Impact of Risk-based Sexually Transmitted Infection Screening in the Emergency Department

Abstract

Objectives:

Sexually transmitted infections (STI), including chlamydia, gonorrhea, and human immunodeficiency virus 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 sexually transmitted infection 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. non-participants (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.

Conclusions:

Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations.

Introduction

Sexually transmitted infections (STIs) are a significant cause of morbidity in the adolescent population. Untreated, these infections can lead to scarring, sexual dysfunction, chronic pelvic pain, ectopic pregnancy, infertility and in some instances, mortality.^1,2 Adolescents bear a disproportionate burden of Chlamydia trachomatis and Neisseria gonorrhoeae infections, and are at high risk for human immunodeficiency virus (HIV).^1,3 Adolescents presenting to the emergency department (ED) are at particularly high risk for STIs due to their low utilization of primary care, infrequent barrier contraceptive use, and higher risk sexual practices.^4,5 Despite well established guidelines for STI/HIV screening,⁶ many sexually active adolescents are not being screened or tested by their medical providers when it is recommended.^5,7-11 The Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) recommend yearly gonorrhea/chlamydia testing in sexually active young adults and yearly HIV testing in adolescents and adults. However fewer than 50% of patients who should be tested actually receive it.^7,12,13 Universal STI screening is one efficacious and cost-effective approach to increase detection rates, but may not be well accepted by adolescents.^14,15 The incidence of these infections, continue to increase,⁸ and sustainable programs designed to identify and provide testing to at-risk adolescents are essential.

We previously piloted a program in our pediatric ED, which paired Audio-enhanced Computer-assisted Self-interviews (ACASIs) with a decision support tool to identify youth in need of gonorrhea/chlamydia testing,^13,16 regardless of their ED complaint. Our pilot study demonstrated that this screening method effectively facilitated identification of patients with STIs who otherwise might not have received testing.¹³ We developed a version of this program for long-term use and instituted it as standard practice in our ED. The purpose of this manuscript is to describe STI-testing rates and outcomes from our first year after implementation.

Methods

Study Design, Setting, and Population

The Washington University Institutional Review Board classified this study as exempt (not human subjects research), since we analyzed existing data collected as part of standard-of-care activities.¹⁷ Our pediatric ED is situated in an urban, metropolitan area with a high incidence of STIs;¹⁸pre-COVID our ED saw approximately 500 patients per month between 15-21 years old. We began administering the ACASI in the ED in May 2017 and paused ACASI use at the end of May 2018 when our hospital switched electronic health records (EHRs), requiring a change in the software platform and ED workflow. We subsequently incorporated our program into our new EHR (Epic) with changes to accommodate its workflow. We conducted a retrospective cohort study of data collected during that initial period following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines (Supplementary Figure 1).¹⁹

We previously published the questionnaire and decision algorithms from our pilot work.¹³ We have also described the software platform developed for our new sustainable program, our ED workflow and utilization, challenges encountered during implementation, and characteristics of participants vs. eligible non-participants.¹⁷ Briefly, we designed the ACASI questionnaire to obtain a focused sexual history from adolescents to use a built-in decision-support tool to provide STI testing recommendations. The decision-support tool was based on recommendations from the CDC and AAP^6,17,20 as well as expert opinion from adolescent medicine and pediatric infectious disease (ID) experts at our institution. Similar to our pilot work, participants received 1 of 4 possible recommendations for gonorrhea/chlamydia testing: 1) Patient met criteria for testing and should be offered it in the ED 2) Patient did not meet criteria for immediate testing but endorses behaviors increasing their risk for STIs, provider should consider testing 3) Patient did not meet criteria for immediate testing and does not endorse risky behaviors, testing is not recommended 4) Insufficient responses to provide a recommendation. For HIV, the recommendations were 1) Patient met criteria for testing and should be offered it in the ED 2) Patient is HIV positive and did not need testing 3) Patient did not meet criteria for testing 4) Insufficient responses to provide a recommendation. After completion, patients were shown their testing recommendations on the tablet and who had immediate testing recommended could subsequently “opt-in” for STI/HIV testing electronically. Women could also request pregnancy testing.

