Under-reporting of pelvic inflammatory disease in Hawaii: a comparison of state surveillance and hospitalization data

Pelvic Inflammatory Disease Trends Among Emergency Department Visits in North Carolina, 2008 to 2017

BACKGROUND

Pelvic inflammatory disease (PID) is an infection of the upper female reproductive organs that can lead to infertility and ectopic pregnancies. It is a reportable condition in North Carolina (NC) but is likely underreported. We aimed to quantify PID diagnoses in NC emergency department (ED) visits.

METHODS

The NC Disease Event Tracking and Epidemiology Collection Tool tracks all ED visits in NC. We identified PID diagnoses among women of reproductive age (15-44 years) between 2008 and 2017 using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, and calculated the yearly proportion with PID diagnoses. We assessed the number of PID visits per patient each year, and the proportion of ED visits with a PID diagnosis by age, proportion of the patient's ZIP code living below the poverty line, insurance coverage, and NC provider region.

RESULTS

The percent of women with PID decreased from 6189 (1.0%) in 2008 to 4337 (0.58%) in 2016 before increasing slightly to 4371 (0.61%) in 2017. We identified 54,502 (0.45%) ED visits among 51,847 (0.76%) women with ≥1 PID diagnosis code. Most (95.5%) women with PID had one ED visit during the calendar year. Each year, the proportion with PID was highest among women aged 20 to 24 years, covered under public insurance, from the most impoverished areas, and whose provider was in the Coastal region of NC.

CONCLUSIONS

The percent with PID among women visiting EDs decreased between 2008 and 2017 in NC. Although this decline was observed across all demographics, disparities associated with PID continued to persist over time.

Assessing the Accuracy of Physician Self-disclosed PID Reporting: A Comparison of Data from a Physician Survey and Actual PID Case Reports from a State Surveillance System

Pelvic inflammatory disease is a state-mandated notifiable disease in Hawai'i. A survey assessing pelvic inflammatory disease (PID) reporting to the Hawai'i Department of Health (HDOH) PID surveillance system, was administered to physicians in Hawai'i in April 2012. To measure the accuracy of self-disclosed PID reporting, data from the survey were compared to HDOH PID surveillance system case reports. Concordance between the two data sources was assessed using Cohen's kappa statistic. We first linked data by physician name. An adjusted kappa was also calculated to minimize prevalence and bias effects. A second analysis linked data according to physician name or practice setting. In the name-based analysis, the HDOH PID surveillance database successfully matched only ten of 118 physicians (8.5%) who self-disclosed reporting a PID case. Only "slight agreement" (k= 0.09, 95% confidence interval [CI]: 0.02-0.16) was demonstrated between the two databases. The prevalence-adjusted, bias-adjusted kappa demonstrated "moderate agreement" (κ=0.53, 95% CI: 0.45-0.60). In the second (name or practice-based setting) analysis, 77 physicians with linkages were found in the HDOH surveillance database, reflecting "moderate agreement" (κ=0.52, 95% CI 0.43, 0.61). Our findings provide evidence that individual physicians are submerging their case reports into group practice/HMO aggregate reports and not reporting individually as legally mandated and hence are compromising PID surveillance quality.

Physician Survey Assessing Pelvic Inflammatory Disease Knowledge and Attitudes to Identify Diagnosing and Reporting Barriers

BACKGROUND

Pelvic inflammatory disease (PID) is a notifiable disease in Hawaii with legal implications for noncompliance. A previous study comparing PID diagnoses in Hawaii's hospitals and state surveillance data confirmed underreporting in Hawaii. Reasons for noncompliance and underreporting are not well understood.

METHODS

All licensed primary care physicians in Hawaii were mailed a survey addressing PID diagnosis and reporting attitudes and practices. Hierarchical logistic regression was used to determine if physician characteristics, PID knowledge, or attitudes related to the diagnosis or reporting of PID, increased the odds of diagnosing and reporting PID.

RESULTS

Among survey respondents (486 of 1,062; response rate of 45.8%), 104 (21.4%) had diagnosed PID. The PID reporting rate was 55.8% (58 of 104). The majority of physicians who diagnosed PID reported that PID reporting was time consuming. In hierarchical regression, obstetrician/gynecologists and family practitioners had the highest odds of diagnosing PID and internists had the lowest odds of reporting PID, those 15 years or longer since residency were less likely to report PID than those fewer than 15 years since residency, and increased PID diagnosing and reporting knowledge increased the odds of PID reporting by 1.63 times.

CONCLUSION

Our findings suggest the need for training of all physicians on reportable diagnoses on a regular basis. There is a need to simplify the reporting process, because the time burden of reporting may present a modifiable barrier to reporting. Increased PID-related communication between local health departments and physicians is essential, and physicians should be provided technical assistance with reporting.