Pelvic inflammatory disease among privately insured women, United States, 2001-2005

Diagnosed Gonorrhea Among Privately Insured Women: Analysis of United States Claims Data

Background: Gonorrhea incidence in the United States has risen by nearly 50% in the last decade, while screening rates have increased. Gonorrhea sequelae rates could indicate whether increased gonorrhea incidence is due to better screening. We estimated the association of gonorrhea diagnosis with pelvic inflammatory disease (PID), ectopic pregnancy (EP), and tubal factor infertility (TFI) in women and detected changes in associations over time. Materials and Methods: This retrospective cohort study included 5,553,506 women aged 18-49 tested for gonorrhea in the IBM MarketScan claims administrative database from 2013-2018 in the United States. We estimated incidence rates and hazard ratios (HRs) of gonorrhea diagnosis for each outcome, adjusting for potential confounders using Cox proportional hazards models. We tested the interaction between gonorrhea diagnosis and the initial gonorrhea test year to identify changes in associations over time. Results: We identified 32,729 women with a gonorrhea diagnosis (mean follow-up time in years: PID = 1.73, EP = 1.75, TFI = 1.76). A total of 131,500 women were diagnosed with PID, 64,225 had EP, and 41,507 had TFI. Women with gonorrhea diagnoses had greater incidence per 1000 person-years for all outcomes (PID = 33.5, EP = 9.4, TFI = 5.3) compared to women without gonorrhea diagnoses (PID = 13.9, EP = 6.7, TFI = 4.3). After adjustment, HRs were higher in women with a gonorrhea diagnosis vs. those without [PID = 2.29 (95% confidence interval, CI: 2.15-2.44), EP = 1.57, (95% CI: 1.41-1.76), TFI = 1.70 (95% CI: 1.47-1.97)]. The interaction of gonorrhea diagnosis and test year was not significant, indicating no change in relationship by initial test year. Conclusion: The relationship between gonorrhea and reproductive outcomes has persisted, suggesting a higher disease burden.

Pelvic Inflammatory Disease Trends Among Emergency Department Visits in North Carolina, 2008 to 2017

BACKGROUND

Pelvic inflammatory disease (PID) is an infection of the upper female reproductive organs that can lead to infertility and ectopic pregnancies. It is a reportable condition in North Carolina (NC) but is likely underreported. We aimed to quantify PID diagnoses in NC emergency department (ED) visits.

METHODS

The NC Disease Event Tracking and Epidemiology Collection Tool tracks all ED visits in NC. We identified PID diagnoses among women of reproductive age (15-44 years) between 2008 and 2017 using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, and calculated the yearly proportion with PID diagnoses. We assessed the number of PID visits per patient each year, and the proportion of ED visits with a PID diagnosis by age, proportion of the patient's ZIP code living below the poverty line, insurance coverage, and NC provider region.

RESULTS

The percent of women with PID decreased from 6189 (1.0%) in 2008 to 4337 (0.58%) in 2016 before increasing slightly to 4371 (0.61%) in 2017. We identified 54,502 (0.45%) ED visits among 51,847 (0.76%) women with ≥1 PID diagnosis code. Most (95.5%) women with PID had one ED visit during the calendar year. Each year, the proportion with PID was highest among women aged 20 to 24 years, covered under public insurance, from the most impoverished areas, and whose provider was in the Coastal region of NC.

CONCLUSIONS

The percent with PID among women visiting EDs decreased between 2008 and 2017 in NC. Although this decline was observed across all demographics, disparities associated with PID continued to persist over time.

Pelvic inflammatory disease among users and non-users of an intrauterine device

The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) has been debated. We aimed to evaluate the differences between IUD users and non-users among women hospitalised with a diagnosis of PID. Our hypothesis was that the role of a present IUD among PID patients is minimal, if any. We performed a retrospective cohort study during 2010-2018 in a tertiary university hospital. Overall, 474 hospitalised patients were diagnosed with PID. Of these, 121 patients were IUD users. The patients without an IUD were younger and had lower gravidity and parity. Among the patients without an IUD, higher rates of prior history of PID and fever at presentation were noticed. In 23.9% (29/121) of women, the IUD was inserted less than four weeks prior to the PID diagnosis. The patients with an IUD insertion-associated PID, had lower rates of tubo-ovarian abscess (2 (6.9%) versus 24 (26.0%), OR [95% CI] 0.18 (0.04-0.84), p = .02) at presentation, as well as a shorter length of stay (LOS) (median 4 versus 5 days, p = .05). In a patient in whom the IUD was retained, hospitalisation period was shorter (median LOS 4 days versus 5 days, p = .007). PID inpatients who carry an IUD represent a specific subset of patients with a milder disease.Impact statementWhat is already known on this subject? The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) is debateable.What the results of this study add? PID inpatients who carry an IUD represent a specific subset of patients with milder disease.What the implications are of these findings for clinical practice and/or further research? Our results show that in IUD users with PID, the practice of IUD removal as part of their PID treatment is of little benefit.

