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Symum H, Van Handel M, Sandul A, Hutchinson A, Tsang CA, Pearson WS, Delaney KP, Cooley LA, Gift TL, Hoover KW, Thompson WW. Testing trends and co-testing patterns for HIV, hepatitis C and sexually transmitted infections (STIs) in Emergency departments. Prev Med Rep 2024; 44:102777. [PMID: 39099772 PMCID: PMC11295952 DOI: 10.1016/j.pmedr.2024.102777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 08/06/2024] Open
Abstract
Background Many underserved populations use Emergency Department (EDs) as primary sources of care, representing an important opportunity to provide infectious disease testing and linkage to care. We explored national ED testing trends and co-testing patterns for HIV, hepatitis C, and sexually transmitted infections (STIs). Methods We used 2010-2019 Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample data to estimate ED visit testing rates for HIV, hepatitis C, chlamydia, gonorrhea, and syphilis infections, identified by Current Procedural Terminology codes. Trends and co-testing (visit with tests for > 1 infection) patterns were analyzed by sociodemographic, hospital, and visit characteristics. Trends were evaluated as the average annual percentage change (AAPC) using the Joinpoint Regression. Results During 2010-2019, testing events per 1000 visits (AAPCs) increased for HIV from 1.3 to 4.2 (16.3 %), hepatitis C from 0.4 to 2.2 (25.1 %), chlamydia from 9.1 to 16.0 (6.6 %), gonorrhea from 8.4 to 15.7 (7.4 %), and syphilis from 0.7 to 2.0 (12.9 %). Rate increases varied by several characteristics across infections. The largest AAPC increases were among visits by groups with lower base rate testing in 2010, including persons aged ≥ 65 years (HIV: 36.4 %), with Medicaid (HIV: 43.8 %), in the lowest income quintile (hepatitis C: 36.9 %), living in the West (syphilis: 49.4 %) and with non-emergency diagnoses (hepatitis C: 44.1 %). Co-testing increased significantly for all infections except hepatitis C. Conclusions HIV, hepatitis C, and STI testing increased in EDs during 2010-2019; however, co-testing patterns were inconsistent. Co-testing may improve diagnosis and linkage to care, especially in areas experiencing higher rates of infection.
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Affiliation(s)
- Hasan Symum
- Program and Performance Improvement Office, Office of the Director, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Michelle Van Handel
- Program and Performance Improvement Office, Office of the Director, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Amy Sandul
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Angela Hutchinson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Clarisse A. Tsang
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - William S. Pearson
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Kevin P. Delaney
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Laura A. Cooley
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Thomas L. Gift
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - Karen W. Hoover
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
| | - William W. Thompson
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), United States
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Sweitzer S, Sharp J, Baker D, Lynch A, Stauch MA, Wheatley M, Lora M, Cantos VD, Gruen J. Opt-Out Syphilis Screening at an Urgent Care Center in Atlanta: Evaluation of a Pilot Program. Sex Transm Dis 2024; 51:516-520. [PMID: 38647243 DOI: 10.1097/olq.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) and syphilis disproportionately impact communities with low access to primary care, who often utilize urgent care centers (UCCs) for sexual health care. UCC visits represent an opportunity for identification and treatment of syphilis and linkage to HIV testing and prevention services. We describe a universal, opt-out syphilis screening program pilot at an Atlanta UCC. METHODS A chart review was performed on patients 18 years and older who were offered opt-out syphilis screening and had a rapid plasma reagin (RPR) test collected from September 1, 2021 to December 31, 2021. Demographic data, syphilis stage and treatment, and HIV testing and serostatus were abstracted from the electronic health record. Patients with reactive RPRs were contacted by a study physician for syphilis staging and treatment, counseling, and referral for HIV preexposure prophylaxis (PrEP) or treatment. RESULTS From September 1, 2021 to December 31, 2021, 5794 patients were triaged and 1381 underwent RPR screening (23.8%). Eighty (5.8%) had reactive RPRs, and 42 (52.5%) had active syphilis. Of those with active syphilis, 39 (92.9%) received any treatment, and 35 (83.3%) completed treatment. Patients with late syphilis were less likely to complete syphilis treatment (adjusted odds ratio, 0.03; P = 0.009; 95% confidence interval, 0.002-0.42). Among 955 offered PrEP, 41 (4.3%) expressed interest in PrEP, and 7 (0.7%) completed PrEP clinic intake. Univariate analysis did not identify any factors associated with interest in PrEP. CONCLUSIONS In a UCC setting, routine, opt-out syphilis testing resulted in increased syphilis identification and treatment. It also provided an opportunity for PrEP counseling and referral, although few patients completed PrEP clinic intake.
