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Guest Editorial February 2009

Missed Opportunities for Chlamydia Screening

Karen Hoover, MD, MPH; Charlotte Kent, PhD

Chlamydia is the most common bacterial sexually transmitted infection in the United States, with more than one million cases reported to the CDC in 2006.1 Most of these cases were diagnosed among young women aged 15 to 24 years. The infection is usually asymptomatic; thus, many cases are undiagnosed because women are not screened. As most ObGyns are likely aware, undiagnosed and untreated chlamydia can progress to pelvic inflammatory disease (PID) and result in potentially devastating long-term outcomes such as infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydia also increases a woman’s risk of acquiring human immunodeficiency virus. Because of chlamydia’s prevalence, typically asymptomatic nature, and potential long-term sequelae from PID, the CDC and other organizations have recommended annual screening of sexually active women aged 25 years and younger since 1989. Yet, most ObGyns are not screening young, asymptomatic women.

Chlamydial infection in a woman is easily diagnosed and treated. An endocervical specimen may be collected during a speculum examination, or the residual specimen from a liquid-based Papanicolaou (Pap) test may be tested for Chlamydia trachomatis.2 Alternatively, a provider-collected or patient self-collected vaginal swab may be used. If a pelvic examination is not performed, a urine sample may be tested. A single dose of azithromycin may be used to effectively treat an infection. Screening can thus be performed during any routine preventive or gynecologic visit.

Chlamydia screening of young women is an underutilized preventive health service in the United States. The National Committee on Prevention Priorities ranked preventive services using US Preventive Services Task Force (USPSTF) recommendations and deemed chlamydia screening one of the top 6 priority preventive services based on its clinically preventable burden and cost-effectiveness, and its low current utilization rate.3 While the Healthcare Effectiveness Data and Information Set (HEDIS) demonstrates increasing chlamydia screening rates since first measured in 1999, rates are still suboptimal.4 Our recent studies, using data from nationally representative samples of US physicians and hospital outpatient clinics, found that screening rates were extremely low among women seeking care in physician offices and outpatient clinics.5,6

In 2005, ObGyns conducted 36% (2.6 million) of all preventive visits and 71% (2.3 million) of all Pap tests for women aged 15 to 25 years, providing a unique opportunity to easily implement chlamydia screening in young women—yet, chlamydia testing was conducted at only 16% of those preventive visits, and at only 23% of those visits that included a Pap test.5 Such visits are missed opportunities for chlamydia screening. Even more discouraging is that primary care physicians, who conducted 64% (4.7 million) of all 2005 preventive visits made by women aged 15 to 25 years, only screened young women for chlamydia at 6.8% of the visits. Chlamydia tests were conducted at less than 1% of the 3 million visits including a urinalysis where a urine specimen could be easily tested for Chlamydia trachomatis. This, too, is a missed opportunity for chlamydia screening by physicians who do not normally perform pelvic examinations.

Few studies have been done to identify barriers that might be preventing chlamydia screening in ObGyn practices in the United States. Given the paucity of studies, we can gain insight from both international studies that identify chlamydia screening barriers, and domestic studies that identify barriers to the provision of other recommended preventive screening services. From these studies, we have learned that providers do not feel comfortable or skillful while conducting a sexual history, and that competing priorities and insufficient time during a brief office visit make it difficult to perform all recommended preventive services. Chlamydia screening also may not be routinely performed in an ObGyn office because physicians perceive that their patients are not at risk of acquiring an infection.

What can be done to increase chlamydia screening of young, sexually active women by ObGyns? Educating physicians about the importance of routine screening for all sexually active women aged 25 years and younger is an important step. Although most ObGyns are aware of the consequences of undiagnosed and untreated infection, many are probably unaware that about 5% of sexually active young women in the United States are infected with chlamydia.7 Delivering these messages to ObGyns is likely to be beneficial, but is probably not sufficient to influence screening rates. In addition to educational campaigns, other interventions are needed, such as structural interventions. These include placement of a sampling swab alongside a Pap test kit, bundling of lab tests to include chlamydia testing of liquid-based cervical cytology specimens and urine specimens, and reminder systems as a component of electronic medical records. Payment for the time required to counsel and screen patients and access to local HEDIS chlamydia screening data for use as a benchmark are additional system interventions that may be effective. The outcomes of these screening interventions will need to be evaluated in small pilot studies, and then widely implemented in appropriate settings if found to be successful. The CDC has made chlamydia screening a national priority and has formed the National Chlamydia Coalition—which includes ACOG—to identify, develop, and implement interventions to increase chlamydia screening nationally.

ObGyns are uniquely poised to lead and champion the national effort to increase screening, given their expertise in women’s reproductive health as well as opportunities that exist in their clinical practice to facilitate screening. Diagnosis and treatment of chlamydial infection is essential for protecting young women’s reproductive health by preventing infertility, ectopic pregnancy, and chronic pelvic pain. In accordance with guidelines, all sexually active women aged 25 years and younger should be screened annually for chlamydia.

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Karen Hoover, MD, MPH, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA

REFERENCES

1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. www.cdc.gov/std/stats/pdf/Surv2006.pdf. Accessed October 23, 2008.
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR. 2006;55 (RR-11);1-94.
3. Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006; 31(1):52-61.
4. National Committee of Quality Assurance. The state of health care quality 2007. Chlamydia Screening. www.ncqa.org/Portals/0/Publications/ResourceLibrary/SOHC/SOHC_07.pdf. Accessed October 23, 2008.
5. Hoover K, Tao G. Missed opportunities for chlamydia screening of young women in the United States. Obstet Gynecol. 2008;111(5): 1097-1102.
6. Hoover K, Tao G, Kent C. Low rates of both asymptomatic chlamydia screening and diagnostic testing of women in US outpatient clinics. Obstet Gynecol. 2008;112(4):891-898.
7. Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA. 2004;291(18):2229-2236.