Why Aren't US Emergency Departments an Optimal Source for STD Care?

The Centers for Disease Control and Prevention report that sexually transmitted diseases (STDs) in the United States have reached an unprecedented high, and the number of cases continue to rise.

Now, a “Short Communication” published in Elsevier reports that this increased incidence, along with a “deteriorating public health infrastructure,” is the reason more of these diseases are being seen in emergency departments (EDs). However, not only is it more expensive for STDs to be treated in the EDs, but care in these settings is less than optimal, as these diseases are often either over-treated or under-treated, which can result in these organisms developing resistance to antibiotics.

The authors of the paper report that “STI surveillance has shown consistently that STIs are diagnosed and treated outside traditional STD clinics, including [in] emergency departments, when gaps in the US public health infrastructure are created by the closure of such STD clinics.” Due to the notable rise in STDs, the researchers decided to evaluate any changes in the number of ED visits for STD treatment that occurred over time and compare those findings with ED visits consisting of all other diagnoses.

Using data from the National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) collected throughout two time periods (2008-2010 and 2011-2013), the researchers were able to glean estimates of the number of all ED visits as well as ED visits with a STD diagnosis. They also categorized the visits based on the drug that had been prescribed or given during each visit, mainly azithromycin, doxycycline, or ceftriaxone—antibiotics commonly used for STD treatment.

That’s not all; the researchers also calculated the average age of patients as well as “the percentages of visits made by females, non-white patients, and those with Medicaid or State Children’s Health Insurance Program (SCHIP) as the expected payment source.” They used chi-square tests to compare: differences between time periods, differences between drugs prescribed for STD visits, and drugs prescribed for visits unrelated to STDs. Finally, using two-tailed t-tests, the researchers compared “the estimate average age of patients.”

Their findings? There was a 2% increase in the number of ED visits for all diagnoses from 2008-2010 and 2011-2013, and a 39% increase in the number of ED visits with an STD diagnosis. Furthermore, when it came to the prescribed drugs, they found increases across the board:

• Azithromycin prescription increased by 10% for all visits, and by a staggering 83% in visits with an STD diagnosis.
• Doxycycline prescription increased by 3% for all visits, and by 24% in visits with an STD diagnosis.
• Ceftriaxone prescription increased by 6% for all visits, and by 82% in visits with an STD diagnosis.

When comparing the ED visits that occurred between 2011 and 2013 with all visits, the researchers found that, during this time period, those with an STD diagnosis were younger (26.9 years vs. 37.6 years), “predominantly non-white” (70.4% vs. 27.1%), and were covered by public insurance (42.7% vs. 26.3%).

According to the authors, “These analyses show that the number of visits for STI care in ED setting has risen at a faster rate than the number of ED visits for all diagnoses, and that the use of antibiotics for STIs in this setting has outpaced the use of antibiotics for other indications.”

The authors underscore the fact that treating STDs in the ED setting “is not optimal,” as several studies have shown that “both over-treatment and under-treatment of chlamydia and gonorrhea as well as increased costs for testing of these diseases” occur in this setting.

For example, one study consisting of women visiting two inner-city emergency departments due to “lower abdominal pains or vaginal complaints” found that “empirical treatment for these conditions led to significant over-treatment of both chlamydia and gonorrhea.” Another study that reviewed 500 “randomly selected cases of suspected chlamydia or gonorrhea in an urban, academic ED showed that only 54% of treated patients received appropriate antibiotics at the initial visit;” almost half, or 46% of the patients were “treated presumptively.” A potential explanation for presumptive treatment in the ED setting? “Vague empiric treatment guidelines,” the extended time it takes to receive test results, and the limited follow-up may all be responsible contributors to presumptively treating patients. Furthermore, over- and under-treating patients for STDs can have several consequences, chief among them, is antibiotic resistance. In fact, the authors point out that Neisseria gonorrhea has developed resistance to drugs, an issue that has become a national priority.

There are many reasons why individuals might choose to seek treatment in an ED rather than other treatment-specific facilities, but research is limited in this area. The results of these analyses highlight that there are limitations of care for these diseases in the ED. Stronger screening of at-risk populations and providing “proper diagnosis and treatment,” can work to cut down the number of STDs.

“The findings here in these analyses demonstrate the increased burden placed on emergency departments which may not be the most optimal source for STI care, by the substantial increase in STIs in the US and point to the need for increased prevention efforts for these diseases,” the authors concluded.