Chlamydia Screening Practices of Primary-Care Providers -- Wake County, North Carolina, 1996

Genital chlamydial infection is the most commonly reported infectious disease in the United States (1), and the prevalence of Chlamydia trachomatis genital infections in sexually active adolescents is 5%-15%, regardless of socioeconomic status (2-4). Although chlamydial infections frequently are asymptomatic in women, untreated infections can cause extensive inflammation and scarring of the female reproductive tract (5). In addition, chlamydial infections may facilitate human immunodeficiency virus transmission (6). Because of the risks and complications associated with this infection, CDC and the U.S. Preventive Services Task Force have recommended that all sexually active adolescent women undergoing a pelvic examination receive routine screening for chlamydia (7,8). To characterize the chlamydia screening practices of primary-care providers in Wake County, North Carolina, a county with high reported rates of chlamydial genital infection, the Wake County Human Services Public Health Center conducted a survey of primary-care providers during August-October 1996. This report summarizes the results of that survey, which document missed opportunities for the detection of chlamydia infection by health-care providers in both public and private practices.

A list of all primary-care practices in Wake County (1995 population: 512,944) was compiled using the county telephone directory and the physician registry from the North Carolina Medical Society. Primary-care practices included private physician offices, urgent-care centers, local health department clinics, hospital emergency departments and outpatient clinics, university health centers, community health centers, health maintenance organization (HMO) clinics, and nonprofit clinics (e.g., Planned Parenthood). Managed care was defined as a either a free-standing HMO clinic (e.g., Kaiser Permanente) or a practice participating in a preferred provider organization (PPO). A questionnaire was mailed to a total of 159 primary-care practices in Wake County, of which 127 (80%) responded; of these, 117 (92%) practices reported serving adolescent patients (aged 12-19 years). Routine chlamydia screening was defined as the performance of chlamydia testing during all or annual pelvic examinations.

Of the 117 responding practices that served adolescents, 94 (80%) reported that they performed chlamydia testing, and 34 (29%) reported that they routinely screened adolescent women. Practices that described their financial charter as private-for-profit were less likely to screen routinely than other practices (e.g., private nonprofit, health department, community health services, and university health centers) (15% versus 77%; prevalence ratio {PR}=0.2; 95% confidence interval {CI}=0.1-0.3) (Table_1). Practices with any patients insured through managed care were less likely to screen than those without managed-care patients (20% versus 58%; PR=0.3; 95% CI=0.2-0.6) or if they served patients with fee-for-service private insurance (20% versus 65%; PR=0.3; 95% CI=0.2-0.5). Practices were less likely to screen routinely if they reported lower proportions of non-Hispanic blacks (19% versus 39%; PR=0.5; 95% CI=0.2-0.9) or Hispanics (14% versus 41%; PR=0.3; 95% CI=0.2-0.8). Practices without written protocols for chlamydia testing were less likely to test routinely than practices with written protocols (17% versus 59%; PR=0.4; 95% CI=0.2-0.7). The proportion of practices conducting routine screening were similar in urban and rural (outside of the two main metropolitan areas, Raleigh and Cary) locations, by number of patient visits per year, or by medical specialty. A multivariate logistic regression model was constructed using backward elimination beginning with the variables identified as significant on univariate analysis. Based on the multivariate analysis, the only characteristics significantly associated with lack of routine screening were private-for-profit financial charter (odds ratio {OR}=0.1; 95% CI=0.02-0.17) and a low proportion of Hispanic patients (OR=0.3; 95% CI=0.1-0.9).

Of the 60 practices that provided chlamydia testing but did not provide routine testing of adolescents during all or annual pelvic examinations, all reported testing for chlamydia if signs and symptoms of infection were present; 58 (97%) if the patient reported that his/her partner had a chlamydial infection; 12 (20%) if the patient reported a new sex partner; and 18 (30%) if the adolescent reported multiple sex partners.

Approximately one fourth (23%) of practices serving adolescents reported that any of their clinicians had received any kind of continuing medical education that addressed genital chlamydial infections or pelvic inflammatory disease (PID) during the preceding year. Thirty-five percent expressed interest in obtaining continuing medical education in chlamydia or PID.