Trends in Pelvic Inflammatory Disease Among American Indian and Alaska Native Women, Indian Health Service, 2001-2015

OBJECTIVES

To describe trends in rates of pelvic inflammatory disease (PID) encounters among American Indian/Alaska Native (AI/AN) women aged 15 to 44 years in the United States receiving care within the Indian Health Service (IHS).

METHODS

We analyzed IHS discharge data sets for PID encounters during 2001 to 2015 with International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes. We calculated rates of PID encounters per 100 000 women overall and stratified by age group, region, and health care setting. We used regression to identify trends in the total, annual, and average annual percent changes in the rate of PID encounters.

RESULTS

There were 44 042 PID encounters during 2001 to 2015 (rate = 825 per 100 000). The highest rates were among women aged 20 to 24 years (1104) and from the Alaska region (1556). Rates significantly decreased overall (2001: 1084; 2015: 512; P < .001) and within all age groups and health care settings. There was variability in Alaska, with large increases during 2001 to 2010 followed by large decreases during 2010 to 2015.

CONCLUSIONS

We observed decreasing trends in PID encounters among AI/AN women aged 15 to 44 years during 2001 to 2015, with the exception of increases in the Alaska region.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Trends in pelvic inflammatory disease emergency department visits, United States, 2006-2013

BACKGROUND

Pelvic inflammatory disease is a female genital tract disorder with severe reproductive sequelae. Because of the difficulties in diagnosing pelvic inflammatory disease, it is not a reportable condition in many states. Females seeking care in emergency departments are a sentinel population for pelvic inflammatory disease surveillance.

OBJECTIVE

The objective of the study was to determine trends in diagnoses of acute pelvic inflammatory disease in a nationally representative sample of emergency departments.

STUDY DESIGN

All emergency department visits among females aged 15-44 years with an International Classification of Diseases, ninth revision, Clinical Modification diagnosis code indicating pelvic inflammatory disease during 2006-2013 were assessed from the HealthCare Utilization Project Nationwide Emergency Department Sample. Total and annual percentage changes in the proportion of pelvic inflammatory disease emergency department visits were estimated using trend analyses.

RESULTS

While the number of emergency department visits among females aged 15-44 years during 2006-2013 increased (6.5 million to 7.4 million), the percentage of visits due to pelvic inflammatory disease decreased from 0.57% in 2006 to 0.41% in 2013 (total percentage change, -28.4%; annual percent change, -4.3%; 95% confidence interval, -5.7% to -2.9%). The largest decreases were among those aged 15-19 years (total percent change, -40.6%; annual percentage change, -6.6%; 95% confidence interval, -8.6% to -4.4%) and living in the South (total percentage change, -38.0%; annual percentage change, -6.2%; 95% confidence interval, -7.8% to -4.6%). Females aged 15-19 years who lived in the South had a 47.9% decrease in visits due to pelvic inflammatory disease (annual percentage change, -8.4%, 95% confidence interval, -10.4 to -6.5). Patients living in ZIP codes with the lowest median income (<$38,000) had the highest percent of visits with a pelvic inflammatory disease diagnosis; the smallest declines over time were in patients living in ZIP codes with the highest median income (i.e., >$64,000, total percent change, -24.4%; annual percent change, -3.8%; 95% confidence interval, -5.2% to -2.4%). The percentage of emergency department visits due to pelvic inflammatory disease was highest among patients not charged for their visit, self-paying, or those covered by Medicaid, with total percentage changes in these 3 groups of -27.8%, -30.7%, and -35.1%, respectively. Patients with Medicaid coverage had the largest decrease in visits with a diagnosis of pelvic inflammatory disease (total percent change, -35.1%; annual percent change, -5.8%; 95% confidence interval, -7.2% to -4.3%).

