TOPLINE:

Implementation of broad-scale sexually transmitted infection (STI) screening in pediatric emergency departments (EDs) was associated with higher rates of infection detection (+2.59 per 1000 patient visits) and testing than usual care, a comparative effectiveness trial showed.

METHODOLOGY:

• Researchers conducted a comparative effectiveness, multicenter pragmatic trial using a type 3 hybrid stepped-wedge crossover design across six pediatric EDs in the US from 2021 to 2022. The trial included 98,413 ED visits by adolescents aged 15-21 years, with 51.7% aged 16-18 years and 57.9% girls (mean age, 17 years). Participants were able to provide consent for a computerized sexual health survey (cSHS) and urine testing for gonorrhea and chlamydia (GC/CT).
• Three screening strategies were implemented and compared: usual care, based on the clinician's discretion for GC/CT screening; targeted screening, in which a validated risk score derived from patient-reported behavioral data in the survey was integrated into the electronic health record to provide clinical decision support [CDS] for GC/CT screening; and universally offered screening, in which all eligible participants were screened, CDS for testing was based on the patient's decision to undergo testing, and survey results were not displayed to clinicians.
• During the study period, 7504 GC/CT tests were ordered — 19.1% during usual care, 42.9% during targeted screening, and 38% during universally offered screening. Raw testing rates did not differ by screening strategy.
• The primary outcome measure was GC/GT detection rates per 1000 patients per 2-week interval, and effectiveness was compared across all three screening strategies. Secondary outcomes included testing rates, positivity among those tested, CDS adherence, survey/consent uptake, and ED length of stay. Analyses were adjusted for site and temporal trends.

TAKEAWAY:

• Detection rates were higher with targeted and universal screening than with usual care (adjusted difference in infections detected per 1000 visits: +2.59; 95% CI, 2.46-2.73 with targeted screening and +1.81; 95% CI, 1.67-1.94 with universal screening). Per‑protocol analyses showed larger increases (+22.11 with targeted and +12.78 with universal screening).
• Testing rates increased under both strategies vs usual care (adjusted increase in tests per 1000 visits: +50.85 with targeted screening and +46.81 with universal screening). Among those tested, raw positivity was highest with usual care (19.3%) vs targeted (16.8%) and universal (15.6%) screening (P = .008).
• In the targeted period, testing rates were higher among patients who completed cSHS (26.3%) than among those who declined screening (8.3%) or those who were not offered screening (6.0%; P < .001). Testing and detection rates rose with risk category — testing rate: 3.2% at low risk, 43.3% at risk, and 57.6% at high risk (P < .001) and detection rate: 2.7% at low risk, 10.6% at risk, and 16.0% at high risk (P = .03). In the universal period, patients who consented on the cSHS were far more likely to be tested (65.8% vs 5.3%) and had higher detection rates (14.9% vs 7.6%; P = .04) than those who declined screening.
• Survey administration differed by strategy (16.6% with the targeted strategy vs 15.2% with the universal strategy; P < .001). ED length of stay was similar across strategies.

IN PRACTICE:

"Findings from this comparative effectiveness trial suggest that a targeted or universally offered screening tool in a pediatric ED setting was associated with higher detection and testing rates than usual care, with targeted screening identifying more infections at a population level compared to universally offered or usual care strategies," the authors wrote. "Multicenter studies to assess this method with improved rates of uptake are needed to determine whether this will remain true when a larger proportion of patients participate in the screening," they added.

SOURCE:

The study was led by Jennifer L. Reed, MD, MS, Cincinnati Children's Hospital Medical Center, Cincinnati. It was published online on September 8, 2025, in JAMA Pediatrics.

LIMITATIONS:

The study used substantial information technology for computerized cSHS/CDS, which may have restricted its adoption elsewhere due to resource and cost constraints. The exclusion of non-English-speaking patients omitted an important demographic group. As the study was conducted during the COVID-19 pandemic, it experienced interruptions in rollout, staffing and STI test supply shortages, and infection‑control constraints, which may have reduced uptake and led to underestimation of effects.

DISCLOSURES:

This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Pediatric Emergency Care Applied Research Network. Some authors reported having financial ties with various sources. Details are provided in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.