1. Cervical Cancer Screening Guidelines and Rates of Chlamydia Screening Allison Ursu, MD Ananda Sen, PhD Mack Ruffin, MD, MPH April 27, 2015 Department of Family Medicine, University of Michigan @UMFamilyMed

2. Disclosures None

3. Background Centers for Disease Control and Prevention (2013)

4. Background Centers for Disease Control and Prevention (2013)

5. Predictors of chlamydia screening for ages 15-24 –Provider characteristics –Privacy during a health visit Sexually active females screened for cervical cancer were more likely to be screened for chlamydia Background Skala (2010);Tao (2010)

6. Purpose of this study To assess whether a change in the cervical cancer screening guideline altered rates of chlamydia screening in women age 15-21 in primary care clinics

7. Methods Repeated cross-sectional study Summary data used to identify visits for 15-21 year old women for five family medicine clinics Two separate groups created –Visits prior to 2009 –Visits 2011 to 2012

8. Excluded visits for pregnancy and with diagnoses where PAP or chlamydia testing would be diagnostic Logistic regression to predict outcome Primary outcome: completion of chlamydia testing UM IRB not regulated Methods

9. Results Characteristics of Study Sample Pre-Guideline GroupPost-Guideline Group Total visits 48475005 Total patients 16261846 Mean age ± SD, y 17.65 ± 1.5917.81 ± 1.72 Total PAP tests (%) 394 (24%)73 (3.9%) Total chlamydia tests (%) 502 (31%)37 (2.0%) Total chlamydia when PAP tested (%) 311 (62%)4 (10.8%)

10. Results A woman was more likely to be screened for chlamydia prior to the guideline change OR 13.97, 95% CI 9.17-21.29 Controlled for age, concurrent PAP screening, clinic site, number of visits, and provider type

11. Results Predictors of Chlamydia Screening Both GroupsPre-Guideline GroupPost-Guideline Group VariablesOR (95% CI)P ValueOR (95% CI)P ValueOR (95% CI)P Value Number of visits 1.25 (1.20-1.29) <.001 1.30 (1.24-1.35) <.001 1.06 (0.94-1.19).37 Concurrent PAP 73.43 (54.27-99.36) <.001 90.83 (65.09-126.73) <.001 12.25 (3.78-39.66) <.001

12. Results Secondary analysis of clinic type –Women seen at resident training clinics were more likely to be screened for chlamydia –OR 2.11, 95% CI 1.67-2.67

13. Limitations One department at one academic center Numbers of PAP and chlamydia testing are low in second group, limiting ability to determine predictors Did not have demographic information, provider gender, sexually active status Data was only completed tests

14. Discussion Chlamydia screening in women 15-21 is more likely to be performed when cervical cancer screening is recommended and performed at the same visit Need to ‘uncouple’ chlamydia screening from cervical cancer screening Identify other opportunities for screening

15. Questions

16. References 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2012. Atlanta: U.S. Department of Health and Human Services; 2013. 2. Centers for Disease Control and Prevention. Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States. Atlanta, US: Department of Health and Human Services; 2013. 3. LeFevre ML. Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161(12):902. doi:10.7326/M14-1981. 4. Centers for Disease Control and Prevention. Chlamydia Screening Percentages Reported by Commercial and Medicaid Plans by State and year. Atlanta, US: Department of Health and Human Services; 2011. http://www.cdc.gov/std/chlamydia/stats.htm.http://www.cdc.gov/std/chlamydia/stats.htm 5. Skala SL, Secura GM, Peipert JF. Factors associated with screening for sexually transmitted infections. Am J Obstet Gynecol. 2012;206(4):324.e1-e324.e6. doi:10.1016/j.ajog.2012.02.020. 6. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin Number 109: Screening for cervical cancer. Obstet Gynecol. 2009;114(6):1409-1420. doi:10.1097/AOG.0b013e3181c6f8a4. 7. Tao G, Hoover KW, Kent CK. 2009 Cervical Cytology Guidelines and Chlamydia Testing Among Sexually Active Young Women: Obstet Gynecol. 2010;116(6):1319-1323. doi:10.1097/AOG.0b013e3181f91442. 8. Oakeshott P, Kerry S, Hay S, Hay P. Opportunistic screening for chlamydial infection at time of cervical smear testing in general practie: prevalence study. BMJ. 1998;316(7128):351-352. 9. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(1):67. doi:10.7326/M14-0701. 10. Kettinger LD. A Practice Improvement Intervention Increases Chlamydia Screening Among Young Women at a Women’s Health Practice: A Practice Improvement Intervention Increases Chlamydia Screening. J Obstet Gynecol Neonatal Nurs. 2013;42(1):81-90. doi:10.1111/j.1552- 6909.2012.01427.x.

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