Spotlight on chlamydia: Boost your screening rate in young women
Some 2 million cases go undiagnosed and untreated, national figures say
If adolescents and young women are not being routinely screened for chlamydia at your facility, it is time to reverse the trend, says the American College of Obstetricians and Gynecologists (ACOG). Information released during the annual meeting of the national organization underscores the urgency of screening for the sexually transmitted infection (STI).
According to the Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics, chlamydia remains the most commonly reported STI in the United States. In 2005, there were just more than 976,000 reported chlamydial infections, but because many cases are not diagnosed or reported, the agency estimates there may be as many as 2.8 million new cases annually.1 About 75% of chlamydial infections in women are asymptomatic; if symptoms do occur, they are often vague, causing women to delay seeking medical care and treatment. If chlamydia is not treated, up to 40% of women infected with chlamydia may develop pelvic inflammatory disease (PID), which can lead to ectopic pregnancy and infertility. When PID develops, it can be devastating; one in five women with PID becomes infertile.2
Why don't all clinicians screen for chlamydia? One reason may be that they don't consider their patients at risk for an STI, says David Soper, MD, professor of obstetrics and gynecology at the Medical University of South Carolina in Charleston.
To consider risk, one needs to evaluate age, which is a simple thing to do because all women younger than 25 years of age should be screened for chlamydia on an annual basis, he says. Such practice is spelled out in guidelines issued by ACOG, CDC, American Medical Association, American Academy of Pediatrics, American College of Preventive Medicine, and the U.S. Preventive Services Task Force.
Further support for chlamydia screening comes from managed care. Screening of sexually active women ages 15-25 has been one of the performance measures included in the National Committee for Quality Assurance's Health Plan Employer Data and Information Set since 2000.
Clinicians also need to consider sexual behavior when evaluating risk for STIs, says Soper. If clinicians don't ask the question about having a new sex partner, multiple partners, or having a past history of an STD, then they may mischaracterize a patient's risk, Soper observes. Clinicians also may believe that they "never see it" when it comes to chlamydia risk; however, this becomes a self-fulfilling prophesy because if clinicians don't do a chlamydia test, they won't see a positive test.
According to a 2006 study sponsored by the CDC and the Agency for Healthcare Research and Quality (AHRQ), only about 50% of indicated chlamydia screening is being performed, notes Soper.3 "This is low-hanging fruit in our fight against sexually transmitted infections," comments Soper.
Up the numbers
How can your clinic improve its services when it comes to chlamydia screening? Take a look at the recent efforts at the Cowell Student Health Center at the University of California, Davis. What prompted the facility to push for increased chlamydia testing?
"Our program has been looking for ways to enhance collaborations between health education and health promotion outreach services and our clinical care services," says Michelle Famula, MD, director at the student health center. "This was a proposal from our health education program staff to help add a clinical element to a planned outreach campaign for Sexual Health Awareness Month."
Medical personnel had been promoting annual chlamydia testing for sexually active women up to age 26 in accordance with the current CDC guidelines, as well as reminding staff to encourage this testing as a routine part of general primary care wellness, she explains. With the facility's recent adoption of urine STI testing with GenProbe (GenProbe, San Diego) chlamydia/gonorrhea technology, patients could be tested without the psychological barrier of a genital sampling or the access barrier of a physical examination appointment time, says Famula.
By putting these elements together, it was proposed that the center encourage and promote patient requests to "add an STI test" to any medical visit and for providers to encourage scheduled patients to "add an STI test" for any care appointment for sexually active patients, reports Famula. During the center's routine testing practice the prior year, STI testing required a provider visit ($10) to obtain an order for the test ($20).
"At the request of our health education student interns, who felt strongly that cost was a factor for some students, we reduced the cost of testing from $20 to $10 during the month of April," she says. "Therefore, a student seen for a simple refill of allergy medication, which is a $10 visit charge, could request STI testing without the addition of a physical exam or a need for a second appointment [an additional $10 charge], with a 50% discount in the testing cost."
For the tracking period observed, the center experienced a 16% increase in the number of chlamydia tests completed compared to the prior year, Famula states.
Screening highlighted with multiple outreaches
How did the facility get the word out to students about the screening? Polly Paulson, MPH, MA, a sexual health educator at the center, spearheaded efforts to increase chlamydia/gonorrhea testing during the April 2007 "Sexual Health Awareness Month" campaign. Outreach tools employed included:
- Ads at Facebook (www.facebook.com, a web-based social networking site) that linked to the appropriate Cowell Student Health Center web site page;
- stand-up table-top fliers at campus eateries;
- fliers posted around campus, as well as in exam rooms;
- poster in campus kiosk;
- student newspaper ads;
- buttons worn by providers to encourage patients to request the test;
- laminated information cards for patients to read in exam rooms.
What other types of information are available to students to help them understand the importance of chlamydia screening? The center provides information on its web site, www.healthcenter.ucdavis.edu. (Click on "Online Health Resources," "Health Topics," and "Chlamydia." Listing includes links to Chlamydia Questions and Answers and a CDC Fact Sheet.) The center also provides information through clinical staff at in- person visits and through advice nurses by phone, says Paulson. It also offers information through health education and promotion program staff and interns through outreach and education services.
Are there plans to re-establish the reduced testing rate? At this time, the center is exploring options for nonvisit test ordering through online secure provider-patient communications, Famula says. Another possibility is through advice nurse screening protocols using standardized advance practice procedures, which is a free service, coupled with the $20 test price, she says.
"We also are exploring the possibility of reducing the direct cost of testing permanently, to $10 or $5, through subsidized charges offset by income from other service charges — funding resources permitting," she notes.
Get value for the dollar
According to the 2006 CDC/ARHQ study, chlamydia is one of the five highest-ranking services being used by less than half of the people who need them. The other most cost-effective services include discussing daily aspirin use with at-risk adults; screening adults above age 50 for colorectal cancer; intervening with smokers to help them quit; and vaccinating older adults against bacterial pneumonia.3
Adding chlamydia testing is not a hardship, notes Andrew Kaunitz, MD, professor and assistant chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. For several years, his facility has used polymerase chain reaction (PCR)-based screening of at-risk patients. One swab is performed using the Leukorrhea Panel, which tests for chlamydia, gonorrhea, and trichomonas, from Hamilton, NJ-based Medical Diagnostic Laboratory.
"We are not aware of any false-positives with this testing and have found this technology to be convenient and useful in our practice setting," he says.
Use urine screening to increase chlamydia detection, agrees Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor — UCLA Medical Center in Torrance. Remember that patients do not need a pelvic exam to get hormonal contraception; chlamydia screening does not change this practice, says Nelson.
References
- Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2005. Atlanta: U.S. Department of Health and Human Services; November 2006.
- Centers for Disease Control and Prevention. Tracking the Hidden Epidemics: Trends in STDs in the United States, 2000. Atlanta; 2000.
- Maciosek MV, Edwards NM, Coffield AB, et al. Priorities among effective clinical preventive services: Methods. Am J Prev Med 2006; 31:90-96.
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