Clinicians Appear to Under-Screen, Under-Treat Patients with STIs
Insurance claims data from tens of millions of outpatient cases of patients seeking treatment for lower genitourinary tract symptoms (LGUTS) revealed testing for sexually transmitted infections (STIs) occurred in only 17.6% of all episodes.1
Women with pelvic inflammatory disease (PID) and men with orchitis/epididymitis and acute prostatitis received STI testing in less than 15% of cases. Only half received antibiotic treatment within three days.1
The most common notifiable STIs in the United States are Chlamydia trachomatis and Neisseria gonorrhoeae, and these STIs did not appear in claims data — meaning there likely was no screening for them.
“We used an IBM database from commercial payers, Medicare, and Medicaid,” explains Rebecca Lillis, MD, an associate professor of clinical medicine at Louisiana State University School of Medicine and medical director of LSU-CrescentCare Sexual Health Center in New Orleans. “We didn’t use things that were nonspecific like abdominal pain because that could be GI related.” Instead, Lillis and colleagues looked for lower urogenital tract symptoms, which could be caused by an STI.
“We looked at stats based on ICD-10 symptomatic urogenital infection, and we also looked [at coding] for gonorrhea, chlamydia, and trichomoniasis,” Lillis says.
Their data excluded people with prior STIs and symptoms — only studying those with a new problem.
“We also excluded people who had screening codes within two weeks before the visit. We wanted new episodes,” Lillis adds.
Patients younger than 14 years of age and older than 65 years of age also were excluded.
“The first date of any ICD code of interest was captured,” Lillis explains. “If it was captured within 21 days, a second time, it was considered ongoing. After that 21-day window, we considered it to be a new episode.”
The findings of low rates of STI testing and treatment were shocking, Lillis says.
“If women come in with pelvic inflammatory disease and complain of abdominal pain and may have a fever, low rates of antibiotic treatment is really concerning,” Lillis says. “I would have expected rates for pelvic inflammatory disease treatment to approach 100%.”
Clinicians cannot know whether a patient’s PID is caused by an STI unless they screen for that. But the data show strikingly low rates of testing for STIs among patients with a PID diagnosis.1
“Only 15% [of people with PID] received a gonorrhea or chlamydia test,” Lillis notes. “I don’t have an explanation for it.”
One possibility is that clinicians were overcoding. They could be using the PID code to bill at a higher level for the visit.
“If I’m going to code for PID, I’ll treat for PID with CDC-approved treatment regimen, and I’d order appropriate testing,” Lillis says.
It also is possible clinicians were treating these infections but not coding for the treatment. If patients were seen in a public health clinic and provided with free STI treatment, then it might not appear in the insurance claims database.
“But I feel those rates are still low, even if you exclude all the patients seen in an STI clinic,” Lillis says. “There are more patients seen at the primary care provider’s office or in urgent care settings.”
If patients ask to not be tested for STIs or if clinicians fail to ask them about STI testing, then this could lead to the nation’s STI rates being artificially low. It also would be a public health problem since the reports are used to decide resources for STI control programs.”
“Isn’t the partner contact happening?” Lillis asks. “If they go in with urinary symptoms, do they tell their partner if they don’t know if they had gonorrhea or chlamydia?”
Another problem with failing to test for STIs is that clinicians may treat the patient’s symptoms with a broader antibiotic than is necessary. That could lead to suboptimal antimicrobial stewardship.
One solution to undertesting for STIs is the point-of-care STI testing kit. This can give providers information about what infection the patient has at the time they are writing the prescription.
“Patients who are sexually active should be tested for sexually transmitted infections,” Lillis says. “A bigger problem here is that providers are not getting sexual history from patients to know they’re at risk.”
If clinicians doubt an STI could be the diagnosis, then they will not order the test, and the sexual history is needed.
“The lower rates of testing in the older population group — up to age 64 years — would indicate providers are not thinking about STIs when older patients come in with symptoms of urogenital tract syndrome,” Lillis explains.
Lillis and colleagues’ findings may concern public health officials and clinicians because of the implications for STI surveillance and funding.
“The findings of this study underscore the importance of taking a good sexual history when you see a patient and for testing of gonorrhea, chlamydia, and trichomoniasis in women with lower urinary tract symptoms, in particular, and for gonorrhea and chlamydia in men,” Lillis says.
- Lillis R, Kuritzky L, Huynh Z, et al. Outpatient sexually transmitted infection testing and treatment patterns in the United States: A real-world database study. BMC Infect Dis 2023;23:469.
Insurance claims data from tens of millions of outpatient cases of patients seeking treatment for lower genitourinary tract symptoms revealed testing for sexually transmitted infections occurred in only 17.6% of all episodes.
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