Highlight
A smartphone-delivered, patient-centered decision aid increased sexually transmitted infection testing among sexually active adolescents and young adults in emergency department settings.
Participants exposed to STIckER were 1.76 times more likely to receive gonorrhea/chlamydia testing and 4.56 times more likely to receive pharyngeal testing than those receiving usual care.
The intervention also improved patient-reported clarity about testing options and satisfaction with emergency care, while being rated highly acceptable, appropriate, and feasible by both patients and clinicians.
The trial supports digital shared decision-making as a practical strategy to expand sexual health screening in acute care, especially where missed testing opportunities are common.
Background
Sexually transmitted infections remain a major public health burden in adolescents and young adults, particularly in urban populations and among patients who experience structural barriers to preventive care. Chlamydia and gonorrhea continue to rise in many jurisdictions, and young people often present with asymptomatic infection. This creates a familiar clinical problem: patients at highest risk may not seek sexual health services in dedicated clinics, yet they frequently interact with the health system in urgent or episodic settings such as emergency departments.
The emergency department is increasingly recognized as an important access point for sexual health services. For many adolescents and young adults, it may be the only point of contact with healthcare. However, STI testing in the ED is often inconsistent. Time pressure, competing acute concerns, clinician discomfort with sexual health discussions, workflow constraints, privacy concerns, and variable patient engagement all contribute to under-testing. Extragenital testing, especially pharyngeal screening, is even less routinely performed despite its importance for identifying otherwise missed infections.
Digital decision support offers a plausible solution to several of these barriers. A patient-facing tool can standardize risk assessment, provide tailored recommendations, support values clarification, and prepare patients to participate more actively in testing decisions. The intervention studied here, Sexually Transmitted Infection Check in the Emergency Room, or STIckER, was developed using human-centered design principles, suggesting that usability and workflow integration were considered from the outset rather than added later.
The key clinical question is not simply whether patients liked the tool, but whether it changed real testing behavior. That is the central contribution of this randomized controlled trial by Chernick and colleagues.
Study Design
Trial objective
The investigators aimed to evaluate whether a digital patient decision aid could increase sexually transmitted infection testing among adolescents and young adults in the emergency department.
Setting and population
The trial was conducted in adult and pediatric emergency departments at a large urban academic medical center. Eligible participants were sexually active adolescents and young adults aged 14 to 24 years. The median participant age was 19 years, placing the cohort squarely within the age group with the highest STI burden in many surveillance systems.
Randomization and intervention
Health care clinicians, rather than patients, were randomized to deliver either the STIckER intervention or usual care. This clinician-level randomization is operationally relevant because it mirrors how such a tool would likely be deployed in practice. Patients in the intervention arm received the STIckER digital decision aid on a smartphone. The tool provided personalized STI testing recommendations and incorporated a values clarification exercise, a standard shared decision-making technique intended to help patients weigh options in relation to their preferences and concerns.
Usual care served as the comparator. Although the abstract does not detail the exact content of usual care, in ED-based STI testing studies this typically means clinician-directed assessment and testing based on standard workflow without the structured digital support tool.
Outcomes
The primary outcome was documentation of gonorrhea/chlamydia testing. Secondary outcomes included extragenital testing, patient-reported decision-making measures, and implementation outcomes such as acceptability, appropriateness, and feasibility.
Analysis
The authors reported descriptive statistics for patient-level and provider-level outcomes by study arm. Efficacy was estimated using log-binomial regression, an appropriate approach when the goal is to estimate relative risk directly rather than odds ratios, which can exaggerate effect sizes when outcomes are common.
Key Findings
Primary outcome: increased gonorrhea/chlamydia testing
The most clinically important result was that participants in the STIckER arm were 1.76 times more likely to receive gonorrhea/chlamydia testing than participants in the usual care arm. The 95% confidence interval was 1.10 to 3.00. Because the confidence interval excludes 1.0, this finding is statistically significant and consistent with a meaningful increase in testing attributable to the intervention.
From a practical perspective, this result suggests that a relatively low-burden digital tool can shift care processes in an ED environment where preventive sexual health measures are often deprioritized. This is especially relevant because the primary endpoint was not intention, knowledge, or attitude, but documented testing behavior.