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Affiliation(s)
| | | | - Dylan Baker
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Meredith Lora
- From the Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Valeria D Cantos
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Stanford KA, Almirol E, Meyer M, McNulty MC. An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department. Am J Infect Control 2024; 52:770-773. [PMID: 38309531 PMCID: PMC11193631 DOI: 10.1016/j.ajic.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. METHODS This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. RESULTS The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. DISCUSSION An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. CONCLUSIONS Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.
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Affiliation(s)
- Kimberly A Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, IL.
| | - Ellen Almirol
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Makenna Meyer
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Moira C McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
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4
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Moncrieff L, O'Reilly M, Hall L, Heal C. Interventions aimed at increasing syphilis screening among non-pregnant individuals in healthcare settings: a systematic review and meta-analysis. Sex Health 2024; 21:SH24019. [PMID: 38771948 DOI: 10.1071/sh24019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
Syphilis remains a pressing public health concern with potential severe morbidity if left untreated. To improve syphilis screening, targeted interventions are crucial, especially in at-risk populations. This systematic review synthesises studies that compare syphilis screening in the presence and absence of an intervention. A systematic search of four databases was conducted (Medline, Embase, Cinahl and Scopus). The primary outcomes evaluated included syphilis screening, re-screening and detection rates. Findings were synthesised narratively. Where multiple studies were clinically heterogenous, a pooled odds ratio was calculated. Twenty-four studies were included. A variety of interventions showed promise including clinician alerts, which increased syphilis screening rate (OR range, 1.25-1.45) and patient SMS reminders that mostly improved re-screening/re-attendance rates (OR range, 0.93-4.4). Coupling syphilis serology with routine HIV monitoring increased the proportion of HIV-positive individuals undergoing both tests. However, pooling three studies with this intervention using the outcome of syphilis detection rate yielded inconclusive results (pooled OR 1.722 [95% CI 0.721-2.723], I 2 =24.8%, P =0.264). The introduction of hospital-based packaged testing for screening high-risk individuals is unique given hospitals are not typical locations for public health initiatives. Nurse-led clinics and clinician incentives were successful strategies. Including syphilis screening with other existing programs has potential to increase screening rates (OR range, 1.06-2.08), but requires further investigation. Technology-driven interventions produced cost-effective, feasible and positive outcomes. Challenges were evident in achieving guideline-recommended screening frequencies for men who have sex with men, indicating the need for multifaceted approaches. Wider application of these interventions may improve syphilis screening and detection rates.
