Screening and Treating Patients for Asymptomatic STDS in an Inner-City Emergency Department

1. Screening and Treating Patients for Asymptomatic STDS in an Inner-City Emergency Department Nancy R. Glick, MD Mount Sinai Hospital, Chicago National STD Prevention Conference, 2004 Good Morning! My name is Abigail Silva and I am an epidemiologist here at the Urban Health Institute. This morning I would like to share with you some preliminary results from a project based in the ED.. My presentation is entitled…Good Morning! My name is Abigail Silva and I am an epidemiologist here at the Urban Health Institute. This morning I would like to share with you some preliminary results from a project based in the ED.. My presentation is entitled…

2. Project Site Mount Sinai Emergency Department (ED) Located in the west side of Chicago Level one trauma center ~44,000 visits per year Half of its patients are African American, 40% Hispanic, and 10% Caucasian <30% have private health insurance Serves community areas with high rates of Chlamydia, Gonorrhea, and AIDS

3. Chlamydia Rates, 1999 ARE THESE GOING TO HAVE MAPS (THE NEXT 3 SLIDES)?ARE THESE GOING TO HAVE MAPS (THE NEXT 3 SLIDES)?

4. Gonorrhea Rates, 1999

5. AIDS Rates, 1999

6. Overall Project Goals Evaluate the feasibility of routinely recommending HIV and STD testing in the ED Assess the sustainability of such an endeavor

7. Project Partners Cooperative agreement between Mount Sinai Hospital and the Centers for Disease Control and Prevention Chicago Department of Public Health (CDPH) STD Program support This project is actually part of a larger project entitled “Routinely Recommended HIV and STD Testing in an Urban ED”. Under this larger project we are then routinely recommending and testing for HIV (using rapid testing technology), in addition we are providing STD (CT, GC, P&S) testing for for age-eligible patients. This project is funded under a cooperative agreement between CDC and Sinai which means both institutions work together in most all aspects of the project. In addition, the CDPH STD program is an important project partner as they are providing the funding for STD testing, and are a referral site for free STD treatment.This project is actually part of a larger project entitled “Routinely Recommended HIV and STD Testing in an Urban ED”. Under this larger project we are then routinely recommending and testing for HIV (using rapid testing technology), in addition we are providing STD (CT, GC, P&S) testing for for age-eligible patients. This project is funded under a cooperative agreement between CDC and Sinai which means both institutions work together in most all aspects of the project. In addition, the CDPH STD program is an important project partner as they are providing the funding for STD testing, and are a referral site for free STD treatment.

8. Background: STD Testing in EDs High rates of asymptomatic STDs in urban EDs Patient willingness to test for an STD during ED visit Limited evidence that patients can be successfully treated after testing positive for an STD in an ED High rates of STDs (GC, CT) were found in EDs in St. Louis, New Orleans, Baltimore, Birmingham.. Some of these studies also showed that Patients were actually willing to consent to test for STDs. However, we only found one study that tried to assess if patients who tested positive in the ED could be successfully linked to treatment. However they only screened women who had symptoms of STDs. So not particularly representative of the ED population. High rates of STDs (GC, CT) were found in EDs in St. Louis, New Orleans, Baltimore, Birmingham.. Some of these studies also showed that Patients were actually willing to consent to test for STDs. However, we only found one study that tried to assess if patients who tested positive in the ED could be successfully linked to treatment. However they only screened women who had symptoms of STDs. So not particularly representative of the ED population.

9. STD Project Objectives Assess prevalence of asymptomatic STDs (Gonorrhea and Chlamydia) in ED Determine success rate of treating ED patients who test positive for an STD

10. Methods Eligibility criteria: 15-25 year olds Exclusion criteria • Symptomatic • Under alcohol/drugs influence • Critical condition • Prisoners/detainees • Unable to provide consent • Non-English/Spanish speaker • Unstable psych. Condition • Non-sexually active 15-18 y.o. Patients who were symptomatic were offered testing and treatment, but were excluded from this portion of the study.Patients who were symptomatic were offered testing and treatment, but were excluded from this portion of the study.

11. Methods (Cont.) 2 health educators offer free CT and GC testing Monday-Friday, 11am-9pm, for one year Test urine samples by nucleic acid amplification (BD-ProbeTech) Refer patients testing positive for free treatment Mt. Sinai- ER/Fast Track/hospital CDPH clinic Primary Care Provider

12. Follow up was ascertained by discussion with the primary MD, review of Fast track/er record or f/u from CDPHFollow up was ascertained by discussion with the primary MD, review of Fast track/er record or f/u from CDPH

13. Preliminary Results Results represent data collected from April 23, 2003 to January 16, 2004 196 (44%) consented to STD testing 167 (85%) provided usable urine sample 445 people were eligible for testing with 44% agreeing to testing. The patients who did not provide a usable sample were either unable to provide urine or left the ER prior to providing a sample (IS THIS CORRECT?)445 people were eligible for testing with 44% agreeing to testing. The patients who did not provide a usable sample were either unable to provide urine or left the ER prior to providing a sample (IS THIS CORRECT?)

14. Preliminary Results: Acceptors vs. Refusers In general, there were differences by gender and race/ethnicity between those who accepted vs refused. Men were more likely to accept than women and NHB more likely to accept than Hisp and NHW. No differences by age. . In general, there were differences by gender and race/ethnicity between those who accepted vs refused. Men were more likely to accept than women and NHB more likely to accept than Hisp and NHW. No differences by age. .

15. Preliminary Results: Primary Reasons for Refusal No perceived risk 33% Recently tested 37% Has own doctor/provider 9% Other 21% WHAT WAS THE CUTOFF FOR RECENT TESTING 3 MONTHS?WHAT WAS THE CUTOFF FOR RECENT TESTING 3 MONTHS?

16. Preliminary Results: Positivity Rates

17. Preliminary Results: Positives 3 co-infected 18 CT positive 5 GC positive 7/21 women were pregnant 4 had received prenatal care 5 were in their first trimester WERE THE 3 THAT WERE COINFECTED MEN OR WOMEN? 7/21 OF THE WOMEN WERE PREGNANT? DO YOU KNOW IF THEY WERE COINFECTED WITH GC OR CHLAMYDIA…IT CAN HAVE EFFECT ON FETAL OUTCOMEWERE THE 3 THAT WERE COINFECTED MEN OR WOMEN? 7/21 OF THE WOMEN WERE PREGNANT? DO YOU KNOW IF THEY WERE COINFECTED WITH GC OR CHLAMYDIA…IT CAN HAVE EFFECT ON FETAL OUTCOME

18. Preliminary Results: Treatment

19. Conclusions Preliminary data show… High rates of asymptomatic STDs in ED Patients with asymptomatic STDs can be identified in the ED Patients testing positive for an STD in an ED can be successfully linked to treatment Patients are willing to get treated and we were able to reach a population of patients who may not otherwise get tested- AA men- unless they are symptomaticPatients are willing to get treated and we were able to reach a population of patients who may not otherwise get tested- AA men- unless they are symptomatic

20. Implication for Policies Health departments and EDs can partner to establish successful STD screening programs in high prevalence areas. Ensuring treatment after testing in the ED is possible but needs the dedication of staff to follow-up. EDs may offer STD testing to patients, especially young men, that may otherwise never receive STD counseling and testing.

21. Project Staff Investigators Nancy Glick, MD Steve Whitman, PhD Abigail Silva, MPH ED liaison Les Zun, MD Health educators Dyanna Charles Jacqueline Franqui Project coordinator Sandra Allen, RN