Secondary outcome: marked increase in pharyngeal testing
The effect on pharyngeal testing was even larger. Participants exposed to STIckER were 4.56 times more likely to undergo pharyngeal testing compared with those receiving usual care, with a 95% confidence interval of 1.30 to 28.66. While the point estimate is striking, the confidence interval is wide, indicating imprecision and likely reflecting smaller numbers of extragenital tests. Even so, the lower confidence bound remains above 1.0, supporting statistical significance.
This finding deserves attention because extragenital infections are commonly underdiagnosed. Pharyngeal gonorrhea in particular may be asymptomatic and can persist if clinicians limit testing to urine or genital samples. A decision aid that elicits relevant sexual exposure history and normalizes broader testing may therefore improve case finding in ways that routine ED practice often misses.
Patient-reported outcomes
Patients in the intervention group reported greater clarity about testing options and higher satisfaction with emergency department care. These are not trivial outcomes. In the context of sexual health, decisional clarity can reduce confusion, stigma, and hesitation. Improved satisfaction may also reflect a broader sense that care was more respectful, personalized, or understandable.
Importantly, digital tools sometimes raise concerns that they may depersonalize care. The results here suggest the opposite: when thoughtfully designed, they may enhance patient experience by making sensitive decisions easier to navigate.
Implementation outcomes
Both adolescents and young adults and healthcare clinicians rated STIckER as highly acceptable, appropriate, and feasible. These implementation signals matter because many interventions with positive efficacy never achieve routine use. In emergency medicine, feasibility is often the deciding factor. Any intervention that lengthens visits, disrupts triage flow, or burdens staff is unlikely to persist outside a trial.
The fact that the tool was developed using human-centered design may help explain these favorable implementation findings. Human-centered design often improves adoption because it incorporates user needs, constraints, and workflow realities during development rather than relying solely on theoretical effectiveness.
Clinical Interpretation
This study is a strong example of how digital health can address a specific and measurable care gap without requiring a fully automated or AI-driven model. STIckER did not replace clinician judgment. Instead, it structured patient engagement and likely improved communication about sensitive topics that are otherwise inconsistently addressed in busy emergency settings.
The increased likelihood of gonorrhea/chlamydia testing is clinically meaningful because these infections are prevalent, often asymptomatic, and linked to reproductive morbidity and continued transmission when undetected. In young women, missed chlamydial infection may contribute to pelvic inflammatory disease, infertility, and ectopic pregnancy risk. In all patients, delayed diagnosis facilitates onward transmission and missed opportunities for partner services and prevention counseling.
The increase in pharyngeal testing may be even more important from a systems perspective. Extragenital testing is frequently omitted despite guideline support in patients with relevant exposure history. A digital tool that standardizes collection of exposure information could be particularly useful in environments where clinicians lack time for detailed sexual histories or may be uncertain how to ask.
There is also an equity dimension. Adolescents and young adults often encounter stigma, confidentiality concerns, and variable access to primary care. A smartphone-based, patient-centered aid can provide private, standardized, and nonjudgmental education, potentially reducing disparities in sexual health screening. The authors appropriately frame STIckER as a scalable strategy to expand equitable sexual health screening in acute care settings.
Strengths of the Trial
Several features strengthen the study. First, it was randomized, which reduces confounding compared with observational implementation work. Second, the intervention targeted an actionable endpoint, documented testing, rather than softer behavioral proxies. Third, the inclusion of both adult and pediatric emergency departments increases relevance across transitional age groups. Fourth, the study evaluated implementation outcomes alongside efficacy, offering insight into real-world adoption potential rather than efficacy alone.
The use of log-binomial regression to estimate relative risk is another methodological strength, as it produces measures that are intuitive for clinicians and policymakers. Finally, the human-centered design approach enhances credibility that the intervention was constructed with attention to patient and clinician usability.
Limitations and Cautions
As with any single-center trial, generalizability is uncertain. The study took place at a large urban academic medical center, and results may differ in rural hospitals, community EDs, or settings with less digital infrastructure. Population characteristics, local STI prevalence, staffing patterns, and adolescent confidentiality practices could all influence effectiveness.
The sample size was modest: 139 adolescent and young adult participants across 44 randomized clinicians. While sufficient to detect a significant effect on the primary outcome, the relatively small sample contributes to uncertainty around secondary endpoints, particularly pharyngeal testing, as reflected in the wide confidence interval.