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Affiliation(s)
- Leah Moncrieff
- College of Medicine and Dentistry, James Cook University, Building K Level 1, 475 Bridge Road, Mackay, Qld 4740, Australia
| | - Morgan O'Reilly
- College of Medicine and Dentistry, James Cook University, Building K Level 1, 475 Bridge Road, Mackay, Qld 4740, Australia
| | - Leanne Hall
- College of Medicine and Dentistry, James Cook University, Building K Level 1, 475 Bridge Road, Mackay, Qld 4740, Australia
| | - Clare Heal
- College of Medicine and Dentistry, James Cook University, Building K Level 1, 475 Bridge Road, Mackay, Qld 4740, Australia
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Solnick RE, López LH, Martinez PM, Zucker JE. Sexually Transmitted Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:335-368. [PMID: 38641394 DOI: 10.1016/j.emc.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
As the United States faces a worsening epidemic of sexually transmitted infections (STIs), emergency departments (EDs) play a critical role in identifying and treating these infections. The growing health inequities in the distribution and disproportionate impact of STIs add to the urgency of providing high-quality sexual health care through the ED. Changes in population health are reflected in the new Centers for Disease Control recommendations on screening, diagnostic testing, and treatment of STIs. This review covers common, as well as and less common or emerging STIs, and discusses the state-of-the-art guidance on testing paradigms, extragenital sampling, and antimicrobial treatment and prevention of STIs.
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Affiliation(s)
- Rachel E Solnick
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA.
| | - Laura Hernando López
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA
| | - Patricia Mae Martinez
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine- Research Division, 555 West 57th Street, 5th Floor Suite 5-25, New York, NY 10019, USA
| | - Jason E Zucker
- Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, Box 82, New York, NY 10032, USA
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6
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White DAE, Solnick RE. Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department. Emerg Med Clin North Am 2024; 42:369-389. [PMID: 38641395 DOI: 10.1016/j.emc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Rachel E Solnick
- Icahn School of Medicine at Mount Sinai Hospital, 555 West 57th Street 5-25, New York, NY 10019, USA
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Hunt JH, Laeyendecker O, Rothman RE, Fernandez RE, Dashler G, Caturegli P, Hansoti B, Quinn TC, Hsieh YH. A Potential Screening Strategy to Identify Probable Syphilis Infections in the Urban Emergency Department Setting. Open Forum Infect Dis 2024; 11:ofae207. [PMID: 38813260 PMCID: PMC11135134 DOI: 10.1093/ofid/ofae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/10/2024] [Indexed: 05/31/2024] Open
Abstract
Background Syphilis diagnosis in the emergency department (ED) setting is often missed due to the lack of ED-specific testing strategies. We characterized ED patients with high-titer syphilis infections (HTSIs) with the goal of defining a screening strategy that most parsimoniously identifies undiagnosed, untreated syphilis infections. Methods Unlinked, de-identified remnant serum samples from patients attending an urban ED, between 10 January and 9 February 2022, were tested using a three-tier testing algorithm, and sociodemographic variables were extracted from ED administrative database prior to testing. Patients who tested positive for treponemal antibodies in the first tier and positive at high titer (≥1:8) for nontreponemal antibodies in the second tier were classified as HTSI. Human immunodeficiency virus (HIV) status was determined with Bio-Rad enzyme-linked immunosorbent assay and confirmatory assays. Exact logistic regression and classification and regression tree (CART) analyses were performed to determine factors associated with HTSI and derive screening strategies. Results Among 1951 unique patients tested, 23 (1.2% [95% confidence interval, .8%-1.8%]) had HTSI. Of those, 18 (78%) lacked a primary care physician, 5 (22%) were HIV positive, and 8 (35%) were women of reproductive age (18-49 years). CART analysis (area under the curve of 0.67) showed that using a screening strategy that measured syphilis antibodies in patients with HIV, without a primary care physician, and women of reproductive age would have identified most patients with HTSI (21/23 [91%]). Conclusions We show a high prevalence of HTSI in an urban ED and propose a feasible, novel screening strategy to curtail community transmission and prevent long-term complications.