CONCLUSION

Nationally representative data indicate the percentage of emergency department visits with a pelvic inflammatory disease diagnosis decreased during 2006-2013 among females aged 15-44 years, primarily driven by decreased diagnoses of pelvic inflammatory disease among females aged 15-19 years and among women living in the southern United States. Despite declines, a large number of females of reproductive age are receiving care for pelvic inflammatory disease in emergency departments. Patients with lower median income and no or public health insurance status, which may decrease access to and use of health care services, consistently had the highest percentage of emergency department visits due to pelvic inflammatory disease. Future research should focus on obtaining a better understanding of factors influencing trends in pelvic inflammatory disease diagnoses and ways to address the challenges surrounding surveillance for this condition.

Gonorrhea Control, United States, 1972-2015, A Narrative Review

Gonorrhea is the second most commonly reported infection. It can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility. Rates of gonorrhea decreased after the National Gonorrhea Control Program began in 1972, but stabilized in the mid 1990s. The emergence of antimicrobial resistant strains increases the urgency for enhanced gonorrhea control efforts. To identify possible approaches for improving gonorrhea control, we reviewed historic protocols, reports, and other documents related to the activities of the National Gonorrhea Control Program using Centers for Disease Control and Prevention records and the published literature. The Program was a massive effort that annually tested up to 9.3 million women, and treated up to 85,000 infected partners and 100,000 additional exposed partners. Reported gonorrhea rates fell by 74% between 1976 and 1996, then stabilized. Testing positivity was 1.6-4.2% in different settings in 1976. In 1999-2008, the test positivity of a random sample of 14- to 25-year-olds was 0.4%. Gonorrhea testing rates remain high, however, partner notification efforts decreased in the 1990s as attention shifted to human immunodeficiency virus and other sexually transmitted diseases. The decrease and subsequent stabilization of gonorrhea rates was likely also influenced by changes in behavior, such as increases in condom use in response to acquired immune deficiency syndrome. Renewed emphasis on partner treatment might lead to further decreases in rates of gonorrhea.

A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement

BACKGROUND

Misperceptions persist that intrauterine device placement is related to pelvic infections and Chlamydia and gonorrhea testing results are needed prior to placement.

OBJECTIVE

We sought to evaluate the relationship of Chlamydia and gonorrhea screening to pelvic infection for up to 2 years following placement of the levonorgestrel 52-mg intrauterine system.

STUDY DESIGN

A total of 1751 nulliparous and multiparous females 16 to 45 years old enrolled in a multicenter trial designed to evaluate the efficacy and safety of a new levonorgestrel intrauterine system for up to 7 years. Participants had Chlamydia screening at study entry and yearly if they were age ≤25 years. Women also had baseline gonorrhea screening if testing had not been performed since starting their current sexual relationship. Those who changed sexual partners during the trial had repeated Chlamydia and gonorrhea testing. Intrauterine system insertion could occur on the same day as screening. Participants did not receive prophylactic antibiotics for intrauterine system placement. Investigators performed pelvic examinations after 12 and 24 months and when clinically indicated during visits at 3, 6, and 18 months after placement and unscheduled visits. Pelvic infection included any clinical diagnosis of pelvic inflammatory disease or endometritis.

RESULTS

Most participants (n = 1364, 79.6%) did not have sexually transmitted infection test results available prior to intrauterine system placement. In all, 29 (1.7%) participants had positive baseline testing for a sexually transmitted infection (Chlamydia, n = 25; gonorrhea, n = 3; both, n = 1); 6 of these participants had known results (all with Chlamydia infection) prior to intrauterine system placement and received treatment before enrollment. The 23 participants whose results were not known at the time of intrauterine system placement received treatment without intrauterine system removal and none developed pelvic infection. The incidence of positive Chlamydia testing was similar among those with and without known test results at the time of intrauterine system placement (1.9% vs 1.5%, respectively, P = .6). Nine (0.5%) participants had a diagnosis of pelvic infection over 2 years after placement, all of whom had negative Chlamydia screening on the day of or within 1 month after intrauterine system placement. Infections were diagnosed in 3 participants within 7 days, 1 at 39 days, and 5 at ≥6 months. Seven participants received outpatient antibiotic treatment and 2 (diagnoses between 6-12 months after placement) received inpatient treatment. Two (0.1%) participants had intrauterine system removal related to infection (at 6 days and at 7 months after placement), both of whom only required outpatient treatment.

