Cervicitis: To Treat or Not To Treat? The Role of Patient Preferences and Decision Analysis

Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado, United States
Journal of Adolescent Health (Impact Factor: 3.61). 01/2007; 39(6):887-92. DOI: 10.1016/j.jadohealth.2006.06.005
Source: PubMed


Mucopurulent cervicitis is neither a sensitive nor a specific indicator of antibiotic sensitive infection. This analysis examines the positive and negative ramifications of treating cervicitis empirically as a Chlamydial (CT) infection. It begins where prior analyses leave off, with the number of cases of pelvic inflammatory disease (PID) prevented.
Three treatments were compared: 1) treat empirically/refer partner; 2) test, treat, and base partner treatment on results; 3) test, base treatment on results. The outcomes were the physical sequelae of PID and the psychological sequelae of being diagnosed with CT in a hypothetical cohort of 500 teenagers with cervicitis, among whom the prevalence of CT averaged 33%, but ranged between 10% and 70%.
At a CT prevalence of 33%, Treatments 1 and 2 prevented three times as many cases of PID-related physical sequelae (n = 14) as Treatment 3 (n = 5). However, to prevent these 14 cases of physical sequelae, with Treatment 1, 163 teens needlessly suffer the psychological sequelae of a false CT diagnosis and with Treatment 2, 101 do so. The ratio of physical sequelae prevented to psychological sequelae caused, changed in relationship to the prevalence of CT, but was always numerically most favorable with Treatment 3. Moreover, it was the only therapeutic approach for which overall morbidity never exceeded the PID-related physical morbidity incurred in the absence of treatment.
By including the effects of over diagnosing and treating CT, we have demonstrated how the risks and benefits of empiric and nonempiric cervicitis therapy vary in relationship to CT prevalence. Failure to consider both the physical and the psychological aspects of patient well-being may mean that well-intentioned policies to reduce physical morbidity do not result in an overall improvement in health of teenagers.

5 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: There is limited information about how the consumers of adolescent pelvic inflammatory disease (PID) care value health states associated with the disorder. The aim of this study is to determine and compare adolescent and parent PID-related health utilities. Adolescent girls (N=134) and parents (N=121) completed a web-based utility elicitation survey. Participants reviewed five scenarios describing the health states associated with PID (outpatient treatment (mild-moderate disease), inpatient treatment (severe disease), ectopic pregnancy, infertility and chronic abdominal pain). After each scenario, participants were asked to rate health-related quality of life (HRQL) using a Visual Analogue Scale (VAS) and to complete a time trade-off (TTO) assessment. Data were evaluated using multiple linear (VAS) and quantile (TTO) regression analyses. Adolescents had significantly lower mean valuations (p<0.01) than the parents on the VAS for HRQL in each health state (outpatient (62 vs 76), inpatient (57 vs 74), ectopic (55 vs 73), infertility (59 vs 68) and chronic abdominal pain (48 vs 61)). Using quantile regression analysis, adolescents were also willing to give up more time for health gains indicated by lower median TTO scores (p<0.01) for outpatient treatment (0.98 vs 1.0), inpatient treatment (0.96 vs 1.0) and ectopic pregnancy (0.98 vs 1.0). The authors demonstrate that adolescents assign more disutility (lower valuations) than parents for HRQL and three of five of the TTO assessments for PID-related health states. Future economic evaluations using patient-specific preferences to determine resource allocation for PID management in adolescents should include adolescent health outcomes and utilities.
    Sexually transmitted infections 12/2011; 87(7):583-7. DOI:10.1136/sextrans-2011-050187 · 3.40 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Productivity losses can arise when employees miss work to seek care for sexually transmissible infections (STIs). We estimated the average productivity loss per acute case of four nonviral STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis. Methods: We extracted outpatient claims from 2001-2005 MarketScan databases using International Classification Disease ver. 9 (ICD-9) codes. We linked claims with their absence records in the Health and Productivity Management database by matching enrolee identifiers and the service dates from the claims such that our final data included only those who were absent because they were sick and were diagnosed with an STI on the day of their visit. To ensure that the visit was for the STIs being examined, we restricted the criteria to records with the specified ICD-9 codes only, excluding claims with other codes. We estimated the average number of hours absent and multiplied it by the mean hourly wage rate including benefits ($29.72 in 2011 United States dollars) to estimate the average productivity loss per case. Results: The average productivity losses per case were: $262 for chlamydia, $197 for gonorrhoea, $419 for syphilis and $289 for trichomoniasis. There were no significant differences between males and females. Conclusions: Among those who take sick leave to seek care, productivity losses associated with treating nonviral STIs may be higher than their estimated direct medical costs. These productivity cost estimates can help to quantify the overall STI burden, and inform cost-effectiveness analyses of prevention and control efforts.
    Sexual Health 08/2013; 10(5). DOI:10.1071/SH13021 · 1.37 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.
    Annals of Epidemiology 09/2014; 24(9):691. DOI:10.1016/j.annepidem.2014.06.048 · 2.00 Impact Factor