Potential delayed and/or missed STI diagnoses among outpatients presenting with lower genitourinary tract symptoms: a real-world database study

Figures & data

Figure 1. Flowchart of exclusion steps to determine final GAP cohort.

AZM, azithromycin; BV, bacterial vaginosis; CEP, cephalosporins; CFM, cefixime; CRO, ceftriaxone; CT, Chlamydia trachomatis; CTX, cefotaxime; CXT, cefoxitin; DOX, doxycycline; FLQ, fluoroquinolone; FOS, fosfomycin; GEN, gentamicin; LGUTS, lower genitourinary tract symptoms; N, number; NG, Neisseria gonorrhoeae; STI, sexually transmitted infection; TMP-SMX, trimethoprim-sulfamethoxazole; TV, Trichomonas vaginalis; UAI, urinary anti-infective; UTI, urinary tract infection.

^aTreatment with cephalosporins, intramuscular gentamicin and azithromycin, doxycycline, and/or azithromycin.

^bPotential CT/NG treatment refers to fluoroquinolone with or without urinary anti-infectives, and/or azithromycin, and/or doxycycline, and/or gentamicin and azithromycin, cephalosporins, doxycycline, azithromycin, intramuscular gentamicin and azithromycin.

^cNot cephalosporins.

^dNot fluoroquinolone, cephalosporins or gentamicin and azithromycin.

^eNot fluoroquinolone, cephalosporins, doxycycline, or urinary anti-infectives.

Table 1. Patient characteristics of the GAP cohort (episode-level).

	All		Males		Females
	N	%	n	%	n	%
Total	833,574	100.0	148,631	100.0	684,943	100.0
Sex
Men	148,631	17.8	148,631	100.0	0	0.0
Women	684,943	82.2	0	0.0	684,943	100.0
Age at index, years
14–19	46,980	5.6	5,250	3.5	41,730	6.1
20–24	70,347	8.4	7,801	5.2	62,546	9.1
25–29	62,740	7.5	7,395	5.0	55,345	8.1
30–34	68,448	8.2	8,961	6.0	59,487	8.7
35–39	75,187	9.0	10,860	7.3	64,327	9.4
40+	509,872	61.2	108,364	72.9	401,508	58.6
Age at index, years
Mean (SD)	43.3 (14.1)	-	47.3 (13.4)	-	42.4 (14.2)	-
Median (IQR)	45.0 (32.0–56.0)	-	51.0 (38.0–59.0)	-	44.0 (31.0–55.0)	-
Insurance
Commercial	688,103	82.5	130,051	87.5	558,052	81.5
Medicaid	145,471	17.5	18,580	12.5	126,891	18.5
Place of service
Urgent care	35,661	4.3	4,667	3.1	30,994	4.5
ER visits	95,611	11.5	17,307	11.6	78,304	11.4
Non-ER out-patient visits	126,814	15.2	22,170	14.9	104,644	15.3
Office visits	453,925	54.5	83,129	55.9	370,796	54.1
Other	121,563	14.6	21,358	14.4	100,205	14.6
Missing/Not reported	0		0		0
Race/ethnicity*
White, white-Hispanic	82,864	9.9	9,693	6.5	73,171	10.7
Black, black-Hispanic	40,584	4.9	5,344	3.6	35,240	5.1
Hispanic	3,268	0.4	340	0.2	2,928	0.4
Other	14,102	1.7	2,296	1.5	11,806	1.7
Missing/Not reported	692,756	83.1	130,958	88.1	561,798	82.0

ER, emergency room; IQR, interquartile range; N, number of episodes; n, subgroup number of episodes; SD, standard deviation.

*Only available in the Medicaid database, not in the commercial database.

Table 2. STI testing rates and number of return visits for the GAP cohort post index (days +4).

