Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department.

OBJECTIVE: To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control. STUDY DESIGN: In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral). RESULTS: We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up. CONCLUSIONS: SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT03341975.

Recommendations for Delivering COVID-19 Vaccine in Jails: Evidence from Kansas, Iowa, Nebraska, and Missouri.

We report on data we collected from a 2018 survey examining jails' human papillomavirus virus vaccine delivery capacity and on a secondary analysis we conducted to describe factors similarly associated with delivery planning for the COVID-19 vaccine. We provide recommendations for delivering the COVID-19 vaccine in jails, based on evidence from Kansas, Iowa, Nebraska, and Missouri. Our key finding is that jails have limited staff to implement vaccination and will require collaboration between jail administrators, jail medical staff, and local health departments.

Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate - Kansas, June 1-August 23, 2020.

Wearing masks is a CDC-recommended* approach to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), by reducing the spread of respiratory droplets into the air when a person coughs, sneezes, or talks and by reducing the inhalation of these droplets by the wearer. On July 2, 2020, the governor of Kansas issued an executive order† (state mandate), effective July 3, requiring masks or other face coverings in public spaces. CDC and the Kansas Department of Health and Environment analyzed trends in county-level COVID-19 incidence before (June 1-July 2) and after (July 3-August 23) the governor's executive order among counties that ultimately had a mask mandate in place and those that did not. As of August 11, 24 of Kansas's 105 counties did not opt out of the state mandate§ or adopted their own mask mandate shortly before or after the state mandate was issued; 81 counties opted out of the state mandate, as permitted by state law, and did not adopt their own mask mandate. After the governor's executive order, COVID-19 incidence (calculated as the 7-day rolling average number of new daily cases per 100,000 population) decreased (mean decrease of 0.08 cases per 100,000 per day; net decrease of 6%) among counties with a mask mandate (mandated counties) but continued to increase (mean increase of 0.11 cases per 100,000 per day; net increase of 100%) among counties without a mask mandate (nonmandated counties). The decrease in cases among mandated counties and the continued increase in cases in nonmandated counties adds to the evidence supporting the importance of wearing masks and implementing policies requiring their use to mitigate the spread of SARS-CoV-2 (1-6). Community-level mitigation strategies emphasizing wearing masks, maintaining physical distance, staying at home when ill, and enhancing hygiene practices can help reduce transmission of SARS-CoV-2.

A retrospective study comparing outcomes in a midwestern US population after introduction of IADPSG guidelines for gestational diabetes.

OBJECTIVE: More evidence is required to endorse the 1-step approach for gestational diabetes mellitus (GDM) for clinical practice. Since 2010, our department has pragmatically allowed faculty to self-select the guidelines they use to screen and diagnose GDM. We sought to compare the maternal and neonatal outcomes from these two simultaneous cohorts. STUDY DESIGN: We performed a retrospective cohort study of all singleton pregnancies delivered between October 2011 and -November 2013 at our hospital. Patients were excluded if they had preexisting diabetes, were not screened or screened inappropriately, or their fetus had congenital anomalies. Patients were grouped by their screening strategy, and maternal and neonatal outcomes were analyzed. RESULTS: The 1-step group had a higher incidence of GDM (21.6% versus 5.0%). Initial results suggested higher rates of neonatal hypoglycemia, phototherapy for hyperbilirubinemia, and a lower rate of gestational HTN. After adjustment, these differences disappeared, but a lower rate of large for gestational age (LGA) infants was discovered (adjusted odds ratios (aOR) 0.78). CONCLUSION: The picture remains unclear as to whether the 1-step approach is associated with significantly improved outcomes compared with the 2-step approach. We did find a lower risk for a LGA infant in our 1-step cohort, but it is unlikely that the 1-step approach would be cost-effective due to the absence of other improved outcomes.

Development of a Novel Computerized Clinical Decision Support System to Improve Adolescent Sexual Health Care Provision.