CONCLUSION

Conducting Chlamydia and gonorrhea testing on the same day as intrauterine system placement is associated with a low risk of pelvic infection (0.2%). Over the first 2 years of intrauterine system use, infections are infrequent and not temporally related to intrauterine system placement. Pelvic infection can be successfully treated in most women with outpatient antibiotics and typically does not require intrauterine system removal. Women without clinical evidence of active infection can have intrauterine system placement and sexually transmitted infection screening, if indicated, on the same day.

Risk of reproductive complications following chlamydia testing: a population-based retrospective cohort study in Denmark

BACKGROUND

Uncertainty in the risk of reproductive complications (pelvic inflammatory disease, ectopic pregnancy, and tubal factor infertility) following chlamydia infection and repeat infection hampers the design of evidence-based chlamydia control programmes. We estimate the association between diagnosed chlamydia and episodes of hospital health care (inpatient, outpatient, and emergency department) for a reproductive complication.

METHODS

We constructed and analysed a retrospective population-based cohort of women aged 15-44 years from administrative records in Denmark (1995-2012). We used a subset of the national Danish Chlamydia Study. The master dataset contains all residents of Denmark (including Greenland) who had a positive chlamydia test recorded by a public health microbiology laboratory from Jan 1, 1992, to Nov 2, 2011. Individuals were randomly matched (by age and sex) to four individuals drawn from the population register (Danish Civil Registration System) who did not have a positive chlamydia test during this interval. The outcomes in the study were hospital episodes of health-care (inpatient, outpatient, and emergency department) with a diagnosis of pelvic inflammatory disease, ectopic pregnancy, or tubal factor infertility.

FINDINGS

The 516 720 women (103 344 positive, 182 879 negative, 230 497 never-tested) had a mean follow-up of 7·96 years. Compared with women with only negative tests, the risk of each complication was 30% higher in women with one or more positive tests (pelvic inflammatory disease, adjusted hazard ratio [AHR] 1·50 [95% CI 1·43-1·57]; ectopic pregnancy, AHR 1·31 [1·25-1·38]; tubal factor infertility, AHR 1·37 [1·24-1·52]) and 60% lower in women who were never-tested (pelvic inflammatory disease, AHR 0·33 [0·31-0·35]; ectopic pregnancy, AHR 0·42 [0·39-0·44]; tubal factor infertility AHR 0·29 [0·25-0·33]). A positive test had a minor absolute impact on health as the difference in the lifetime incidence of complications was small between women who tested positive and those who tested negative (pelvic inflammatory disease, 0·6%; ectopic pregnancy, 0·2%; tubal factor infertility, 0·1%). Repeat infections increased the risk of pelvic inflammatory disease by a further 20% (AHR 1·20, 95% CI 1·11-1·31).

INTERPRETATION

A single diagnosed chlamydia infection increased the risk of all complications and a repeat diagnosed infection further increased the risk of pelvic inflammatory disease. Therefore, control programmes must prevent first and repeat infections to improve women's reproductive health.

FUNDING

Unrestricted partial funding from Frederiksberg Kommune, Frederiksberg, Denmark. BD held an Medical Research Council Population Health Scientist Fellowship (G0902120). KT held an National Institute for Health Research Post-Doctoral Fellowship 2009-02-055.

Physician Specialty Influences Care of Pelvic Inflammatory Disease

BACKGROUND

CDC guidelines recommend Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV testing, as well as specific antibiotic regimens in the diagnosis and treatment of pelvic inflammatory disease (PID), although latitude in adhering to these guidelines is common. We hypothesized that adherence to CDC guidelines for antibiotic regimens and laboratory testing, coverage for anaerobic organisms, and the use of diagnostic imaging techniques do not differ significantly between practitioners with emergency medicine (EM) versus obstetrics and gynecology (OB-GYN) training.

MATERIALS AND METHODS

We conducted a retrospective medical chart review on patients (N = 351) discharged with a diagnosis of PID over a 20-month period at two neighboring emergency care facilities-one with EM-trained providers and the other with OB-GYN-trained providers.

