1536 - Impact of Type of Provider on Appropriateness of Treatment for Gonorrhea and Chlamydia in Outpatient Clinics

Background: Patients with sexually transmitted infections (STIs) receive care in a variety of outpatient settings with medical providers of different levels of training and expertise, especially regarding STIs. We aimed to determine the impact of type of provider on the appropriateness of treatment for chlamydia and gonorrhea in a large integrated health system.

Methods: We conducted a retrospective cohort study of adult patients diagnosed with chlamydia and/or gonorrhea at any outpatient clinic within an integrated health system in Des Moines, Iowa. Nucleic-acid amplification tests were used for diagnosis, and all samples were processed at the same laboratory. Adequate treatment was defined as prescription for appropriate antibiotic, dose and duration within 7 days of the positive test. Logistic regression models with robust standard errors and adjusting for clustering by clinic were built.

Results: We identified 481 unique patients and a total of 515 unique encounters. Considering unique patients only, the median patient age was 23 years (IQR 20-26), 466/481 (96.9%) were female (96.9%), 15/481 (3.1%) were male, and 79/481 (16.4%) were pregnant. Table 1 shows the patient demographic and provider characteristics by appropriateness of treatment for individual visits.
A total of 53 patients had inappropriate treatment, some with multiple errors which are described in Table 2. 
Provider type, age, type of infection, and pregnancy status were significantly associated with appropriateness of treatment. After adjusting for type of infection, pregnancy status and clustering by clinic, compared to physicians, certified nurse midwives (CNMs) had 33% lower odds of prescribing appropriate treatment (95% CI 0.49-0.91; p-value = 0.010), with no difference in appropriateness of prescribing by mid-level providers (OR 1.61, 95% CI 0.82-3.17; p-value = 0.167). Pregnancy was independently associated with lower odds of appropriate treatment (OR 0.35, 95% CI 0.24-0.52; p-value < 0.001), as was infection with gonorrhea (OR 0.29, 95% CI 0.12-0.68; p-value = 0.004).Table 1. Demographic characteristics of adult patients diagnosed with chlamydia and/or gonorrhea in outpatient clinics by appropriateness of treatment. Des Moines, Iowa, January 1, 2019 to December 31, 2019
Table 2. Type of therapeutic errors encountered among patients diagnosed with chlamydia or gonorrhea


Conclusion: CNMs had lower odds of prescribing appropriate treatment for STIs. Efforts aimed at improving prescribing by healthcare providers should actively engage with this group.