Ambulatory STD management in an inner-city emergency department: descriptive epidemiology, care utilization patterns, and patient perceptions of local public STD clinics

Racial and Ethnic Differences in Chlamydia and Gonorrhea Testing Locations Among Medicaid-Insured Youth

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infections are common among 15- to 24-year-olds, with Black and Hispanic youth disproportionately affected. Understanding where youth receive CT/GC testing is necessary to address disparities in CT/GC care. Our objective was to identify if differences exist in CT/GC testing locations by race and ethnicity.

METHODS

We used 2019 MarketScan Medicaid data to examine CT/GC testing location by youth race and ethnicity.

RESULTS

There were 418,623 CT/GC tests during the study period. Tests were most frequently ordered at medical offices for all races and ethnicities, although less frequently for Black (37.6%) and Hispanic (37.3%) than for White youth (49.3%). Black youth were frequently tested in emergency departments (19.6%), while Hispanic youth were frequently tested in Federally Qualified Health Centers (19.0%).

DISCUSSION

We found significant racial and ethnic disparities in the location of CT/GC testing among Medicaid-insured-youth; these findings should be used to guide strategies that address inequities in CT/GC care.

Prediction model for gonorrhea, chlamydia, and trichomoniasis in the emergency department

OBJECTIVE

History and physical examination findings can be unreliable for prediction of genitourinary tract infections and differentiation of urinary tract infections from sexually transmitted infections (STIs). The study objective was to develop a prediction tool to more accurately identify patients with STIs.

METHODS

A retrospective review of 64,490 emergency department (ED) encounters between April 18, 2014, and March 7, 2017, where patients age 18 years or older had urinalysis and urine culture or testing for gonorrhea, chlamydia, or trichomonas, was used to develop a prediction model for men and women with Neisseria gonorrhoeae or Chlamydia trachomatis, or both, and for women with Trichomonas vaginalis. The data set was randomly divided into two-thirds discovery and one-third validation. Groups were assigned through a random number generator. Backward step regression modeling was used to identify the best model for each outcome.

RESULTS

With use of age, race, marital status, and findings from vaginal wet preparation (white blood cells [WBCs], clue cells, and yeast) and urinalysis (squamous epithelial cells, protein, leukocyte esterase, and WBCs), the models had areas under the receiver operating characteristic curve of 0.80 for men with N gonorrhoeae or C trachomatis, or both; 0.75 for women with N gonorrhoeae or C trachomatis, or both; and 0.73 for women with T vaginalis.

CONCLUSIONS

The model estimated likelihood of ED patients having STIs was reasonably accurate with a limited number of demographic and laboratory variables. In the absence of point-of-care STI testing, use of a prediction tool for STIs may improve antimicrobial stewardship.

Trichomonas Infection Rates in Males Presenting to the Emergency Department for Sexually Transmitted Infections

BACKGROUND

Trichomonas vaginalis (TV) is one of the most common sexually transmitted infections (STIs). Overall prevalence is reported to be 3.1%, with rates approaching 12.9-14.4% in high-risk female populations. Although there is a plethora of data on TV in the female population, the corresponding data for the male population are limited.

OBJECTIVE

Our aim was to determine the infection rate of TV in male patients seeking care for STIs in the emergency department (ED) and determine the symptoms associated with TV infection in male patients.

METHODS

We conducted a retrospective study of male patients aged 13 years or older who presented to the ED for STI evaluation. Male patients included had nucleic acid amplification test (NAAT) TV testing as part of standard STI evaluation.

RESULTS

Of the 2137 male patients included, 95 (4.4%) were positive for TV. Male patients who tested positive were significantly older (mean age 38.9 years vs. 30.7 years for male patients who tested negative; p < 0.05). Black male patients were more likely than White male patients to be positive for TV (6.3% prevalence vs. 1.8%; p < 0.05). TV-positive male patients were more likely to have discharge, specifically clear penile discharge, on examination (p < 0.05), and were less likely to have testicular pain or testicular tenderness (p < 0.05). Higher rates of TV were seen in an urban (4.9%) compared with suburban ED (1.6%; p < 0.05).

CONCLUSIONS

Rates of TV in male patients who receive STI testing in the ED are similar to rates published previously for female patients. We found higher rates among older and African-American male patients. TV among male patients is prevalent and testing should continue when evaluating for STIs.

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department

BACKGROUND

The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

OBJECTIVES

Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

METHODS

Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

RESULTS

Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

CONCLUSION

Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.

Presenting to the Emergency Department Versus Clinic-Based Sexually Transmitted Disease Care Locations for Testing for Chlamydia and Gonorrhea: A Spatial Exploration

BACKGROUND

Rates of sexually transmitted diseases (STDs) including chlamydia and gonorrhea are increasing in the United States while public health funding for STD services is decreasing. Individuals seek care in various locations including the emergency department (ED). The objective of this study is to investigate whether there are more physically proximal clinic-based STD care locations available to individuals who present to the ED in a major metropolitan area.