RESULTS

Adjusted for demographic predictors and chief complaint, there was no significant difference in adherence to N. gonorrhoeae and C. trachomatis antibiotic coverage guidelines between the two facilities (adjusted odds ratio [AOR] 1.34; 95% CI 0.66-2.74), using the OB-GYN facility in the numerator of the AOR. Anaerobic coverage was significantly more common at the OB-GYN facility (AOR 9.11; 95% CI 5.36-15.48). Both sites had very low rates of adherence to CDC laboratory testing guidelines with overall rates of adherence at 4.0% (95% CI 1.9%-5.9%). Utilization of diagnostic tests differed greatly between facilities: ultrasound utilization was 66.7% (95% CI 58.2%-75.2%) at the OB-GYN facility and 39.7% (95% CI 33.4%-45.9%) at the EM facility.

CONCLUSIONS

The diagnostic pathway for PID and adherence to guidelines differ significantly depending on physician specialty and practice environment, suggesting the need for further standardization, perhaps with cross-disciplinary training.

Positive Testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the Risk of Pelvic Inflammatory Disease in IUD Users

BACKGROUND

Unintended pregnancies are a major public health problem in the United States, and intrauterine devices (IUDs) are among the most effective reversible birth control methods available. Historically, there have been concerns about IUD use and infection among young and/or high-risk women that may increase the risk of pelvic inflammatory disease (PID) and subsequent infertility.

METHODS

The Contraceptive CHOICE Project (CHOICE) was a prospective cohort study of over 9,000 women 14-45 years of age residing in the St. Louis area who were interested in initiating a new form of reversible contraception. At enrollment, participants were counseled regarding long-acting contraceptive methods with the goal of increasing awareness of all reversible methods available. Participants were also tested for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) during enrollment and were provided with contraception at no cost for 2-3 years.

RESULTS

We estimate the frequency of self-reported PID in new IUD users compared with women using other contraceptive methods. Among both new IUD users who tested positive for GC and/or CT and those who tested negative, the PID rate was 1% or below.

CONCLUSIONS

Our results demonstrate that IUD use is safe for all women, including women at high risk for sexually transmitted infections.

Pelvic inflammatory disease: identifying research gaps--proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases, November 3-4, 2011

In November 2011, the National Institutes of Health convened a workshop of basic researchers, epidemiologists, and clinical experts in pelvic inflammatory disease to identify research gaps hindering advances in diagnosis, treatment, and prevention. This article summarizes the presentations, discussions, and conclusions of this group and highlights significant controversies that reveal aspects of pelvic inflammatory disease research that would most greatly benefit from the application of newer molecular, immunologic, and radiologic techniques. Multiple limitations to performing new clinical trials exist; however, emerging data from ongoing clinical trials will add to the current body of knowledge regarding prevention and treatment strategies. In addition, use of established health care databases could serve as a valuable tool for performance of unbiased epidemiologic outcome studies.

The consistency of relative incidence rates of nonviral sexually transmissible infections from health insurance claims and surveillance data, 2005-10

BACKGROUND

Given the growing popularity of administrative data for health research, information on the differences and similarities between administrative data and customary data sources (e.g. surveillance) will help to inform the use of administrative data in the field of sexually transmissible infections (STIs). The objective of this study was to compare the incidence rates of three nonviral STIs from a large health insurance administrative database (MarketScan) with surveillance data.

METHODS

We computed and compared STI rates for 2005-10 from MarketScan and national surveillance data for three major nonviral STIs (i.e. chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis (Treponema pallidum)). For administrative data, we assessed the sensitivity of the rates to enrollee inclusion criteria: continuous (≥320 member-days) versus all enrollees. Relative rates were computed for 5-year age groups and by gender.

RESULTS

The administrative database rates were significantly lower (P<0.01) than those in the national surveillance data, except for syphilis in females. Gonorrhoea and syphilis rates based on administrative data were significantly lower (P<0.01) for all enrollees versus continuous enrollees only. The relative STI rates by age group from the administrative data were similar to those in the surveillance data.

CONCLUSIONS

Although absolute STI rates in administrative data were lower than in the surveillance data, relative STI rates from administrative data were consistent with national surveillance data. For gonorrhoea and syphilis, the estimated rates from administrative data were sensitive to the enrollee inclusion criteria. Future studies should examine the potential for administrative data to complement surveillance data.

Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women and can cause significant reproductive health sequelae for women. Although a definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge. Therefore, diagnosis and treatment algorithms advise a high index of suspicion for PID in any woman of reproductive age with pelvic or abdominal pain. Antibiotic therapy should be started early, and given for an adequate period of time to reduce the risk of complications. Coverage for anaerobic organisms should be considered in most cases.

Under-reporting of pelvic inflammatory disease in Hawaii: a comparison of state surveillance and hospitalization data

Hawaii is one of only 19 states for which pelvic inflammatory disease (PID) is a mandated notifiable disease. In order to assess the completeness of PID reporting, we compared the number of hospitalized PID cases in the state of Hawaii with the total number of PID cases reported to the Hawaii State Department of Health surveillance system from 2007 through 2010. While 828 unique PID cases were diagnosed in Hawaii hospitals, only 240 unique PID cases were reported through the state's surveillance system. Severe PID underreporting was seen despite mandatory reporting laws.

Opportunities for chlamydia control in the era of healthcare reform: lessons from two decades of innovative family planning care

In the USA, family planning clinics are primary providers of reproductive healthcare to young women and their male partners and have long provided quality sexually transmitted infection (STI) care and prevention. Chlamydia, an easily treatable STI that can lead to serious adverse outcomes if untreated, is the most common bacterial STI in the USA, and annual chlamydia screening is recommended for sexually active women aged ≤25 years. As early adopters of routine screening, family planning clinics screen >50% of all care-seeking eligible women for chlamydia, performing better than private sector healthcare plans. To achieve high levels of quality care, family planning clinics have been leaders in implementing evidence-based care delivery and developing prevention innovations. As national healthcare reform is implemented in the USA and categorical STI clinics close, public-sector demand on family planning clinics will increase.

Cost-effectiveness analysis of Chlamydia trachomatis screening via internet-based self-collected swabs compared with clinic-based sample collection

BACKGROUND

Although the Centers for Disease Control and Prevention have recommended population-wide Chlamydia trachomatis screening of sexually active women less than 26 years of age, more than half of sexually active young women are not routinely screened. A Website (IWTK, www.iwantthekit.org), was developed in 2004 to promote home-based sample collection.

METHODS

A decision tree was designed to model a hypothetical cohort of 10,000 women per year who order an internet-based C. trachomatis screening kit. We compared the incremental cost-effectiveness of 2 screening strategies: self-sampling via the IWTK website, and traditional, clinic-based screening by the same cohort of women who used IWTK. Probabilities and costs were estimated for each node in the decision tree. Estimates were derived from primary data, published data, and unpublished health data.

RESULTS

The internet-based screening strategy prevented 35.5 more cases of pelvic inflammatory disease and saved an additional $41,000 in direct medical costs as compared with the clinic-based screening strategy.

CONCLUSION

Our model estimates demonstrated that an internet-based, self-swab screening strategy was cost-effective compared with the traditional, clinic-based screening strategy. Assuming that the popularity of the use of the internet as a resource for information about healthcare and sexually transmitted infections leads to an increased use of IWTK, the public health benefit of this cost-effective strategy will be even greater.

Chlamydia public health programs and the epidemiology of pelvic inflammatory disease and ectopic pregnancy

BACKGROUND

Many countries have witnessed a disturbing increase in cases of Chlamydia trachomatis infection despite enhanced control programs. Since the goal of Chlamydia control is to prevent reproductive complications such as pelvic inflammatory disease and ectopic pregnancy, an understanding of recent trends in these conditions is needed to fully evaluate the effect of control efforts.

METHODS

We analyzed 2 provincial, comprehensive health services administrative databases (encompassing hospitalizations and all physician-delivered services) for pelvic inflammatory disease and ectopic pregnancy trends from 1992 through 2009 in women of reproductive age in British Columbia, Canada. Trends were compared to provincial Chlamydia surveillance data by time-series analysis, using the cross-correlation function method and Granger causality testing.

RESULTS

Chlamydia cases substantially increased from 1992 through 2009. Inpatient, outpatient, and total diagnoses of pelvic inflammatory disease and ectopic pregnancy declined from 1992 through 2003. After 2003, pelvic inflammatory disease rates continued to fall, while ectopic pregnancy rates significantly increased. The male Chlamydia urethritis rate increased from 39.4 to 173.6 cases/100,000 from 1996 to 2009.

CONCLUSIONS

In the context of increasing Chlamydia infection rates, the reproductive complications of Chlamydia infection in women are declining overall. A recent increase in rates of ectopic pregnancies is cause for concern.