ED nurses offered the ACASI to all patients 15-21 years of age receiving care in our ED, regardless of time of day or reason for visit. Patients were excluded if they were disabled and could not independently use a tablet computer, severely ill, or did not speak English.¹³ Patients receiving an evaluation for suspected sexual abuse were also excluded.¹⁷ We excluded patients who could not independently use a tablet computer to ensure patients were able to confidentially provide us with sensitive information needed to understand if they need STI testing. The ability to maintain confidentiality was the highest priority of our adolescent medicine experts who supported the program, and our priority when making these decisions.

Parents and families were given a brochure (Supplementary Figure 2) providing an overview of the screening process without disclosing the content. The questionnaire content and responses were confidential – if parents demanded to know the content of the questionnaires in the platform, the patient was excluded to maintain confidentiality.¹⁷ Patients completed the ACASI on a tablet computer provided to them; it had a privacy screen, and patients received a free pair of earbuds for audio. Participants could read an introductory screen or watch a video describing the specific content, and could opt-out at any time. Our pilot demonstrated the language in the ACASI was appropriate for 6^th grade,¹³ and the questionnaire was utilized in the platform that was instituted as standard practice in the ED.

A summary of patient responses and the STI-testing recommendations were electronically integrated into the EHR for real-time use by the ED clinicians.¹⁷ For patients who agreed to testing, the EHR automatically generated and processed STI test orders, allowing nurses to collect specimens and send them to the lab without requiring a physician’s review. HIV testing is free, and gonorrhea/chlamydia testing is billed with other ED charges. Patients were informed of the billing process via the ACASI, and they could decline testing for this or any other reason. If a patient was offered testing via the ACASI but declined it, it was at the discretion of the provider to discuss their decision with them. Some patients who declined testing via the ACASI, or were never offered it, may have still received STI/HIV testing at the discretion of the ED provider and as a part of routine clinical care.

Testing & Follow-up of Results

Gonorrhea and chlamydia testing was performed using the Aptima 2 nucleic acid amplification test, which is highly specific (>98%) and sensitive (>95%).^21,22 Testing in asymptomatic patients was performed primarily using urine samples to maintain confidentiality, though for women, cervical swabs could be obtained if a pelvic examination was planned, and self-collected vaginal swabs could be used if the patient preferred it. Testing was performed once daily by our laboratory, with results available in 1-3 business days.

Patients were notified of gonorrhea/chlamydia test results by hospital-employed nurses. For patients with positive tests, they review the ED visit documentation to determine the preferred method to notify the patient. Treatment plans were based on CDC recommendations and periodically reviewed by local content experts. For patients who did not receive empiric treatment in the ED, plans could include a return visit to the ED solely for medication, a prescription sent to a local pharmacy, or a referral where appropriate care could be obtained.

HIV testing was performed using the Oraquick Advance HIV-1/2 Rapid Antibody Test (sensitivity 99.3% and specificity 99.8%).^23,24 Testing required a cotton swab of the buccal mucosa, and results were available in 20 minutes. If a patient tested positive for HIV, an attending physician was notified prior to notifying the patient, and results were given to the patient in private by the treating provider, and the on-call pediatric ID consultant was notified for additional guidance. Standard of care was to obtain confirmatory testing using the HIV 1/2 antibody + p24 antigen test. Patients with a confirmed positive test were referred to pediatric ID and the Washington University Linkage to Care program, which provided expedited outpatient follow-up for adolescents and adults with HIV.

Statistical methods

Two-sample t-tests were used to compare distributions of age between two groups. Pearson’s Chi-square tests or Fisher’s exact tests were used to measure associations between categorical variables, as appropriate. Unadjusted logistic regression analysis was performed to assess the effects of each risk factor on testing positive for each STI among participants. Potential risk factors used in this context included EHR variables regarding chief complaint, gender, and Emergency Severity Index (ESI) triage level, as well as more granular ACASI variables: self-reported race, ethnicity, gender, condom use, medical care in past year, sexual attraction, sexual orientation, type of intercourse, gender of partner, number of partners, history of gonorrhea/chlamydia/HIV tests, and use of birth control. Significant risk factors identified in the unadjusted models were included in multivariable models to determine the factors independently associated with testing positive for each STI while adjusting for other variables; race and ethnicity were two important societal risk factors included in the multivariable models regardless of their significance. Odds ratios with 95% confidence intervals were calculated to describe the magnitude of the associations of each risk factor compared to the reference group. A p-value of 0.05 or less was considered statistically significant. Data were analyzed using SAS^® 9.4 version (SAS Institute Inc., Cary, NC, USA).