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Affiliation(s)
- Joanne H Hunt
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Oliver Laeyendecker
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard E Rothman
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gaby Dashler
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Patrizio Caturegli
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Scott K, Faryar KA, Patil N, Gripshover B, Hammond C, Purohit M, Schmotzer C, Suleman-Civis L, Niforatos J, Avery A, Yax J. Evaluation of an emergency department opt-out provider-driven HIV and syphilis screening and linkage-to-care program. Am J Emerg Med 2024; 77:187-193. [PMID: 38163414 DOI: 10.1016/j.ajem.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVE While the effectiveness of emergency departments (ED) in screening for HIV and syphilis is understood, less is known about dual screening programs. We aim to evaluate the impact of an opt-out provider-initiated HIV and syphilis program on screening, diagnosis, and linkage to care outcomes. METHODS We performed a retrospective review of patients screened pre (2014-2017) and post (2017-2021) program implementation. Primary outcomes include HIV and syphilis screening, incidence of positive tests, and proportion of patients linked to care. Secondary outcomes included pre-exposure prophylaxis (PrEP) referral and successful linkage rates for HIV-negative syphilis-positive patients. RESULTS Pre-implementation, 882 HIV tests were performed, of which 22 (2.49%) were new cases and 18 (81.82%) were linked to care; 754 syphilis tests were performed, of which 33 (4.38%) were active infections and 30 (90.91%) were treated. No eligible patients received PrEP referral. Post-implementation, 12,999 HIV tests were performed, of which 73 (0.56%) were new cases and 55 (75.34%) were linked to care; 10,885 syphilis tests were performed, of which 216 (1.98%) were active infections and 188 (87.04%) were treated. 25 (9.09%) eligible patients were referred for PrEP, and four (16.0%) attended their appointment. CONCLUSIONS Post-implementation, there was a 1373.81% and 1343.63% increase in screening, and a 231.82% and 554.55% increase in positive cases of HIV and syphilis, respectively. Dual screening programs can be successfully implemented within the existing ED framework to increase screening and early detection for HIV and syphilis.
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Affiliation(s)
- Kristal Scott
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA.
| | - Kiran A Faryar
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA
| | - Nirav Patil
- Clinical Research Center, University Hospitals, Cleveland, OH, USA
| | - Barbara Gripshover
- Department of Infectious Disease, University Hospitals, Cleveland, OH, USA
| | | | - Maulik Purohit
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christine Schmotzer
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Joshua Niforatos
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ann Avery
- MetroHealth Medical Center, Cleveland, OH, USA
| | - Justin Yax
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA
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9
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Clarkson-During A, Almirol E, Eller D, Hazra A, Stanford KA. Risk factors for treatment non-completion among patients with syphilis. Ther Adv Infect Dis 2024; 11:20499361241265941. [PMID: 39091981 PMCID: PMC11292680 DOI: 10.1177/20499361241265941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 06/14/2024] [Indexed: 08/04/2024] Open
Abstract
Background With recent increases in syphilis, there is growing interest in expanding screening; however, treatment rates have historically been low. Objectives This study examines demographic and clinical factors that may contribute to non-completion of syphilis treatment. Design This is a retrospective comparative cohort study of all patients with syphilis from January through November 2018 at an urban, tertiary care hospital. Methods Demographics and clinical information were extracted from the electronic medical record. Descriptive statistics and odds ratios (ORs) were calculated. Results Of 171 patients with syphilis, 89 (52.0%) completed treatment. Patients ages 40-49 were least likely to complete treatment (OR 0.14; 95% CI 0.03-0.72, p = 0.02) compared to those ages 18-24. Non-heterosexual patients were significantly more likely to complete treatment (OR 3.60; 95% CI 1.13-11.49, p = 0.03) compared to heterosexual patients. Patients diagnosed in the emergency department completed treatment at the lowest rate. Conclusion A major gap in syphilis treatment still exists, which must be addressed to achieve optimal impact from syphilis screening programs.