OBJECTIVE: The objective was to develop an acceptable clinical decision support (CDS) system to facilitate evidence-based sexual health care for adolescents in the emergency department (ED). METHODS: In this multiphased iterative process, we engaged an expert group to synthesize evidence on a wide range of sexual health services (e.g., contraception, condoms, identification and treatment of previously diagnosed sexually transmitted infection). We created a computerized questionnaire and embedded our decision tree, utilizing patient-entered responses to create tailored, evidence-based recommendations, and embedded links to study-related resources such as the emergency contraception (EC) quick guide. We utilized mixed methodology to explore perspectives of adolescents aged 14 to 19 years and clinicians at two general and two pediatric EDs after they interacted with the system. Clinicians reported usefulness (Likert scale 1 = not at all, 4 = very); adolescents reported acceptability. We used the chi-square test to compare responses between subgroups. We collected adolescents' verbatim responses to open-ended questions; clinicians self-entered responses. Four authors independently generated themes from qualitative responses before compiling key findings and achieving consensus on final themes. RESULTS: Among 57 clinicians (23 physicians, 23 nurses, 11 nurse practitioners; 54% female; 65% aged < 40 years), the mean system usefulness rating was 3.4 ± 0.7. Sex, age, clinician role, or ED type were not associated with rating the system "somewhat/very" useful. Clinicians identified barriers (e.g., time constraints) that could be overcome by implementation considerations (e.g., training) as well as benefits including improved care. For future assessments, providers preferred computer (65%) over face-to-face interview (26%). Among 57 adolescents (mean age = 16.2 years; 75% female; 56% sexually experienced), nearly all (95%) reported that it was "very/somewhat easy" to complete the computerized questionnaire and to understand the questions. Most adolescents understood the EC quick guide and correctly identified that ulipristal, compared to levonorgestrel, required a prescription and was more effective. For future assessments, adolescents preferred computer (69%) over face-to-face interviews (9%). CONCLUSIONS: We developed a sexual health CDS system that is easy to use and can facilitate evidence-based care to reduce health outcome gaps. Evaluation of system impact on service delivery and, ultimately, health outcomes is needed.

Three-Hour Bundle Compliance and Outcomes in Patients With Undiagnosed Severe Sepsis.

BACKGROUND: The aim of this study was to compare completion of the Surviving Sepsis Campaign 3-hour treatment recommendations and patient-centered outcomes between patients with severe sepsis who received a sepsis-specific diagnosis code with those who did not. METHODS: This was a retrospective cohort analysis of adult patients admitted through an academic medical center ED who received an antibiotic and met criteria for severe sepsis. We measured and compared the Surviving Sepsis Campaign 3-hour treatment recommendations along with patient-centered outcomes in patients who were diagnosed with severe sepsis and those who were not. RESULTS: A total of 5,631 patients were identified (60.6 ± 17.2 years of age; 48.9% women). Less than half (32.8%) received an International Classification of Diseases, ninth revision, diagnosis code of 995.92. Completion of all four bundle components in < 3 hours was low for all patients (8.72%). Therapeutic components (a broad-spectrum antibiotic and IV fluids) were completed more often (31.3%). Those with a diagnosis code received all four bundle components (10.2% vs 7.9%; P < .005), as well as therapeutic components at a higher frequency (36.0% vs 29.0%; P < .001). Patients with a diagnosis code had higher mortality (6.3% vs 2.3%), more frequent ICU admissions (44.7% vs 22.5%), and longer hospitalizations (9.2 ± 6.9 days vs 6.9 ± 6.7 days) than did patients with severe sepsis with no diagnosis code (all P < .001). CONCLUSIONS: Severe sepsis continues to be an underdiagnosed and undertreated condition. Patients who were diagnosed had higher treatment rates yet experienced worse outcomes. Continued investigation is needed to identify factors contributing to diagnosis, treatment, and outcomes in patients with severe sepsis.

Frequency of 6-week follow-up appointment scheduling after intrauterine device insertion.

INTRODUCTION: Long-acting reversible contraception (LARC) is widely recommended to reduce unintended pregnancy in the USA. As intrauterine device (IUD) use increases, evaluating the role of post-insertion follow-up is important. METHODS: A retrospective patient record review was conducted to assess the follow-up experience of women who had an IUD placed at the University of Kansas Medical Center from 1 January to 30 June 2015. Data were collected on patient demographics, IUD placement, follow-up visit attendance, and outcomes in the 12 months following placement. The primary outcome of interest was the proportion of patients who attended a 6-week follow-up visit. Secondary outcomes included adverse events detected at the 6-week visit and IUD removal within a year of placement. RESULTS: Among 380 women who had an IUD inserted, physician documentation of a recommended 6-week follow-up visit was present in 91.3% of patient medical records. Two-thirds (66.6%) of patients receiving a recommendation returned for a follow-up visit. Of the 380 women who had an IUD placed, 66 (17.4%) had their IUD removed within 1 year of placement. Of those, 50 women attended the 6-week follow-up visit and 16 did not (19.8% vs 12.6%, p=0.08). Of the IUD removals, 14 occurred at the 6-week visit. After excluding IUD removals which occurred at the 6-week visit, attending a 6-week follow-up visit was not associated with IUD removal or retention (p=0.52). CONCLUSION: Despite recommendations to forgo the 6-week follow-up visit, visits were still common, with no demonstrated value added.

