Reliability of administrative data to identify sexually transmitted infections for population health: a systematic review.

INTRODUCTION: International Classification of Diseases (ICD) codes in administrative health data are used to identify cases of disease, including sexually transmitted infections (STIs), for population health research. The purpose of this review is to examine the extant literature on the reliability of ICD codes to correctly identify STIs. METHODS: We conducted a systematic review of empirical articles in which ICD codes were validated with respect to their ability to identify cases of chlamydia, gonorrhoea, syphilis or pelvic inflammatory disease (PID). Articles that included sensitivity, specificity and positive predictive value of ICD codes were the target. In addition to keyword searches in PubMed and Scopus databases, we further examined bibliographies of articles selected for full review to maximise yield. RESULTS: From a total of 1779 articles identified, only two studies measured the reliability of ICD codes to identify cases of STIs. Both articles targeted PID, a serious complication of chlamydia and gonorrhoea. Neither article directly assessed the validity of ICD codes to identify cases of chlamydia, gonorrhoea or syphilis independent of PID. Using ICD codes alone, the positive predictive value for PID was mixed (range: 18%-79%). DISCUSSION AND CONCLUSION: While existing studies have used ICD codes to identify STI cases, their reliability is unclear. Further, available evidence from studies of PID suggests potentially large variation in the accuracy of ICD codes indicating the need for primary studies to evaluate ICD codes for use in STI-related public health research

Redefining the Social Geography of Community STI Risk: An Ecological Study of the Association, Mediators, and Moderators of Area-Level Prostitution Arrests

Background: Core groups such as sex workers have been implicated in contributing to higher area STI risk but no studies have analyzed mediators and moderators of this relationship using population data. Objectives: Assess the overall association of area-level prostitution and STI risk, and mediators and moderators of the relationship. Methods: Point-level prostitution and drug arrests were geocoded and aggregated by Census blockgroup. Chlamydia (CT), gonorrhea (GC), syphilis and incident HIV positive test results were aggregated by blockgroup after eliminating same-organism positive tests within 14 days of an initial positive test. Census data also defined moderators: blockgroups with >75% black and >20% Latino (top decile) and >60% below 200% of the federal poverty line (top quartile). Negative binomial and zero-inflated negative binomial regressions were used to estimate incident rate ratios (IRR) of each STI. Results: There was a dose-response relationship between prostitution arrest blockgroup quintiles and IRR of each STI. In models including drug arrest data, this association was completely eliminated. Though % black blockgroup composition had significant interaction with prostitution arrest rates and with respect to its relationship with STI IRR, % Latino did not consistently have this association. Blockgroups with proportions of low minority and low poverty had highest drug arrest IRR for each STI. In these areas, prostitution arrest IRR were only significant for CT and GC and were consistently lower than drug arrest IRRs. Conclusions: Though prostitution arrests are associated with STI risk, this relationship is mediated by drug arrests. Associations of both arrest rates are strongest in low minority, low poverty communities, indicating that high baseline STI prevalence is not moderated by levels of drug and prostitution arrests. Implications for Programs, Policy, and Research: These data suggest that important relationships exist for prostitution and, to a greater degree, drug arrests within communities traditionally defined as ‘low-risk’

An Integrated Surveillance System to Examine Testing, Services, and Outcomes for Sexually Transmitted Diseases

Despite laws that require reporting of sexually transmitted diseases (STDs) to governmental health agencies, integrated surveillance of STDs remains challenging. Data and information about testing are fragmented from information on treatment and outcomes. To overcome this fragmentation, data from multiple electronic systems spanning clinical and public health environments were integrated to create an STD surveillance registry. Electronic health records, disease case records, and birth registry records were linked and then stored in a de-identified, secure server for use by health officials and researchers. The registry contains nearly 6 million tests for 628,138 individuals over a 12-year period. The registry supports efforts to understand the epidemiology of STDs as well as health services and outcomes for those diagnosed with STDs. Specialized disease registries hold promise for collaboration across clinical and public health domains to improve surveillance efforts, reduce health disparities, and increase prevention efforts at the local level

Use of Cell Phone Diaries to Understand Risk Contexts of Sexual Events Among Female Sex Workers