Participant responses and testing recommendations from the ACASI were merged with EHR data to provide additional information about participants and eligible non-participants seen during this time, including STI testing outcomes. Race data was not available in our EHR data set, thus we cannot report race data for non-participants. Race data was self-reported by ACASI participants and available for inclusion in analysis within the ACASI participant cohort. We classified patients with ED chief complaints of genitourinary concerns, gynecological concerns, or abdominal/pelvic pain (in females only) as more likely referable to an STI, similar to our prior work.^13,16 This was based on the triage chief complaint categories used by our nurses, and capture the patients where ED providers are most likely to consider STI testing during the ED encounter.

Outcomes

The primary outcome was STI-testing recommendations given to ACASI participants, and STI test results for the ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not participate.

Results

During the 13-month study period, 7128 patients 15-21 years of age received care in our ED. Of that population, 6194 (86.9%) were eligible for ACASI and 28.9% (1788/6194) completed the ACASI. We have previously published data regarding the screened, eligible, and excluded patients, but it should be noted that 52.7% of the eligible non-participants (2320/4406) did not have a reason for non-participation documented by nurses, 29.2% (1285/4406) were not interested, and 10.2% (449/4406) felt too ill to participate.¹⁷ Among all 6194 eligible patients during this time period, 20.1% of participants received gonorrhea/chlamydia testing compared to only 4.8% of non-participants; 19.8% of participants received HIV testing compared to only 3.0% of non-participants received HIV testing (Table 1).

Table 1.

Characteristics of ED patients eligible for participation

Characteristics	Participants (N=1788)	Non-Participants (N=4406)	P-value
Mean Age (years) (SD)	16.6 ± 1.3	16.5 ± 1.4	0.6772
Gender, no. (%)			<0.0001
Female	1169 (65.4%)	2541 (57.7%)
Male	619 (34.6%)	1865 (42.3%)
Chief Complaint Referable to an STI1 no. (%)
All patients
Yes	304 (17.0%)	425 (9.6%)	<0.0001
No	1484 (83.0%)	3981 (90.4%)
Female Patients
Yes	257 (22.0%)	378 (14.9%)	<0.0001
No	912 (78.0%)	2163 (85.1%)
Male patients
Yes	47 (7.6%)	47 (2.5%)	<0.0001
No	572 (92.4%)	1818 (97.5%)
Has Insurance, no. (%)			0.0706
Yes	1661 (93.0%)	4008 (91.6%)
No	126 (7.0%)	369 (8.4%)
ESI Triage Level 2 , no. (%)			<0.0001
ESI level 2	186 (10.4%)	885 (20.1%)
ESI level 3	1201 (67.2%)	2697 (61.2%)
ESI level 4	385 (21.5%)	759 (17.2%)
ESI level 5	16 (0.9%)	47 (1.1%)
X- Unknown	0 (0.0%)	16 (0.4%)
Disposition 3 , no. (%)			<0.0001
Admit	234 (13.1%)	820 (18.7%)
Discharge	1501 (84.0%)	3266 (74.3%)
Other	53 (3.0%)	308 (7.0%)
Received gonorrhea/chlamydia testing	359 (20.1%)	212 (4.8%)	<0.0001
Gonorrhea/chlamydia test positive	89 (24.8%)	52 (24.5%)	0.9439
Chlamydia test positive	75 (20.9%)	47 (22.17%)	0.7188
Gonorrhea test positive	28 (7.8%)	13 (6.1%)	0.4559
Received HIV testing 4	354 (19.8%)	130 (3.0%)	<0.0001
HIV test positive	2 (0.6%)	0 (0%)	>0.9999

¹STI-related chief complaints contain genitourinary, gynecologic, and abdominal or pelvic pain (in women only)

²Unknown ESI Triage Level was excluded from the comparison

³Other dispositions includes left before treatment complete, left without being seen, operating room, intensive care unit, transfer, and death

⁴Positive test percentages are among those who received testing

Also shown in Table 1, neither age nor insurance status differed significantly between participants and non-participants. Participants were more likely to be female than male and to have less-severe ESI triage scores. Participants were more likely to have an ED complaint referable to an STI compared to non-participants; however most eligible patients did not have complaints referable to an STI. A greater proportion of participants than non-participants were discharged home (84.0% vs. 74.3%). We did not collect race data on non-participants, however participants’ self-reported race via the ACASI reflects the overall demographics of our ED patient population.

