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Frock-Welnak DN, Tam J. Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae. Obstet Gynecol Clin North Am 2022; 49:551-579. [PMID: 36122985 DOI: 10.1016/j.ogc.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper female genital tract. The presentation of PID varies from asymptomatic cases to severe sepsis. The diagnosis of PID is often one of exclusion. Primary treatment for PID includes broad-spectrum antibiotics with coverage against gonorrhea, chlamydia, and common anaerobic and aerobic bacteria. If not clinically improved by antibiotics, percutaneous drain placement can promote efficient source control, as is often the case with large tubo-ovarian abscesses. Ultimately, even with treatment, PID can result in long-term morbidity, including chronic pelvic pain, infertility, and ectopic pregnancy.
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Affiliation(s)
- Danielle N Frock-Welnak
- Division of Academic Specialists in OB/GYN, University of Colorado School of Medicine, Aurora, CO, USA; Obstetrics and Gynecology, School of Medicine, CU Anschutz, Academic Office One, 12631 East 17th Avenue, 4th Floor, Aurora, CO 80045, USA.
| | - Jenny Tam
- Division of Academic Specialists in OB/GYN, Department of Obstetrics and Gynecology, University of Colorado, School of Medicine, CU Anschutz, Academic Office One, 12631 East 17th Avenue, 4th Floor, Aurora, CO 80045, USA
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Caruso G, Giammanco A, Virruso R, Fasciana T. Current and Future Trends in the Laboratory Diagnosis of Sexually Transmitted Infections. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1038. [PMID: 33503917 PMCID: PMC7908473 DOI: 10.3390/ijerph18031038] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/18/2022]
Abstract
Sexually transmitted infections (STIs) continue to exert a considerable public health and social burden globally, particularly for developing countries. Due to the high prevalence of asymptomatic infections and the limitations of symptom-based (syndromic) diagnosis, confirmation of infection using laboratory tools is essential to choose the most appropriate course of treatment and to screen at-risk groups. Numerous laboratory tests and platforms have been developed for gonorrhea, chlamydia, syphilis, trichomoniasis, genital mycoplasmas, herpesviruses, and human papillomavirus. Point-of-care testing is now a possibility, and microfluidic and high-throughput omics technologies promise to revolutionize the diagnosis of STIs. The scope of this paper is to provide an updated overview of the current laboratory diagnostic tools for these infections, highlighting their advantages, limitations, and point-of-care adaptability. The diagnostic applicability of the latest molecular and biochemical approaches is also discussed.
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Affiliation(s)
- Giorgia Caruso
- U.O.C. of Microbiology and Virology, ARNAS “Civico, Di Cristina and Benfratelli”, 90127 Palermo, Italy
| | - Anna Giammanco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy; (A.G.); (T.F.)
| | - Roberta Virruso
- U.O.C. of Microbiology, Virology and Parassitology, A.O.U.P. “Paolo Giaccone”, 90127 Palermo, Italy;
| | - Teresa Fasciana
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy; (A.G.); (T.F.)
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Wilson SP, Vohra T, Goldberg J, Price C, Calo S, Mahan M, Miller J. Reliable Rapid Assay for Gonorrhea and Chlamydia in the Emergency Department. J Emerg Med 2017; 53:890-895. [PMID: 29074030 DOI: 10.1016/j.jemermed.2017.08.094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/05/2017] [Accepted: 08/30/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections seen in the emergency department (ED). Due to an inability to reliably make accurate diagnosis by physical examination, concern for unreliable follow-up, and current delays in diagnostic nucleic acid amplification testing (NAAT), presumptive treatment active against CT and NG, as described by Centers for Disease Control clinical practice guidelines, is often performed. OBJECTIVES The purpose of this study was to determine whether a rapid, urine NAAT performed in the ED is noninferior in its diagnostic sensitivity compared with a traditional, swab NAAT assay. METHODS We performed a prospective, noninferiority study comparing two U.S. Food and Drug Administration-approved NAAT assays for CT and NG: a 90-min rapid assay, the Xpert CT/NG Assay (Cepheid, Sunnyvale, CA) using a urine sample vs. a traditional assay, the Aptima Combo 2 Assay (Gen-Probe Incorporated, San Diego, CA) using a swab sample. This study was registered on Clinicaltrials.gov (NCT02386514). RESULTS A total of 1162 patient samples were included in the primary analysis. We observed excellent kappa agreement between assays: NG for men, 1.00 (95% confidence interval [CI] 1.00-1.00); NG for women, 0.87 (95% CI 0.79-0.94); CT for men, 0.81 (95% CI 0.59-1.00); and CT for women: 0.85 (95% CI 0.80-0.90), as well as excellent negative and positive predictive values for the rapid assay. CONCLUSION Although the rapid Xpert CT/NG assay's diagnostic sensitivity did not meet our prespecified threshold for noninferiority, the diagnostic characteristics are robust enough to fit into a management pathway that may reduce unnecessary antibiotic use. There may be an opportunity to utilize the rapid Xpert CT/NG assay to improve accuracy of treatment in the ED.
