MANAGEMENT OF STIs

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A Clinical Decision Support Tool for the Management of Sexually Transmitted Infections
Among Women

Leighanna D. Lawson
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Leighanna D. Lawson is a registered nurse.
She has no known conflict of interest to disclose.
Correspondence should be addressed to Leighanna D. Lawson, Edson College of Nursing and
Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ
85004. Email: ldlawson@asu.edu

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Abstract

Sexually transmitted infections (STIs) are a variety of infections caused by pathogens acquired
and transmitted through sexual activity (World Health Organization [WHO], 2021). STIs are
associated with an increase in chronic pelvic pain, pelvic inflammatory disease (PID), infertility,
and pregnancy complications (Centers for Disease Control and Prevention [CDC], 2021e). A
clinical decision support (CDS) tool provides assistance to healthcare providers to use a logical,
step-by-step method in patient management by incorporating different reminders or guidelines
into practice. The purpose of this project is to assist healthcare providers to manage positive STI
results per the CDC guidelines via a CDS tool. A CDS tool for positive STI management was
implemented as a system wide practice change. A retrospective chart audit revealed the CDS tool
was used 49% of the time. When the CDS tool was utilized, documented partner treatment,
screening for additional STIs, documented follow-up, condoms offered, provider discussion of
screening of other STIs, and treatment of the STI all increased. This project displays that
utilization of a CDS tool can improve the management of positive STIs in a women’s healthcare
setting.
Keywords: clinical decision support tool, sexually transmitted infections, STIs, primary
care clinic

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A Clinical Decision Support Tool for the Management of Sexually Transmitted Infections
Among Women
There are numerous diseases acquired throughout the United States (U.S.) each year, in
which the spread of many of these can be decreased with proper preventable measures. Sexually
transmitted infections (STIs) consist of a variety of clinical complaints and infections that are
acquired and transmitted through sexual activity (Centers for Disease Control and Prevention
[CDC], 2021a). STIs are caused by 30 different bacteria, viruses, and parasites that give rise to
chlamydia, gonorrhea, syphilis, trichomonas, hepatitis B, hepatitis C, herpes simplex virus
(HSV), human papillomavirus (HPV), and human immunodeficiency virus (HIV) (WHO, 2021).
Healthcare providers have a duty to ensure that they are properly treating their patients
based on evidence-based practice (EBP). STIs are being diagnosed in various health care
settings. A principle of STI care is timely management of infections. There are many national
initiatives addressing the management of positive STI results. The CDC released an evidencebased prevention, diagnostic, and treatment guideline to provide a source for clinical guidance
(CDC, 2021a). Proper management of STIs includes effective diagnosis, treatment, counseling,
and follow-up of infected persons and their sex partners (CDC, 2021a). Understanding the
treatment and follow-up to positive STI results can help lead to an overall decrease in STI rates,
a decrease in costs associated with STIs, increase partner treatment therapy, and an increase in
patient and provider education.
Background and Significance
Problem Statement
Healthcare providers play a critical role in managing STIs and help prevent the spread of
infection. Negative health outcomes for women associated with positive STIs include increased

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risk of HIV infection, chronic pelvic pain, pelvic inflammatory disease (PID), infertility,
pregnancy and newborn complications, and infant death (CDC, 2021e). Chlamydia and
gonorrhea are preventable causes PID and infertility. If chlamydia is left untreated, 10-15% of
women will develop PID (CDC, 2021d).
Screening for STIs.
There any many national initiatives for healthcare providers that provide guidance of STI
management. The U.S. Preventive Services Task Force (USPTF) and the CDC provide screening
recommendations for STIs. For chlamydia and gonorrhea, it is recommended for routine
screening in all sexually active women 24 years or younger and in women 25 years or older who
are at an increased risk for infection (CDC, 2021a; USPTF, 2021). Syphilis screening should
occur in those at increased risk including men who have sex with men, persons who are positive
for HIV, a history of incarceration, partake in sex work, and males younger than 29 years old
(CDC, 2021a; USPSTF, 2016). One major strategy in prevention and control of STIs is
identification of asymptomatically infection persons and persons with symptoms associated with
STIs (CDC, 2021a).
Screening for other STIs.
After a positive STI result, the first line of action is treating the STI as indicated by the
CDC’s STI Treatment Guidelines, 2021 (CDC, 2021a). Another management consideration of a
positive STI result is to screen for additional STIs. For individuals who receive a diagnosis of
chlamydia, they should be tested for HIV, gonorrhea, and syphilis (CDC, 2021a). Similarly,
when a person tests positive for gonorrhea they should be tested for chlamydia, syphilis, and
HIV (2021a). Primary and secondary syphilis diagnoses should be followed up with testing for
HIV (CDC, 2021a).

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Expedited partner therapy.
Another management guideline includes treating sexual partners of those that have been
exposed following a positive STI diagnosis of an individual. Expedited partner therapy (EPT)
gives healthcare providers the ability to prescribe medications to patient’s partners without
examining them first (American College of Obstetricians and Gynecologists [ACOG], 2018).
EPT should be offered to all sexual partners within the last two months who are unable to seek
medical services (ACOG, 2018). EPT is permissible in 46 states including Arizona (CDC,
2021f). Written education materials should be provided when providing EPT and include
potential therapy-related allergies and adverse effects (ACOG, 2018; CDC 2021a). Sexual
partners should be advised to seek medical evaluation to discuss screening for other STIs.
Patients and partners should be informed to abstain from sexual intercourse for seven days after
completion of medication treatment (ACOG, 2018). Persons exposed to primary, secondary, or
early latent syphilis should be evaluated clinically and serologically and treated according to
CDC recommendations (CDC, 2021a). High rates of STIs can be attributed to reinfection from
partners. Therefore, healthcare providers ability to use EPT is beneficial.
Other management considerations.
Follow-up testing for STIs is the action of testing for the same STI that was positive to
ensure eradication or cure after treatment. After a positive chlamydia or gonorrhea diagnosis,
retesting is recommended at three months post treatment while an individual with a positive
syphilis diagnosis is recommended to receive retesting at six months (CDC, 2021a). Additional
STI management would include offering behavioral counseling interventions to those individuals
that are at an increased risk for STIs, have been diagnosed with an STI within the past year, do
not use condoms, and those who have multiple sex partners (USPSTF, 2020). Best practice