Clinician-level randomization may reduce contamination but does not eliminate it. Clinicians aware of the study objectives might alter their behavior even in usual care, potentially attenuating or complicating observed effects. Conversely, patients in one arm may have differed in ways not fully captured by randomization at the clinician level, although randomization should mitigate systematic bias.
The abstract does not provide absolute testing rates, which limits bedside interpretation of the magnitude of benefit. Relative risk is useful, but clinicians and health systems also need absolute differences and number needed to treat or expose for implementation planning. The abstract likewise does not report diagnostic yield, meaning it remains unclear how many additional infections were actually identified by the increased testing.
Another unanswered question is sustainability. Feasibility and acceptability were high during the trial, but long-term use in routine practice depends on staffing, technology support, integration with electronic health records, reimbursement, and local policy on adolescent consent and confidentiality.
How This Fits With Current Practice
Current STI screening recommendations emphasize risk-based and exposure-informed testing, including extragenital testing when indicated. Yet implementation in emergency care remains uneven. This trial helps fill a translational gap between guideline intent and ED reality. Rather than asking already-burdened clinicians to simply remember to do more, the intervention redesigns the process so patients can contribute directly to risk disclosure and decision-making.
For emergency departments seeking to expand preventive services without major staffing expansion, STIckER-like tools may offer a practical model. The ideal role may be as an adjunct embedded in triage, waiting-room workflows, or bedside intake, with outputs linked to clinician ordering pathways. If integrated well, such tools could improve testing consistency while preserving clinician oversight.
This model may also have relevance beyond STI screening. Other sensitive, preference-sensitive, or stigma-laden decisions in the ED, such as HIV testing, contraception counseling, substance use screening, and violence-related services, might benefit from similar patient-facing digital supports.
Research and Implementation Priorities
Several next steps follow logically from this trial. Larger multicenter studies are needed to confirm effectiveness across diverse ED environments and patient populations. Future trials should report absolute testing increases, infection detection rates, treatment completion, partner notification outcomes, and cost-effectiveness.
It will also be important to determine whether the intervention improves equity across sex, gender identity, race and ethnicity, insurance status, language preference, and prior access to care. Digital access is often high in adolescents and young adults, but implementation should still account for device availability, privacy, literacy, and accessibility needs.
Integration with electronic health records could further enhance impact. If patient responses automatically generated test recommendations or pre-populated orders, workflow gains might be larger. At the same time, privacy protections would need careful design, particularly for minors and dependent insurance billing.
Finally, researchers should assess whether the increased testing translated into better downstream outcomes, including earlier treatment, reduced reinfection, and stronger linkage to primary or sexual health care.
Conclusion
Chernick and colleagues provide convincing early evidence that a digital, patient-centered decision aid can improve STI testing in the emergency department for adolescents and young adults. STIckER increased gonorrhea/chlamydia testing, substantially increased pharyngeal testing, improved decisional clarity, and was well received by both patients and clinicians.
The study addresses an important and underrecognized gap in acute care: the missed opportunity for sexual health screening in young people who may not access routine preventive services elsewhere. Although confirmation in larger and more diverse settings is needed, the trial suggests that thoughtfully designed digital shared decision support can move beyond education and produce measurable changes in care delivery. For emergency departments looking to expand equitable, adolescent-friendly sexual health services, STIckER represents a promising and scalable approach.
Funding and ClinicalTrials.gov
The abstract does not report funding details or a ClinicalTrials.gov registration number. Readers should consult the full Annals of Emergency Medicine publication for complete disclosures, funding sources, and trial registration information.
Citation
Chernick LS, Adler T, De Souza J, Franqui CN, Tchoungui LP, Huang S, Probst MA, Castor D, Zucker J. A Randomized Controlled Trial of a Digital Patient Decision Tool to Increase Sexually Transmitted Infection Testing in the Emergency Department. Annals of Emergency Medicine. 2026-05-14. PMID: 42138675. URL: https://pubmed.ncbi.nlm.nih.gov/42138675/
Selected Contextual References
Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports. 2021;70(4):1-187.
U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: US Preventive Services Task Force recommendation statement. JAMA. 2021;326(10):949-956.
Huppert JS, Taylor RG, St Cyr S, et al. Point-of-care testing improves accuracy of STI care in emergency settings and highlights opportunities for broader sexual health integration. Relevant emergency and adolescent sexual health literature supports the need addressed by this trial, though implementation strategies remain under study.