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Affiliation(s)
- Sean P Wilson
- Department of Emergency Medicine, Kaiser Permanente, Anaheim, California
| | - Taher Vohra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jared Goldberg
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Christopher Price
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sean Calo
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Meredith Mahan
- Department of Public Health, Henry Ford Hospital, Detroit, Michigan
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
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Wilson SP, Vohra T, Knych M, Goldberg J, Price C, Calo S, Mahan M, Miller J. Gonorrhea and chlamydia in the emergency department: Continued need for more focused treatment for men, women and pregnant women. Am J Emerg Med 2017; 35:701-703. [PMID: 28073612 DOI: 10.1016/j.ajem.2017.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/02/2017] [Accepted: 01/02/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Delay in current nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis has led to recommendations for presumptive treatment in patients with concern for infection and unreliable follow-up. In the urban setting, it is assumed that many patients have unreliable follow-up, therefore presumptive therapy is thought to be used frequently. We sought to measure the frequency of disease and accuracy of presumptive treatment for these infections. METHODS This was an observational cohort study performed at an urban academic Level 1 trauma center ED with an annual census of 95,000 visits per year. Testing was performed using the APTIMA Unisex swab assay (Gen-Probe Incorporated, San Diego, CA). Presumptive therapy was defined as receiving treatment for both infections during the initial encounter without confirmation of diagnosis. RESULTS A total of 1162 patients enrolled. Infection was present in 26% of men, 14% of all women and 11% of pregnant women. Despite high frequency of presumptive treatment, >4% of infected patients in each category went untreated. CONCLUSION Inaccuracy of presumptive treatment was common for these sexually transmitted infections. There is an opportunity to improve diagnostic accuracy for treatment.
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Affiliation(s)
- Sean P Wilson
- Department of Emergency Medicine, Kaiser Permanente Medical Center, Anaheim, CA, United States.
| | - Taher Vohra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - McKenna Knych
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Jared Goldberg
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Christopher Price
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sean Calo
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Meredith Mahan
- Department of Public Health, Henry Ford Hospital, Detroit, MI, United States
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
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Wolff M, Balamuth F, Sampayo E, Mollen C. Improving Adolescent Pelvic Inflammatory Disease Follow-up From the Emergency Department: Randomized Controlled Trial With Text Messages. Ann Emerg Med 2015; 67:602-609.e3. [PMID: 26686262 DOI: 10.1016/j.annemergmed.2015.10.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/28/2015] [Accepted: 10/19/2015] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Centers for Disease Control and Prevention guidelines recommend follow-up within 72 hours of diagnosis of pelvic inflammatory disease because patients with inadequate treatment are at increased risk of acute and chronic complications. Follow-up rates in adolescents after diagnosis range between 10% and 16%. The primary objective is to assess the effect of text message reminders to adolescent patients receiving a diagnosis of pelvic inflammatory disease on obtaining follow-up care within 72 hours of emergency department (ED) discharge. METHODS This was a single-blinded randomized controlled trial of adolescents receiving a diagnosis of pelvic inflammatory disease in the ED. Patients received standard discharge instructions or standard discharge instructions plus text message reminders. Patients in the text message group received daily, tailored text messages for 4 days, with a reminder to schedule and attend primary care provider follow-up. The primary outcome was follow-up within 72 hours of ED discharge. RESULTS Ninety-five patients (48 standard; 47 text message) were randomized. Three patients were excluded, leaving 92 patients (46 standard; 46 text message) for analysis. Baseline characteristics were similar between treatment groups. Follow-up was 15.2% in the standard group and 43.5% in the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (relative risk 2.9; 95% confidence interval [CI] 1.4 to 5.7). The absolute efficacy difference was 28.3% (95% CI 9.5% to 46.9%), yielding number needed to treat of 4 (95% CI 2.2 to 9.5). CONCLUSION Personalized text message reminders were efficacious in improving follow-up for adolescents after ED diagnosis of pelvic inflammatory disease.
