Executive Summary
Results from a University of Michigan study of five clinics indicate that when Pap smear schedules were revised in 2009, the number of annual chlamydia screenings dropped in women ages 16-21.
-
In 2009, the American College of Obstetricians and Gynecologists recommended beginning cervical cancer screening at age 21. The professional group previously had recommended beginning screening three years after first sexual intercourse or by age 21, whichever occurred first. Prior to 2009, clinicians often performed Pap smears and chlamydia screenings during the same exam.
-
Computer systems now in use in clinics can be set to prompt providers during a visit to perform tests recommended for each patient, including chlamydia screening for teen and young adult women.
Remember when an annual Pap smear for a young woman also provided a chance for routine chlamydia screening? Results from a University of Michigan study of five clinics indicate that when Pap smear schedules were revised in 2009, the number of annual chlamydia screenings dropped in women ages 16-21.1
The U.S. Preventive Services Task Force recommends chlamydia screening for sexually active women aged younger than 24.2 Early detection of the disease and treatment with antibiotics can prevent long-term effects such as pelvic inflammatory disease (PID) that can affect the fallopian tubes and lead to infertility or ectopic pregnancy.
In 2009, the American College of Obstetricians and Gynecologists recommended beginning cervical cancer screening at age 21.3 The professional group previously had recommended beginning screening three years after first sexual intercourse or by age 21, whichever occurred first. Prior to 2009, clinicians often performed both screenings during the same exam.
Pap smear change
When the Pap smear schedule for young women was changed in 2009 to reduce the chance of unneeded follow-up tests, it made an impact on chlamydia screening, researchers found.1
“This research was prompted by our clinical work where we noticed a trend in decreased cervical cancer screening after the 2009 guideline change, as well as possible missed opportunities for chlamydia screening,” says Allison Ursu, MD, clinical lecturer in the Department of Family Medicine at the University of Michigan in Ann Arbor. Ursu served as lead author of the current paper.
To perform the current analysis, Ursu and colleagues looked at the tests given to sexually active young women ages 16-21 with no chlamydia symptoms who came to the University’s five family medicine clinics in the year before the new Pap test guideline and two years later. Those in the earlier group were nearly 14 times more likely to get a chlamydia test than those seen later, even though there was no drop in clinic visits by such patients. Women had higher odds of being screened for chlamydia before versus after the guideline change (odds ratio = 13.97; 95% confidence interval, 9.17-21.29; P<.001). The analysis indicates that both tests were performed together 60% of the time before the guideline change, but only 10% of the time two years later.1
Look at EMRs
Computer systems in clinics can be set to prompt providers during a visit to perform tests recommended for each patient.
A reminder in the MiChart system, a proprietary electronic health record system in use across all of the University of Michigan Health System’s primary care clinics, has greatly increased chlamydia screening for teen and young adult women, say officials. More than 66% of sexually active patients with no symptoms are screened each year, they note. Researchers plan further analysis of the impact of the new reminder prompt on chlamydia infections, PID cases, and ectopic pregnancies seen among clinic patients.
Mack Ruffin, MD, MPH, senior author and Max and Buena Lichter Research Professor of Family Medicine at the University of Michigan, says, “Patients are very aware of Pap tests, and many still think they need one yearly. There’s much less awareness of chlamydia screening. The takeaway from this study is that we have to find other opportunities to screen.”
Reminder prompts within electronic medical records can be useful tools to improve chlamydia screening rates, but they are limited as standalone interventions, notes Karen Hoover, MD, MPH, a medical epidemiologist in the Centers for Disease Control and Prevention’s (CDC’s) Division of STD Prevention.
“Prompts have been shown to be most effective when packaged with other interventions such as provider training efforts and social marketing campaigns to increase patient demand of screening,” Hoover says.
Missed opportunities
Hoover is familiar with missed opportunities. She and other CDC researchers performed a 2012 analysis of data from the 2006-2008 cycle of the National Survey of Family Growth, a nationally representative household survey. Their research showed 62%, which is more than nine million young women, were not screened as recommended for chlamydia.4 (Contraceptive Technology Update reported on the research. See “Too few young women get tested for chlamydia,” June 2012.)
Putting reminder prompts in electronic medical records is just the first step, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
“The new technologies for self-administered vaginal swab tests for chlamydia and high-risk HPV [human papillomavirus] are going to make us all have to revise the way we track our patients and their needed testing,” states Nelson.
-
Ursu A, Sen A, Ruffin M. Impact of cervical cancer screening guidelines on screening for chlamydia. Ann Fam Med 2015; 13(4):361-363.
-
LeFevre ML; U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 161(12):902-910.
-
ACOG Committee on Practice Bulletins — Gynecology. ACOG Practice Bulletin No. 109: Cervical cytology screening. Obstet Gynecol 2009; 114(6):1409-1420.
-
Tao G, Hoover KW, Leichliter JS, et al. Self-reported Chlamydia testing rates of sexually active women aged 15-25 years in the United States, 2006-2008. Sex Transm Dis 2012; 39(8):605-607.
