Measuring Quality STI Care among Adolescent Female Primary Care Patients in Philadelphia

Abstract

Objectives:

Engagement in guideline-recommended STI care is fundamental to ending the STI epidemic in the United States. However, the United States 2021–2025 STI National Strategic Plan and STI surveillance reports do not include a framework to measure quality STI care delivery. This study developed and applied an STI Care Continuum that can be used across settings to improve STI care quality, assess adherence to guideline-recommended care, and standardize measurement of progress towards National Strategic goals.

Methods:

Review of the Centers for Disease Control and Prevention STI Treatment guidelines identified seven distinct steps of STI care for Gonorrhea, Chlamydia, and Syphilis: (1) STI testing indication, (2) STI test completion, (3) HIV testing, (4) STI diagnosis, (5) partner services, (6) STI treatment, and (7) STI retesting. Steps one through four, six, and seven for Gonorrhea and/or Chlamydia (GC/CT) were measured among 16–17 year-old females with a clinic visit at an academic pediatric primary care network in 2019. We used Youth Risk Behavior Surveillance Survey data to estimate step one, and electronic health record data for steps two, three, four, six, and seven.

Results:

Among 5,484 16–17 year-old female patients, an estimated 44% had an STI testing indication. Among those patients, 17% were tested for HIV, of whom none tested positive, and 43% were tested for GC/CT, 19% of whom were diagnosed with GC/CT. Of these patients, 91% received treatment within 2 weeks and 67% were retested within six weeks to one year after diagnosis. On retesting, 40% were diagnosed with recurrent GC/CT.

Conclusions:

Local application of a STI Care Continuum identified STI testing, retesting, and HIV testing as areas for improvement. The development of an STI Care Continuum identified novel measures for monitoring progress towards National Strategic indicators. Similar methods can be applied across jurisdictions to target resources, standardize data collection and reporting, and improve STI care quality.

Introduction

One in five people in the United States were diagnosed with sexually transmitted infections (STI) in 2018.¹ Failure to diagnose, treat, and prevent STIs increases morbidity, facilitates HIV transmission, and contributes to $16 billion in costs.¹ To address the STI epidemic, the U.S. 2021–2025 STI National Strategic Plan identifies core outcomes, disparities indicators, and priority populations and regions.² National Strategy objectives include increasing STI quality measurement, assessing guideline adherence, and improving mechanisms to evaluate progress towards goals. Missing from the National Strategy, however, is a health services framework delineating metrics of quality STI care. To address this gap and maximize implementation of the National Strategy, we present the application of an STI care continuum.

Care continuum frameworks for HIV and HIV pre-exposure prophylaxis (PrEP) have supported implementation of the National HIV/AIDS Strategy and standardized treatment and prevention outcome measurement.^3–5 The HIV Care Continuum measures engagement in HIV care from diagnosis to linkage and retention in care, receipt of antiretroviral therapy, and viral suppression.^4,6 The HIV Care Continuum has gauged progress towards national Ending the HIV Epidemic (EHE) goals. In 2015, the Centers for Disease Control and Prevention (CDC) set targets of 90% of individuals with HIV being aware of their diagnosis, 85% linked to care, and 80% virally suppressed by 2020.⁶ In 2019, the CDC reported 87% of individuals with HIV were diagnosed, 81% linked to care, but only 57% were virally suppressed,⁵ highlighting the need for interventions promoting viral suppression. Similarly, the PrEP Care Continuum progresses from identifying individuals with HIV risk, enhancing HIV risk and PrEP awareness, facilitating access, linking to care, prescribing PrEP, initiating and adhering to PrEP, and retaining individuals in care, thus standardizing benchmarks and outcome measurements.³ These continuums are now incorporated into an HIV status-neutral framework adopted by the National HIV/AIDS Strategy.⁵ Adopting an STI care continuum is a promising approach to bolster efforts to end the STI Epidemic.

Surveillance of U.S. STIs demonstrates room for expanding outcome measurement. The CDC reports national rates of Chlamydia, Gonorrhea, and Syphilis, and provides testing indications to identify populations missed in STI testing efforts.⁹ However, surveillance data do not include outcome measures of all guideline-recommended care,^7,8 including screening, treatment completion, retesting, and partner services, which are essential to ending the STI epidemic. Currently, core outcome and disparities indicators in the STI National Strategic Plan are limited to reducing STI prevalence.

In Philadelphia, Gonorrhea and Chlamydia (GC/CT) prevalence rates are over double the national average, and predominately impact people aged 15–24.^8,10 We recently reported low rates of GC/CT retesting among Philadelphia youth that likely contribute to transmission rates.¹¹ Building on this work, we sought to identify metrics of engagement in guideline-recommended STI care and develop an STI care continuum framework to inform efforts to reduce STI transmission and measure progress towards ending the STI epidemic.

Methods

The proposed STI Care Continuum, based on the 2021 CDC STI Treatment Guidelines, focuses on Gonorrhea, Chlamydia, and Syphilis⁹–the STIs included in CDC surveillance reports and the focus of 10 of the 14 National Strategy indicators.^2,7 The STI Care Continuum (Figure 1) consists of seven steps: STI testing indication, STI test completion, HIV test completion, STI diagnosis, partner services, treatment, and retesting. This cyclic framework, wherein negative testing results loop back to STI testing indications, emphasizes routine testing across the lifespan.

Figure 1.

Sexually transmitted infection (STI) care continuum. PrEP, pre-exposure prophylaxis.

