Disease surveillance in the ED: factors leading to the underreporting of gonorrhea

Economic burden of sexually transmitted infections: incidence and direct medical cost of Chlamydia, gonorrhea, and syphilis among Illinois adolescents and young adults, 2005-2006

BACKGROUND

Local assessment of sexually transmitted infections (STI) magnitude and economic burden can aid in targeting resources and prevention programs.

METHODS

Reported cases of Chlamydia, gonorrhea, and primary and secondary syphilis (obtained from the Illinois Department of Public Health) were used to estimate the number of incident cases among persons aged 15 to 24 years, accounting for the proportion of undiagnosed and unreported cases, and sexually active population. STI costs were obtained from the published literature, and multiplied by the estimated incident cases of STIs in 2005 and 2006 to determine direct medical costs of incident infections. Incident rates per 100,000 population and costs in 2007 US dollars are estimated by age, gender, race, and county.

RESULTS

Chlamydia incidence and cost were estimated at 5030 infections per 100,000 population and $27,576,686 in 2005, and 5259 infections per 100,000 population and $28,779,734 in 2006. Gonorrhea incidence and cost were estimated at 1740 infections per 100,000 population and $7,698,135 in 2005, and 1704 infections per 100,000 population and $7,546,500 in 2006. Syphilis incidence and cost were estimated at 9.4 per 100,000 and $59,940 in 2005, and 10.4 per 100,000 population and $66,333 in 2006. Incidence and costs of all STIs were highest among women and blacks. Ten counties accounted for >80% of the estimated statewide morbidity and costs.

CONCLUSIONS

Estimates of STI incidence and costs are conservative, yet represent a significant economic burden in Illinois. Focusing prevention efforts on locales with the highest STI rates may maximize effectiveness in terms of disease prevention and cost reduction.

Gonorrhea prevention and clinical care in the private sector: lessons learned and priorities for quality improvement

We reviewed literature on gonorrhea prevention and clinical care in the private sector, the setting where most gonorrhea cases in the United States are now diagnosed. Although most private-sector health settings had a low prevalence of gonorrhea (0.1-2.5%), some private emergency departments and specialty clinics that serve a large number of high-risk or infected patients had prevalences ranged from 1.7% to 11.0%. Studies of diverse settings and populations suggest that, in general, diagnostic testing of symptomatic patients (69-83%), appropriate treatment (61-100%), and case reporting (64-94%) are delivered more commonly than risk assessment for asymptomatic patients (15-28%), routine screening of pregnant women (31-77%), risk-reduction counseling (35-78%), and sex partner management (0-82%). To sustain the recent declines in gonorrhea incidence in the United States, private-sector providers and health systems must continue to offer gonorrhea prevention and clinical services and consider implementing interventions to improve delivery of risk assessment, risk-reduction counseling, and partner management services.

Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: a longitudinal analysis

This study tests the effect of neighborhood changes on gonorrhea rates. Prior studies that indicate gonorrhea rates are associated with alcohol outlet density and neighborhood deterioration have been cross-sectional and cannot establish causality. After the 1992 Civil Unrest in Los Angeles, 270 alcohol outlets surrendered their licenses due to arson and vandalism thus providing a natural experiment. We geocoded all reported gonorrhea cases from 1988 to 1996 in LA County, all annually licensed alcohol outlets, and all properties damaged as a result of the civil unrest. We ran individual growth models to examine the independent effects of changes in alcohol outlets and damaged buildings on gonorrhea. The individual growth model explained over 90% of the residual variance in census tract gonorrhea rates. After the civil unrest, a unit decrease in the number of alcohol outlets per mile of roadway was associated with 21 fewer gonorrhea cases per 100,000 (p<.01) in tracts affected by the Unrest compared to those not affected. Neighborhood alcohol outlets appear to be significantly associated with changes in gonorrhea rates. The findings suggest that efforts to control sexually transmitted diseases, including gonorrhea and HIV, should address contextual factors that facilitate high-risk behaviors and disease transmission.

The Cost Effectiveness of Gonorrhea Screening in Urban Emergency Departments

BACKGROUND

The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical.

GOAL

The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests.

STUDY

We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs.

RESULTS

Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs.

CONCLUSION

Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

Incompleteness of Reporting of Laboratory-Confirmed Chlamydial Infection by Providers Affiliated With a Managed Care Organization, 1997–1999

BACKGROUND

Surveillance for sexually transmitted diseases (STDs) depends on the receipt of positive STD test results from laboratories or reports of STD diagnoses from clinicians to local or state health departments.

GOAL

The goal of this study was to evaluate incompleteness of reporting of chlamydial infection in a large staff-model managed care organization (MCO) using laboratory data and provider-based reports.

METHODS

All cases of chlamydial infection in 2 databases, one from the MCO during January 1997 through June 1999 and the other from the state STD registry, were compared by using a standard algorithm alone that included patient's name, sex, and date of specimen collection, and by using the standard algorithm together with the patient's medical record number.

RESULTS

Of 833 cases of chlamydial infection in the MCO case database, 597 were matched to the cases in the state registry using the standard algorithm alone and 671 were matched using the standard algorithm together with the patient's medical record number. In addition, 89 cases of chlamydial infection in the state registry had been reported from the MCO during the same timeframe but were not matched to cases in the MCO case database by these algorithms. The estimated incompleteness of reporting ranged from 9% to 28% depending on matching algorithms used and the criteria used to define completeness.

CONCLUSION

Based on this comparison of MCO data with the state STD registry data, the estimated incompleteness of reporting in a MCO depended on matching algorithms used and the criteria used to define completeness. Incompleteness of STD case reporting could be reduced if confidential electronic reporting methods and more complete case characteristic variables were used.

Emergency medicine and public health: new steps in old directions

Emergency medicine and public health have opportunities to interact in at least 4 areas: surveillance of diseases, injuries, and health risks; monitoring health care access; delivering clinical preventive services; and developing policies to protect and improve the public's health. Recent, cross-cutting initiatives and innovations in these 4 areas follow pathways first explored more than a generation ago and provide an important impetus for future work. An analysis of recent contributions also points to various obstacles and challenges that must be addressed to take full advantage of existing and rapidly developing ties between emergency medicine and public health. The connections between these 2 fields will continue to create important partnership opportunities and the strong possibility of achieving new benefits for patients, the public, and the professionals who serve them.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts

BACKGROUND

Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested.

GOAL

To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

STUDY DESIGN

Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment.

RESULTS

Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae.

CONCLUSION

Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.