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would consist of implementing behavioral counseling or referring patients to counseling.
Behavioral counseling includes in person counseling, videos, websites, written materials,
telephone support, and text message support (USPSTF, 2020). Future implications consist of
increasing on-site and point-of-care behavioral counseling services within a variety of settings
and patient populations to ensure compliance from patients and increase STI health outcomes
(Barrow, 2020).
Chlamydia
Chlamydia infections are the most frequently reported bacterial infectious disease in the
U.S. and prevalence is highest among persons aged less than 24 years old (CDC, 2021a). Serious
complications for women from chlamydia include PID, ectopic pregnancy, and infertility (CDC,
2021a). Treating persons with chlamydia prevents adverse reproductive health outcomes and
continued sexual transmission. Initiating EPT remains low. Data suggests that only 50% of
healthcare providers have ever used EPT and up to 27% report always using EPT (Barrow,
2020).
Gonorrhea
Gonorrhea is the second most commonly reported bacterial communicable disease (CDC,
2021a). Among women, gonorrhea is commonly asymptomatic (CDC, 2021a). Data shows that
while gonorrhea is routinely treated per the CDC recommendations, only 31% of the time
follow-up care was accomplished within 3 months of initial testing with a reinfection rate of 56%
(Boyajian et al., 2016). In this same study, 60% of healthcare providers did not document partner
therapy (Boyajian et al., 2016).
Syphilis

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Syphilis is a systemic disease divided into stages on the basis of clinic findings, which
guides treatment and follow-up (CDC, 2021a). Data shows that 88% of healthcare providers and
medical students have no experience or feel they are inexperienced with diagnosing and treating
syphilis (Bonnewell et el., 2020).
Epidemiological Data
National rates of STIs continue to be on the rise and the state of Arizona is increasingly
contributing to these levels. In 2019 there were more than 2.5 million cases of chlamydia,
gonorrhea, and syphilis reported in the U.S. leading to an all-time high for the sixth consecutive
year (CDC, 2021c). In 2019 the state of Arizona surpassed the national rates for chlamydia,
gonorrhea, and syphilis (CDC, 2021e). National rates for chlamydia were 552.8 per 100,000
population while Arizona was at 600.4 per 100,000 (CDC, 2021e). National rates for gonorrhea
were 188.4 per 100,000 population and the state of Arizona reported 285.1 per 100,000 (CDC,
2021e). U.S. syphilis rates were 39.7 per 100,000 population and Arizona had a rate of 58.6 per
100,000 (CDC, 2021e). High rates of STIs can be attributed to a reduction in screening,
treatment, prevention, and partner services (CDC, 2021c). According to the CDC, increasing
rates of STIs can be linked to management or a lack thereof (CDC, 2021c).
Purpose and Rationale
Healthcare providers ability to incorporate national guidelines for the management of
positive STIs can lead to a decrease in STI rates, a decrease in associated medical costs, and an
increase in partner treatment leading to a decrease in community transmission rates. The purpose
of this literature review is to establish an intervention that can be implemented by healthcare
providers to ensure that they are following current national guidelines for the management of
positive STI results.

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Internal Evidence
A federally qualified healthcare center (FQHC) within the Southwestern U.S. provides
women’s healthcare that includes STI testing as part of routine care. In 2020, the women’s health
department screened a total of 15,921 patients for chlamydia and gonorrhea in which 846 results
were positive. Syphilis was screened in 7,642 patients and 160 results were positive. During a
peer-to-peer review, inconsistency in the management of positive STI results was noted.
Inquiring about proper STI management has led to the PICO question, “In women who test
positive for a sexually transmitted infection, how does a clinical decision support tool compared
to no clinical decision support tool assist healthcare providers to manage positive sexually
transmitted infections?”
Evidence Synthesis
Search Strategy
PubMed.
The PubMed database was utilized in part of an exhaustive literature search. Keywords
used were decision support systems, primary care clinic, primary care, clinical decision support
systems, clinical decision support tool, and primary health care. The first search was done using
a previously retrieved journal article title of “Development and implementation of a clinical
decision support tool for treatment of uncomplicated urinary tract infections in a family
medicine resident clinic” which yielded one result. The MESH term of decision support systems,
clinical yielded 6,072 results. The third search within this database was decision support systems
AND primary care clinic, this yielded 2,636 results. The database search of decision support
systems AND primary care clinic with a limitation on publication year from 2015-2021 yielded
1,356 results. Clinical decision support systems AND primary care yielded 2,520 results.

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Clinical decision support systems AND primary care with the publication year limitation of
2015-2021 yielded 1,300 results. Using Boolean phrases yielded better results, “clinical decision
support tool” AND “primary care clinic” OR “primary care” OR “primary health care” had 73
results. “Clinical decision support tool” AND “primary care clinic” OR “primary health care”
with the limitations on publication year of 2015-2021 yielded 57 results. Inclusion criteria
included English written articles and those that were published within the years of 2015-2021.
No population age group was excluded and exclusions were not made on the type of illness the
decision support tool was attempting to improve.
CINAHL.
Literature searches were done within the Cumulative Index of Nursing and Allied Health
(CINAHL) database. The first search of “decision support system” AND “primary care” OR
“primary health care” OR “primary healthcare”, yielded 478 results. “Decision support system”
AND “primary care clinics” OR “primary health care” OR “primary healthcare” with the
limiters of publication date between 2015-2021 yielded 237 results. The search within the
database of “clinical decision support systems” OR “cdss” AND “primary care clinics” OR
“primary health care” OR “primary healthcare” with publication years of 2015-2021 produced
206 results. “Clinical decision support tool” AND “primary care” OR “primary health care”
OR “primary healthcare” yielded 76 results. “Clinical decision support tool” AND “primary
care” OR “primary health care” OR “primary healthcare” with the limiter of publication year
of 2015-2021 had 58 results. Inclusion criteria for articles retrieved in CINAHL was publication
years of 2015-2021. No population age group was excluded and exclusions were not made on the
type of illness the decision support tool was attempting to improve.
Cochrane library.

