Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings.

BACKGROUND: We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. METHODS: Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards. RESULTS: Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment. CONCLUSIONS: An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

Urinary symptoms associated with human T-cell lymphotropic virus type I infection: evidence of urinary manifestations in large group of HTLV-I carriers.

OBJECTIVES: To describe the frequency of urologic manifestations in human T-cell lymphotropic virus type I (HTLV-I) seropositive individuals from Salvador and other cities in Bahia, Brazil, with or without clinical HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). METHODS: A total of 218 HTLV-I seropositive subjects referred from blood banks or neurologic clinics were admitted to the HTLV-I multidisciplinary outpatient clinic from January 2001 to April 2004. They were assessed using a standardized questionnaire to determine urinary complaints and quality of life. Neurologic impairment was established using the Expanded Disability Status Scale (EDSS). HAM/TSP was considered as an EDSS score of 2 or greater. RESULTS: Nocturia (35.8%) was the most frequent finding, followed by incontinence (29.8%), urgency (25.2%), frequency (22.0%), and dysuria (15.6%). Differences were found between individuals with an EDSS score of 0 and those with an EDSS score greater than 0 but less than 2 regarding frequency, nocturia, urgency, urinary loss of any degree, and quality of life. Dysuria and great or total urinary loss were more frequent among those with severe HAM/TSP (EDSS score greater than 6). CONCLUSIONS: Even HTLV-I subjects considered not to have HAM/TSP may have prominent urinary findings already present. Urologic manifestations, including nocturia and urinary loss, might be early manifestations of neurologic disease in those with HTLV-I.