Step 1 in the STI continuum identifies individuals with an STI testing indication. Testing is always indicated for symptomatic individuals. Routine asymptomatic STI screening is indicated for sexually active females aged <25 years, men who have sex with men, individuals in correctional facilities, those who are pregnant, have a history of an STI diagnosis, and/or present for partner services. Step 2 measures STI test completion, which may be accompanied by risk reduction counseling. Step 3, HIV testing, is best completed concurrently with Step 2, but if not, should be completed with Steps 4–7. Individuals with reactive HIV tests merge into the HIV Care Continuum, and those with nonreactive results may merge into the PrEP Care Continuum. Step 4 is receiving an STI diagnosis. Step 5, concurrent with diagnosis, is partner services, entailing contact tracing, exposure notifications, and expedited partner therapy. Step 6, STI treatment, should be completed as soon as possible and observed directly when possible. Step 7, STI retesting, is recommended 3–12 months following GC/CT and 6 months following Syphilis diagnosis. Individuals with positive retesting results return to Step 3. (Figure 1).

We applied this Continuum to GC/CT outcomes among 16–17-year-old females with clinic visits in 2019 at a combined pediatric primary care and family planning health system using electronic health record (EHR) data. We separated the Continuum into two stages: (1) Testing and Diagnosis and (2) Post-Diagnosis. We estimated the proportion of individuals in our study population with STI testing indications using Youth Risk Behavior Surveillance Survey (YRBSS) estimates for the proportion of 11^th grade U.S. females “ever having sexual intercourse.” We identified test orders and STI diagnoses using Current Procedural Terminology (CPT) and International Classification of Diseases codes. We measured timely STI treatment using data for azithromycin, doxycycline, and ceftriaxone prescriptions within two weeks of STI diagnosis. Post-diagnosis outcomes between White and non-White participants were compared using chi-square tests. Race is a social construct that was defined using EHR data entered at visit registration. White race was defined as non-Hispanic White, and non-White race was defined by Hispanic or Latinx ethnicity and/or any non-White race (e.g., Black, Asian, etc.). The Institutional Review Boards at the Children’s Hospital of Philadelphia and Access Matters approved the study (IRB 18–015008). Informed consent was not obtained as all data were previously collected in routine healthcare.

Results

There were 5,484 16–17-year-old females with ≥1 clinic visit in 2019, of whom 44% (N = 2413) were estimated to have an STI testing indication (Figure 2). Among those, 1,040 (43%) received GC/CT testing, 193 (19%) of whom were diagnosed with GC/CT at least once, and 411 (17%) were tested for HIV, of whom none tested positive. Non-White individuals were more likely to be diagnosed with GC/CT (21% vs. 6%, p <0.001). Among those with GC/CT, 176 (91%) received treatment within two weeks. Among those treated, 118 (67%) were retested within six weeks to one year of diagnosis. Lastly, among those retested, 47 (40%) were diagnosed with recurrent GC/CT. Of the 13 White patients diagnosed with GC/CT 100% received treatment within 2 weeks, and of the 149 non-White patients diagnosed with GC/CT 89% received treatment within 2 weeks. Due to small sample size descriptive statistics were not meaningfully interpretable for post-diagnosis outcomes.

Figure 2.

STI Care Continuum outcomes among female adolescent primary care patients in an academic paediatric primary care system, 2019. STI, sexually transmitted infection.

Discussion

The STI Care Continuum strengthens the U.S. STI National Strategy and STI surveillance by delineating metrics of quality service delivery. Applying the STI Care Continuum to Philadelphia’s STI epidemic, we identified STI screening, retesting, and HIV testing as areas most in need of improvement. Similar methods using EHR and claims data can be applied across jurisdictions to target resources aimed at ending the STI epidemic and standardize data collection and reporting.

The STI Care Continuum aligns with recommendations from the National Academy of Sciences, Engineering, and Medicine to develop benchmarks supporting consistent delivery of sexual health services, modernize STI data collection, and align public health resources with health care delivery systems.¹³ For example, we used national survey data to estimate the proportion of patients with an STI screening indication and EHR CPT codes to measure test completion. Policymakers can use these measurement strategies to identify inequitable STI care delivery and focus quality improvement efforts. Using the STI Care Continuum, our findings suggest racial disparities that should be explored in future research. The STI Care continuum can also facilitate service implementation in settings engaging populations disproportionately impacted by STIs such as substance use treatment programs, homeless shelters, and correctional facilities.

Our approach has limitations. We used population estimates to determine the proportion of patients with an STI testing indication. However, as our EHR data was limited to those who completed STI testing, we were not able to compare differences in test completion by race. Our data did not include partner services outcomes. Strategies for evaluating partner services is an area where innovative methods are sorely needed. The STI Care Continuum utilizes EHR data, which is readily available in most U.S. healthcare settings and is well-suited to monitoring clinical quality improvement and implementation strategies. Public health STI surveillance data currently do not include engagement in care and testing indications. Capturing these metrics, similar to HIV and PrEP surveillance practices, will be needed for population-level applications of the STI Care Continuum. Finally, primary data are needed to monitor patient experiences of STI care to assure patient-centeredness.

In conclusion, applying metrics for engagement in STI care can identify key areas for improving quality service delivery, and strengthen health systems’ ability to understand drivers of changing prevalence rates. The STI Care Continuum framework can thus build on the success of HIV and PrEP continuum frameworks, and catalyze measurement of quality of STI care, outcomes monitoring, and advancement of efforts to end the STI epidemic.