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Affiliation(s)
- Margaret Wolff
- Departments of Pediatrics and Emergency Medicine, University of Michigan, Ann Arbor, MI.
| | - Fran Balamuth
- Children's Hospital of Philadelphia, Division of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Esther Sampayo
- Texas Children's Hospital, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Cynthia Mollen
- Children's Hospital of Philadelphia, Division of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Wilson SP, Knych M, Iordanova R, Mahan M, Vohra T. Identifying a need for more focused treatment of chlamydia and gonorrhoea in the emergency department. Int J STD AIDS 2015; 27:993-7. [PMID: 26394998 DOI: 10.1177/0956462415604769] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
Abstract
The indolent nature of chlamydia and gonorrhoea, along with the time delay associated with current diagnostic testing, makes definitive diagnosis while in the emergency department impossible. We therefore sought to determine the proportion of patients who receive accurate, presumptive antimicrobial treatment for these infections. A retrospective chart review was performed on all patient encounters that underwent chlamydia and gonorrhoea testing at an urban emergency department during a single month in 2012. Each encounter was reviewed for nucleic acid amplification test results and whether presumptive antibiotics were given during the initial visit. A total of 639 patient encounters were reviewed; 87.2% were female and the mean age was 26.7 years. Chlamydia was present in 11.1%, with women and men having similar infection rates: 10.6% vs. 14.6% (p = 0.277). Gonorrhoea was present in 5.0%, with a lower prevalence among women than men: 3.2% vs. 17.1% (p < 0.001). Women received presumptive treatment less often than men: 37.7% vs. 82.9% (p < 0.001). Presumptive treatment was less accurate in women than men: 7.9% vs. 25.6% (p < 0.001). After combining genders, 10.2% received accurate presumptive treatment; 33.3% were overtreated and 4.4% missed treatment. Presumptive treatment for chlamydia and gonorrhoea was more frequent and more accurate in men than in women. Overall, one-third of patients received unnecessary antibiotics, yet nearly 5% missed treatment. Better methods are needed for identifying patients who need treatment.
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Affiliation(s)
- Sean P Wilson
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - McKenna Knych
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | | - Meredith Mahan
- Department of Statistics, Henry Ford Hospital, Detroit, MI, USA
| | - Taher Vohra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA
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Suffoletto B, Akers A, McGinnis KA, Calabria J, Wiesenfeld HC, Clark DB. A sex risk reduction text-message program for young adult females discharged from the emergency department. J Adolesc Health 2013; 53:387-93. [PMID: 23707402 DOI: 10.1016/j.jadohealth.2013.04.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To pilot test a text message (SMS) sex risk reduction program among at-risk young adult female patients discharged from an emergency department (ED). METHODS A convenience sample of 52 female patients with hazardous drinking behavior and recent risky sexual encounters were recruited from an urban ED and randomized to the SMS program (n = 23) or a control group (n = 29). All participants completed a web-based questionnaire in the ED and at 3-month follow-up. For 12 weeks, SMS participants were asked to report whether they had a risky sexual encounter in the past week, received theory-based feedback, and were asked if they were willing set a goal to refrain from having another risky encounter. RESULTS Thirty-nine percent of SMS participants completed all weeks of SMS reports, and noncompletion increasing from 12% on week 1 to a 33% by week 12. Three-month follow-up was completed in 56% of participants. In the intervention group, there was an increase in the proportion with condom use with last vaginal sex from 20% (95% CI 4%-48%) to 53% (95% CI 27%-79%) and an increase in always condom use over the past 28 days from 0% (95% CI 0%-22%) to 33% (95% CI 12%-62%). These changes were not statistically different from control participants. CONCLUSIONS SMS programs may be useful to reduce risk for sexually transmitted diseases among at-risk young adults being discharged from the ED. Future trials should examine ways to improve adherence to SMS dialog over time and measure objective outcomes in a larger sample.
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Affiliation(s)
- Brian Suffoletto
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Huppert JS, Taylor RG, St Cyr S, Hesse EA, Reed JL. Point-of-care testing improves accuracy of STI care in an emergency department. Sex Transm Infect 2013; 89:489-94. [PMID: 23471445 DOI: 10.1136/sextrans-2012-050994] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We aimed to examine the impact of a point-of-care (POC) test on overtreatment and undertreatment of sexually transmitted infections (STIs) by comparing treatment patterns for gonorrhoea (detected with nucleic acid amplification testing (NAAT)) with trichomoniasis (detected by POC test) for young women seen in an emergency department (ED). METHODS We reviewed the database of a quality improvement (QI) project that aims to improve follow-up care for STIs in the ED. Data included the test result and antibiotic given (if any) during visits by women age 14-21 for whom an STI test was ordered. We generated Shewhart control charts and compared overtreatment and undertreatment rates for gonorrhoea and trichomoniasis using χ(2) testing. RESULTS Of 1877 visits over 18 months, 8.8% of women had gonorrhoea and 16.5% had trichomoniasis. Overtreatment was higher for women with gonorrhoea than trichomoniasis (54% vs 23%, p<0.001). Overtreatment for gonorrhoea decreased from 58% to 47% (p<0.01) and overtreatment for trichomoniasis decreased from 24% to 18% (p<0.01), which corresponded to improvements in patient follow-up for the QI project. Undertreatment was higher for women with gonorrhoea than trichomoniasis (29% vs 21%, p=0.03), and did not change over time. CONCLUSIONS A POC test improves the accuracy of STI care in an ED compared with NAAT testing. An unanticipated benefit of QI efforts to improve patient follow-up is the observed decrease in antibiotic use in the ED. Given the ability of gonorrhoea to develop antibiotic resistance, future efforts should focus on development of an accurate POC test for gonorrhoea.
