Considering the prevalence of sexually transmitted diseases (STDs) in adolescents and young adults, should pediatric EDs screen for STDs when these patients present to the ED? From a cost-effectiveness standpoint, the answer is yes, according to a team of researchers who examined this issue recently.1
In a simulation study, investigators compared three screening techniques for a hypothetical population of 10,000 patients age 15 to 21 years who presented to the ED: no screening, targeted screening (which involves the completion of a sexual history survey to estimate STD risk), and universally offered screening to every patient.
Assuming under a conservative estimate that 3.6% of all these patients presented with either chlamydia or gonorrhea, the researchers concluded targeted screening resulted in the detection and successful treatment of 95 out of 360 STDs. The incremental cost-effectiveness ratio (ICER) for targeted screening when compared to no screening was $6,444 per detected and treated case.
Under universally offered screening, 112 STD cases were identified and successfully treated, and the ICER per identified and treated case when compared to no screening was $12,139.
The investigators concluded both targeted and universal screening approaches for STDs are cost-effective, although universal screening detects more cases. Further, they noted cost-effectiveness improves substantially when the prevalence of STDs is roughly tripled, a figure some analyses suggest is closer to the actual incidence of STDs in this population.
Two researchers involved with this study, Jennifer Reed, MD, MS, director of scientific review and development in the division of emergency medicine at Cincinnati Children’s Hospital Medical Center, and Monika Goyal, MD, a pediatric emergency medicine specialist and associate division chief of emergency medicine and trauma services at Children’s National Hospital in Washington, DC, jointly responded to questions about the implications of their findings and remaining barriers in terms of getting more pediatric EDs to adopt either targeted or universal screening approaches for STDs.
“Because many adolescents often use the ED as their only access to healthcare, the ED is now being viewed as a strategic setting for the provision of preventive health services, especially to high-risk populations. However, it can be challenging to provide sexual health services in the ED because it is fast-paced, with many competing priorities, and there are adolescent confidentiality issues,” they explained. “Therefore, developing a process for efficient screening in an ED setting without interfering with patient flow and acute care is of utmost importance. We are in the process of studying several approaches for gonorrhea/chlamydia screening in the ED that would not impact the clinical workflow.”
Reed and Goyal noted there are significant clinical and financial consequences from undetected and untreated STDs. “Patients can develop pelvic inflammatory disease [PID], orchitis, and chronic pelvic pain, which may ultimately lead to infertility issues, if left untreated,” they said. “From a cost perspective, over $1 billion is spent yearly on PID treatment, which could be avoided with appropriate screening and treatment of gonorrhea and chlamydia infections.”
Screening techniques also are important, considering some STDs, especially chlamydia, can be asymptomatic for extended periods.
“Patients may not be aware of their health status until they have developed complications from the untreated infection. Further, if left undiagnosed and untreated, adolescents may be unknowingly transmitting the infection to their partners,” the researchers said.
Reed and Goyal acknowledged it is difficult today to offer guidance on whether a targeted or universal screening approach would be best for a specific ED. However, they are working to shed more light on this question.
“We are currently enrolling adolescents at six pediatric EDs across the country into a study that evaluates the clinical and cost-effectiveness of targeted vs. universally offered gonorrhea and chlamydia screening,” they shared.
- Eckman MH, Reed JL, Trent M, Goyal MK. Cost-effectiveness of sexually transmitted infection screening for adolescents and young adults in the pediatric emergency department. JAMA Pediatr 2021;175:81-89.