Richard Lechtenberg, MPHUniversity of California, BerkeleyCalifornia Dept. of Public Health

Enough to Make You CRiNGe:Variation in Adherence

to the Treatment Guidelines for Neisseria gonorrhoeae,

California, 2009-2011

Gonorrhea: Nothing to Clap About• 2nd most common reported infectious disease• Risk factor for…– Pelvic inflammatory disease– Ectopic pregnancy– Infertility

• Facilitates transmission and acquisition of HIV• Largest racial health disparities• Antimicrobial resistance

2

3

Study Question

• How does adherence to the CDC treatment guidelines for gonorrhea vary by clinical practice setting?

4

Provider diagnosis Positive lab test

Case report Lab report

Local health jurisdiction

Electronic submission to the state

Random sample of cases drawn

Pre-populated interview record sent via secure e-mail

Patient and provider interviewed by phone

Data entered at the state

Small LHJs

The California Gonorrhea Surveillance System

2006 guidelinesin effect 2010 guidelines

in effect

lag

12/16/10

Adherent Treatment 8/4/2006 – 12/16/2010 12/17/2010 – 8/9/2012

Cervix,

Urethra, &

Rectum

Ceftriaxone 125 mg IM OR

Cefixime 400 mgCeftriaxone 250 mg IM OR, IF NOT AN OPTION

Cefixime 400 mgPLUS

Azithromycin 1g OR Doxycycline 100 mg BIDx7

Pharynx

Ceftriaxone 125 mg IMCeftriaxone 250 mg IM

PLUSAzithromycin 1g

OR Doxycycline 100 mg BIDx7

6

Analysis

Inclusion and exclusion criteria related to specific diagnoses

Bivariate associations tested using weighted χ2 tests

Directed acyclic graphs (DAG) used to identify confounders

Independent cumulative incidence ratios (CIR) estimated using weighted generalized linear models

Adjusted Wald tests used to test the significance of sets of coefficients (α=0.10)

7

Software

• Dataset compiled in SAS 9.2• Analyses in R 2.13.1• DAG in daggity.net

9

Percent receiving a non-rec. treatment by clinical setting

STD clinic

HIV clinic

Comm./Pbl Hlth clinic

Family planning facility

Private physician/HMO

Hospital

Other

ER/Urgent Care

Correctional facility

Military/VA

0% 5% 10% 15% 20% 25% 30% 35% 40%

Causal Diagram & Modeling Process

10

p=0.48

11

12

13

14

15

Summary and Recommendations• >2-fold increase in risk of non-rec. tx in

nearly all settings compared to STD clinics; esp. high at...–Military/VA facilities–Correctional facilities

• But intervention may be most fruitful at…– family planning facilities –private physicians/HMOs

16

17

Summary and Recommendations (contd.)

• Lower risk of receiving a non-rec. tx among…–MSM–Blacks and Hispanics

• Directions for future research–Identification of specific barriers to the

provision of guideline-concordant treatment

18

Limitations Strengths

Selection Bias•Response Bias•Reporting Bias

Information Bias•Misclassification of the outcome

Sample size•Large

Data•variety of clinical settings•Large geographic region

Robust results•Robust to sensitivity analyses

19

• Colleagues at CDPH– Michael Samuel, DrPH*– Heidi Bauer, MD, MS,

MPH*– Joan Chow, DrPH, MPH– Ina Park, MD, MS– Nicole Olson, MPH*– Scott Baker, MPH– Jessica Frasure-Williams,

MPH– Mary Fredrickson– Carol Kong, MPH*

• My professors at UC Berkeley– Kyle Bernstein, PhD, ScM*– Maureen Lahiff, PhD*– Barbara Abrams, DrPH– Jack Colford, MD, PhD

*Co-authors

Acknowledgements

Contact Info

Richard Lechtenberg, MPHrjlechtenberg@gmail.com