Availability of Long-Acting Reversible Contraception in Kansas Health Departments.

PURPOSE: Unintended pregnancy persists as a public health problem in the United States. Local health departments (LHDs) could play an important role in preventing unintended pregnancy by promoting and providing long-acting reversible contraception (LARC, intrauterine devices [IUDs] and implants), particularly in rural states that may lack robust family planning service infrastructure. The objective of this study was to determine availability of LARC in LHDs in Kansas. METHODS: From October 2015 to January 2016, LHD administrators in Kansas were contacted to participate in a structured, cross-sectional phone survey assessing LARC availability, staff trained to place LARC, the process for obtaining LARC, and barriers to offering LARC. The main outcome measure was the proportion of Kansas LHDs offering LARC. FINDINGS: Of 101 eligible LHDs, staff from 98 agreed to be interviewed (97.0%). Of 69.4% providing family planning services, 20.6% provided LARC (20.6% provided IUDs, 11.8% provided implants and IUDs, and none provided implants only). Overall, only 29.4% of LHDs reported discussing contraception routinely regardless of reason for visit. Rural health departments were less likely to offer testing for sexually transmitted infections and LARCs and less likely to have trained staff on site to insert LARCs when compared to nonrural LHDs. CONCLUSIONS: LARC methods are not commonly available in Kansas LHDs. Small LHDs in a rural state like Kansas could benefit from increased capacity to provide LARC to populations with limited access to health care. An increase in funding to prevent unintended pregnancy through expanded LARC access could result in substantial state savings and lead to fewer unintended pregnancies.

Assessing Residency Program Approaches to the Transgender Health CREOG Objective.

Purpose: The transgender population is a small yet distinctive portion of the gynecology patient population, requiring both primary care and specialty services. Recognizing the need for increased education, the Council on Resident Education in Obstetrics and Gynecology (CREOG) developed objectives specific to the care of transgender patients. This study is to assess residency program directors' knowledge about the transgender health CREOG objectives, describe how objectives are being implemented in training programs, and identify what types of educational materials would be useful if available. Methods: In May 2014, an 11-item anonymous survey was sent through e-mail to all eligible program directors of accredited obstetrics and gynecology residency programs. The short questionnaire contained questions about program demographics, approach to training residents with regard to the CREOG objectives, and opinions on tools they would like to use to train their residents on the transgender CREOG objectives. Results: Just under half (47%) of the 86 geographically diverse respondents were from hospital-based programs. The majority reported that the transgender health objectives were important (82%); however, only 70% were familiar with the objectives themselves. Most respondents (96%) felt that providing an educational activity in their training program would be beneficial for their residents' education. Conclusions: Most program directors support the CREOG transgender health objectives and are in favor of implementing educational tools to meet the objectives, suggesting that development of new tools to meet this need would be useful. Future endeavors will be made toward build a training module to facilitate obstetrics and gynecology (Ob-Gyn) programs meeting the CREOG objectives.

Is an isolated ventricular septal defect detected before 24 weeks on ultrasound associated with fetal aneuploidy?

OBJECTIVE: Whether the isolated VSD (i-VSD) is associated with aneuploidy to the same degree as a more severe heart anomaly is unclear. Our objective was to determine the likelihood of aneuploidy in pregnancies at a tertiary referral center when an i-VSD is detected before 24 weeks. METHODS: A retrospective chart review of all detailed anatomy ultrasounds before 24 weeks performed at the University of Kansas Medical Center from 08/23/2006 to 06/07/2012 was conducted. A complete evaluation of the fetal heart was accomplished using gray scale and spectral/color Doppler examinations. The outcomes of each pregnancy were reviewed for any diagnoses of aneuploidy. Odds ratios were calculated. RESULTS: A total of 4078 pregnancies with complete obstetric and neonatal data were reviewed. The prevalence of an i-VSD was 2.7% (112/4078). The odds ratio of aneuploidy when an i-VSD was present was (OR: 36.0, 95% CI: 5.0, 258.1). This odds ratio remained large when either an abnormal or unknown serum screen was present. CONCLUSION: The presence of an i-VSD present before 24 weeks does increase the risk of fetal aneuploidy. Whether a normal serum screen or first trimester screen for aneuploidy negates the association of an i-VSD with aneuploidy still remains undetermined.