As presented in Table 2, 54.0% (965/1788) of participants reported being sexually active. Most respondents self-identified as heterosexual, and nearly 11% reported being bisexual. Similarly, most respondents reported only opposite-sex attraction, but almost 19% endorsed attraction to both sexes. Among participants reporting a history of sexual intercourse, most reported at least one partner in the preceding three and 12 months, and almost two-thirds reported at least one new partner in the preceding three months. Among sexually active participants, 81.9% (790/965) received recommendations for gonorrhea/chlamydia testing, and 81.5% (786/965) received a recommendation for HIV testing. Using the ACASI, 40.6% (321/790) of patients “opted-in” for recommended gonorrhea/chlamydia testing, and 43.8% (344/786) of patients “opted-in” for recommended HIV testing.

Table 2.

Frequencies of responses to ACASI questions (N=1788)

ACASI Response	N (%)
Sexual Attraction
Opposite-sex only	1317 (73.7%)
Same-sex only	71 (4.0%)
Both sexes	338 (18.9%)
Not sure	31 (1.7%)
Skipped	31 (1.7%)
Sexual Orientation
Heterosexual/straight	1420 (79.4%)
Homosexual or gay/lesbian	68 (3.8%)
Bisexual	195 (10.9%)
Skipped	105 (5.9%)
History of Intercourse
None	823 (46.0%)
Anal	148 (8.3%)
Oral	715 (40.0%)
Vaginal	863 (48.3%)
Types of Partners
Opposite-sex only	797 (83.9%)
Same-sex only	53 (5.5%)
Both sexes	100 (10.4%)
Skipped	15 (1.6%)
New Partners Last 3 Months
0	316 (32.8%)
1	464 (48.1%)
2 or more	149 (15.4%)
Skipped	36 (3.73%)
Total Partners Last 3 Months
0	157 (16.3%)
1	574 (59.5%)
2 or more	200 (20.7%)
Skipped	34 (3.5%)
Total Partners Last 12 Months, no. (%)
0	83 (8.6%)
1	482 (50.0%)
2 or more	365 (37.8%)
Skipped	35 (3.6%)
Gonorrhea/chlamydia testing recommended	790 (44.2%)
Opted-in to testing via ACASI*	321 (40.6%)
HIV testing recommended	786 (44.0%)
Opted-in to testing via ACASI*	344 (43.8%)

^*Percentage of those who received a recommendation for testing

Of the 59.4% (469/790) of participants who declined testing via the ACASI, the most common reason chosen for declining was the participant did not think needed testing [84.9% (398/469)]; 3.0% (14/469) indicated they were worried about the cost of testing, and 1.7% (8/469) indicated they were worried someone would find out, and the remainder did not provide a reason. For HIV testing, which is provided free of charge, 56.2% (442/786) participants declined testing. Of these, 84.2% (372/442) did not think they needed testing, 2.9% (13/442) were worried someone would find out, and the remainder did not provide a reason. Of those who electronically declined testing, 15.6% (73/469) still received gonorrhea/chlamydia testing and 10.4% (46/442) still ultimately received HIV testing at discretion of the provider. Overall, 24.8% (89/359) of participants tested positive for chlamydia and/or gonorrhea. The number of HIV infections was low, with 0.6% (2/354) participants testing positive.

Table 3 and Supplementary Table 1 provides comparisons of participants who opted-in vs. opted-out to testing for gonorrhea/chlamydia and HIV. Those who opted-in to testing were more likely to be African-American, female, have an ED complaint referable to an STI, have had 2+ partners, and to have a prior history of STIs. We also noted that patients without insurance were more likely to opt-in to testing via the ACASI than those with insurance. Supplementary Table 2 provides test outcomes among all ACASI participants, including those who did not receive a recommendation for testing but received it as part of their ED care. Overall, 177 participants whom we classified as having an ED complaint unrelated to STIs received a recommendation for testing from the ACASI and also received the testing; of these, 20.9% (37/177) were positive for chlamydia and/or gonorrhea.

Table 3.

