15-25 years to outpatient clinics: 21.3% were by black non-Hispanic women, 15.2% by Hispanic women, 41.9% by women with Medicaid/State Children's Health Insurance Program insurance, and 10.8% by women with signs or symptoms of chlamydia. These young women were not screened at 84.0% of 1.2 million asymptomatic preventive visits, and were not tested for chlamydia at 78.3% of 0.6 million visits where they presented with signs or symptoms of chlamydia. Women aged 26-35 years were not tested at 86.3% of 0.4 million visits where they presented with signs or symptoms of chlamydia. While low chlamydia screening coverage has been reported, the low level of diagnostic testing in outpatient clinics was unexpected. Simple and effective interventions are needed to increase both diagnostic testing and screening of young women for Chlamydia in outpatient clinics, a venue that provides care to at-risk populations.
    Obstetrics and Gynecology 11/2008; 112(4):891-8. · 4.80 Impact Factor
  • Karen Hoover, Michele Bohm, Kenneth Keppel
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    ABSTRACT: The Centers for Disease Control and Prevention (CDC) defines a health disparity as a "[health] difference that occurs by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation." Health equity is achieved by eliminating health disparities or inequalities. Measuring health disparities is a critical first step toward reducing differences in health outcomes. To determine the methods to be used in measuring a health disparity, several decisions must be made, which include: (1) selecting a reference group for the comparison of 2 or more groups; (2) determining whether a disparity should be measured in absolute or in relative terms; (3) opting to measure health outcomes or health indicators expressed as adverse or favorable events; (4) selecting a method to monitor a disparity over time; and (5) choosing to measure a disparity as a pair-wise comparison between 2 groups or in terms of a summary measure of disparity among all groups for a particular characteristic. Different choices may lead to different conclusions about the size and direction of health disparities at a point in time and changes in disparities over time.The objective of this article is to review the methods for measuring health disparities, provide examples of their use, and make specific recommendations for measuring disparities in the incidence of sexually transmitted diseases (STDs).
    Sexually transmitted diseases 11/2008; 35(12 Suppl):S40-4. · 2.58 Impact Factor
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    Karen Hoover, Guoyu Tao
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    ABSTRACT: To identify missed opportunities for chlamydia screening in ambulatory care offices. We analyzed data from the 2005 National Ambulatory Medical Care Survey to estimate the number of visits to obstetrician-gynecologists and primary care physicians (family and general practitioners, internists, and pediatricians) for preventive care, pelvic examinations, Pap tests, and urinalyses for nonpregnant women aged 15-25 years, and the proportion of these visits at which chlamydia tests were not performed. Obstetrician-gynecologists provided care for nonpregnant women aged 15-25 years at 6.3 million office visits during 2005, and primary care physicians at 20.9 million visits. Although obstetrician-gynecologists conducted only 23.1% of visits made by young women, they conducted 68.8% of visits with pelvic examinations and 71.1% of visits with Pap tests. Primary care physicians conducted 77.5% of visits with urinalyses. Obstetrician-gynecologists did not perform a chlamydia test at 3.2 of 3.8 million (82.1%) visits with pelvic examinations and at 1.8 of 2.3 million (77.3%) visits with Pap tests. Primary care physicians did not perform a chlamydia test at 2.9 of 3.0 million (99.1%) visits with urinalyses. There are many missed opportunities for chlamydia testing of young women in ambulatory care visits - during pelvic examinations, Pap tests, and urinalyses. Effective and simple interventions are needed to increase targeted chlamydia screening of women by physicians. III.
    Obstetrics and Gynecology 06/2008; 111(5):1097-102. · 4.80 Impact Factor