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Affiliation(s)
| | - Ellen Almirol
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, IL, USA
| | - Dylan Eller
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, IL, USA
| | - Aniruddha Hazra
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, IL, USA
| | - Kimberly A. Stanford
- Section of Emergency Medicine, The University of Chicago, 5841 S. Maryland Avenue, MC 5068, Chicago, IL 60637, USA
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McDonald R, O'Callaghan K, Torrone E, Barbee L, Grey J, Jackson D, Woodworth K, Olsen E, Ludovic J, Mayes N, Chen S, Wingard R, Johnson Jones M, Drame F, Bachmann L, Romaguera R, Mena L. Vital Signs: Missed Opportunities for Preventing Congenital Syphilis - United States, 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:1269-1274. [PMID: 37971936 PMCID: PMC10684351 DOI: 10.15585/mmwr.mm7246e1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Introduction Congenital syphilis cases in the United States increased 755% during 2012-2021. Syphilis during pregnancy can lead to stillbirth, miscarriage, infant death, and maternal and infant morbidity; these outcomes can be prevented through appropriate screening and treatment. Methods A cascading framework was used to identify and classify missed opportunities to prevent congenital syphilis among cases reported to CDC in 2022 through the National Notifiable Diseases Surveillance System. Data on testing and treatment during pregnancy and clinical manifestations present in the newborn were used to identify missed opportunities to prevent congenital syphilis. Results In 2022, a total of 3,761 cases of congenital syphilis in the United States were reported to CDC, including 231 (6%) stillbirths and 51 (1%) infant deaths. Lack of timely testing and adequate treatment during pregnancy contributed to 88% of cases of congenital syphilis. Testing and treatment gaps were present in the majority of cases across all races, ethnicities, and U.S. Census Bureau regions. Conclusions and implications for public health practice Addressing missed opportunities for prevention, primarily timely testing and appropriate treatment of syphilis during pregnancy, is important for reversing congenital syphilis trends in the United States. Implementing tailored strategies addressing missed opportunities at the local and national levels could substantially reduce congenital syphilis.
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11
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Gupta P, Fairley CK, Chen MY, Bradshaw CS, Fehler G, Plummer EL, Vodstrcil LA, Tran J, Aung ET, Chow EP. Increased syphilis testing and detection of late latent syphilis among women after switching from risk-based to opt-out testing strategy in an urban Australian sexual health clinic: a retrospective observational study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100875. [PMID: 38116502 PMCID: PMC10730308 DOI: 10.1016/j.lanwpc.2023.100875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 12/21/2023]
Abstract
Background The Melbourne Sexual Health Centre (MSHC) implemented an opt-out syphilis test for women in December 2017. We aimed to examine the differences in syphilis testing uptake and confirmed syphilis cases among women after switching from risk-based to opt-out testing strategies. Methods This was a retrospective study examining all women attending the MSHC for the first time in periods of risk-based testing (2015-2017) and opt-out testing (2018-2020). We calculated the proportion of women who tested for syphilis and the proportion of women with confirmed syphilis in each period. A chi-square test was performed to determine the differences in proportion between the risk-based testing and opt-out periods. Findings A total of 27,481 women (i.e. 13,059 in the risk-based testing period and 14,422 in the opt-out period) were included in the final analysis, and the mean age was 26.8 years (standard deviation = 6.9). The proportion of women who were tested for syphilis at their first consultation increased from 52.8% (6890/13,059) in the risk-based testing period to 67.4% (9725/14,422) in the opt-out period (p < 0.0001). Syphilis positivity did not differ between the two periods (0.48% [33/6890] vs 0.71% [69/9725], p = 0.061) but late latent causes increased from 36.4% [12/33] to 60.9% [42/69] (p = 0.033). Interpretation The opt-out testing strategy increased syphilis testing among women with increased detection of asymptomatic late latent syphilis. The opt-out syphilis testing strategy is beneficial in sexual health services. Health education and awareness may be required to improve syphilis testing uptake. Funding National Health and Medical Research Council.
