STD Clinic Data Elements

[NCCHSTP] Strengthening US Response to Resistant Gonorrhea (SURRG)

Att 3A STD Clinic Facility Data Elements

STD Clinic Data Elements

OMB: 0920-1242

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Public reporting burden of this collection of information is estimated to average 16 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1242)



Strengthening United States Response to Resistant Gonorrhea (SURRG)

Attachment 3A

SURRG Facility STD Clinic Data Elements




Variable name

Data element

Description/Question

Response codes

CL_PATIENTID

PatientID of case

Unique patient/person identification number

This unique SURRG Patient ID will be assigned by the local SURRG Epi Coordinator or other designee. It must be unique per person. This patient ID cannot include any personally identifiable information (PII). SURRG grantees might elect to have this ID match the unique patient ID that is generated from their NEDDS Surveillance system for patients with gonorrhea cases


Note: This Patient ID must be same as the Patient ID attached to SURRG isolates sent to the ARLN, and will be used to link all the clinical, laboratory, and epi investigation data as appropriate.

Character ID

CL_EVENTID

Event ID/case ID of case

Event identifier distinguishes each GC diagnosis or for GC-negative contacts, each clinic testing visit event. Regardless of how a jurisdiction comes up with the EVENTID, this ID must be unique for each case of GC or GC testing event, and should (1) stay the same for all associated clinic visits (i.e., testing, treatment, TOC), AND (2) match with data in all other tables associated with this patient GC episode or GC testing event (including the LAB, CS, CT, PTSP tables). The ID can be up to 18 digits. This data element must not be ‘null’ or contain missing values.

Character ID

CL_STATE

State code

Identifies state of SURRG site (using digit state FIPS code)

06=California (CA)

08=Colorado (CO)

18=Indiana (IN)

36=New York (NY)

37=North Carolina (NC)

42=Pennsylvania (PA)

53=Washington (WA)

55=Wisconsin (WI)

99=Unknown

VISDATE

Date of clinic visit


Character; YYYYMMDD

CL_FACILITY_LOCATION

Facility location

Unique facility/clinic identifier

This ID is generated specifically for the SURRG activity and identifies the health center. A 3-character sentinel site code, hyphen, 2 digits (keep preceding 0 for single digits).

Unique facility/clinic identifier

This ID generated specifically for the SURRG activity and identifies the health center. A 3-character sentinel site code, hyphen, 2 digits

COUNTYRES

County of patient’s residence

3-digit FIPS county code

(Use 999 if unknown)

Character

PTJURIS

Whether patient resides in funded jurisdiction

Does the patient reside in the funded jurisdiction? (typically the county funded for SURRG; CA – SURRG region; NYC – NYC)

0=No

1=Yes

9=Unknown

GENDER

Patient’s gender

How do you describe your gender identity?

1=Male

2=Female

3=Female-to-male transgender (FTM)

4=Male-to-female transgender (MTF)

5=Other gender identity

8=Refused to Answer

9=Unknown

SEXBIRTH

Sex on birth certificate

What sex were you assigned at birth, on your original birth certificate?

1=Male

2=Female

8=Refused to Answer

9=Unknown

PT_AGE

Patient age (in years)

How old is the patient?

[Calculated as visitdate-birthdate; do not round up]

Numeric; 999=Unknown

HISP_ETH

Ethnicity: Hispanic or Latino

Is the patient of Hispanic or Latino ethnicity?

0=No

1=Yes

8=Refused to Answer

9=Unknown

AIAN

Race: AI/AN-American Indian or Alaskan Native

Does the patient identify as American Indian or Alaska Native?

0=No

1=Yes

8=Refused to Answer

9=Unknown

ASIAN

Race: Asian

Does the patient identify as Asian?

0=No

1=Yes

8=Refused to Answer

9=Unknown

NHOPI

Race: NH/PI-Native Hawaiian or Other Pacific Islander

Does the patient identify as Native Hawaiian or Pacific Islander?

0=No

1=Yes

8=Refused to Answer

9=Unknown

BLACK

Race: Black or African American

Does the patient identify as Black or African American?

0=No

1=Yes

8=Refused to Answer

9=Unknown

WHITE

Race: White

Does the patient identify as white?

0=No

1=Yes

8=Refused to Answer

9=Unknown

MULTIRACE

Race: Multirace

Does the patient identify as multiracial?

0=No

1=Yes

8=Refused to Answer

9=Unknown

OTHRACE

Race: Other

Does the patient identify as another race not listed?

0=No

1=Yes

8=Refused to Answer

9=Unknown

PREGNANT

Pregnancy status at clinic visit

Is the patient pregnant today?