Comparison of patient characteristics between those who opt-in vs. opt-out of gonorrhea/chlamydia testing via the ACASI

Characteristics	Opt-in	Opt-out	P-value
Gonorrhea/chlamydia testing (N=790 recommended)	(N=321)	(N=469)
Mean Age (years) (SD)	17.1 ± 1.3	16.7 ± 1.3	0.0003
Gender, no. (%)			0.0027
Female	236 (73.5%)	297 (63.3%)
Male	85 (26.5%)	172 (36.7%)
Chief Complaint Referable to an STI1 no. (%)			<0.0001
Yes	123 (38.3%)	65 (13.9%)
No	198 (61.7%)	404 (86.1%)
Race, no. (%)			<0.0001
African-American	260 (81%)	260 (55.4%)
Caucasian	35 (10.9%)	166 (35.4%)
Other5	16 (5%)	31 (6.6%)
Skip this question	10 (3.1%)	12 (2.6%)
Ethnicity, no. (%)			0.0702
Hispanic or Latino	7 (2.2%)	25 (5.3%)
Not Hispanic or Latino	268 (83.5%)	371 (79.1%)
Skip this question	46 (14.3%)	73 (15.6%)
Has Insurance, no. (%)			0.0205
Yes	283 (88.2%)	436 (93.0%)
No	38 (11.8%)	33 (7.0%)
ESI Triage Level 2 , no. (%)			0.8523
ESI level 2	24 (7.5%)	40 (8.5%)
ESI level 3	215 (67.0%)	321 (68.5%)
ESI level 4	80 (24.9%)	105 (22.4%)
ESI level 5	2 (0.6%)	3 (0.6%)
New partners prior 3 months, no. (%)			<0.0001
0	71 (22.1%)	185 (39.4%)
1	172 (53.6%)	208 (44.4%)
2 or more	72 (22.4%)	52 (11.1%)
Skipped	6 (1.9%)	24 (5.1%)
Total partners prior 3 months, no. (%)			<0.0001
0	29 (9.0%)	102 (21.7%)
1	186 (57.9%)	279 (59.5%)
2 or more	102 (31.8%)	64 (13.7%)
Skipped	4 (1.3%)	24 (5.1%)
Total partners prior 12 months, no. (%)			<0.0001
0	14 (4.3%)	58 (12.4%)
1	128 (39.9%)	260 (55.4%)
2 or more	172 (53.6%)	129 (27.5%)
Skipped	7 (2.2%)	22 (4.7%)
Types of intercourse (multiple choices), no. (%)
Anal	62 (19.3%)	61 (13.0%)	0.0213
Oral	246 (76.6%)	354 (75.5%)	0.7089
Vaginal	286 (89.1%)	415 (88.5%)	0.7898
Types of Partners, no. (%)			0.0090
Opposite-sex only	256 (79.8%)	400 (85.3%)
Same-sex only	18 (5.6%)	25 (5.3%)
Both sexes	44 (13.7%)	33 (7.0%)
Skipped	3 (0.9%)	11 (2.4%)
Prior history of any STI 3 , no. (%)			<0.0001
Yes	113 (35.2%)	58 (12.4%)
No	159 (49.5%)	374 (79.7%)
I don’t know/Skip this question	49 (15.3%)	37 (7.9%)
Received gonorrhea/chlamydia testing 4 ,no. (%)	237 (73.8%)	73 (15.6%)	<0.0001
Gonorrhea/chlamydia test positive	66/237 (27.9%)	13/73 (17.8%)	0.0852
Chlamydia test positive	57/237 (24.1%)	8/73 (11.0%)	0.0163
Gonorrhea test positive	18/237 (7.6%)	6/73 (8.2%)	0.8615

¹STI-related chief complaints contain genitourinary, gynecologic, and abdominal or pelvic pain (in women only)

²Unknown ESI Triage Level was excluded from the comparison

³STI includes gonorrhea, chlamydia, HIV, syphilis, herpes, human papilloma virus, trichomonas, and bacterial vaginosis

⁴Positive test percentages are among those who received testing; some patients who opted-in to testing did not receive it, and some who opted-out received it as part of their routine ED care

⁵Other race includes American Indian or Alaska Native, Asian, native Hawaiian or other Pacific Islander, biracial, and multiracial.

Shown in Table 4 are adjusted effects of risk factors on positive chlamydia test or positive gonorrhea test in multivariable logistic regression models, adjusting for other risk factors that were significantly associated with the outcome in unadjusted tests (Supplementary Tables 3 and 4). There were too few patients testing positive for HIV to perform multivariable analysis.

Table 4.

Multivariate logistic regression model of risk factors associated with a Positive Result among ACASI participants.