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Literature searches were also obtained within the Cochrane library. The first search of
“clinical decision tool” posed 23 results. “Primary care clinic” yielded 510 results. “Clinical
decision tool” AND “primary care clinic” achieved 0 results. The next search that was done
included, “clinical decision support tool” AND “primary care” that yielded 28 results.
“Decision support system” AND “primary care clinic” had 12 results. The final search of
“clinical decision support system” AND “primary care” yielded 97 results. Inclusion criteria for
the articles retrieved from the Cochrane database were within the years of 2015-2021. No
population age group was excluded and exclusions were not made on the type of illness the
decision support tool was attempting to improve. One article was retrieved from Cochrane
library as there were not ample amounts of research articles that were geared towards managing
clinical illnesses with a clinical decision support (CDS) tool.
Grey literature.
Grey literature was obtained from the CDC and USPSTF. STI treatment guidelines were
examined from the CDC’s STI Treatment Guidelines, 2021, these guidelines are evidence
based for the management of STIs (CDC, 2021a). There are many national initiatives
currently in place and aimed at prevention and management measurements for STIs. The
U.S. Department of Health and Human Services (HHS), has a Sexually Transmitted
Infections National Strategic Plan (2019). HHS’s goal is to prevent new STIs, reduce
adverse outcomes; increase research of STIs, reduce health disparities; and increase efforts to
address the STI epidemic (HHS, 2019). Healthy People 2030 is a federal government
prevention agenda for building a healthier nation, with the goal of increasing STI screening
and prevention measures in women (HHS, 2020).
Critical Appraisal

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Ten studies were chosen for critical appraisal from the exhaustive literature search.
Multiple quantitative studies were examined to interpret similarities and differences to better
understand how to correlate a design in order to eliminate gaps seen with properly treating
different STIs seen in women (see Appendices A, Tables A1 and A2). Research that was studied
ranged from the years between 2017 and 2020. Eight out of the ten studies were performed in the
U.S., whereas the other two studies were done within the United Kingdom or Canada. Study
participants ranged from 27 to 22,279. All but one research study was done within a primary care
setting; the outlier was performed within an emergency setting. Most of the studies used an
innovation theory to develop a CDS tool to assist healthcare providers in screening for and
managing their patient’s diagnoses. Development of a CDS tool was seen as a strength within all
of the studies as there was statistical data that correlated with better management of patients.
Bias’s seen within the studies were either none, publication bias, or selection bias. Publication
bias came from pharmaceutical companies that were funding the research projects and in turn the
increased use of a medication with the assistance of the CDS tool. Selection bias was due to
researchers picking and choosing exactly which healthcare providers they would like to target to
use the CDS tool, which does not allow for random selection and could pose a harder ability to
replicate study results. Common weaknesses seen between all studies was the use of the CDS
tool was limited as it was only used within one health care system. However, the application of a
CDS tool could prove beneficial within other health care systems and results would likely be
replicated.
Synthesis of Evidence
The use of a CDS tool is shown to improve management of patients. CDS tools act as
alerts or reminders and can focus on clinical guidelines, condition-specific order sets,

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documentation templates, or diagnostic support (Arbogast et al., 2017; Connelly & Bickel, 2020;
Cox et al., 2020; Karas et al., 2018; Kessler et al, 2017; Kharbanda et al., 2018; Miller et al.,
2019; Palen et al, 2019; Pell et al., 2020; Siaki et al., 2021). According to the evidence seen
within the literature there was a positive increase in healthcare providers ability to better treat
their patients. The assistance of a CDS tool allows healthcare providers to use a logical, step-bystep tool in patient management. Based on some diagnoses or treatment plans, there may be
multiple steps that need to be taken by the healthcare provider to ensure evidence-based care.
When healthcare providers receive a positive STI test for patients, there are multiple EBP
actions. The ability of healthcare providers to care properly for their patients that have STIs can
help ensure that the patient is treated properly and have a decreased chance of returning with
concern of reinfection or a new STI. Based on the evidence, a CDS tool can help ensure proper
management of positive STIs.
Theoretical Framework & Implementation Framework
Theory Application
According to Ludwig von Bertalanffy his identification of the General System Theory is
an understanding of how systems interact with one another in which new properties emerge
(1968). His theory can directly relate to the evidence that is seen within the research literature
(see Appendix B, Figure B1). The theory envelopes a system of analysis, design, development,
and implementation. This theory directly relates to the literature as there was a need for
standardization of the management of positive STI results; this would be the analysis portion of
the General System Theory. The identification of a clinical problem and the desire to adapt a
systems change is the first step within this theory, and the first step needed in order to
standardize care. The design of the electronic CDS tool came from the data that was expressed

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within the internal evidence. After the CDS tool design, development of the tool for positive STI
results was created. After developing the CDS tool, the instrument was incorporated into an
electronic health record (EHR) as a system wide practice change.
Innovation Model
The quality improvement model used to guide this project was developed by Dr. Walter
Shewhart in 1993. This improvement cycle design incorporates the concepts of plan, do, study,
and act (PDSA) (Shewhart, 1993). The PDSA model is a circular model in which each stage
feeds off the past stage in order to obtain one goal of improvement (see Appendix B, Figure B2).
The “Plan” step within the PDSA model can be attributed with an overall goal of the
standardization of positive STI management, design of the CDS tool, creation of the chart audit
tool, and healthcare provider education on the CDS tool. Within the “Do” step of the PDSA
model, a retrospective chart audit obtained pre and post CDS tool implementation occurred. The
“Study” portion of this model is illustrated with healthcare provider usage of CDS tool and
studying data analysis for any gaps in CDS tool usage amongst healthcare providers. “Act” can
be implemented by making CDS tool changes based on data analysis and providing healthcare
provider education based on gaps of care.
Methods
Ethical Considerations
Four elements of ethics that one should be mindful of is autonomy, justice, beneficence,
and non-maleficence. Autonomy is a requirement in which an individual needs to have the full
authority to make health care decisions on their own, based on the principle that they fully
understand all associated risks and benefits (Medical Ethics 101, n.d.). The participants within
this project are healthcare providers at the project site. This project is in compliance with a

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change of practice and all healthcare providers have been educated on this change of practice.
Justice is the idea that all benefits and downfalls of any experimental treatment must be
distributed in a way that is equal to all participants (Medical Ethics 101, n.d.). The project
adhered to this principle by ensuring that all participants within the project were given equal
access to the CDS tool. Beneficence is the defined as healthcare providers taking ownership of
their skills and knowledge for the benefit and good of the patient (Medical Ethics 101, n.d.). The
project accomplished this as this project enhances healthcare providers’ knowledge and skills on
properly treating women who have a positive STI result. Non-maleficence is a do no harm
principle in which healthcare providers need to ensure that all procedures are not harmful to the
patient or others in society (Medical Ethics 101, n.d.). The project adhered to this by ensuring
there was no harm to subjects. There were no risks with patient information as all data was deidentified when recorded on the chart audit tool. Participants’ rights and risks are ensured to be
protected by means of total transparency and proper confidentiality. IRB expedited approval was
obtained by Arizona State University (ASU).
Setting and Stakeholders
The setting in which this project took place was a FQHC within the Southwestern U.S.
The project site offers a wide variety of services including pediatrics, women’s health/pregnancy,
internal/family medicine, pharmacy, dental, and women, infants, and children (WIC) services.
The project site is accredited by The Joint Commission and are deemed a facility under the
Health Resources and Services Administration’s Federal Tort Claims Act (FTCA). Employees
from this organization range from nurse practitioners, physicians, physician assistants, registered
dieticians, and psychiatrists. The goal of this organization is to work with the communities it