Optional


[Use response 7 if patient is cisgender male or female transgender (MTF); use response 9 if didn’t assess on female patient]

0=No

1=Yes

7=Not Applicable

8=Refused to Answer

9=Unknown

GISP_GCHX

Previous self-reported history of gonorrhea (ever)


0=No

1=Yes

8=Refused to Answer

9=Unknown

SURV_GCHX

Previous documented history of gonorrhea (ever)


0=No

1=Yes

9=Unknown

GISP_GCHXN

Previous episodes of gonorrhea

Number of previous documented episodes of gonorrhea (past 12 months)

Numeric

99=number is unknown, missing, or not captured

GISP_ANTIBIOT

Antibiotic use

Has patient used any antibiotics during the previous 2 months?

0=No

1=Yes

8=Refused to Answer

9=Unknown

GISP_SEXWRK

History of sex work

Does patient have a history of giving or receiving drugs/money for sex in the previous 12 months?

0=No

1=Yes

8=Refused to Answer

9=Unknown

GISP_IDU

History of injection drug use

Does patient have a history of injection drug use in the previous 12 months?


0=No

1=Yes

8=Refused to Answer

9=Unknown

GISP_NONIDU

History of non-injection recreational drug use

Does patient have a history of non-injection recreational drug use in the previous 12 months? (excludes alcohol, medications for erectile dysfunction, and steroids)

0=No

1=Yes

8=Refused to Answer

9=Unknown

GISP_ETRVL

Case travel status and sex activity

Has the patient traveled outside of US in the past 2 months, and had condomless oral, anal, or vaginal sex with someone other than a US-based traveling companion?


[Optional if not contained in EMR]

0=No

1=Yes

8=Refused to Answer

9=Unknown

GISP_ETRVL2

Partner travel status and sex activity

In the past two months, has the patient had condomless oral, anal, or vaginal sex with someone who recently traveled to or from another country?


[Optional if not contained in EMR]

0=No

1=Yes

8=Refused to Answer

9=Unknown

PENALLERGY

Penicillin allergy

Does patient report a penicillin allergy?

0=No

1=Yes

8=Refused to Answer

9=Unknown

MENSEX

Number of male sex partners

How many MEN did the patient have sex with in the previous 2 or 3 months?

Numeric

999=number is unknown, missing, or not captured

MEN_TIME

Time interval used to capture patient’s number of male sex partners

What interview period was used to obtain the patient’s number of male sex partners?

1=2 months

2=3 months

9=Unknown/Not Applicable

FEMSEX

Number of female sex partners

How many WOMEN did the patient have sex with in the previous 2 or 3 months?

Numeric


999=number is unknown, missing, or not captured

FEM_TIME

Time interval used to capture patient’s number of female sex partners

What interview period was used to obtain the patient’s number of female sex partners?

1=2 months

2=3 months

9=Unknown/Not Applicable

GENDER_SP

Gender of sex partners

Provider documented gender of patient’s sex partners

1=Males only

2=Females only

3=Both Males and Females

9=Unknown

ExpSTD_PTR

Partner notification of gonorrhea exposure

Before you came to the clinic today, did any of your sex partners tell you that you might have recently been exposed to gonorrhea?


0=No

1=Yes

8=Refused to Answer

9=Unknown

ExpSTD_HD




Health department notification of gonorrhea exposure

Before you came to the clinic today, did the health department/DIS tell you that you might have had sex with someone with gonorrhea (or an STD)?

0=No

1=Yes

8=Refused to Answer

9=Unknown

SXPHARYNGEAL

Reported pharyngeal/throat pain

Does the patient report pharyngeal/throat pain?

0=No

1=Yes

8=Refused to Answer

9=Unknown

SXDYSURIA

Reported dysuria (painful urination)

Does the patient report dysuria?

0=No

1=Yes

8=Refused to Answer

9=Unknown

SXDISCHARGE

Reported genital discharge

Does the patient report genital discharge?

0=No

1=Yes

8=Refused to Answer

9=Unknown

SXRECTAL

Reported rectal symptoms

Does the patient report rectal symptoms (e.g., pain or tenesmus)?

0=No

1=Yes

8=Refused to Answer

9=Unknown

SXABDOMEN

Reported abdominal pain

Does the patient report abdominal pain?

0=No

1=Yes

8=Refused to Answer

9=Unknown

EVERHIV

Prior HIV testing self-reported

Has the patient ever been tested for HIV (prior to today)?

0=No

1=Yes

8=Refused to Answer

9=Unknown

WHENHIVM

Last HIV test self-reported

When was the patient’s last HIV test?

Leave Blank if EverHIV=0, 8, or 9

MM (month reported); 99=Unknown

WHENHIVY

Last HIV test self-reported

When was the patient’s last HIV test?

Leave Blank if EverHIV=0, 8, or 9

YYYY (year reported); 9999=Unknown

HIVRESULTLAST

HIV result self-reported

What was the result of that patient’s HIV test (excluding testing on today’s visit)?