Risk factors (Reference group)	Estimate	Standard Error	OR (95% CL)	P-value
Positive Chlamydia Result among ACASI participants (N=264)
Condom Use (Always)
Never	0.7758	0.2616	4.44 (1.60, 14.35)	0.0030
Sometimes	−0.0618	0.2437	1.92 (0.72, 5.95)	0.7998
Medical Care in Past Year (Received)
Not received	0.5169	0.1957	2.81 (1.34, 6.31)	0.0083
Total Partners in Last 12 Months (0)
1	−0.3868	0.3226	0.78 (0.19, 4.47)	0.2306
2 or more	0.5207	0.3123	1.93 (0.49, 10.92)	0.0954
Race (African American)
Caucasian	−2.1911	0.9868	N/A 1	0.0264
Other	1.4167	0.6634	1.90 (0.44, 6.97)	0.0766
Ethnicity (Not Hispanic or Latino)
Hispanic or Latino	−0.1657	0.8504	0.72 (<0.01, 8.40)	0.8455
Positive Gonorrhea Result among ACASI participants (N=291)
Chief Complaint (Non-STI related Complaint)
STI related complaint2	0.3768	0.2347	2.12 (0.84, 5.73)	0.1085
Total Partners in Last 12 Months (1)
0	0.2337	0.6000	2.14 (0.21, 11.86)	0.6969
2 or more	0.2911	0.3728	2.26 (0.85, 6.82)	0.4349
Race (African American)
Caucasian	−0.4174	0.6295	0.70 (0.07, 3.0)	0.5073
Other	0.4708	0.6521	1.69 (0.18, 8.0)	0.4703
Ethnicity (Not Hispanic or Latino)
Hispanic or Latino	0.0996	0.7852	N/A1	0.8990

¹N/A = not available; odds ratio not calculated if there was any zero cell

²STI-related chief complaints contain genitourinary, gynecologic, and abdominal or pelvic pain (in women only).

Skipped questions and missing data were excluded from the analysis. Only patients with non-missing data of all factors were included in the model.

Discussion

Prior efforts to examine risk-based STI testing in the ED, including our own, were limited in scope,^13,25 and screening methods were not integrated into routine clinical care. These efforts demonstrate the potential for risk-based programs to improve over the current standard-of-care, which is primarily focused on STI testing in patients who report symptoms of STIs. Both our pilot and our more recent work showed that STI testing was significantly higher among those completing the ACASI than those who did not, with testing dropping significantly when the ACASI was not available.¹³ While universal HIV screening in the ED has become common,^26-28 similar programs for gonorrhea/chlamydia screening are not widely used. A high proportion of our patients tested positive for chlamydia and/or gonorrhea, which underscores the need for expanded STI testing in high-risk adolescents, even among those who do not report STI symptoms. The association of patients lacking medical care in the past year with acceptance of recommended STI testing highlights that our approach may be addressing an unmet healthcare need for patients who have limited health care access.

Many participants with ED complaints not considered related to an STI tested positive for chlamydia. This is an important validation for broader risk-based screening by integrating the ACASI as standard practice in the ED, so that patients who may not have been well represented in our pilot research would be more likely to be represented in this cohort. Although HIV testing was not part of our pilot work, we integrated the assessment of HIV risk into the ACASI computer program. While we found very few new HIV infections, the rates of HIV infection correspond to our local epidemiology,¹⁸ and the importance of early diagnosis cannot be overemphasized for these patients. Additionally, among patients whose chief complaints were potentially referable to an STI, patients who completed the ACASI were far more likely to receive HIV testing than those who did not complete it. This finding demonstrates an additional benefit, because even among patients whose ED complaints should prompt consideration of STI testing, not all patients in this group received HIV testing. We have opportunities to continue to improve the ACASI to better serve and understand our adolescent patients. This includes expanding our gender/sexual identity response choices and using this information to provide more nuanced STI risk assessments, and providing solutions for non-English speakers. We are currently working on a planned secondary analysis from this cohort to better understand reported behaviors and STI testing outcomes among sexual and gender non-conforming patients; this information will help us better serve the unique needs of the adolescent population.

