Emergency department patients: A potential population for gonorrhea and chlamydia control intervention

Background. Urban Emergency Departments (EDs) often serve patients from neighboring communities. The Johns Hopkins Hospital (JHH) ED serves a primarily inner-city population, in a previously geographically defined high STD-incidence area. We hypothesized that patients accessing the JHH ED would have similarly high rates of STD. We sought to determine the prevalence of gonorrhea and chlamydia, and risk factors for infection among JHH ED patients. Additionally, we compared the ED clinicians' diagnostic acumen with results from this study. To evaluate the potential effectiveness of ED-based screening, we conducted a cost-effectiveness analysis (CEA).;Methods. This study employed a cross-sectional design, with prospective systematic sampling of 700 patients aged 18--44 in the JHH ED. Participants were administered an in-person survey to collect demographic and behavioral information. Relevant clinical data to determine ED clinician index of suspicion were abstracted by medical chart review and review of electronic patient laboratory results. Urine was tested for GC and CT by ligase chain reaction (LCR). The main outcome measure was gonorrhea or chlamydia diagnosis by urinary LCR. Probabilities for decision analysis trees were determined by study results.;Results. 13.6% of 434 18--31 year-olds and 1.8% of 221 32--44 year-olds had positive results for GC and/or CT. Many of these infections (76.2%) were clinically unsuspected. Among patients aged 18--31, predictive risk factors for prevalent infection by multivariate logistic regression analysis included age 1 sex partner in the past 90 days, and history of STD. Adjusting for these risk factors, living 1,000 -- <2,500 in from the hospital was also associated with an increased odds of infection. ED clinician sensitivity for treatment (either on basis of diagnosis or presumptive) was 23.8% and specificity was 92.6%. Compared to LCR, ED laboratory assays had 40% sensitivity and 97.4% specificity. Screening patients aged 18--31 universally detected more cases of disease and was cost-saving when compared to standard ED practice.;Conclusions. The logistic regression, clinical analysis, GIS, and cost-effectiveness analysis results from this study build a strong argument for the continued evaluation of the ED as a venue for gonorrhea and chlamydia screening among young adults. This study indicates that urban emergency departments can serve as sites for early detection and treatment of significant numbers of gonorrhea and chlamydia infections, with potential for community impact.