Monday, July 27, 2015

Did eliminating annual pap tests worsen chlamydia screening rates?

- Jennifer Middleton, MD, MPH

Despite the USPSTF's recommendation to screen all sexually active women aged 15-24 for chlamydia annually (along with women over age 24 at increased risk), many women do not receive this testing. Even worse, a recent study in the Annals of Family Medicine found that the rate of annual chlamydia screening in young women in one health care system decreased after 2009, the year the American College of Obstetrics and Gynecology (ACOG) updated their cervical cancer screening recommendations and increased both the initial age of screening and the recommended screening interval for cervical cancer (which is consistent with the United States Preventive Services Task Force [USPSTF]'s current recommendations). Given that asymptomatic chlamydia infections can cause serious, potentially permanent complications in women, this study should prompt each of us to examine how and when we are screening for chlamydia in our offices.

The study researchers obtained data from 5 outpatient family medicine offices in a university-based health care system. They looked at the number of visits made by women aged 15-21 for any reason and calculated the percentage of women who had received chlamydia screening during two 13-month intervals, the first spanning 2008-2009 and the second 2011-2012. The total number of office visits for each cohort was similar. The odds ratio for having chlamydia screening done in the 2008-2009 group compared to the 2011-2012 group was 13.97 (95% confidence interval 9.17-21.29); in these offices, at least, chlamydia screening happened significantly more often when annual gyn exams were still the norm.

As discussed in the current issue of Family Practice Management, the Choosing Wisely campaign's goal is to eliminate medical overuse - unnecessary, potentially harmful care. Annual cervical cancer screening certainly falls into this category, as do annual screening pelvic examinations. Many of us family physicians currently practicing, however, learned to associate sexually transmitted disease (STD) screening with these no-longer annual visits; a decrease in chlamydia screening may be an unintended consequence of scaling back on cervical cancer screening.

The importance of this screening regarding our female patients' reproductive health cannot be overstated; the Centers for Disease Control (CDC) estimates that 60% of female infertility could be eliminated with appropriate chlamydia screening. Family physicians may find it helpful to measure the rate of chlamydia screening in their own practices, and, if suboptimal, consider implementing an office quality improvement initiative to increase screening. Using a urine sample to screen, which is as accurate as a cervical sample, may be one way to reduce barriers for both patients and clinicians. The National Committee for Quality Assurance (NCQA) has a publication addressing chlamydia screening which includes several additional strategies to try.

There's an AFP By Topic on STDs if you'd like to read more, and the collection contains this 2012 article on chlamydia infection screening, diagnosis, and management.

How is your office screening women for chlamydia?