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Affiliation(s)
- Palak Gupta
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Christopher K. Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Marcus Y. Chen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Catriona S. Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Glenda Fehler
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Erica L. Plummer
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lenka A. Vodstrcil
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julien Tran
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ei T. Aung
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric P.F. Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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Stanford KA, Almirol E, Eller D, Hazra A, Schneider J. Routine, Opt-Out, Emergency Department Syphilis Testing Increases HIV Preexposure Prophylaxis Uptake. Sex Transm Dis 2023; 50:292-297. [PMID: 36689476 PMCID: PMC10116839 DOI: 10.1097/olq.0000000000001774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Many people vulnerable to HIV do not perceive themselves at risk or consider preexposure prophylaxis (PrEP). This study hypothesizes that syphilis diagnosis through universal, emergency department (ED) screening would increase PrEP uptake. METHODS This prospective cohort study enrolled patients tested for syphilis through ED screening between July 2019 and July 2021. Participants completed a survey about behaviors, HIV and PrEP knowledge, and opinions at the time of enrollment. All were offered PrEP if they met Centers for Disease Control and Prevention guidelines for PrEP use. Information about PrEP use and HIV status was collected 6 months later. Bivariate analysis was used to compare outcomes between groups testing positive versus negative for syphilis. RESULTS The study enrolled 97 participants, 49 with syphilis and 48 testing negative. Overall, 11 (11.3%) started PrEP, all in the syphilis group, despite 28 (58.3%) in the negative group having indications for PrEP. Participants with syphilis less frequently reported low perceived HIV risk than syphilis-negative participants who reported HIV transmission behaviors (83.7% vs. 92.9%). Participants reporting moderate to high HIV risk perception were significantly more likely to start PrEP (odds ratio, 10.5; 95% confidence interval, 1.41-78.1; P = 0.02). At 6 months, 3 participants remained on PrEP (follow-up data available for 63.5% of PrEP-eligible participants). CONCLUSIONS Syphilis diagnosis was associated with increased perception of HIV risk and increased PrEP initiation. Individuals who otherwise might not seek testing for syphilis because of perceived low risk may be identified through routine screening, thus providing an important opportunity to link more people to HIV prevention and PrEP services.
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Affiliation(s)
| | - Ellen Almirol
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
| | - Dylan Eller
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
| | - Aniruddha Hazra
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
| | - John Schneider
- Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
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Wiginton JM, Eaton LA, Kalinowski J, Watson RJ, Kalichman SC. Lifetime prevalence of syphilis infection among predominantly Black sexual and gender minorities living with HIV in Atlanta, Georgia: a cross-sectional analysis. ETHNICITY & HEALTH 2023; 28:159-169. [PMID: 34818951 PMCID: PMC9126996 DOI: 10.1080/13557858.2021.2007225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Syphilis infection disproportionately impacts Black sexual and gender minorities (SGM) in the United States. The extent of this impact among those living with HIV has been minimally examined. This study sought to examine lifetime syphilis prevalence and associated factors in a community sample of predominantly Black SGM living with HIV in the Southeastern US. DESIGN Participants (N = 174) enrolled in a stigma-mitigation trial for people living with HIV in Atlanta, Georgia, completed a sub-study involving testing for Treponema pallidum antibodies, indicative of lifetime syphilis infection. We performed chi-square and Fisher's exact tests to assess sociodemographic and healthcare differences by presence/absence of lifetime syphilis infection. RESULTS Most participants identified as non-Hispanic Black (n = 142/174; 81.6%) and cisgender male (n = 146/174; 83.9%). More than two thirds (n = 120/174) identified as gay/homosexual. We documented a 55.7% (n = 97/174) lifetime prevalence of syphilis infection and observed differences by sexual identity, with 77.3% (n = 75/97) of those screening positive reporting gay/homosexual identity relative to 58.4% (n = 45/77) of those screening negative (chi-square[1] = 7.8, p < 0.010). CONCLUSION Findings underscore how syphilis prevention efforts have missed the most marginalized, warranting a renewed, comprehensive strategy for improving the sexual health of Black SGM. Embedding targeted, respectful community engagement, expanded testing access, and healthcare provider training into broader sexual health and psychosocial wellness efforts is needed.