METHODS

Addresses of EDs, clinics, and patients 13 years or older in St. Louis City or County given a nucleic acid amplification test and assigned an STD diagnosis (n = 6100) were geocoded. R was used to analyze clinics within 5 radii from the patients' home address and assess missed clinic opportunities (open, no charge, with walk-in availability) for those living in an urban versus suburban area.

RESULTS

In urban areas, 99.1% of individuals lived closer to a clinic than the ED where they sought STD services; in suburban areas, 82.2% lived closer to a clinic than the ED where they presented. In the region, 50.6% lived closer to the health department-based STD care location than the hospital where they presented. Up to a third of ED patient visits for STD care could have occurred at a clinic that was closer to the patient's home address, open, no charge, and available for walk-in appointments.

CONCLUSIONS

Clinic availability is present for most of the individuals in our study. Clinics providing STD services can increase advertising efforts to increase public awareness of the services which they provide.

A New Strategy for Trichomonas Testing Female Adolescents in the Emergency Department

STUDY OBJECTIVE

Sensitive trichomonas diagnostic testing has become available, including nucleic acid amplification tests (NAATs) and a rapid antigen test. The study purpose was to determine if adding sensitive trichomonas testing to routine female sexually transmitted infection (STI) evaluations would increase trichomonas identification and treatment.

DESIGN

Two study time periods. Study time 1 (T1) was used for a retrospective review. Study time 2 (T2) was used for a prospective study.

SETTING

Emergency Department.

PARTICIPANTS

Symptomatic female patients aged 13-20 years (N = 447).

INTERVENTIONS

Implementation of routing trichomonas testing in the Emergency Department during T2.

MAIN OUTCOME MEASURES

Trichomonas diagnosis and treatment rates were compared during T1 and T2.

RESULTS

During T1 31 of 234 of eligible patients (13%) were trichomonas-tested. Laboratory-confirmed trichomonas was identified in 3 of 234 (1.3%). During T2, 212 of 213 of eligible patients (99.5%) were trichomonas-tested; 39 of 212 tested trichomonas-positive (18.4%); 29 of 212 tested rapid trichomonas antigen test-positive (13.6%; P < .001), and 33 of 188 tested trichomonas NAAT-positive (15.5%; P < .001). Trichomonas treatment was given to 3 of 3 laboratory-confirmed trichomonas cases during T1 (100%) compared with 37 of 39 during T2 (95%; P = .688). During T1, 14 of 17 women who received trichomonas treatment (82.4%) did not have a laboratory-confirmed trichomonas diagnosis and during T2 13 of 52 women without a laboratory-confirmed trichomonas diagnosis (25%) were treated for trichomonas (P < .001). Rapid trichomonas antigen tests and trichomonas NAATs were concordant in 178 of 188 patients (94.6%).

CONCLUSION

Incorporating trichomonas rapid antigen tests and NAATs into routine female adolescent STI testing significantly increased the number of laboratory-confirmed adolescent trichomonas diagnosis and treatment and are useful Emergency Department STI screening tools.

A randomized controlled trial of the effects of a brief intervention to increase chlamydia and gonorrhea testing uptake among young adult female emergency department patients

OBJECTIVES

The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women.

METHODS

This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment.

RESULTS

A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing.

CONCLUSIONS

The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.

Sexually transmitted infections during pregnancy

Two million of the 15 million (13.3%) new cases of sexually transmitted infections (STIs) among persons 15 to 49 years old occur in pregnant women. Access to care and a provider's ability to assess risk, screen, and treat STIs are critical factors in preventing adverse pregnancy outcomes. Significant variations in provider STI screening and treatment practices exist despite recommended guidelines. This article reviews issues related to screening and management of common STIs during pregnancy, with emphasis on the new 2006 US Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines and recently revised recommendations for HIV testing of pregnant women in healthcare settings.

Patient-Delivered Partner Treatment and Other Partner Management Strategies for Sexually Transmitted Diseases Used by New York City Healthcare Providers

OBJECTIVES

The objectives of this study were to measure frequency and predictors of patient-delivered partner treatment (PDPT) and the frequency of other partner management strategies among New York City healthcare providers (HCPs) as well as to determine whether use of PDPT detracts from other partner management strategies.

STUDY DESIGN

The authors conducted a cross-sectional survey of New York City HCPs.