0=Negative

1=Positive

2=Indeterminate

7=Never tested

8=Refused to Answer

9=Unknown

GISP_HIVRESULT

HIV result self-reported at clinic visit

If tested at this visit, what was the result of this patient’s HIV test?

0=Negative

1=Positive

2=Indeterminate

7=Not tested today

8=Refused to Answer

9=Unknown

PREP

PrEP use

Is the patient currently using HIV pre-exposure prophylaxis (PrEP)?


[Response=7 if HIV-positive]

0=No

1=Yes

7=Not applicable

8=Refused to Answer

9=Unknown

PREP_REFER

PrEP referral

If not on PrEP, was the patient offered or referred for PrEP (on day of visit)?


[Response=7 if HIV-positive or already on PrEP]

1=Yes referred

2=Not referred, but eligible for referral

3=Not referred, due to ineligibility

7=Not applicable

9=Unknown

HIVCARE

HIV care

Has the patient been receiving HIV medical care in the past 12 months? (i.e., currently receiving care)


[Response=7 if HIV-negative or never HIV tested]

0=No

1=Yes

7=Not applicable

8=Refused to Answer

9=Unknown

HIVCARE_REFER

HIV care referral

If not currently receiving HIV medical care, was patient referred to care?


[Response=7 if HIV-negative or never tested]

0=No

1=Yes

7=Not applicable

9=Unknown

DATETX

Date of Gonorrhea treatment

Date patient received gonorrhea treatment

Character; YYYYMMDD

TRMT1



Primary Gonorrhea treatment

What is the patient’s primary treatment for gonorrhea?


[If not treated, select 00]





00=none

03=spectinomycin (Trobicin) 2 gm

04=ceftriaxone (Rocephin) 250 mg

05=ceftriaxone (Rocephin) 125 mg

06=ciprofloxacin (Cipro) 500 mg

07=cefoxitin (Mefoxin) 2 gm

12=cefixime (Suprax) 400 mg

14=cefpodoxime proxetil (Vantin) 200 mg

15=ofloxacin (Floxin) 400 mg

17=ceftizoxime (Cefizox) 500 mg

18=cefotaxime (Claforan) 500 mg

21=azithromycin (Zithromax) 2 gm

22=levofloxacin (Levaquin) 250 mg

23=cefpodoxime proxetil (Vantin) 400 mg

24=ceftibuten (Cedax) 400 mg

25=cefdinir (Omnicef) 300 mg

26=cefdinir (Omnicef) 600 mg

27= gemifloxacin 320 mg

28= gentamicin 240 mg (or weight-based dosage)

29 = ceftriaxone 500 mg

30 = ceftriaxone 1000 mg

77=other (please indicate in other medication prescribed)

99=unknown

MEDICATION1_OTH

Other medication prescribed

If the patient received a medication other than what is listed above (and Medication 1 was coded as 77 for ‘other’), please provide the name of the other medication.


Leave blank if not applicable

Free text field

TRMT2

Secondary Gonorrhea treatment

What (if any) second antimicrobial was used as part of dual therapy for gonorrhea treatment or treatment of chlamydia?


[If not treated for gonorrhea {TRMT1=00} or a second antimicrobial treatment was not given, choose 00=none]

00=none

01=ampicillin/amoxicillin

09=doxycycline (Vibramycin) 100mg bid x 7 days

11=azithromycin (Zithromax) 1 gm

21=azithromycin (Zithromax) 2 gm

77=other

99=unknown

TOC_VIS

Test of cure (TOC) visit identification

Was this a test of cure visit or was this patient recently treated for gonorrhea at this clinic (or a partnering clinic) within the past 4 weeks?

0=No (stop)

1=Yes (potential treatment failure or persistent infection; proceed to next question)

TCT_SEX

Sexual activity

Has patient engaged in any sexual activity with a new sex partner since recent GC treatment?

(If yes, proceed to condomless sexual activity question. If no, proceed to sexual activity with same partner question)

0= No (potential treatment failure)

1=Yes (potential new infection)

8=Refused to Answer

9=Unknown

TCT_CONDUSE

Condomless sexual activity

Did patient use condoms or barrier method every time they’ve had sex with this new sex partner




0= No (potential treatment failure)

1=Yes (potential new infection)

8=Refused to Answer

9=Unknown

TCT_SAMEPTR

Sexual activity with same partner

Since recent GC treatment, has patient engaged in any sexual activity with someone they also had sex with in the 2 months prior to recent treatment?

(If yes, proceed to condomless sexual activity with same partner question)

0= No (potential treatment failure)

1=Yes

8=Refused to Answer

9=Unknown

TCT_SAMPETRCU

Condomless sexual activity with same partner

Since recent GC treatment, did patient use condoms or barrier method every time they had sex with this/these on-going sex partners?


0=No (new infection)

1=Yes (potential treatment failure)

8=Refused to Answer

9=Unknown






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