Background Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test. Methods Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and >100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility. Results 119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic. Conclusion Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies. Disclosures All Authors: No reported disclosures.
Background Sexually transmitted infections (STIs) remain a serious public health concern. The state of Utah has the lowest percentage of adults 18-64 years-old ever tested for HIV (26.5%) and the lowest percentage tested for HIV in the previous 12 months (6.5%). Increasing HIV testing in Utah is of the utmost importance. Delayed diagnoses and missed testing opportunities for HIV and other STIs exist. Encounters for evaluation of possible gonorrhea (GC) or chlamydia (CT) infection is a critical opportunity to co-test for HIV and syphilis. With continued growth, urgent care (UC) sites are well-positioned to increase STI diagnosis and treatment. We aimed to develop a multi-faceted quality improvement (QI) bundle to increase STI testing in our UC centers. Methods Intermountain Healthcare (IH) is a vertically integrated healthcare network predominantly in Utah and operates a network of 35 UC clinics across the state. In 2020, qualitative interviews to evaluate barriers to STI testing were performed with UC clinicians. Based on these interviews a QI initiative was designed and implemented throughout 2021. The bundle included clinician education, electronic health record (EHR) improvements, and automatic referral for patients with a new diagnosis of HIV to an Infectious Diseases (ID) physician (Methods Image 1). We compared co-testing rates before (July 2018 – December 2020) and after the intervention began (March 2021 – April 2022). Methods Table 1 The quality improvement (QI) initiative began in 2021 and consisted of multiple components as detailed below. Results 13,715 and 5,628 UC encounters were associated with GC/CT testing during the pre-intervention and intervention periods, respectively. HIV co-testing was performed in 2,784 (20.3%) GC/CT testing encounters in the pre-intervention period and in 1,674 (29.7%) encounters during the intervention, a relative increase of 37.6%. HIV/syphilis co-testing was performed in 2,304 (16.8%) GC/CT testing encounters and 1,225 (21.8%) encounters during the pre-intervention and intervention phases, respectively. From January 1 2022 – April 1 2022 3 new outpatient HIV diagnoses were identified. The average time from diagnosis to contact with an ID provider was 30.0 hours. Results Image 1 Co-testing rates for GC/CT UC encounters are presented for HIV (blue), syphilis (green), and HIV/syphilis (orange). Testing reagent quality issues in early 2022 lead to an abrupt decline in syphilis co-testing and once these issues were resolved co-testing trends returned to similar rates prior to the reagent quality issue and testing limitation. Conclusion Multi-modal QI initiatives may increase STI testing rates within UC centers of integrated healthcare systems. Further study is needed to optimize STI screening, diagnosis, and care in UC centers. Disclosures Kimberly D. Brunisholz, PhD, MST, Johnson and Johnson: Advisor/Consultant.
Background Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system. Methods This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity. Results 93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1 Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold. Conclusion Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts. Disclosures All Authors: No reported disclosures.
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