Group that received potential CT/NG treatment post index (days 4+)	Total episodes	Received CT/NG testing	Non-CT/NG test only	No testing	Number of return visits
					0	1	2	3
GAP cohort
Men, number (%)	148,631 (100)	6,818 (4.6)	45,294 (30.5)	96,519 (64.9)	74,324 (50.0)	50,443 (33.9)	17,538 (11.8)	6,326 (4.3)
Women, number (%)	684,943 (100)	36,876 (5.4)	277,303 (40.5)	370,764 (54.1)	308,454 (45.0)	268,344 (39.2)	80,975 (11.8)	27,170 (4.0)
FLQ subgroup
Men, number (%)	104,283 (100)	2,278 (2.2)	34,025 (32.6)	67,980 (65.2)	51,802 (49.7)	35,724 (34.3)	12,336 (11.8)	4,421 (4.2)
Women, number (%)	464,683 (100)	14,434 (3.1)	212,327 (45.7)	237,922 (51.2)	195,848 (42.1)	192,615 (41.5)	57,300 (12.3)	18,920 (4.1)
AZM and/or DOX subgroup
Men, number (%)	31,813 (100)	2,468 (7.8)	6,281 (19.7)	23,064 (72.5)	18,976 (59.6)	9,262 (29.1)	2,739 (8.6)	836 (2.6)
Women, number (%)	149,237 (100)	11,563 (7.7)	28,361 (19.0)	109,313 (73.2)	97,155 (65.1)	39,701 (26.6)	9,598 (6.4)	2,783 (1.9)
CEP subgroup
Men, number (%)	12,512 (100)	2,070 (16.5)	4,975 (39.8)	5,467 (43.7)	3,541 (28.3)	5,448 (43.5)	2,458 (19.6)	1,065 (8.51)
Women, number (%)	70,931 (100)	10,874 (15.3)	36,571 (51.6)	23,486 (33.1)	15,425 (21.7)	35,987 (50.7)	14,064 (19.8)	5,455 (7.7)
GEN and AZM subgroup
Men, number (%)	23 (100)	2 (8.7)	13 (56.5)	8 (34.8)	5 (21.7)	9 (39.1)	5 (21.7)	4 (17.4)
Women, number (%)	92 (100)	5 (5.4)	44 (47.8)	43 (46.7)	26 (28.3)	41 (44.6)	13 (14.1)	12 (13.0)

AZM, azithromycin; CEP, cephalosporins; CT, Chlamydia trachomatis; DOX, doxycycline; FLQ, fluoroquinolone; GEN, gentamicin; NG, Neisseria gonorrhoeae.

Table 3. Time to post-index STI treatment among patients within the GAP cohort who were diagnosed with a UTI and/or acute cystitis at index.

Group that received potential CT/NG treatment post-index (days 4+)	Total episodes	Patients diagnosed with UTI and/or acute cystitis at index (day 1)*
	N (%)	N (%)	Median number of days from index to post-index STI treatment (IQR)
GAP cohort
Men	148,631 (100)	77,390 (52.1)
Women	684,943 (100)	467,842 (68.3)
FLQ subgroup
Men	104,283 (100)	58,270 (55.9)	7.0 (4.0–12.0)
Women	464,683 (100)	334,487 (74.1)	7.0 (4.0–13.0)
AZM and/or DOX subgroup
Men	31,813 (100)	12,129 (38.1)	8.0 (5.0–12.0)
Women	149,237 (100)	72,981 (48.9)	9.0 (6.0–13.0)
CEP subgroup
Men	12,512 (100)	6,972 (55.7)	8.0 (5.0–13.0)
Women	70,931 (100)	50,311 (70.9)	8.0 (5.0–14.0)
GEN and AZM subgroup
Men	23 (100)	19 (82.6)	14.0 (6.5–19.0)
Women	92 (100)	53 (57.6)	8.0 (5.0–14.0)

AZM, azithromycin; CEP, cephalosporins; CT, Chlamydia trachomatis; DOX, doxycycline; FLQ, fluoroquinolone; GEN, gentamicin; IQR, interquartile range; N, number; NG, Neisseria gonorrhoeae; STI, sexually transmitted infection; UTI, urinary tract infection.

Table 4. Conditions diagnosed at index (day 1) within the GAP cohort.

