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ED syphilis and gonorrhea/chlamydia cotesting practices before and after the implementation of an electronic health record-based alert
  1. James S Ford1,
  2. Tasleem Chechi1,
  3. Michella Otmar1,
  4. Melissa Baker2,
  5. Sarah Waldman1,
  6. Brittany Morgan1,
  7. David Tan1,
  8. Nam K Tran3,
  9. Larissa May1
  1. 1 Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
  2. 2 Georgetown University School of Medicine, Washington, DC, USA
  3. 3 Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, California, USA
  1. Correspondence to Dr Larissa May; lsmay{at}


Background The prevalence of syphilis is increasing in many countries, including the USA. The ED is often used by underserved populations, making it an important setting to test and treat patients who are not evaluated in outpatient clinical settings. We aimed to assess the utility of an ED-based syphilis and gonorrhoea/chlamydia cotesting protocol by comparing testing practices before and after its implementation.

Methods We implemented an electronic health record (EHR) alert that prompted clinicians to order syphilis testing in patients undergoing gonorrhoea/chlamydia testing. We performed a retrospective cohort analysis that compared outcomes between the preimplementation period (January–November 2018) and the postimplementation period (January–November 2019). Patients were tested for Treponema pallidum antibody (TPA) using a multiplex flow immunoassay (MFI), and positive results were confirmed by rapid plasma reagin (RPR). The primary implementation outcome was the number of syphilis tests/month, and the primary clinical outcome was the number of syphilis diagnoses/month (defined as positive TPA MFI and RPR). We performed an interrupted time-series analysis to evaluate the effect of implementing the alert over time.

Results Four-hundred and ninety-four and 1106 unique patients were tested for syphilis in the preimplementation and postimplementation periods, respectively. Syphilis testing increased by 55.6 tests/month (95% CI 45.9 to 65.3, p<0.001) following alert implementation. Patients tested in the postimplementation period who were tested using the alert were much younger (difference: 14 years (95% CI 12 to 15)) and were more likely to be female (difference: 15% (95% CI 8 to 21)) and African-American (difference: 11% (95% CI 5 to 17)) than patients tested by clinician-initiated testing. Presumptive syphilis diagnoses increased from 3.4 diagnoses/month to 7.9 diagnoses/month (difference, 4.5 (95% CI 2.2 to 6.9), p<0.001).

Conclusions Our study demonstrates that use of a targeted EHR alert testing protocol can increase syphilis testing and diagnosis and may reduce clinician bias in testing.

  • diagnosis
  • epidemiology
  • infection
  • infectious diseases
  • infectious diseases
  • bacterial

Data availability statement

Data are available on reasonable request. Data will be made available on reasonable request. Please contact the study’s senior author, Dr Larissa May, for data inquiries.

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Data availability statement

Data are available on reasonable request. Data will be made available on reasonable request. Please contact the study’s senior author, Dr Larissa May, for data inquiries.

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  • Handling editor Roland C Merchant

  • Contributors Study concept and design: TC, NKT and LM. Acquisition of data: MB, TC and MO. Analysis and interpretation of data: JF, TC and BM. Drafting of the manuscript: JF, TC, MO, LM, DT, MW and SW. Critical revision: JF, TC, MO, NKT, LM and BM. Acquisition of funding: LM.

  • Funding This work was supported by Gilead’s FOCUS program. In the USA, the FOCUS Program is a public health initiative that enables partners to develop and share best practices in routine blood-borne virus (HIV, hepatitis C virus (HCV) and HBV) screening, diagnosis and linkage to care in accordance with screening guidelines promulgated by the US Centers for Disease Control and Prevention, the US Preventive Services Task Force and state and local public health departments. FOCUS funding supports HIV, HCV and HBV screening and linkage to a first appointment. FOCUS partners do not use FOCUS awards for activities beyond linkage to a first appointment.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.