Guideline change affects chlamydia screening rate

The revised recommendation on cervical cancer screening issued by the American College of Obstetricians and Gynecologists in 2009 not only resulted in a dramatic decrease in the rate of Pap testing among women aged 15 to 21 years, but it was also followed by an even greater drop in chlamydia screening within this population at high risk for the sexually transmitted infection, reported researchers from the University of Michigan.

The study, recently published in the Annals of Family Medicine, analyzed data from patient visits at the university’s family medicine ambulatory clinics over 14-month periods before and after release of the 2009 guideline that recommended cervical cancer screening be initiated at age 21 instead of according to age of sexual initiation.

After excluding visits where Pap testing and chlamydia testing were likely done for diagnosis rather than screening, the investigators found that the total number of visits by women aged 15 to 21 years as well as the mean number of visits per patient was similar comparing the time periods January 1, 2008 to February 28, 2009 and January 1, 2011 to February 28, 2012. However, the proportion of patients having Pap testing decreased from 24.2% before the guideline change to 3.9% after, and the chlamydia screening rate fell from 30.9% to 2.0%. Results of an adjusted analysis showed that the odds of having a chlamydia screen at a clinic visit were 14-fold higher during the period before versus after the guideline change.

Allison Ursu, MD, lead author of the published paper, notes that a study analyzing data from ob/gyn clinics might yield different findings considering the difference in clinical framework of the visits-patients presenting for gynecological care are more likely to have a pelvic exam or present for a sexual health-related reason. Nevertheless, the data should prompt ob/gyn practitioners to consider whether they are doing fewer Pap tests and pelvic exams in patients aged 21 years and younger and if as an unintended consequence of that, they might be missing opportunities to do chlamydia screening.

“Chlamydia is the most commonly reported sexually transmitted infection in the United States, and in females, it can be associated with more serious conditions, including pelvic inflammatory disease, chronic pain, and infertility. Based on this information, the US Preventive Services Task Force recommends screening for chlamydia in sexually active women age 24 years and younger because they have the highest burden of disease,” said Dr Ursu, clinical lecturer, department of family medicine, University of Michigan, Ann Arbor.

“Our study shows the importance of unlinking chlamydia screening from the pelvic examination and cervical cancer screening.”

The investigators also believe their findings point to a need for identifying strategies that will ensure appropriate chlamydia screening. One barrier they identified among family practitioners at the University of Michigan is a low rate of awareness about the availability of a chlamydia urine test.

“Chlamydia testing has been closely linked with the pelvic exam and Pap testing such that physicians were relying on the cervical swab collection for the chlamydia screen. In our study, almost two-thirds of the chlamydia screens were concurrent with Pap testing before the guideline change, compared with just over 10% after the 2009 guideline was released,” Dr Ursu said.

“It is important for clinicians to know that chlamydia screening can be easily done with a urine test even if a pelvic exam is not being performed.” 

With the aims of improving capture rates for chlamydia screening among sexually active females ages 16 to 24 and streamlining the screening process, Dr Ursu and colleagues from the family medicine department collaborated with colleagues in ob/gyn, internal medicine, pediatrics, and the University Health Service to introduce an electronic medical record-based reminder protocol. They are preparing to analyze their data to evaluate the success of the program and ultimately will be looking to see if higher chlamydia screening rates translate into reduced consequences of chlamydia infection.