National trends in pelvic inflammatory disease among adolescents in the emergency department

OBJECTIVE: In 2002 the CDC broadened the pelvic inflammatory disease (PID) diagnostic criteria to increase detection and prevent serious sequelae of untreated PID. The impact of this change on PID detection is unknown. Our objective was to estimate trends in PID diagnosis among adolescent emergency department (ED) patients before and after the revised CDC definition and identify factors associated with PID diagnoses. METHODS: We performed a retrospective repeated cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2000–2009 of ED visits by 14 to 21 year old females. National estimates of PID rates were calculated. Multivariable logistic regression analyses and tests of trends were performed. RESULTS: During 2000–2009, of the 77 million female adolescent ED visits, there were an estimated 704,882 (95% CI 571,807, 837,957) cases of PID. Following the revised criteria, PID diagnosis declined from 5.4 cases per 1000 U.S. adolescent females to 3.9 cases per 1000 (p=0.03). In a multivariable model, age ≥17 years (OR 2.14, 95% CI 1.25, 3.64) and Black race (OR 2.04, 95% CI 1.36, 3.07) were associated with PID diagnosis CONCLUSIONS: Despite broadened CDC diagnostic criteria, PID diagnoses did not increase over time. This raises concern about awareness and incorporation of the new guidelines into clinical practice

Underuse of pregnancy testing for women prescribed teratogenic medications in the emergency department

OBJECTIVES: To estimate the frequency of pregnancy testing in emergency department (ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X), and to determine factors associated with non-receipt of a pregnancy test. METHODS: This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40 years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with non-receipt of pregnancy testing was assessed using multivariable logistic regression. RESULTS: Of 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% CI = 8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were: benzodiazepines (52.2%; 95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI = 10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [AOR] 0.57, 95% CI = 0.42 to 0.79), non-Hispanic white females (AOR 0.71; 95% CI = 0.54 to 0.93), visits in the Northeast region (AOR 0.60; 95% CI = 0.42 to 0.86), and visits during which teratogenic medications were administered in the ED only (AOR 0.74; 95% CI = 0.57 to 0.97) as compared to prescribed at discharge only, were less likely to have pregnancy testing. CONCLUSIONS: A minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity

Frequency of pregnancy testing among adolescent emergency department visits

OBJECTIVE: To estimate the frequency of pregnancy testing among adolescent emergency department (ED) patients and to determine factors associated with testing. METHODS: This was a retrospective cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005-2009 of ED visits by females ages 14 to 21 years. We estimated the frequency of pregnancy testing among all visits, those for potential reproductive health complaints, and those associated with exposure to potentially teratogenic radiation. Multivariable logistic regression modeling was performed to calculate adjusted probabilities and odds ratios with 95% confidence intervals to evaluate factors associated with pregnancy testing by patient characteristics. RESULTS: We identified 11,531 visits, representing an estimated 41.0 million female adolescent ED visits. Of these, 20.9% (95% CI 19.3%, 22.5%) included pregnancy testing. Among visits for potential reproductive health complaints and those associated with exposure to potentially teratogenic radiation, 44.5% (95% CI 41.3%, 47.8%) and 36.7% (95% CI 32.5%, 40.9%), respectively, included pregnancy testing. Among the entire study population, we found statistically significant differences in pregnancy by testing (p<0.001 for all) by age, race/ethnicity, hospital admission, and geographic region. CONCLUSIONS: A minority of female adolescent ED visits included pregnancy testing even if patients presented with potential reproductive health complaints or received exposure to ionizing radiation. Small but statistically significant differences in pregnancy testing rates were noted based on age, race/ethnicity, ED disposition, and geographic region. Future studies should focus on designing quality improvement interventions to increase pregnancy testing in adolescent ED patients, especially among those in whom pregnancy complications or the risk of potentially teratogenic radiation exposure is higher