Impact of risk‐based sexually transmitted infection screening in the emergency department

Abstract

Objectives: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents. Methods:We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real-time into the electronic health record. Patients who tested positive received treatment according to our standard-of-care practices.All patients 15-21 years of age were asked to complete this on an opt-out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non-English speaking. Our primary outcome was to describe STI-testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it.Results: In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. nonparticipants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non-participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia.

The Use of the Consolidated Framework for Implementation Research to Understand Facilitators and Barriers to Sexually Transmitted Infection Screening in Primary Care

“…1,15,16 We previously implemented an STI risk assessment tool into our electronic health record (EHR) to improve STI testing among at-risk patients, regardless of the reason for visit. 9,16,17 Building on the success of our ED work, we sought to implement this program into pediatric primary care practices.…”

“…7,[10][11][12][13][14] The St. Louis metropolitan region has a high incidence of STIs, with up to 50% of adolescents receiving care in our pediatric ED previously shown to be at high risk for STIs, even when receiving care for unrelated reasons. 1,15,16 We previously implemented an STI risk assessment tool into our electronic health record (EHR) to improve STI testing among at-risk patients, regardless of the reason for visit. 9,16,17 Building on the success of our ED work, we sought to implement this program into pediatric primary care practices.…”

Adapting an Electronic STI Risk Assessment Program for Use in Pediatric Primary Care

“…In the ED, 15 to 21 years old patients and their families are given a brochure giving a non-specific overview of the program and discussing the need for privacy and confidentiality when the patient answers the questionnaire. 6,9 Patients using the questionnaire read a brief introduction explaining the purpose of the questionnaire-to identify if they should be offered STI testing during the visit. They were then asked a series of questions to obtain a sexual history; an integrated decision rule then provides recommendations as to whether the patient should be offered testing for gonorrhea/ chlamydia and/or HIV during the visit.…”

“…[10][11][12] We demonstrated similar findings when implementing this program in our ED, and it led to increased STI diagnoses. 6 The St. Louis region has among the highest incidences of STIs in the United States and has a critical need for improved STI screening among adolescents. 1 Pediatric primary care clinics may be even better positioned for STI risk assessments, as they often offer greater privacy and confidentiality, a less stressful patient environment, and greater opportunity for longitudinal care.…”

“…We previously piloted and implemented an STI risk assessment program in our pediatric emergency department (ED). 6 - 9 This platform utilized a novel electronic questionnaire and software platform that integrated into the electronic health record (EHR). 9 A robust literature has already shown that adolescents prefer disclosing sensitive information such as sexual histories via digital means instead of face-to-face interviews.…”