Comparative effectiveness of a rapid point-of-care test for detection of Chlamydia trachomatis among women in a clinical setting

OBJECTIVES

To compare the effectiveness and cost-effectiveness of a promising new point-of-care (POC) chlamydia test with traditional nucleic acid amplification testing (NAAT), and to determine the characteristics that would make a POC test most cost-effective.

METHODS

A decision tree was constructed to model chlamydia screening visits to a sexually transmitted disease clinic by a hypothetical cohort of 10,000 women. The model incorporated programmatic screening costs, treatment costs and medical costs averted through prevention of pelvic inflammatory disease (PID) and its sequelae. Parameter values and costs were estimated for each node in the decision tree based on primary data, published data and unpublished health data.

RESULTS

For the base-case scenario (POC sensitivity 92.9%; 47.5% of women willing to wait 40 min for test results; test cost $33.48), POC was estimated to save US$5050 for each case of PID averted compared with NAAT. One-way sensitivity analyses indicated that POC would dominate NAAT if the POC test cost is <US$41.52 or if POC sensitivity is ≥ 87.1%. In a probabilistic sensitivity analysis (Monte Carlo simulations, 10 000 iterations), 10.8% of iterations indicated that the POC strategy dominated the NAAT strategy. The mean incremental cost-effectiveness ratio indicated that the POC strategy would save US$28 in total, and avert 14 PID cases.

CONCLUSIONS

A promising new chlamydia POC test is likely to be cost-effective compared with traditional NAAT. The POC test sensitivity, cost and proportion of women willing to wait for the POC test result are key elements to determining the cost-effectiveness of any new POC test strategy.

Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are typically asymptomatic, but, if untreated, can lead to sequelae including pelvic inflammatory disease (PID) and ectopic pregnancy. The objective was to describe trends of these sequelae in Philadelphia after implementing citywide screening in a high-morbidity population (>6% positivity).

METHODS

In this ecologic study, which used data from 1996 to 2007, multivariable linear regression analysis was used to assess the association between the number of annual CT/GC screening tests by gender and the number of women aged 14-30 years hospitalized for PID or ectopic pregnancy. A standardized hospitalization database provided the number of admissions with a discharge diagnosis of PID or ectopic pregnancy. Positive CT/GC laboratory results reported by hospitals and emergency departments (EDs) were used as a proxy for outpatient PID.

RESULTS

Between 1996 and 2007, CT/GC screening increased by 188%, whereas declines were noted in hospitalized PID cases (36%, -173 cases), ectopic pregnancy (38%, -119 cases), and ED-diagnosed CT/GC cases (39%, -727 cases). Screening 10,000 females for CT/GC corresponded with 26.1 fewer hospitalized PID cases (95% confidence interval 11.2-41.1), whereas screening 10,000 males corresponded to 10.4 (95% CI: 2.6-18.2) fewer cases. Although male screening was not significantly associated with ectopic pregnancy, screening 10,000 females was associated with 28.6 fewer ectopic pregnancies (95% CI: 7.4-49.8).

CONCLUSIONS

This ecologic analysis found a correlation between large-scale CT/GC screening in a high-morbidity population and reductions in hospitalized PID, ectopic pregnancies, and ED-diagnosed CT/GC.

Detection of pelvic inflammatory disease: development of an automated case-finding algorithm using administrative data

ICD-9 codes are conventionally used to identify pelvic inflammatory disease (PID) from administrative data for surveillance purposes. This approach may include non-PID cases. To refine PID case identification among women with ICD-9 codes suggestive of PID, a case-finding algorithm was developed using additional variables. Potential PID cases were identified among women aged 15-44 years at Group Health (GH) and Kaiser Permanente Colorado (KPCO) and verified by medical record review. A classification and regression tree analysis was used to develop the algorithm at GH; validation occurred at KPCO. The positive predictive value (PPV) for using ICD-9 codes alone to identify clinical PID cases was 79%. The algorithm identified PID appropriate treatment and age 15-25 years as predictors. Algorithm sensitivity (GH = 96.4%; KPCO = 90.3%) and PPV (GH = 86.9%; KPCO = 84.5%) were high, but specificity was poor (GH = 45.9%; KPCO = 37.0%). In GH, the algorithm offered a practical alternative to medical record review to further improve PID case identification.