Estimating chlamydia re-infection rates: an empirical example.

OBJECTIVE: Chlamydia re-infection data are used to inform and evaluate chlamydia control programmes. We quantitatively investigated the effect of denominator selection on estimating re-infection rates and trends. METHODS: Using data on women aged 15-44 years enrolled in Group Health Cooperative (GH), a Pacific Northwest health plan, annual chlamydia re-infection rates from 1998 to 2006 were calculated. Three different denominators were compared using person-years contributed by: (1) all women; (2) women with a prior documented chlamydial infection regardless of whether they were retested; and (3) women with a prior chlamydial infection who were retested within 14 months. RESULTS: From 1998 to 2006, among all women 15-44 years enrolled in GH, re-infection rates increased from 64 to 149 cases per 100 000 person-years. Among women with a prior infection, rates decreased from 10 857 to 8782 cases per 100 000 person-years. Among women with a prior infection who were retested, rates increased from 29 374 to 42 475 cases per 100 000 person-years. CONCLUSIONS: Using the same dataset, we demonstrate that it is possible to tell three different stories about the magnitude of rates and trends in chlamydia re-infection among women by using different denominators. All of these strategies have limitations, but restricting the denominator to women with a prior infection who are retested may best represent the population at-risk for re-infection. Still, rates do not account for additional factors influencing the number of re-infections diagnosed, including screening coverage and changes in test technology. Caution is needed in examining and comparing re-infection data.

Opportunities for chlamydia control in the era of healthcare reform: lessons from two decades of innovative family planning care.

In the USA, family planning clinics are primary providers of reproductive healthcare to young women and their male partners and have long provided quality sexually transmitted infection (STI) care and prevention. Chlamydia, an easily treatable STI that can lead to serious adverse outcomes if untreated, is the most common bacterial STI in the USA, and annual chlamydia screening is recommended for sexually active women aged ≤25 years. As early adopters of routine screening, family planning clinics screen >50% of all care-seeking eligible women for chlamydia, performing better than private sector healthcare plans. To achieve high levels of quality care, family planning clinics have been leaders in implementing evidence-based care delivery and developing prevention innovations. As national healthcare reform is implemented in the USA and categorical STI clinics close, public-sector demand on family planning clinics will increase.

Long-term trends in Chlamydia trachomatis infections and related outcomes in a U.S. managed care population.

BACKGROUND: Given recent increasing case rates of Chlamydia trachomatis infection, we evaluated trends in chlamydia rates and related health outcomes in women and men aged 15 to 44 years who were enrolled in a Pacific Northwest health plan. METHODS: We identified chlamydia, pelvic inflammatory disease (PID), ectopic pregnancy, and male urethritis cases occurring annually during 1997-2007 using computerized health plan databases, calculating rates per 100,000 person-years (py) by gender and 5-year age groups. We also calculated annual chlamydia testing rates. RESULTS: In women, chlamydia testing rates increased by approximately 23% (220 tests per 1000 py in 1997 to 270 tests per 1000 in 2007). Chlamydia diagnosis rates rose from 449 cases/100,000 py in 1997 to 806/100,000 in 2007, a 79% increase (P = 0.01). Increases were greatest during 2005-2007, also the period of major conversion to nucleic acid amplification test. PID rates in this interval declined steadily from 823 cases/100,000 py to 473/100,000 (P < 0.01). Ectopic pregnancy rates remained unchanged. In men, chlamydia testing rates increased nearly 3.5-fold, from 12 to 42 tests per 1000 py. Chlamydia rates for men also rose significantly throughout the study interval (from 91 cases/100,000 py to 218/100,000; P < 0.01) as did urethritis diagnosis rates (P < 0.01). CONCLUSION: Between 1997 and 2007, annual health plan chlamydia rates increased significantly for both women and men. These trends may be due in part to increased testing rates and increased use of more sensitive tests, but they likely do not explain the increased urethritis rates. During this same interval, we observed steady declines in PID rates, consistent with other national data sources.

Chlamydia trachomatis trends in the United States among persons 14 to 39 years of age, 1999-2008.