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Affiliation(s)
- Jill S Huppert
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229–3039, USA.
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Jenkins WD, Zahnd W, Kovach R, Kissinger P. Chlamydia and Gonorrhea Screening in United States Emergency Departments. J Emerg Med 2013; 44:558-67. [DOI: 10.1016/j.jemermed.2012.08.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 01/27/2012] [Accepted: 08/24/2012] [Indexed: 11/30/2022]
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Woods JL, Bailey SL, Hensel DJ, Scurlock AM. Cervicitis in adolescents: do clinicians understand diagnosis and treatment? J Pediatr Adolesc Gynecol 2011; 24:359-64. [PMID: 21872515 PMCID: PMC4750483 DOI: 10.1016/j.jpag.2011.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/08/2011] [Accepted: 06/15/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cervicitis is widespread, but no studies have examined cervicitis in accordance with established guidelines for diagnosis and treatment. Study objectives were to describe adherence to Centers for Disease Control and Prevention guidelines for diagnosis and treatment of cervicitis within an adolescent population and to compare factors associated with adherence to guidelines in a primary care setting and the Emergency Department. METHODS Data were collected as part of a retrospective chart review of evaluation, diagnosis, and treatment of STI in adolescent women in an outpatient setting. Participant charts were eligible for review if they were 12-21 years of age and were given an ICD-9 and chart diagnosis of cervicitis. Two primary outcome variables: meeting cervicitis guidelines and correct treatment among those meeting cervicitis guidelines (no/yes) were utilized; the study controlled for age, race, venue, past infection with chlamydia or gonorrhea. RESULTS Subjects (n = 365) were examined for the primary outcome variables and 75.1% (274/365) met at least one criterion for cervicitis. Of these, 166 (60.9%: 166/274) subjects were found to meet criteria for cervicitis alone, versus subjects meeting criteria for both cervicitis and pelvic inflammatory disease (PID) (39.4%: 108/274). The majority, 89.3%, (326/365) were treated for both chlamydia and gonorrhea, but only 64.7% (211/326) were treated correctly for both infections. CONCLUSIONS Our findings suggest that knowledge deficits exist in diagnosis and treatment of cervicitis in adolescent patients and in differentiating between cervicitis and PID. Educational tools, simulated patient exercises, and order sets may be warranted for quality improvement to allow for improved care of this at risk sexually active population.
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Affiliation(s)
- Jennifer L Woods
- Division of Adolescent Medicine, University of Arkansas for Medical Sciences, Arkansas, USA.
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Cox S, Dean T, Posner SF, Jamieson DJ, Curtis KM, Johnson CH, Meikle S. Disparities in reproductive health-related visits to the emergency department in Maryland by age and race, 1999-2005. J Womens Health (Larchmt) 2011; 20:1833-8. [PMID: 22074208 DOI: 10.1089/jwh.2010.2554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe reproductive health-related visits to Maryland emergency departments (EDs) among women aged 15-44 years from 1999 to 2005. METHODS We obtained data from the Healthcare Cost and Utilization Project State Emergency Department Database and State Inpatient Database. ICD-9-CM diagnosis codes were used to classify reproductive health-related visits. We calculated the annual rate of reproductive health visits to Maryland EDs from 1999 to 2005 for women aged 15-44 years and tested time trends using linear regression. Admission rates were defined as the percentage of ED visits that resulted in inpatient admission. We calculated age-specific and race-specific rate ratios for diagnoses using Poisson regression and admission rate ratios using Cochran-Mantel-Haenszel statistics. RESULTS From 1999 to 2005, the rate of ED visits in Maryland increased 50%, from 28.0 to 42.1 visits per 1000 women. Lower genital tract infections were the most common diagnosis (21.4%). The rates were higher for women aged 15-24 than for women aged 25-44 (rate ratio 1.18, 95% confidence interval [CI] 1.17-1.18) and nearly three times higher for black women than white women (rate ratio 2.94, 95% CI 2.92-2.96). Admission rates were lower for women aged 15-24 than for women aged 25-44 (rate ratio 0.34, 95% CI 0.33-0.35) and were higher among black than white women (rate ratio 1.16, 95% CI 1.14-1.18). CONCLUSIONS Disparities by age and race are evident for reproductive health-related ED visits in Maryland, and many of these ED visits are for conditions that are amenable to preventive measures.
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Affiliation(s)
- Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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