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serves to sustain and improve health by providing affordable primary care. Stakeholders include
the corporate team, healthcare providers, and the patients seen within this project site.
Change of Practice
Prior to the project, there was no standardized process for management of positive STI
results. A system wide practice change occurred on 06/15/2021 to bring the project site in
alignment with the current national clinical practice guidelines from the CDC via a CDS tool.
Development of the CDS tool is based on the CDC’s STI Treatment Guidelines, 2021 (CDC,
2021a). The tool received face validity and was imported to the project sites’ EHR (see
Appendix C, Figure C1).
After the CDS tool was implemented, ASU IRB approval was granted on 10/15/2021 for
a secondary data analysis. The retrospective chart audit focused on utilization of the CDS tool
and management of positive STI guidelines per the CDC guidelines. A pre-intervention chart
audit was completed on patient charts with a positive chlamydia, gonorrhea, and/or syphilis
result from September 1, 2020 to December 31,2020. A post-intervention chart audit was
completed on patient charts with a positive chlamydia, gonorrhea, and/or syphilis result between
September 1, 2021 to December 31, 2021.These charts were reviewed using a self-developed
chart audit tool in order to examine how many components of national STI guidelines were
adhered to (see Appendix C, Figure C2).
Participants and Recruitment
No recruitment methods were used as this intervention is a universal change of practice at
the project site. No compensation was given to participants and no additional costs were needed
for participation in the project. Participants included any healthcare provider (nurse practitioners
and obstetrical and gynecology physicians) that practiced within the women’s health department

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of the project site. There were no signed consent forms as this is a system practice change. A
retrospective chart audit was completed pre and post intervention. Inclusion criteria for the
retrospective chart audit were: females, 18 years of age or older, receiving care in the women’s
health department, that had a positive chlamydia, gonorrhea, and/or syphilis test result. Exclusion
criteria for the retrospective chart audit was any individual under the age of 18 years of age,
anyone seen in a different department that is not women’s health, or women receiving prenatal
care.
Pre-Intervention Chart Review
A retrospective chart audit was performed using the chart audit tool for charts that met
the inclusion criteria. The chart audit tool received face validity and contained no patient
identifiers. A list of individuals that met the inclusion criteria between 09/01/2020 and
12/31/2020 was given from the project site to perform the chart audits. The list contained
individuals by last name, first name, date of testing, and type of test (chlamydia, gonorrhea,
and/or syphilis). This list was electronic and contained a hyperlink to that individual’s health
record. The chart audits were completed at the project site. The data was accessed through a
password protected laptop provided by the project site containing the project sites EHR. Within
the EHR, data was accessed via the information provided on the list. Components reviewed
within the chart audits for recommended follow up, other STI testing, and treatment is based on
CDC’s STI Treatment Guidelines, 2015 which were in place during the pre-intervention chart
audit timeframe.
Post-Intervention Chart Review
A retrospective chart audit was performed using the chart audit tool for charts that met
the inclusion criteria. The chart audit tool received face validity and contained no identifiers. A

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list of individuals that met the inclusion criteria between 09/01/2021 and 12/31/2021 was given
from the project site to perform the chart audits. The list contained individuals by last name, first
name, date of testing, and type of test (chlamydia, gonorrhea, and/or syphilis). This list was
electronic and contained a hyperlink to that individual’s health record. The chart audits were
completed at the project site. The data was accessed through a password protected laptop
provided by the project site containing the project sites EHR. Within the EHR, data was then
accessed via the information provided on the list. Components reviewed within the chart audits
for recommended follow up, other STI testing, and treatment is based on CDC’s STI Treatment
Guidelines, 2021 which were in place during the post-intervention chart audit timeframe.
Data Collection
The data collected via the chart audit tool contained the following: age, gender, race,
ethnicity, type of positive STI result (chlamydia, gonorrhea, and/or syphilis), clinic location, use
of the CDS tool, treatment per CDC guidelines, if partner treatment was discussed, if EPT was
declined or ordered, if other STIs were screened for/discussed/ordered, if safe sex practices were
discussed, if condoms were offered, if follow-up plan was documented, if follow-up testing was
completed in the recommended time frame, and if the STI was reported to the Arizona
Department of Health Services (ADHS) (see Appendix C, Figure C2). The de-identified data was
recorded on the chart audit tool within a personal password protected laptop. All patient
information was de-identified and each record was assigned a random identification number. All
electronic data was stored in a secure, password protected database.
A statistics database was used to run a descriptive statistical analysis. Dissemination of
data included PowerPoint presentation to the project sites, PowerPoint presentation to students

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and faculty at ASU, project poster presented at ASU for faculty and students, and submission of
manuscript into the ASU repository.
Results
Descriptive Data
The utilization of the CDS tool improves management of positive STIs per CDC
guidelines. The CDS tool was used 49% of the time. A total of 80 charts were audited pre CDS
tool implementation; whereas, a total of 88 charts were audited post CDS tool implementation.
Race, ethnicity, and age.
Homogeneity in race, ethnicity, and age was noted. Pre CDS tool White race was seen at
51% with post CDS tool for White race at 46.59%. Pre CDS tool Black race was seen at 22.5%,
with post CDS tool for Black race at 17.05%. Pre CDS tool American Indian/Alaskan Native
was seen at 1.25%, with post CDS tool American Indian/Alaskan Native being seen at 0%. Pre
CDS tool Asian race was seen at 0%, with post CDS tool for Asian race was 1.14%. Pre CDS
tool for Other race was seen at 25%, with post CDS tool for Other race at 35.23%. Pre CDS tool
ethnicity for Hispanic was 67.5%, with post CDS ethnicity for Hispanic being 73.86%. Pre CDS
tool ethnicity of Not Hispanic was 32.5%, with post CDS ethnicity for Not Hispanic at 26.14%.
Pre CDS tool average age was 26.48 years of age, with post CDS tool average age of 26.69 (see
Appendix D, Figure D1).
Treatment.
Pre CDS tool usage chlamydia was treated per CDC guidelines 96.88% of the time. Post
CDS tool usage, chlamydia was treated per CDC guidelines 98.44% of the time. Pre CDS tool
usage gonorrhea was treated per CDC guidelines 90% of the time. Post CDC tool usage
gonorrhea was treated per CDC guidelines 100% of the time. Pre CDS tool usage, when

