1. Richard Lechtenberg, MPH University of California, Berkeley California Dept. of Public Health Enough to Make You CRiNGe: Variation in Adherence to the Treatment Guidelines for Neisseria gonorrhoeae, California, 2009-2011

2. Gonorrhea: Nothing to Clap About 2 nd most common reported infectious disease Risk factor for… – Pelvic inflammatory disease – Ectopic pregnancy – Infertility Facilitates transmission and acquisition of HIV Largest racial health disparities Antimicrobial resistance 2

3. Study Question How does adherence to the CDC treatment guidelines for gonorrhea vary by clinical practice setting? 3

4. 4 Provider diagnosis Positive lab test Case report Lab report Local health jurisdiction Electronic submission to the state Random sample of cases drawn Pre-populated interview record sent via secure e-mail Patient and provider interviewed by phone Data entered at the state Small LHJs The California Gonorrhea Surveillance System

5. 2006 guidelines in effect 2010 guidelines in effect lag 12/16/10 Adherent Treatment 8/4/2006 – 12/16/201012/17/2010 – 8/9/2012 Cervix, Urethra, & Rectum Ceftriaxone 125 mg IM OR Cefixime 400 mg Ceftriaxone 250 mg IM OR, IF NOT AN OPTION Cefixime 400 mg PLUS Azithromycin 1g OR Doxycycline 100 mg BIDx7 Pharynx Ceftriaxone 125 mg IM Ceftriaxone 250 mg IM PLUS Azithromycin 1g OR Doxycycline 100 mg BIDx7

6. Analysis 6 Inclusion and exclusion criteria related to specific diagnoses Bivariate associations tested using weighted χ 2 tests Directed acyclic graphs (DAG) used to identify confounders Independent cumulative incidence ratios (CIR) estimated using weighted generalized linear models Adjusted Wald tests used to test the significance of sets of coefficients ( α =0.10)

7. Software Dataset compiled in SAS 9.2 Analyses in R 2.13.1 DAG in daggity.net 7

8. Reported (n= 78,369) Sampled (n=7,735) Given some other treatment (n=509) Given recommended or alternative treatment (n=2,731) Interviewed (n= 3,729) Patient refused interview (n=3,772) Provider refused interview (n=1,362) Interview Incomplete (n=4,006) Analyzed (n= 3,240) No confirmed urogenital, rectal, or pharyngeal infection (n=382) Treatment data not available (n=63) PID (n=18) Conjunctival or disseminated infection (n=2) Excluded from Analysis (n=489) Overall, 16.1% (weighted) received a non-rec. tx 8 41.9% (unweighted) of sampled cases included in the analysis

9. Percent receiving a non-rec. treatment by clinical setting 9

10. Causal Diagram & Modeling Process p=0.48

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16. Summary and Recommendations >2-fold increase in risk of non-rec. tx in nearly all settings compared to STD clinics; esp. high at... – Military/VA facilities – Correctional facilities But intervention may be most fruitful at… – family planning facilities – private physicians/HMOs 16

17. Summary and Recommendations (contd.) Lower risk of receiving a non-rec. tx among… – MSM – Blacks and Hispanics Directions for future research – Identification of specific barriers to the provision of guideline-concordant treatment 17

18. LimitationsStrengths Selection Bias Response Bias Reporting Bias Information Bias Misclassification of the outcome Sample size Large Data variety of clinical settings Large geographic region 18 Robust results Robust to sensitivity analyses

19. Colleagues at CDPH – Michael Samuel, DrPH* – Heidi Bauer, MD, MS, MPH* – Joan Chow, DrPH, MPH – Ina Park, MD, MS – Nicole Olson, MPH* – Scott Baker, MPH – Jessica Frasure-Williams, MPH – Mary Fredrickson – Carol Kong, MPH* My professors at UC Berkeley – Kyle Bernstein, PhD, ScM* – Maureen Lahiff, PhD* – Barbara Abrams, DrPH – Jack Colford, MD, PhD *Co-authors Acknowledgements 19 Contact Info Richard Lechtenberg, MPH rjlechtenberg@gmail.com