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Affiliation(s)
- John Mark Wiginton
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa A. Eaton
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
| | - Jolaade Kalinowski
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
| | - Ryan J. Watson
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
| | - Seth C. Kalichman
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA
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Affiliation(s)
- Aniruddha Hazra
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, Illinois
| | - Maggie W Collison
- Division of Infectious Disease, NorthShore University HealthSystem, Evanston, Illinois
| | - Andrew M Davis
- Section of General Internal Medicine, University of Chicago Medicine, Chicago, Illinois
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Ford JS, Shevchyk I, Yoon J, Chechi T, Voong S, Tran N, May L. Risk Factors for Syphilis at a Large Urban Emergency Department. Sex Transm Dis 2022; 49:105-110. [PMID: 34471079 DOI: 10.1097/olq.0000000000001543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of syphilis is increasing in the United States. The emergency department (ED) is an important setting to screen and treat underserved populations. To tailor testing protocols to the local population, we aimed to identify risk factors for syphilis positivity in ED patients. METHODS We performed a retrospective analysis of ED patients who were screened for syphilis between November 2018 and August 2020. Patients were screened for Treponema pallidum antibody using a multiplex flow immunoassay, and positive results were confirmed by rapid plasma reagin or T. pallidum particle agglutination. Risk factors for new syphilis diagnoses were identified using multiple logistic regression. RESULTS We screened 1974 patients for syphilis (mean age, 37 ± 16 years; 56% female). We identified 201 patients with new infections without previous treatment. Independent risk factors for a new diagnosis of syphilis included housing status (undomiciled, 23% [60 of 256]; domiciled, 9% [133 of 1559]; adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.2-3.0]), history of HIV (positive, 44% [28 of 63]; negative, 9% [173 of 1893]; aOR, 5.8 [95% CI, 3.0-11.2]), tobacco use (positive, 15% [117 of 797]; negative, 4% [29 of 665]; aOR, 2.4 [95% CI, 1.5-3.9]), and illicit drug use (positive, 14% [112 of 812]; negative, 8% [52 of 678]; aOR, 2.2 [95% CI, 1.0-2.5]). CONCLUSIONS Undomiciled housing status, history of HIV, history of tobacco use, and history of illicit drug use were independently associated with a new diagnosis of syphilis in the ED. Broadening targeted syphilis screening algorithms beyond sexually transmitted disease-related complaints could help identify new syphilis cases for treatment.
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Affiliation(s)
| | | | | | | | | | - Nam Tran
- Pathology and Laboratory Medicine, UC Davis Health, Sacramento, CA
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[Sexual behavior and prevention of sexually transmitted infections taking the SARS-CoV-2 pandemic into account. Data from a sexual healthcare and medicine center-WIR]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:1440-1451. [PMID: 34665268 PMCID: PMC8523933 DOI: 10.1007/s00103-021-03441-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022]
Abstract
Hintergrund Anwendungsbezogene Daten zu sexueller Gesundheit und sexuellem Verhalten in unterschiedlich sexuell aktiven Populationen stehen nur begrenzt zur Verfügung, sind aber für Präventions- und Versorgungsstrategien sehr relevant. Das multisektorale Versorgungszentrum WIR – Walk In Ruhr hat aufgrund seiner Besucher*innenstruktur Zugang zu Daten aus diversen Lebenswelten. Ziel der Arbeit Aus verschiedenen WIR-internen Datenquellen sollen populationsbezogene Erkenntnisse zu Alter, Geschlecht, sexueller Orientierung, Sexual- und Risikoverhalten gewonnen und Bedarfe für Prävention abgeleitet werden. Einflüsse der SARS-CoV-2-Pandemie auf das Sexualverhalten sollen durch den Vergleich verschiedener Zeiträume untersucht werden. Methoden Ausgewertete Datenquellen sind der Onlinerisikotest