Background Data collection using mobile technologies, such as cell phones, allows more frequent and real-time data collection and is less prone to recall bias. We describe the feasibility of using twice daily cell phone diaries to capture contextual features of STI/HIV-risk that could impact disease acquisition among female sex workers (FSW). Methods Women engaging in transactional sex in the prior 90 days were recruited utilising incentivized snowball sampling. Participants completed STI testing and baseline/exit surveys. Over 4-weeks, they completed twice-daily electronic diaries assessing event-level sexual behaviour, condom use, and drug use. Weekly in-person interviews used open-ended questions to explore geographical characteristics of sexual encounter locations as well as acceptability of event-level monitoring. Results 25/26 participants (median age 43.5 years) completed the 4-week study. At baseline, 27% tested positive for a STI. Participants completed 84.5% of 1,518 expected surveys and 95% of 106 expected interviews. Patterns of diary compliance were stable over time. Partnered sexual activity was captured in 21.4% of diaries. At the participant-level, most reported giving oral sex (84.7%) or vaginal sex (96.1%); fewer (19.2%) reported engaging in anal sex. Among women reporting partnered sexual behaviour with any partner type (i.e., new/regular customers, romantic partners), using condoms was reported 39.2%, 45.5% and 83.3% of the time for giving oral sex, vaginal sex, and anal sex respectively. At the event-level, the frequency of giving oral sex, vaginal sex or anal sex did not significantly change over time. Conclusions It is feasible to engage and retain FSW in a technologically-advanced study to characterise risk contexts of sexual events. Adherence to study protocol was high indicating event-level monitoring using cell phone based diaries is acceptable. These data can be utilised to improve our understanding of the individual, relational and environmental factors that influence STI/HIV acquisition among FSW

Neisseria meningitidis ST11 Complex Isolates Associated with Nongonococcal Urethritis, Indiana, USA, 2015-2016

At a clinic in Indianapolis, Indiana, USA, we observed an increase in Neisseria gonorrhoeae-negative men with suspected gonococcal urethritis who had urethral cultures positive for N. meningitidis. We describe genomes of 2 of these N. meningitidis sequence type 11 complex urethritis isolates. Clinical evidence suggests these isolates may represent an emerging urethrotropic clade

Where Do People Go for Gonorrhea and Chlamydia Tests: A Cross-sectional View of the Central Indiana population, 2003-2014

Background Despite major efforts to control their spread, reported sexually transmitted infections (STI) are increasing. Using data from a mid-sized Midwest metropolitan area, we examined the settings in which individuals are tested for gonorrhea and chlamydia in relation to demographics and test result to determine where interventions may best be focused. Methods A de-identified and integrated registry, containing records from all patients tested for an STI from 2003-2014, was created by combining data from a large health information exchange and the reporting district’s STI Program located in Indianapolis, IN. Individual characteristics and visit settings where gonorrhea and chlamydia testing was performed were analyzed. Results We identified 298,946 individuals with 1,062,369 visits where testing occurred at least once between the ages of 13 and 44 years. Females were tested significantly more often than males and received testing more often in outpatient clinics whereas males were most often tested in the STI clinic. Individuals who utilized both STI and non-STI settings were more likely to have a positive test at an STI or ED visit (6.4% - 20.8%) than outpatient or inpatient setting (0.0-11.3%) (p<.0001). Test visits increased over the study period particularly in emergency departments, which showed a substantial increase in the number of positive test visits. Conclusions The most frequent testing sites remain STI clinics for men and outpatient clinics for women. Yet, emergency departments are increasingly a source of testing and morbidity. This makes them a valuable target for public health interventions that could improve care and population health

Syphilis testing adherence among women with livebirth deliveries: Indianapolis 2014-2016

