Study: ED providers may be missing cases of PID among adolescents
Sexual history, pelvic exam are key to establishing a diagnosis
A new study suggests that ED providers may be missing cases of pelvic inflammatory disease (PID) in adolescents, a condition that, when left untreated, can lead to infertility, chronic pelvic pain, ectopic pregnancy, and pelvic abscesses. In an effort to improve diagnosis of PID, the Centers for Disease Control in Atlanta broadened its criteria for diagnosis in 2002, but data show that diagnosis of PID in adolescents has remained stagnant.
• Experts say part of the problem is that providers are often reluctant to query young people about their sexual histories, a crucial element when diagnosing PID.
• While providers may be missing some cases, the study notes that 70% of adolescents with PID are diagnosed in the ED.
• Hospital and ED administrators should consider using IT tools to track the diagnosis and treatment of PID among adolescents, and to drive quality improvement.
Even with government efforts aimed at increasing the diagnosis of pelvic inflammatory disease (PID), there are new concerns that emergency providers may be missing the diagnosis in adolescents. In a study published in the Journal of Adolescent Health, researchers who reviewed data from the 2000-2009 National Hospital Ambulatory Medical Care Survey found that out of an estimated 77 million visits to the ED by 14- to 21-year-old patients, there were roughly 705,000 diagnoses of PID.1sThis represents a slight decrease in the diagnosis rate since 2002, when the Centers for Disease Control (CDC) in Atlanta, GA, broadened its criteria for diagnosis with the aim of increasing the recognition and treatment of PID cases.
Before 2002, the CDC guidelines noted that patients needed to have both cervical motion tenderness and uterine/sexual tenderness to meet the diagnostic criteria for PID; however, those guidelines were revised so that the presence of either cervical motion tenderness or uterine/sexual tenderness now meets the diagnostic criteria, explains Monika Goyal, MD, a pediatrician at Children's National Medical Center in Washington, DC, and the lead author of the study. "The goal was really to not miss women who may have PID," she says.
Obtain a sexual history
While the study does not clarify why the diagnosis rate for PID among adolescents in the ED setting has remained stagnant, the data suggest that ED providers may be overlooking risk factors for the diagnosis. Goyal explains that there are many reasons why providers might fail to consider PID when teenage women present with pain in the lower abdominal area. For instance, there are any number of conditions that can cause pain in that area, ranging from an inflamed appendix or a urinary tract infection to something as simple as a stomach virus or constipation, but Goyal stresses that PID should be on that consideration list as well. Left untreated, PID can cause infertility, chronic pelvic pain, ectopic pregnancy, and pelvic abscesses, she adds.
"My concern is that providers may not even consider PID in the differential diagnosis," says Goyal. "When we evaluate teenagers, oftentimes we may think of them as children rather than adults. We may not even consider the fact that they may be sexually active, so we may not be obtaining sexual histories on teenagers, and especially younger teenagers, even though we would be obtaining sexual histories on adult women."
Maria Trent, MD, MPH, an associate professor of pediatrics in the Division of Pediatrics and Adolescent Medicine at Johns Hopkins University School of Medicine, Baltimore, MD, and a co-author of the study, adds that obtaining a patient's sexual history is a crucial element in the diagnosis of PID. "Those who acquire PID who are not sexually active are really considered rare, and they are often written up in journals as case reports because they have unusual bacterial organisms," she says. "So you have to take a detailed history, and do an exam, which includes a pelvic examination. Many people consider it invasive, but it is really a standard of care for this type of diagnosis."
Trent has found that while the diagnosis of PID is imprecise, the CDC criteria are broad enough to capture most adolescents who have the condition, but putting those guidelines into practice in an emergency environment requires protocols and ongoing safety checks. "Emergency providers are taking care of people who are coming in with traumas, and they're taking care of people who have other significant types of illness as well," she says. "It is, therefore, important that we have a protocol-driven way to approach these patients so that they all receive care, because even though patients [with PID] are difficult to diagnose, the CDC has laid out a nice framework that allows us not to miss people in terms of diagnostic care."2
Use IT for quality improvement
While providers may be missing some cases, the study notes that 70% adolescents with PID are diagnosed in the ED. Goyal explains that this finding is consistent with other studies that have shown that adolescents comprise one of the age groups least likely to have a primary care provider.
Trent observes that such care patterns are problematic. "We are no longer hospitalizing adolescents for PID. We are discharging them home but we know that many of them are not going to come back [for follow-up], and many of them are at extremely high risk," she says. "They need risk-reduction counseling in terms of family planning, prevention of future sexually transmitted infections, and medication adherence."
Goyal is currently developing a computerized sexual health screening tool that could be given to every patient who comes into the ED. "The hope is that by putting this on a computer tablet, teenagers will feel more comfortable answering these types of questions rather than leaving it up to the provider," she explains.
Also in the works is a pilot study to gauge the acceptability of providing universal screening for sexually transmitted infections in the ED, regardless of what a patient presents with, adds Goyal. "If these steps were implemented, then we would be able to diagnose infection earlier and prevent the development of pelvic inflammatory disease by treating earlier," she says.
Trent would like to see more hospitals use their IT tools to track how many cases of PID are being diagnosed in the ED, and what kind of care is being delivered. "Most institutions have quality and safety officers who can help them come up with an easy way to take a snap shot," she says. "It doesn't have to involve every patient. Just look at the PID patients you have seen in the last six months, and see if they got the kind of care they should have."
Reference
1. Goyal M, Hersch A, Luan X, Locallo MS, Trent M, Zaoutis T. National trends in pelvic inflammatory disease among adolescents in the emergency department. Journal of Adolescent Health 2013;53:249-252.
2. Trent M. Pelvic Inflammatory disease. Pediatrics in Review 2013;34:163-172.
• Monika Goyal, MD, Pediatrician, Children's National Medical Center, Washington, DC. E-mail: [email protected].
• Maria Trent, MD, MPH, Associate Professor of Pediatrics, Division of Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. E-mail: [email protected].