BACKGROUND: We report the first population-based assessment of national trends in chlamydia prevalence in the United States. METHODS: We investigated trends in chlamydia prevalence in representative samples of the U.S. population aged 14 to 39 years using data from five 2-year survey cycles of the National Health and Nutrition Examination Survey from 1999 to 2008. Prevalence estimates and 95% confidence intervals (CI) are reported stratified by age, gender, and race/ethnicity. Percent change in prevalence over this time period was estimated from regression models. RESULTS: In the 2007-2008 cycle, chlamydia prevalence among participants aged 14 to 39 years was 1.6% (95% CI: 1.1%-2.4%). Prevalence was higher among females (2.2%, 95% CI: 1.4%-3.4%) than males (1.1%, 95% CI: 0.7%-1.7%). Prevalence among non-Hispanic black persons was 6.7% (95% CI: 4.6%-9.9%) and was 2.5% (95% CI: 1.6%-3.8%) among adolescents aged 14 to 19 years. Over the five 2-year cycles, there was an estimated 40% reduction (95% CI: 8%-61%) in prevalence among participants aged 14 to 39 years. Decreases in prevalence were notable in men (53% reduction, 95% CI: 19%-72%), adolescents aged 14 to 19 years (48% reduction, 95% CI: 11%-70%), and adolescent non-Hispanic black persons (45%, reduction, 95% CI: 4%-70%). There was no change in prevalence among females aged 14 to 25 years, the population targeted for routine annual screening. CONCLUSIONS: On the basis of population estimates of chlamydia prevalence, the overall chlamydia burden in the United States decreased from 1999 to 2008. However, there remains a need to reduce prevalence in populations most at risk and to reduce racial disparities.

Detection of pelvic inflammatory disease: development of an automated case-finding algorithm using administrative data.

ICD-9 codes are conventionally used to identify pelvic inflammatory disease (PID) from administrative data for surveillance purposes. This approach may include non-PID cases. To refine PID case identification among women with ICD-9 codes suggestive of PID, a case-finding algorithm was developed using additional variables. Potential PID cases were identified among women aged 15-44 years at Group Health (GH) and Kaiser Permanente Colorado (KPCO) and verified by medical record review. A classification and regression tree analysis was used to develop the algorithm at GH; validation occurred at KPCO. The positive predictive value (PPV) for using ICD-9 codes alone to identify clinical PID cases was 79%. The algorithm identified PID appropriate treatment and age 15-25 years as predictors. Algorithm sensitivity (GH = 96.4%; KPCO = 90.3%) and PPV (GH = 86.9%; KPCO = 84.5%) were high, but specificity was poor (GH = 45.9%; KPCO = 37.0%). In GH, the algorithm offered a practical alternative to medical record review to further improve PID case identification.

A public health focus on infertility prevention, detection, and management.

In 2002, 2 million American women of reproductive age were infertile. Infertility is also common among men. The Centers for Disease Control and Prevention (CDC) conducts surveillance and research on the causes of infertility, monitors the safety and efficacy of infertility treatment, and sponsors national prevention programs. A CDC-wide working group found that, despite this effort, considerable gaps and opportunities exist in surveillance, research, communication, and program and policy development. We intend to consult with other federal agencies, professional and consumer organizations, the scientific community, the health care community, industry, and other stakeholders, and participate in the development of a national public health plan for the prevention, detection, and management of infertility.

Screening male prisoners for Chlamydia trachomatis: impact on test positivity among women from their neighborhoods who were tested in family planning clinics.

BACKGROUND: Chlamydia trachomatis screening test positivity among women in the United States has remained high, leading researchers to suggest that programs should also screen men. Men have been screened in Philadelphia prisons since 2002. Philadelphia prisons are similar to jails in other jurisdictions; in 2003 the median duration of incarceration was 17 days. We studied whether screening and treating men in prison influenced C. trachomatis infection among women living in their communities. METHODS: We divided the city into 2 areas: "high-treatment" (high percentage of men were treated for C. trachomatis detected in prison) and "low-treatment" (low percentage of men were treated for C. trachomatis detected in prison). We compared changes in test positivity among women from those areas, who were tested in family planning clinics during the 2 years before versus the 3 years after the male prison screening program began. RESULTS: In 2002 to 2004, prison screening led to treatment of 1054 infections among 23,203 men aged 20 to 24 years living in high-treatment areas and 98 infections among 21,057 men aged 20 to 24 years in low-treatment areas. Test positivity declined among 20- to 24-year-old women in both areas. In high-treatment areas, positivity decreased 9.1% per year from 1999 to 2001 and 4.9% per year from 2001 to 2004. In low-treatment areas, positivity decreased 13.2% per year from 1999 to 2001 and 7.5% per year from 2001 to 2004. CONCLUSION: C. trachomatis test positivity among 20- to 24-year-old women tested in family planning clinics continued to decrease after men were treated for C. trachomatis; however, we found no evidence that the continued decrease was due to the new prison screening program.