Universal testing reduces disparities in adolescent STI screening

Universal testing reduces disparities in adolescent STI screening | Image Credit: © Kzenon - stock.adobe.com.

Racial and ethnic differences in sexually transmitted infection (STI) testing persist in pediatric care, but a new multicenter study indicates that a standardized, universally offered clinical decision support (CDS) tool can mitigate these disparities. The findings, published in Pediatrics Open Science, suggest that integrating universal prompts into the electronic health record (EHR) increases equity in testing for chlamydia (CT) and gonorrhea (GC) among adolescents presenting to the emergency department (ED).¹

Adolescents from minoritized racial and ethnic groups undergo CT and GC testing at higher rates than non-Hispanic white peers, raising concerns about clinician bias. Previous studies have shown testing differences, with one reporting that “differential testing for CT between Black (66% tested) and white (24% tested) adolescents has been demonstrated in the pediatric primary care setting.”² Similarly, emergency department data reveal that nonwhite adolescents are more likely to be tested for STIs than white adolescents.

Study design

This secondary analysis drew on a prospective pragmatic trial conducted at 6 pediatric EDs between January 2021 and September 2022. Patients aged 15 to 21 years completed a tablet-based sexual health screen. Two testing approaches were compared:

• Targeted phase: CDS was triggered by risk identified on the sexual health screen.
• Universally offered phase: Patients were offered testing directly, and their request for CT/GC testing generated a CDS order prompt.

Demographics, including race and ethnicity, were abstracted from the EHR. The primary outcome was whether CT/GC testing occurred.

Results

Across the study, 94,743 adolescents were evaluated: 18,256 in the baseline phase, 40,185 in the targeted phase, and 36,302 in the universally offered phase. The majority were female (57.9%) and non-Hispanic white (34.6%).

At baseline, testing disparities were evident. Non-Hispanic Black adolescents had more than twice the odds of CT/GC testing compared with non-Hispanic white patients (adjusted odds ratio [aOR], 2.10; 95% CI, 1.83–2.41). During the targeted phase, CDS did not alter disparities; “the racial and ethnic differences in CT/GC testing persisted and were not mitigated by the CDS alert” (P = .35).

In contrast, when universally offered testing was implemented, disparities disappeared. The authors reported that “CDS did mitigate racial and ethnic differences in the universally offered phase, meaning all racial and ethnic groups had CT/GC testing at a similar proportion” (P = .01).

The study demonstrates that clinician decision-making influenced by patient-reported risk may perpetuate inequities, whereas universally offered testing reduces opportunities for bias. The authors noted that “universally offered CT/GC testing is adolescent-driven and based on patient desire, requiring the clinician to merely order a test, remaining unaware of the patient’s STI risk.”

However, the researchers also observed inequities in which adolescents were offered tablets to complete the health screen. Hispanic adolescents were more likely to receive a tablet than others, raising concerns that bias may still enter at the point of screening access.

Limitations included reliance on EHR-documented rather than self-reported race and ethnicity, potential site-level differences in implementation, and exclusion of one site due to missing data. Additionally, universal testing may increase detection across all groups but does not directly address infection burden or broader social determinants of health.

Conclusion

The findings provide evidence that universally offered, EHR-integrated CDS can eliminate racial and ethnic differences in CT/GC testing among adolescents in pediatric EDs. The authors concluded that “larger systemic change, including targeted interventions to diversify the medical workforce, bias and microaggression/microaffirmation training for medical professionals, and policy change, are all needed to improve equity in health and care.”

References

1. Pickett ML, Cafferty R, Palmer C, et al. Mitigation of Racial and Ethnic Differences in Chlamydia and Gonorrhea Testing. 2025;1(3):1-9. doi:https://doi.org/10.1542/pedsos.2025-000513
2. Wood S, Min J, Tam V, Pickel J, Petsis D, Campbell K. Inequities in Chlamydia trachomatis Screening Between Black and White Adolescents in a Large Pediatric Primary Care Network, 2015–2019. American Journal of Public Health. 2022;112(1):135-143. doi:https://doi.org/10.2105/ajph.2021.306498