Gonorrhea and Chlamydia Screening for Adolescents and Young Adults in Emergency Departments.

Abstract

Importance Adolescents account for almost half of the 2.5 million diagnosed sexually transmitted infections in the US annually, and the emergency department functions as the primary source of health care for many adolescents. No recommendations exist for emergency department gonorrhea and chlamydia screening. Objective To compare usual care against targeted and universally offered gonorrhea and chlamydia screening approaches. Design, Setting, and Participants This was a comparative effectiveness, multicenter, pragmatic trial with a type 3 hybrid stepped-wedge crossover design implemented over approximately 20 months at 6 pediatric emergency departments in the US. Patients aged 15 to 21 years presenting to the emergency department between January 2021 and September 2022 were included, excluding those who were unable to understand English, were critically ill, were with concern for sexual assault or abuse, had cognitive impairment or altered mental status, or were otherwise unable to provide consent. Of 98 413 emergency department presentations during the study period, 7503 adolescents underwent testing. Interventions Patients completed a computerized sexual health survey. During the universally offered screening intervention, gonorrhea and chlamydia screening was offered to all participants, and clinical decision support for testing was based solely on the patient's decision to undergo testing (survey results were not available to clinicians). During the targeted screening intervention, a validated risk score derived from the survey based on patient-reported behavioral data was integrated into the electronic health record to provide clinical decision support for gonorrhea and chlamydia testing. The usual care phase represented the period before the survey was integrated into emergency department care. Main Outcomes and Measures Gonorrhea and chlamydia detection rates per 1000 eligible patients per 2-week intervals among usual care, targeted, and universally offered screening strategies. Results Of the 98 413 patient visits, 18 633 (19%) took place during the usual care phase, 41 082 (42%) during the targeted screening phase, and 38 698 (39%) during the universally offered screening phase. The study population was predominantly aged 16 to 18 years (n = 50 927 [51.7%]), with a mean (SD) age of 17.03 (1.42) years. A total of 57 013 participants (57.9%) were female. In the usual care phase, 1432 patients had testing ordered vs 3216 in the targeting screening phase and 2855 in the universal screening phase. Compared to usual care, population-level gonorrhea and chlamydia detection rates were higher during the targeted strategy phase (adjusted difference in infections detected per 1000 patient visits, 2.59; 95% CI, 2.46-2.73) and universally offered strategy phase (adjusted difference, 1.81; 95% CI, 1.67-1.94). Conclusions and Relevance In this comparative effectiveness trial, a targeted or universally offered screening tool in pediatric emergency departments was associated with higher detection rates than usual care, with targeted screening identifying higher rates of infections at the population level. The findings indicate that developing processes to integrate broad-scale gonorrhea and chlamydia screening in emergency departments may be warranted. Trial Registration ClinicalTrials.gov Identifier: NCT03715335.