für HIV und STI, die COWIR- und PrEP-Studie sowie die Immunologische Ambulanz und das Gesundheitsamt im WIR. Ergebnis Sexuell übertragbare Infektionen (STI) sind von 2019 auf 2020 trotz Kontaktbeschränkungen gestiegen. Generell haben junge Menschen, Männer, die Sex mit Männern, und Frauen, die Sex mit Frauen haben, ein erhöhtes STI-Risiko aufgrund der gewählten Sexualpraktiken und der Anzahl sexueller Kontakte. Eine hohe Zahl bi- und transsexueller Kontakte ist festzustellen. SARS-CoV‑2 führte zu einer Reduzierung der Sexualkontakte. Sexualpraktiken wurden weiter gelebt. Die STI-Testquote und die Behandlungsrate stiegen an. Diskussion Die Daten aus dem WIR belegen, dass eine junge Klientel mit aktivem Sexualleben erreicht wird. Die Ergebnisse aus Fragebögen und dem Onlinerisikotest zeigen den Zusammenhang von erhöhten positiven STI-Tests mit Sexualverhalten und sexuellen Präferenzen, weshalb spezifische Strategien zu Sexualaufklärung, Prävention, Tests und Therapien erforderlich sind.
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Ford JS, Chechi T, Otmar M, Baker M, Waldman S, Morgan B, Tan D, Tran NK, May L. ED syphilis and gonorrhea/chlamydia cotesting practices before and after the implementation of an electronic health record-based alert. Emerg Med J 2021; 39:emermed-2020-210331. [PMID: 34548414 DOI: 10.1136/emermed-2020-210331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/08/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The prevalence of syphilis is increasing in many countries, including the USA. The ED is often used by underserved populations, making it an important setting to test and treat patients who are not evaluated in outpatient clinical settings. We aimed to assess the utility of an ED-based syphilis and gonorrhoea/chlamydia cotesting protocol by comparing testing practices before and after its implementation. METHODS We implemented an electronic health record (EHR) alert that prompted clinicians to order syphilis testing in patients undergoing gonorrhoea/chlamydia testing. We performed a retrospective cohort analysis that compared outcomes between the preimplementation period (January-November 2018) and the postimplementation period (January-November 2019). Patients were tested for Treponema pallidum antibody (TPA) using a multiplex flow immunoassay (MFI), and positive results were confirmed by rapid plasma reagin (RPR). The primary implementation outcome was the number of syphilis tests/month, and the primary clinical outcome was the number of syphilis diagnoses/month (defined as positive TPA MFI and RPR). We performed an interrupted time-series analysis to evaluate the effect of implementing the alert over time. RESULTS Four-hundred and ninety-four and 1106 unique patients were tested for syphilis in the preimplementation and postimplementation periods, respectively. Syphilis testing increased by 55.6 tests/month (95% CI 45.9 to 65.3, p<0.001) following alert implementation. Patients tested in the postimplementation period who were tested using the alert were much younger (difference: 14 years (95% CI 12 to 15)) and were more likely to be female (difference: 15% (95% CI 8 to 21)) and African-American (difference: 11% (95% CI 5 to 17)) than patients tested by clinician-initiated testing. Presumptive syphilis diagnoses increased from 3.4 diagnoses/month to 7.9 diagnoses/month (difference, 4.5 (95% CI 2.2 to 6.9), p<0.001). CONCLUSIONS Our study demonstrates that use of a targeted EHR alert testing protocol can increase syphilis testing and diagnosis and may reduce clinician bias in testing.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Tasleem Chechi
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Michella Otmar
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Melissa Baker
- Georgetown University School of Medicine, Washington, DC, USA
| | - Sarah Waldman
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Brittany Morgan
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - David Tan
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, California, USA
| | - Larissa May
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
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