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gonorrhea and chlamydia were both positive, treatment per CDC guidelines was followed 80%
of the time. Post CDS tool usage, when gonorrhea and chlamydia were both positive, treatment
per CDC guidelines was followed 100%. There was no change in data pre or post CDS tool
implementation for syphilis treatment per CDC guidelines; pre and post data showed syphilis
was treated per CDC guidelines 100% of the time (see Appendix D, Figure D2).
Partner treatment.
Pre CDS tool, documentation of “partner treatment” was 91% with post CDS tool
showing partner treatment being documented 95.45%; however, when the CDS was used post
implementation documentation of “partner treatment” increased to 100% (see Appendix D,
Figure D3).
Other STI screening ordered.
Pre CDS tool showed healthcare provider documentation for “other STI screening
ordered” at 56% of the time, while documentation post CDS tool showed 64.77% of the time;
however, with CDS tool usage the percentage increased to 79.07% (see Appendix D, Figure D3).
Documented follow-up.
Pre CDS tool healthcare providers “documented follow-up” 80% of the time, while post
CDS tool showed healthcare providers “documented follow-up” 77.27%; however, when the
CDS tool was used “documented follow-up” increased to 90.70% (see Appendix D, Figure D3).
Safe sex practices.
Pre CDS tool “safe sex practices” were documented 72.5% of the time, with post CDS
tool being documented 68.18% of the time; however, when the CDS tool was used percentage of
provider documenting “safe sex practices” was 97.67% (see Appendix D, Figure D3).
Follow-up.

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Pre CDS tool “follow-up completed but not in recommended time frame” was done 60%
of the time, with post CDS tool being done 35.23% of the time. Pre CDS tool “follow-up
completed in recommended time frame” was done 6.82%, with post CDS tool showing 4.55% of
the time; however, with CDS tool usage, “follow-up completed in recommended time frame”
increased slightly to 4.65% (see Appendix D, Figure D3).
EPT.
Pre CDS tool “EPT” was ordered 46.25% of the time, post CDS tool “EPT” was ordered
34.09% of the time; however, when CDS tool was used EPT was ordered 46.51% of the time
(see Appendix D, Figure D3).
Treatment per CDC guidelines.
Pre CDS tool “treatment per CDC guidelines” was followed 95% of the time, post CDS
tool was 98.86% of the time; however, with CDS tool usage “treatment per CDC guidelines”
increased to 100% (see Appendix D, Figure D3).
Other STI screening discussed.
Pre CDS tool “other STI screening discussed” was documented 18.75% of the time, with
post CDS tool being documented for “other STI screening discussed” 42% of the time; however,
when the CDS tool was used documentation increased to 58.14% (see Appendix D, Figure D3).
Condoms offered.
Pre CDS tool “condoms offered” 1.25% of time, post CDS tool “condoms offered”
45.45% of the time; however, with CDS tool usage “condoms offered” increased to 93.02% of
the time (see Appendix D, Figure D3).
Reporting to ADHS.

MANAGEMENT OF STIs

21

Pre CDS tool “reporting to ADHS” was done 67.5% of the time, post CDS tool reporting
was done 62.5% of the time; with CDS tool usage “reporting to ADHS” decreasing to 58.14%
(see Appendix D, Figure D3).
Impact of Project
When the CDS tool was used, an increase was seen in many areas of management of
positive STIs. Post CDS tool implementation and when the CDS was utilized, partner treatment
increased to 100% of the time. This is important as this is the first step in management of a
positive STI. Treatment prevents adverse reproductive health complications and continued
sexual transmission. When the CDS tool was utilized, other STI screenings ordered increased to
79%. This is an important management consideration as it is shown that being positive for one
STI puts an individual at increased risk of having another (CDC, 2022). Other STI screenings
discussed is an important educational piece to positive STI management and increased to 58% if
the CDS tool was utilized. Documented follow-up increased to 90% when the CDS tool was
utilized. This shows healthcare providers knowledge about the recommended guidelines and
provides information about when that individual with a positive STI result should return for
rescreening. Safe sex practices were documented 97% of the time when the CDS tool was
utilized. Safe sex education is an important management strategy to instruct positive STI
individuals on the importance of transmission. EPT slightly increased to 46.51% of the time
when the CDS tool was utilized. Management of sexual partners is an important piece to reduce
community spread of positive STIs. Offering condoms increased to 93% of the time when the
CDS tool was utilized. Condoms offer protection against the spread and obtaining a STI.
Post CDS implementation, a decrease in follow-up in the recommended time frame was
noted. For chlamydia/gonorrhea recommended follow-up is 3 months after treatment and for

MANAGEMENT OF STIs

22

syphilis 6 months after treatment. (CDC, 2021a). Chart audits revealed that too early re-testing
was occurring which can lead to false positive STI results or no rescreening was completed.
Healthcare providers should be encouraged to set reminders or alerts for patients that do not
come back for STI follow-up testing. Pre CDS tool 32.5% of patients did not return for follow-up
STI testing; post CDS tool 31.82% of patients did not return for follow-up testing. Post CDS tool
only 5.68% of patients were scheduled for a follow-up appointment. It would be important to
encourage all patients to get scheduled for follow-up appointment when the patient is made
aware of their positive STI result.
EPT is permitted in the state of Arizona (CDC, 2021f). It would be beneficial in
preventing transmission of STIs if healthcare providers provided EPT services. Chart audits
revealed that providing outside resources for where sexual partners can go for treatment was seen
frequently. Healthcare providers gave outside resources or did not clarify in documentation if
EPT was ordered or declined pre CDS tool implementation 47.5% of the time, post CDS tool
implementation 32.95% of the time. Pre CDS tool 5% of patients declined EPT, post CDS tool
30.68% of patients declined EPT.
A decrease in documented mandatory reporting to the state health department was noted.
Making a standardize workflow for reporting could help increase reporting to ADHS. There is a
need for standardizing how STI results are reported to ADHS at the project site.
Project Sustainability
After the completion of this project, the project site will still be able to use the CDS tool
as this project has encouraged a system wide practice change. The usage of the CDS tool is
encouraged and apart of the workflow for when a healthcare provider encounters a positive STI
individual. Data collection shows that the usage of the CDS tool does help healthcare providers