As many adolescents receiving care in the ED are at high risk of STIs, numerous efforts have looked at both risk-based and universal screening strategies to improve testing for gonorrhea/chlamydia as well as HIV.^29-31 We have focused our efforts on risk-based testing for numerous reasons. First, while rapid, highly accurate point of care tests are available for HIV, we do not have a similar test available for gonorrhea/chlamydia. Tests with more rapid turnaround times may become available in the future.³² Second, risk-based screening allows appropriate utilization of resources and avoids unnecessary testing. Third, universal testing strategies in the adolescent population using electronic tools may result in lower rates of acceptance to testing than risk-based programs. While previous papers showed the potential for acceptance for universal asymptomatic STI screening using in-person, ED physician- and nurse-driven invitations to be screened, this workflow is not feasible in most large, busy ED settings.^33-35 Fourth, Reed et al. utilized an electronic, universally offered STI-screening tool, which informed patients about CDC guidelines for STI screening and the process of STI testing and then asked patients if they would agree to testing while in the ED.³⁶ In this study, the clinical-decision alert was triggered in the EHR for no other reason than the patient agreed to undergo STI screening during the ED visit. The computer program offered testing to all patients using the tablet, irrespective of their sexual history. Moreover, these authors reported patient STI testing agreement rates below 10% in both main ED and satellite locations.³⁶ Notably, by comparison, using our ACASI risk-based tool, much higher rates of agreement to testing and testing overall were observed. Until a study directly comparing universal vs. risk based STI screening is performed in the ED, it will be challenging to ascertain which approach is preferable. It is possible that settings may prefer one approach over another based on resources, local epidemiology, or other factors.

By offering the ACASI as a risk-based, STI screening tool that is not based on chief complaint, we were able to capture a large number of chlamydia and/or gonorrhea infections in this population of adolescents who otherwise would not have been screened/tested. We are currently in the process of adapting our original program for use in pediatric primary care practices in our region (R18 HS026704), an opportunity to use this approach to improve care for adolescents at risk for STIs in other settings. This effort is designed as an implementation science study using the Consolidated Framework for Implementation Research³⁷ and will conform to the Standards for Reporting Implementation Studies statement.³⁸ Using this framework as a guide, we have conducted numerous interviews with physicians, nurses, adolescents, and their guardians to identify the context needed to adapt and implement this program in a pediatric primary care setting. An implementation science approach may help improve the penetrance of the ACASI (proportion of eligible adolescents who are screened, either by addressing nursing barriers to screening and/or or adolescent barriers to acceptance), and further improve the acceptability of STI testing recommendations by adolescents. Future work in the ED in this area could benefit from incorporating a similar approach, whether for STIs or for other relevant conditions among ED patients.

The information obtained via the ACASI allows us to identify sexually active patients who are not using contraception and who may be at-risk for unintended pregnancy. We have used this information as the basis for two randomized controlled trials underway to identify methods to improve contraceptive care for patients seen in our ED, investigating potential additional benefit of this technology (ClinicalTrials.gov NCT03400410 & NCT03559634).

Limitations

As a single-center study, ACASI results may not be generalizable to other EDs or settings with a lower incidence of STIs. We relied on participants’ recall and disclosure of their sexual history, and some participants may not have fully disclosed their sexual history; additional data were collected retrospectively from the EHR and could have been missing relevant information. We had a high number of eligible patients where we did not document a reason for not participating, and we lacked race and ethnicity data for non-respondents. Thus the possibility of selection bias cannot be discounted. Not all participants who received a recommendation for STI screening via the ACASI agreed to be tested, which may have underestimated the overall proportion of patients who tested positive. Unlike many urban EDs, ours serves a very low proportion of adolescents who are non-English speaking, thus very few patients, if any, would be excluded for this reason. Providing the ACASI in other languages should increase the generalizability of our findings to non-English speaking patient populations. Lastly, our categorization of STI-related complaints vs. non-STI related complaints may be subject to inaccuracies if the patient did not disclose the primary reason for their visit during triage.

Conclusions

We demonstrated the impact of an electronic STI risk-assessment tool as part of our ED standard-of-care, screening more at-risk adolescents and identifying many adolescents with chlamydia and gonorrhea who otherwise may not have been identified. More rigorous implementation science methods are needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations. We believe the ACASI may be generalizable to other health care settings, and represents an exemplar of how interactive decision-making tools can assist in enabling patient-driven decision-making in a variety of contexts.

Abbreviations:

ED

emergency department

STI

sexually transmitted infection

ACASI

Audio-enhanced computer-assisted self-interview

CDC

Centers for Disease Control and Prevention

AAP

American Academy of Pediatrics

ESI

Emergency Severity Index

ID

Infectious Disease