RESULTS

Frequent patient referral was reported by 93.6% (368 of 393) of healthcare providers; only 20% (80 of 401) reported frequent use of provider referral. Overall, 49.2% (196 of 398) of HCPs reported ever using PDPT and 27.1% (108 of 398) reported using PDPT frequently. HCP specialty, practice setting, duration of practice, report of frequent provider referral practice, and HCP race/ethnicity were the strongest predictors of PDPT use. HCPs reporting PDPT use were more likely to report frequent provider referral than those who had never used PDPT (26.7% vs. 12.6%; P <0.001).

CONCLUSIONS

PDPT use is common and is being used in conjunction with other partner management strategies.

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.

Diagnosis and treatment of common sexually transmitted diseases

Sexually transmitted diseases (STDs) are common and often are asymptomatic. This article reviews the presentation and treatment recommendations for some of the most common symptomatic STDs, as well as reviews recent advances in diagnostic methods that may impact patient care.

Estimates of Primary and Secondary Syphilis Rates in Persons With HIV in the United States, 2002

BACKGROUND

In the United States, there is a high rate of HIV coinfection in persons with syphilis.

GOAL

The goal of this study was to estimate the rate of primary and secondary (P&S) syphilis in persons living with HIV in the United States in 2002.

STUDY

We approximated the number of new cases of P&S syphilis in HIV-infected persons and divided this by the estimated number of persons living with HIV. Values for the calculations were obtained from national syphilis and HIV/AIDS surveillance reports and other published sources.

RESULTS

We estimated the rate of new cases of P&S syphilis at 186 per 100,000 persons living with HIV in 2002, 25 per 100,000 HIV-infected women, 60 per 100,000 HIV-infected men who have sex with women only, and 336 per 100,000 HIV-infected men who have sex with men. Of the 6862 reported cases of P&S syphilis in 2002, an estimated 1718 (25%) occurred in persons coinfected with HIV.

CONCLUSIONS

The estimated rate of P&S syphilis in persons with HIV is considerably higher than that of the general population. These findings highlight the importance of providing sexually transmitted disease prevention and control services to HIV-infected persons.

Factors associated with sexually transmitted disease clinic attendance

Most people in the United States who are infected with sexually transmitted diseases (STDs) do not attend STD clinics for treatment in spite of the low-cost efficacious treatment. We asked a clinic and a community sample about perceived benefits and problems of attending an STD clinic. Analyses yielded two treatment-oriented and two socially oriented, factors, which were also expressed in qualitative interviews. Further analyses suggested that treatment-oriented factors were more strongly associated with clinic attendance than were social factors, although respondents were more positive about expected quality of treatment than they were about retaining confidentiality. We suggest that implications of the results favor integrating STD care with other health care.

Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients

BACKGROUND

Previous studies have shown screening for gonorrhea and chlamydia to be cost-effective for limiting the sequelae of infection and the associated costs of management.

GOAL

To evaluate the cost-effectiveness of enhanced screening for gonorrhea and chlamydia in an emergency department (ED) setting.

STUDY DESIGN

Five strategies were compared with use of decision analysis for theoretical cohorts of 10,000 female and 10,000 male ED patients aged 18 years to 31 years: standard ED practice, three enhanced screening strategies, and mass treatment. Main outcome measures were untreated gonorrhea or chlamydia cases and their sequelae, transmission to a partner, congenital outcomes, and cost to prevent a case. This analysis, from the perspective of the healthcare sector, included medical case costs expressed in US dollars (1999), discounted at an annual rate of 3%.

RESULTS

Mass treatment was the most cost-effective strategy among women and men. Of the screening strategies for women, universal screening combined with standard practice was the most cost-effective; it was used for treating 499 more cases of gonorrhea and chlamydia than was standard practice, saving $95.70 per case treated. Standard ED practice remained the most cost-effective strategy for men under a variety of circumstances.

CONCLUSION

The authors recommend urine ligase chain reaction screening for gonorrhea and chlamydia in women aged 18 years to 31 years in the ED, in conjunction with standard ED practice, to decrease the occurrence of the sequelae and costs associated with infection.

Towards a public health approach to bioethics

In this paper we examine the central commitments of bioethical enquiry and reasoning from a public health perspective. We argue that a core element of American national culture is individualism, which resonates in scholarly and popular debates. Our contention is that the habitus of bioethical debate is in large measure animated by an overriding concern with the individual, and the resulting social practice of the community has been to downplay the importance and legitimacy of group-level health care dilemmas. This paper calls for re-focusing of bioethics by employing a public health perspective, which would include a population focus, evidence-based research topics, and engagement of the ethical dilemmas that arise from decisions concerning prevention. Racial and ethnic health disparities throughout the life span of a population in central New York State are used to illustrate the need for a public health focus in bioethics.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention

BACKGROUND

Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention.

GOAL

To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection.

STUDY DESIGN

Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay.

RESULTS

Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age < or =31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease.

CONCLUSION

This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.