Stem chlamydia spread in teens with screening

What is your practice when it comes to routinely screening teen-age girls for chlamydia? If you aren’t performing such testing, you are missing a prime opportunity to reduce the most commonly reported sexually transmitted disease (STD) in the United States.1

Routinely screening sexually active teen-age girls during regular provider visits is an effective way to detect chlamydia and help teen-agers avoid infertility due to disease progression, according to a new study of adolescent teens.2 Providers need to step up such screening; teen-age girls are about six times more likely than adult women to contract the disease, according to the study.

Several important sequelae can result from C. trachomatis infection in women; the most serious of these include pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. Some women who have apparently uncomplicated cervical infection already have subclinical upper-reproductive-tract infection. By routinely checking for chlamydia, providers can help prevent these conditions, states Mary-Ann Shafer, MD, professor of pediatrics at the University of California, San Francisco, and lead author of the new study.

Shafer and research associates tested the effectiveness of a system-level clinical practice improvement intervention at Kaiser Permanente clinics in northern California designed to boost chlamydia screening among sexually active adolescent girls during routine checkups at pediatric clinics. They found that an average of 5.8% of sexually active girls ages 14-18 tested positive for chlamydia in routine screening — and they were all patients who otherwise would not have been tested.

Waiting for an annual exam to do such screening may not be the best practice in treating adolescent girls, says Shafer. "Providers need to screen teens whenever they present for any medical care so that an additional visit cost is not incurred," she states.

Has HEDIS helped?

Interest in chlamydia screening has increased since its 2000 inclusion in the HEDIS (Health Plan Employer Data and Information Set) managed care guidelines developed by the Washington, DC-based National Committee for Quality Assurance (NCQA). NCQA is a nationwide organization charged with measuring and reporting on managed care quality.

The HEDIS chlamydia-screening measure is designed to assess the percentage of sexually active women ages 15–25 who are screened for chlamydia. What has been the impact on screening since the guideline was implemented? Current figures show that there is room for improvement: in 2000, 27.5% of sexually active women ages 16-20 and 24.2% of sexually active women ages 21-26 in HEDIS-participating managed care plans were screened for chlamydia infection.3 Only about 180,000 of the more than 650,000 women ages 16-20 who were eligible under the guideline received appropriate screenings in 2000.3

When it comes to Medicaid managed care, chlamydia screening recommendations may not be impacting actual clinical practices.4 A recent study examined the policies and practices of managed care organizations in seven large U.S. cities: Balti-more; Charlotte, NC; Dayton, OH; Louisville, KY; Memphis, TN; Norfolk, VA; and Oklahoma City. All of these are cities with high rates of reported STD cases and large percentages of Medicaid beneficiaries enrolled in managed care. The analysis found that 15% of managed care organizations and 42% of contracted medical groups recommended chlamydia screening for sexually active adolescents, and 55% of primary care providers reported annual screening of sexually active adolescent patients.4

Why aren’t you testing?

Why aren’t providers performing routine chlamydia screenings, particularly in the adolescent population? Harold Wiesenfeld, MD, associate professor in the department of obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh School of Medicine offers three possible reasons:

  • Adolescents may be fearful of a pelvic examination.
  • Because most chlamydia infections in females are asymptomatic, patients may not believe they could be infected.
  • Providers either are unaware of the importance of STD screening in adolescents or deny that STDs are common in their patient population.

Self-testing for chlamydia may be one option in overcoming barriers to testing. Wiesenfeld and other research associates at Magee-Women’s Research Institute found undiagnosed sexually transmitted diseases in 18% of teen-age girls who provided vaginal samples they collected themselves during a two-year study.5 Such a self-testing option was effective in detecting previously undiagnosed STDs in the adolescent population; nearly 13% of the adolescent girls who had never had a gynecological exam tested positive for an STD, and 51% of girls with infections would not have pursued STD testing by traditional gynecological examination.5

Self-collection of STD specimens can overcome some of the barriers of STD testing— namely the uncomfortable pelvic exam — and represents less intrusion on an adolescent’s privacy, says Wiesenfeld. However, providers must be willing to break past their own barriers to implement screening, he asserts.

"Self-collection will have little impact on this [provider] barrier," states Wiesenfeld. "We need to educate providers on the importance of screening all sexually active adolescents."

References

1. Centers for Disease Control and Prevention. Chlamydia in the United States. April 2001. Accessed at www.cdc.gov/nchstp/dstd/Fact_Sheets/chlamydia_facts.htm.

2. Shafer MA, Tebb KP, Pantell RH, et al. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA 2002; 288:2,846-2,852.

3. National Committee for Quality Assurance. The State of Managed Care Quality 2001. Washington, DC; 2001. Accessed at www.ncqa.org/somc2001/CHLAMYDIA/SOMC_2001_CHL.html.

4. Pourat N, Brown ER, Razack N, et al. Medicaid managed care and sexually transmitted diseases: Missed opportunities to control the epidemic. Health Affairs 2002; accessed at www.nccc-online.org/managedcare_8.asp.

5. Wiesenfeld HC, Lowry DL, Heine RP, et al. Self-collection of vaginal swabs for the detection of Chlamydia, gonorrhea, and trichomoniasis: Opportunity to encourage sexually transmitted disease testing among adolescents. Sex Transm Dis 2001; 28:321-325.