MANAGEMENT OF STIs

23

to better manage STIs, this could be beneficial data to educate all departments at the project site
of this systems change and implement the CDS tool on a larger scale.
Discussion
Closing gaps within healthcare provider management of STIs can help decrease rates of
STIs and better assist healthcare providers with treatment and management options. According to
the evidence reviewed, it is apparent that the use of a CDS tool can be used to help treat and
manage multiple different patient diagnoses. The development of the CDS tool was created as a
change of practice. It has the potential to decrease rates of STIs, decrease transmission rates, and
decrease costs associated with high STI rates. A highlight of the CDS tool is proper evidencebased management of STIs, which is the goal for healthcare providers.
Strengths seen with this project is that the CDS tool aligns with current national
guidelines and is applicable to a variety of patient care settings. Limitations to this project is
limited CDS tool usage and the CDS tool does not address risk assessment or pre-exposure
vaccination. Implications are a need for standardization of reporting to ADHS and education
needed on recommended post treatment follow-up. The implementation and use of the CDS tool
has made a positive impact on management of STI results; with continued and improved usage it
could contribute to a decrease in rates and costs associated with high rates of STIs.

MANAGEMENT OF STIs

24
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Appendix A
Evaluation and Synthesis Tables

Table A1
Quantitative Studies Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

(Karas et al., 2018)

Innovation
Theory

Design: Quantitative,
Retrospective review,
quasi-experimental

N= 27 pediatric
primary care
offices

IV: CDS Tool
and popup alerts

CDS tools

P= 0.001

Purpose: identify the
impact of a CDS tool on
screening rates for CT
among female patients
age 13-21; secondary
goal of increasing
provider awareness of
screening guidelines,
incorporating CDS
treatment, follow-up, and
education.

Demographics
of patient
screening:
females, 13-21
years of age.
asymptomatic
for CT

Statistical
test, pre-test
posttest
model, chi
square
analysis

Using a clinical
decision support
tool to increase
chlamydia
screening across a
large primary care
pediatric network
Country:
United States of
America
Funding: The
authors received
no financial
support
Bias: None stated

Setting: Primary
care offices
across Northeast
Ohio
Exclusions:

DV: CT
screening rates

Pop-up alerts
within the EHR
Provider
educational
resources

Odds ratio=
2.143
Confidence
interval: 95%

Level of
Evidence;
Application to
practice/
Generalization

Level of evidence:
III
Strengths:
Increased % of
asymptomatic
patients were
screened for CT
Weaknesses:
Retrospective
review
Setting is limited
to primary care
offices in Ohio
Screening alerts in
EHR are not
linked to outside
EHRs; if patient
has +CT outside
of the clinic it
would not alert the
provider
Beneficial to
clinical practice

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

(Miller et al.,
2019)

Innovation
Theory

Design: Quantitative,
mixed methodology,
cross-sectional survey

n=57 clinicians, 23
physicians, 23
nurses, 11 nurse
practitioners

IV1: CDS tool

Questionnaire
survey

chi-square
test

More favorable
ratings pf CDS
systems in
general p=0.008

Development of a
novel
computerized
clinical decision
support system to
improve
adolescent sexual
health care
provision
Country: United
States
Funding: NICHD
K23 Award
Bias: None stated

Purpose: develop a CDS
system to facilitate
evidence-based sexual
health care for
adolescents in the
emergency department

n=57 adolescents
Demographics:
54% female, 40
years of age or
older, adolescents
75% female, mean
age of adolescents
16.2 years of age
Setting: Four
urban emergency
departments

IV2:
Questionnaire
DV1: Testing
for pregnancy
and STIs
DV2:
pregnancy
prophylaxis
with EC
DV3:
Counseling for
safer sex
behaviors
DV4: treatment
for previously
diagnosed
patient reported
STIs
DV5: Condom
provision

CDS system

more agreement
with asking
about sexual
health p=0.002
offering
condoms
p=0.025
testing for
STIs/pregnancy
p=0.004

31

Level of
Evidence;
Application to
practice/
Generalization
Level of
evidence: II

Strengths:
increased
speed/efficiency,
improve health
care delivery,
Weaknesses:
limited time to
fully use CDS,
CDS tool only
used within an
emergency
department
setting,
Beneficial to
clinical practice
for improved
management of
STIs and
pregnancy

DV6: risky
sexual behavior

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

32

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

(Arbogast et al.,
2017)

Innovation
Theory

Design: Quantitative,
quasi-experimental

n= 14,527 pre
and post
intervention

IV1: Vestibular
oculomotor
examination
performed

CDS tool

Pearson chisquare tests

Confidence
interval= 95%
adjusted odds
ratio

Level of
evidence: III

Improving Primary
Care Provider
Practices in Youth
Concussion
Management
Country: United
States of America

Purpose: Improve
primary care provider
management of
concussions

Demographics:
age 0-19 years
Setting: Primary
care office

Funding: US
Department of
Health and Human
Services, Centers
for Disease
Control and
Prevention,
Children's
Hospital of
Philadelphia

Clinical decision
support for
recognition and
management of

IV2: RTL/RTP
guidelines
discussed
DV1: Patient
age

Strengths:
Improved
provider
behavior
amongst
concussion
patients
Weaknesses:
Study only done
at one specific
primary care
office

DV2: Patient
sex
DV3: Patient
race
DV4: Presence
of other injuries
DV5: first
concussion visit

Bias: None
(Kharbanda et al.,
2018)

in-person training

Innovation
Theory

Design: Cluster
randomized trial
Purpose: Evaluation of
whether an electronic
health record linked CDS
could improve the
recognition and

N= 461

IV1: CDS

TeenBP CDS

IG: 256

DV1: provider
recognition of
HTN

Clinical
documentation
assesses through
chart reviews

CG: 205

Pearson's x2
test, Fisher's
exact test,
independent
sample t test,
linear mixed
model

