Richard Lechtenberg, MPH University of California, Berkeley California Dept. of Public Health

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

2. Gonorrhea: Nothing to Clap About • 2nd 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

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

4. The California Gonorrhea Surveillance System Positive lab test Provider diagnosis Lab report Case report Local health jurisdiction Electronic submission to the state Small LHJs 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

5. Adherent Treatment lag 12/16/10 2010 guidelines in effect 2006 guidelines in effect

6. Analysis • Inclusion and exclusion criteria related to specific diagnoses • Bivariate associations tested using weighted χ2 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

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

9. Causal Diagram & Modeling Process p=0.48 Region HIV Pregnancy Age Race Clinical setting Treatment MSM

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

18. Acknowledgements • 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 Contact Info Richard Lechtenberg, MPH rjlechtenberg@gmail.com