Background: The number of congenital syphilis (CS) cases in the United States are increasing. Effective prevention of CS requires routine serologic testing and treatment of infected pregnant women. The Centers for Disease Control and Prevention (CDC) recommends testing all pregnant women at their first prenatal visit and subsequent testing at 28 weeks gestation and delivery for women at increased risk. Methods: We conducted a cross-sectional cohort study of syphilis testing among pregnant women with a livebirth delivery from January 2014 to December 2016 in Marion County, Indiana. We extracted and linked maternal and infant data from the vital records in a local health department to electronic health records available in a regional health information exchange. We examined syphilis testing rates and factors associated with non-testing among women with livebirth delivery. We further examined these rates and factors among women who reside in syphilis prevalent areas. Results: Among 21260 pregnancies that resulted in livebirths, syphilis testing in any trimester, including delivery, increased from 71.7% in 2014 to 86.6% in 2016. The number of maternal syphilis tests administered only at delivery decreased from 16.6% in 2014 to 4.04% in 2016. Among women living in areas with high syphilis rates, syphilis screening rates increased from 79.6% in 2014 to 94.2% in 2016. Conclusion: Improvement in prenatal syphilis screening is apparent and encouraging, yet roughly 1-in-10 women do not receive syphilis screening during pregnancy. Adherence to recommendations set out by CDC improved over time. Given increasing congenital syphilis cases, the need for timely diagnoses and prevention of transmission from mother to fetus remains a priority for public health

Provider Adherence to Syphilis Testing Guidelines Among Stillbirth Cases

Background The Centers for Disease Control and Prevention (CDC) recommends that all women with a stillbirth have a syphilis test after delivery. Our study seeks to evaluate adherence to CDC guidelines for syphilis screening among women with a stillbirth delivery. Methods We utilized data recorded in electronic health records for women who gave birth between January 1, 2014 and December 31, 2016. Patients were included if they were 18-44 years old and possessed an ICD-9-CM or ICD-10-CM diagnosis of stillbirth. Stillbirth diagnoses were confirmed through a random sample of medical chart reviews. To evaluate syphilis screening, we estimated the proportion of women who received syphilis testing within 300 days before stillbirth, within 30 days after a stillbirth delivery, and women who received syphilis testing both before and after stillbirth delivery. Results We identified 1,111 stillbirths among a population of 865,429 unique women with encounter data available from electronic health records. Among a sample of 127 chart reviewed cases, only 35 (27.6%) were confirmed stillbirth cases, 45 (35.4%) possible stillbirth cases, 39 (30.7%) cases of miscarriage, and 8 (6.3%) cases of live births. Among confirmed stillbirth cases, 51.4% had any syphilis testing conducted, 31.4% had testing before their stillbirth delivery, 42.9% had testing after the delivery, and only 22.9% had testing before and after delivery. Conclusions A majority of women with a stillbirth delivery do not receive syphilis screening adherent to CDC guidelines. Stillbirth ICD codes do not accurately identify cases of stillbirth

Validation of ICD-10-CM Codes for Identifying Cases of Chlamydia and Gonorrhea

Background While researchers seek to use administrative health data to examine outcomes for individuals with sexually transmitted infections, the ICD-CM-10 codes used to identify persons with chlamydia and gonorrhea have not been validated. Objectives were to determine the validity of using ICD-10-CM codes to identify individuals with chlamydia and gonorrhea. Methods We utilized data from electronic health records gathered from public and private health systems from October 1, 2015 to December 31, 2016. Patients were included if they were aged 13-44 years and received either 1) laboratory testing for chlamydia or gonorrhea or 2) an ICD-10-CM diagnosis of chlamydia, gonorrhea, or an unspecified STI. To validate ICD-10-CM codes, we calculated positive and negative predictive values, sensitivity, and specificity based on the presence of a laboratory test result. We further examined the timing of clinical diagnosis relative to laboratory testing. Results The positive predictive values for chlamydia, gonorrhea, and unspecified STI ICD-10-CM codes were 87.6%, 85.0%, and 32.0%, respectively. Negative predictive values were high (>92%). Sensitivity for chlamydia diagnostic codes was 10.6% and gonorrhea was 9.7%. Specificity was 99.9% for both chlamydia and gonorrhea. The date of diagnosis occurred on or after the date of the laboratory result for 84.8% of persons with chlamydia, 91.9% for gonorrhea, and 23.5% for unspecified STI. Conclusions Disease specific ICD-10-CM codes accurately identify persons with chlamydia and gonorrhea. However, low sensitivities suggest that most individuals could not be identified in administrative data alone without laboratory test results