Reported by: PA Leone, MD, L Fiscus, Wake County STD Clinic, Raleigh; D Williams, PhD, EM Foust, MPH, JM Moser, MD, State Epidemiologist, North Carolina Dept of Health and Human Svcs. Epidemiology and Surveillance Br, Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: In November 1996, in a report documenting the high prevalence of sexually transmitted diseases (STDs) among adolescents in the United States, the Institute of Medicine recommended improving clinical STD services for this population, especially within the private sector (9). Screening and treatment programs are effective in decreasing chlamydia prevalence in adolescent women (3,4) and in decreasing the incidence of PID (10).

This report documents low rates of routine chlamydia screening of sexually active adolescent women in an area with known high reported rates of infection. In Wake County, during 1996-1997, the prevalence of chlamydia infection in female adolescents attending family-planning clinics or STD clinics was 10% and 17%, respectively (North Carolina Chlamydia Prevention Program, unpublished data, 1997). Routine chlamydia screening was associated with the clinics' financial charters and with patients' insurance, race, and ethnicity. Some third-party payers in the county (e.g., Medicaid, Kaiser Permanente, some Blue Cross/Blue Shield plans, and some PPOs) already reimburse for chlamydia testing during annual pelvic examinations. Clinicians may have believed that they could predict their patients' risk for chlamydial infection based on their insurance status, race, and ethnicity. However, among sexually active adolescent women, there is a high prevalence of chlamydial infection independent of their demographic factors (2-4).

Local health departments in North Carolina in areas with high prevalences of STDs are informing private physicians of the problem and encouraging additional testing, treatment, and reporting. In addition, plans are under way to assess specific barriers to chlamydia screening of adolescents.

Coordinated efforts between the private and public sectors are necessary to implement recommendations of the Institute of Medicine for STD services for adolescents. Managed-care organizations are beginning to address the importance of routine chlamydia testing for adolescent women: beginning in 1997, a new clinical performance measurement of the Health Employer Data Information Set has been implemented to assess the ability of managed-care organizations to perform and monitor chlamydia tests annually for enrolled women aged less than 25 years. For those settings in which pelvic examinations for adolescent women are not feasible, new diagnostic techniques, such as urine chlamydia testing using DNA amplification, may increase the availability of services. Primary-care providers serving adolescent women need to be educated about the risk for chlamydial infection in this population and need to be encouraged to perform routine screening for all sexually active adolescent women, regardless of symptoms or risk factors.

References

1. CDC. Ten leading nationally notifiable infectious diseases -- United States, 1995. MMWR 1996;45:883-4.

2. Nelson ME. Prevalence of Chlamydia trachomatis infection among women in a multiphysician primary-care practice. Am J Prev Med 1992;8:298-302.

3. Mosure DJ, Berman S, Fine D, Delisle S, Cates W, Boring JR III. Genital chlamydia infections in sexually active female adolescents: do we really need to screen everyone? J Adol Health 1997;20:6-13.

4. Mertz KJ, Levine WC, Mosure DJ, Berman SM, Dorian KJ. Trends in the prevalence of chlamydial infections: impact of community-wide testing. Sex Transm Dis 1997;24:169-75.

5. Westrom L, Wolner-Hanssen P. Pathogenesis of pelvic inflammatory disease. Genitourin Med 1993;69:9-17.

6. Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992;19:61-77.

7. CDC. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR 1993;42:(no. RR-12):7-8.

8. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams and Wilkins, 1996.

9. Institute of Medicine. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1996.

10. Scholes D, Stergachis A, Heidrich FC, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334: 1362-6.

    
    
    

+------------------------------------------------------------------- ---+ | Erratum: Vol. 46, No. 35 | |             | | In the article, "Chlamydia Screening Practices of Primary-Care | | Providers -- Wake County, North Carolina, 1996," an error appears on | | page 821 in the second sentence of the second paragraph of the | | editorial note. The sentence should read, "In Wake County, during | | 1996-1997, the prevalence of chlamydia infection in female | | adolescents attending a family planning clinic was 10% and in | | female adolescents attending an STD clinic was 17% (North Carolina | | Chlamydia Prevention Program, unpublished data, 1997). | |             | +------------------------------------------------------------------- ---+
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