P= 0.001
Clinical
recognition of
HTN (IG)
P= 0.046
Evaluation of
secondary

Level of
evidence: II
Strengths:
improved
recognition of
HTN

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Theory/
Conceptual
Framework

hypertension: A
randomized trial
Country: United
States of America

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

management of
hypertension in
adolescents

Demographics:
Age between 1017 years of age

DV2: Lipid
screening
completed

Female
Setting: 20
different primary
care clinics

DV3: Referral
to dietician or
weight loss or
exercise
program

Provider
satisfaction of
CDS- $50 gift card
given with each
survey

Funding: National
Institutes of Health
Bias: None stated

Exclusion:
Previous lipid
disorder
Lipid test in the
past year
Previous HTN
diagnosis

Data
Analysis

Results/
Findings

causes of HTN
(IG)
P= 0.001
referral to
dietician or
weight loss
program (IG)
P= 0.003 Lipid
screening
completed (IG)

DV4:
antihypertensive
medication
within 6 months
of meeting
criteria

P= 0.48
antihypertensive
medication
within 6 months
of meeting
criteria (IG)

Definitions:
Hypertension

33

Level of
Evidence;
Application to
practice/
Generalization
Increased
referrals to
dieticians and
cholesterol
screening

Weakness:
Majority of
patients were of
white race
Only girls were
included in the
study
Feasibility:
Beneficial to
clinical practice

Electronichealth record
(Pell at el., 2020)
Primary care
management of
lower Urinary
tract Symptoms in
men: protocol for
development and
validation of a

Innovation
Theory

Design: quantitative,
prospective, diagnostic
accuracy
Purpose: which number
of index tests used in
combination best predict
three urodynamic
observations in men who

n= 880

CDS
IV: CDS tool

Setting: Primary
care

DV1: decreased
LUTS

Demographics:
Men, 16 years of
age or older,
present to
general

Index tests,
invasive
urodynamics,
bladder diary,
uroflowmetry,
CDS tool

BOO index,
bladder
contractility
index,
multivariable
logistic
regression
model,
Rubin's rule

p= 0.157
CI= 95%
Attrition rate:
20-25%

Level of
evidence: II
Strengths:
Potential for
better
management of
LUTS
Weaknesses:

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

diagnostic and
clinical decision
support tool (the
PriMUS study)
Country: United
Kingdom
Funding: National
Institute for Health
Research and
Cardiff University
Bias: Publication
bias

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

present to their general
practitioner with LUTS

practitioner with
a complaint of
one or more
bothersome
LUTS, able and
willing to give
informed
consent for
participation in
the study, able
and willing to
undergo all
index tests and
reference test
Exclusions:
neurological
disease or injury
affecting lower
urinary tract
function, LUTS
secondary to
current or past
invasive
treatment or
radiotherapy for
pelvic disease,
contraindications
to urodynamics,
indwelling
catheter,
inability to
consent in

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

34

Level of
Evidence;
Application to
practice/
Generalization

Some test results
might be
missing or have
an inability to be
obtained
Results might be
different when
applied to
practice
Feasibility:
Beneficial to
practice that a
CDS tool is
beneficial for
management of
different
diagnoses seen
in the primary
care clinic

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

N= 23

IV: CDS tool

CDS tool

CI- 95%

n=22,279

DV1: MRI
order

Binary,
mixed
models,

Level of
evidence: II

English or
Welsh

(Palen et al., 2019)
Randomized
Clinical Trial of a
Clinical Decision
Support Tool for
Improving the
Appropriateness
Scores for
Ordering Imaging
Studies in Primary
and Specialty Care
Ambulatory
Clinics

Innovation
theory

Design: quantitative,
Cluster randomized trial
Purpose: evaluate
whether the use of CDS
tool improved the
appropriateness scores of
orders for advanced
imaging in clinical
practice

35

Variables

Setting:
integrated health
care system
Demographics:
physicians and
nonphysicians
who order
advanced
imaging studies

DV2: CT order
DV3:
Appropriateness
scores

p=0.001

Strengths:
provider
appropriate
ordering of
imaging
increased
Weaknesses:
study was done
at one specific
clinic

Country United
States
Funding: Kaiser
Permanente
Colorado and the
Colorado
Permanente
Medical Group

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Innovation
Theory

Design: quantitative,
observational study

N=20

Variables

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

CDS tool, EHR

Two tailed
tests

changes in
appropriate
abortive
medication
prescriptions for
migraine
managementp=0.01
Changes in
Appropriate
Preventive
Medication
Prescriptions
for Migraine
Managementp=0.01

Level of
evidence: VI

Bias: Sampling
bias

(Connelly &
Bickel, 2020)
Primary Care
Access to an
Online Decision
Support Tool is
Associated with
Improvements in
Some Aspects of
Pediatric Migraine
Care

Country: United
States
Funding: Pfizer
independent grants
Bias: Publication
bias

Purpose: To evaluate
whether primary care
provider access to an
online decision support
tool is associated with a
change in evidence-based
primary care medical
management of pediatric
migraine.

n=300
Setting: pediatric
PCPs in
pediatric
community in
Kansas

36

Measurement/
Instrumentation

Changes in
Inappropriate
Medication
Prescriptions
for Migraine
Managementp=0.09

Strengths:
increased rates
of proper
management of
migraines
decreased rates
of prescribing
the wrong
medication
Weaknesses:
CDS was used
upon one
clinical setting
for pediatrics
Feasibility:
study provides
evidence that
CDS usage
within the
clinical setting
can be effective

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

37

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

(Siaki et al., 2021)

Innovation
model

Design: quantitative,
nonrandomized, single
arm

n= 54 patients

IV: CDS tool

n= 16 providers

Level of
evidence: III

Demographics;
patients: 18
years of age or
older,
cognitively
intact, able to
consent, taking 3
or more
antihypertensive
medications for
more than 1
month.
Providers: full
time, current
credentials,
prescribing
privileges.