Group that received potential CT/NG treatment post index (days 4+)	Total episodes	UTI	Dysuria	Orchitis/ epididymitis	Acute prostatitis	Urethritis	Acute cystitis	Vaginitis/vulvitis/ vulvovaginitis	Cervicitis
GAP cohort
Men, number (%)	148,631 (100)	72,257 (48.6)	38,350 (25.8)	21,295 (14.3)	15,060 (10.1)	*	5,884 (4.0)	*	*
Women, number (%)	684,943 (100)	422,883 (61.7)	166,016 (24.2)	*	*	*	50,828 (7.4)	80,408 (11.7)	22,479 (3.3)
FLQ subgroup
Men, number (%)	104,283 (100)	54,486 (52.2)	25,106 (24.1)	13,790 (13.2)	11,587 (11.1)	*	4,358 (4.2)	*	*
Women, number (%)	464,683 (100)	311,964 (67.1)	114,741 (24.7)	*	*	*	36,961 (8.0)	35,589 (7.7)	9,368 (2.0)
AZM and/or DOX subgroup
Men, number (%)	31,813 (100)	11,335 (35.6)	9,590 (30.1)	6,266 (19.7)	2,773 (8.7)	2,321 (7.3)	*	*	*
Women, number (%)	149,237 (100)	66,389 (44.5)	33,195 (22.2)	*	*	*	7,332 (4.9)	37,760 (25.3)	10,953 (7.3)
CEP subgroup
Men, number (%)	12,512 (100)	6,418 (51.3)	3,650 (29.2)	1,239 (9.9)	697 (5.6)	618 (4.9)	*	*	*
Women, number (%)	70,931 (100)	44,484 (62.7)	18,059 (25.5)	*	*	*	6,527 (9.2)	7,049 (9.9)	2,146 (3.0)
GEN and AZM subgroup
Men, number (%)	23 (100)	18 (78.3)	4 (17.4)	*	3 (13.0)	*	1 (4.3)	*	*
Women, number (%)	93 (100)	46 (50.0)	21 (22.8)	*	*	*	8 (8.7)	10 (10.9)	12 (13.0)

AZM, azithromycin; CEP, cephalosporins; CT, Chlamydia trachomatis; DOX, doxycycline; FLQ, fluoroquinolone; GEN, gentamicin; NG, Neisseria gonorrhoeae; UTI, urinary tract infection.

*Values for these conditions are not shown as they were not one of the top five conditions for that group.

Table 5. Conditions diagnosed post index (days 4+) within the GAP cohort.

Group that received potential CT/NG treatment post index (days 4+)	Total episodes	UTI	Dysuria	Orchitis/ epididymitis	Acute prostatitis	Urethritis	Acute cystitis	Vaginitis/vulvitis/vulvovaginitis	Cervicitis
GAP cohort
Men, number (%)	148,631 (100)	35,987 (24.2)	16,551 (11.1)	13,233 (8.9)	11,592 (7.8)	4,628 (3.1)	*	*	*
Women, number (%)	684,943 (100)	270,039 (39.4)	91,575 (13.4)	*	*	*	37,780 (5.5)	39,971 (5.8)	8,863 (1.3)
FLQ subgroup
Men, number (%)	104,283 (100)	27,571 (26.4)	10,650 (10.2)	8,599 (8.2)	9,302 (8.9)	*	2,689 (2.6)	*	*
Women, number (%)	464,683 (100)	205,116 (44.1)	67,659 (14.6)	*	*	*	28,703 (6.2)	19,088 (4.1)	2,931 (0.6)
AZM and/or DOX subgroup
Men, number (%)	31,813 (100)	3,765 (11.8)	3,586 (11.3)	3,299 (10.4)	1,482 (4.7)	2,027 (6.4)	*	*	*
Women, number (%)	149,237 (100)	25,491 (17.1)	11,095 (7.4)	*	*	*	3,004 (2.0)	14,220 (9.5)	3,333 (2.2)
CEP subgroup
Men, number (%)	12,512 (100)	4,638 (37.1)	2,312 (18.5)	1,335 (10.7)	805 (6.4)	1,189 (9.5)	*	*	*
Women, number (%)	70,931 (100)	39,393 (55.5)	12,805 (18.1)	*	*	*	6,063 (8.5)	6,652 (9.4)	2,590 (3.7)
GEN and AZM subgroup
Men, number (%)	23 (100)	13 (56.5)	3 (13.0)	*	3 (13.0)	2 (8.7)	1 (4.3)	*	*
Women, number (%)	92 (100)	39 (42.4)	16 (17.4)	*	*	*	10 (10.9)	11 (12.0)	9 (9.8)

AZM, azithromycin; CEP, cephalosporins; CT, Chlamydia trachomatis; DOX, doxycycline; FLQ, fluoroquinolone; GEN, gentamicin; NG, Neisseria gonorrhoeae; UTI, urinary tract infection.

*Values for these conditions are not shown as they were not one of the top five conditions for that group.

Data availability statement

The patient data that support the findings of this study are available from the IBM (now Merative™) MarketScan Research Databases (Commercial Database and Multi-State Medicaid Database), but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. The databases are available for secondary use on a commercial basis, and requests for access to the data should be sent to IBM Watson Health and not the corresponding author. All data generated from the analysis of the databases are included in this published article.