KolmogorovSmirnov and
Shapiro
goodness-offit tests, twosided fisher
exact test

Change in rates
of BP control
p=0.005

Purpose: determine the
feasibility of a webbased CDS using a reninaldosterone system
(RAS) classification
matrix and drug
sequencing algorithm to
assist providers with the
diagnosis and
management of
uncontrolled HTN

DV1: controlled
blood pressure
rates

Blood pressure
measurements,
CDS tool, reninaldosterone
classification
matrix, drug
sequencing
algorithm,
satisfaction scores

Feasibility of a
Clinical Decision
Support Tool to
Manage Resistant
Hypertension:
Team-HTN, a
Single-arm Pilot
Study
Country: United
States
Funding:
Telemedicine and
Advanced
Technology
Research Center,
Advanced Medical
Technology
Initiative
Bias: selection
bias, information
bias

Exclusions:
patient: unable
to give consent
in English,
pregnant or
breastfeeding
woman,
prisoners,
patients on renal
dialysis,
transplant

DV2: provider
management
time
DV3: end-user
satisfaction

Grade 3
Strengths:
decreased
patient BP
readings
Weaknesses:
small sample
size, time
constraints with
providers having
to learn a new
EHR system
which hindered
providers from
wanting to
participate
Feasibility:
useful within the
clinical setting

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Theory/
Conceptual
Framework

Design/Method/Purpose

Sample/Setting

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

N= 20

IV: CDS tool

Setting: primary
care practice
sites

DV1; improved
management of
hyperlipidemia

Provider survey,
CDS tool

Rao-cramer
adjusted X2
test,
generalized
estimating
equation
model

Level of
significance:
0.05

Level of
evidence: II

patients, chronic
disease, life
expectancy less
then 1-year,
active duty

(Kessler et al.,
2017)
Impact of
electronic clinical
decision support
on adherence to
guidelinerecommended
treatment for
hyperlipidemia,
atrial fibrillation
and heart failure:
protocol for a
cluster randomized
trial

Innovation
model

Design: Quantitative,
cluster randomized, nonblinded
Purpose: to test whether
a CDS improves the
management of
hyperlipidemia, atrial
fibrillation and heart
failure by primary care
clinicians.

38

Variables

DV2: improved
management of
heart failure
DV3: improved
management of
heart failure

Strengths:
development of
CDS tool
Weaknesses:
CDS tool not
available to
nonaffiliated
clinics
Feasibility:
Beneficial to
clinical practice

Country: United
States
Funding: None
stated

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs

Citation

Design/Method/Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice/
Generalization

Innovation
model

Design: Quantitative,
cluster randomized trial

n= 203 primary
care providers
n=1145 adult
patients

IV: CDS tool

CDS tool

Generalized
estimating
equations

primary
efficacy
p=0.926

Level of
evidence:II

Setting: primary
care clinic

DV2: primary
and secondary
outcomes

Bias: selection
bias

(Cox et al., 2020)
Integrated
Management
Program
Advancing
Community
Treatment of
Atrial Fibrillation
(IMPACT-AF): A
cluster randomized
trial of a
computerized
clinical decision
support tool
Country: Canada
Bias: Publication
bias

39

Theory/
Conceptual
Framework

Purpose: We assessed
whether computerized
CDS for primary care
providers would improve
atrial fibrillation
management and
outcomes as compared to
usual care.

Demographics:
18 years of age,
documented past
or management
of AF, can
communicate in
English

DV1: safety
outcomes

safety p=.939

Strengths: Better
patient
management and
safety
Weaknesses;
CDS tool did
not improve
atrial fibrillation
management
Feasibility:
evidence into
the
developmental
needs of CDS
tools

Funding: Bayer
Inc

Key: AF- atrial fibrillation; BP- Blood pressure; CDS- Clinical decision support; CG- Control group; CT- Chlamydia; DV- Dependent variable;
EC- Emergency contraception; EHR- Electronic health record; HTN- Hypertension; IG- Intervention group; IV- Independent variable; LUTSLower urinary tract symptoms; N- Number of studies; n- Number of participants; PCPs- primary care providers; RTL/RTP- return-to-learn/returnto-play; STIs- Sexually transmitted infections

MANAGEMENT OF STIs
Table A2
Synthesis Table
Study (Author, Year)

Karas et al.,
2018

Miller et al.,
2019

Arbogast et
al., 2017

Kharbanda et
al., 2018

Pell at el.,
2020

Palen et al.,
2019

Connelly &
Bickel, 2020

Siaki et al.,
2021

Kessler et al.,
2017

Cox et al.,
2020

27

57

14,527

461

880

22,279

300

70

20

1,348

United States

United States

United States

United States

UK

United States

United States

United States

United States

Canada

X

X

X

X

X

X

X

Quant/II

Quant/II

Sample
n
Country
Setting
Primary Care

X
X

Emergency Care
Design/LOE
Interventions
CDS Tool

Quant/III

+

Quant/II

+

Quant/III

+

Quant/II

Quant/II

Quant/II

Quant/VI

Quant/III

+

+

+

+

+

+

+

X

X

X

X

X

X

X

+

Questionnaire

+

Vestibular Oculomotor
Exam
Findings
Improved patient
management

X

X

X

X

CDS- Clinical decision support; LOE- Level of evidence; n- Number of participants/studies

MANAGEMENT OF STIs

41
Appendix B
Frameworks and Models

Figure B1
General Systems Theory

(Bertalanffy, 1950)

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42

Figure B2
Plan-Do-Study-Act (PDSA) Model

(Shewart, 1993)

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Appendix C
Tools

Figure C1
Clinical Decision Support Tool

43

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Figure C2
STI Chart Audit Tool

44

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Appendix D
Data Charts

Figure D1
Demographics

PRE CDS TOOL
Non-Hispanic
16%

Black
12%

ages

Non-Hispanic
13%

White
25%

Hispanic
34%

Native
Hawaiian or
Other Pacific
Islander
0%

POST CDS TOOL

Other Race
12%

American
Indian/Alaskan
Native
1%
Asian
0%

Black
8%

White
23%
Hispanic
37%

Native
Hawaiian or
Other Pacific
Islander
0%

American
Indian/Alaskan
Native
0%

Other Race
18%

Asian
1%

MANAGEMENT OF STIs
Figure D2
STI Treatment

STI Treatment per CDC Guidelines
100

97

100

98

100

100

100

90

90

80

80

Percentages

70
60
50
40
30
20
10
0

Chlamydia

Gonorrhea
Pre CDS Tool n= 80

Chalmydia & Gonorrhea
Post CDS Tool n= 88

Syphilis

MANAGEMENT OF STIs

47

Figure D3
Pre and Post CDS Tool Chart Audits

Pre and Post CDS Tool Chart Audits
100
90
80

Percentages

70
60
50
40
30
20
10
0

Documented
Partner
Treatment

Other STI
Screening
Ordered

Documented
Follow Up

Documented
Follow Up
Expedited
Treatment per
Discussion of
Completed in Partner Therapy
CDC
Safe Sex Practices Recommended (EPT) Ordered
Time Frame

Pre CDS Tool n= 80

Post CDS Tool n= 88

Used CDS Tool n= 43

Other STI
Screening
Discussed

Condoms Offered

Reporting to
ADHS