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Obstetrics & Gynecology:
doi: 10.1097/AOG.0b013e3181f91442
Original Research

2009 Cervical Cytology Guidelines and Chlamydia Testing Among Sexually Active Young Women

Tao, Guoyu PhD; Hoover, Karen W. MD, MPH; Kent, Charlotte K. PhD

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Author Information

From the Division of STD Prevention, National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

See related article on page 1311.

Corresponding author: Guoyu Tao, PhD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E-80, Atlanta, GA 30333; e-mail: gat3@cdc.gov.

Financial Disclosure The authors did not report any potential conflicts of interest.

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Abstract

OBJECTIVE: An American College of Obstetricians and Gynecologists Practice Bulletin published in 2009 recommended that cervical cancer screening should begin at age 21 years and women younger than 30 years should be rescreened every 2 years rather than annually. The purpose of this study is to estimate the effect that decreased frequency of cervical cancer screening would have on chlamydia screening, which is recommended annually for sexually active women aged 25 years or younger.

METHODS: Using an administrative database of medical claims from commercially insured girls and women, we compared annual chlamydia screening rates of sexually active adolescent girls and young women aged 15 to 25 years in 2007 among those who underwent cervical cancer screening and those who were not screened for cervical cancer.

RESULTS: We identified 701,193 sexually active adolescent girls and young women aged 15 to 25 years. Chlamydia screening rates were significantly higher among adolescent girls and young women who underwent cervical cancer screening compared with those who did not: 43.6% compared with 9.5% for adolescent girls and young women aged 15 to 20 years and 36.1% compared with 12.2% for women aged 21 to 25 years. Among adolescent girls and young women identified as sexually active in 2007, 90.5% had visits for reproductive health services other than cervical cancer screening that could provide opportunities for chlamydia screening.

CONCLUSION: Although the revised American College of Obstetricians and Gynecologists Practice Bulletin recommending less frequent cervical cancer screening will likely reduce chlamydia screening rates in adolescent girls and young women, health care providers should be aware of other opportunities for chlamydial testing. Options include patient self-collected vaginal swabs and urine specimens collected during visits at which adolescent girls and young women seek other reproductive health or preventive services.

LEVEL OF EVIDENCE: II

A recently published American College of Obstetricians and Gynecologists Practice Bulletin recommends that cervical cancer screening be initiated at age 21 years and women younger than 30 years be rescreened only every 2 years,1 rather than annually as previously recommended. In contrast, annual chlamydia screening is recommended for sexually active adolescent girls and young women aged 25 years or younger.2–6 In accordance with the cervical cancer screening guidelines, sexually active adolescent girls and women younger than 21 years will not be screened for cervical cancer, and those between 21 and 25 years will be screened less often. Because there is no longer a need for annual cervical cancer screening that prompts an annual visit to their physicians, it is possible that many adolescent girls and young women will not be seen annually. An annual visit provides a young woman an important opportunity to seek advice and to learn about her reproductive health, to access contraception, to be counseled about sexually transmitted disease (STD) prevention, and to be screened for STD.

A recent study found that one in four U.S. teenage girls has had an STD by age 17 years, soon after they become sexually active.7 Chlamydia is the most frequently reported STD in the United States,8 with the highest prevalence of infection among adolescent girls and women younger than 26 years, especially among adolescent girls and young women aged 14 to 19 years.9 Because chlamydia is usually asymptomatic in adolescent girls and young women, screening is essential to diagnose the infection. If adolescent girls and young women are not screened and treated, then they might be at risk for serious and costly complications, including pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain.2

Several studies have found that chlamydia screening occurred most often during cervical cancer screening.10–13 If cervical cancer screening of adolescent girls and young women is performed less often than annually, then it is likely that chlamydia screening rates will decrease as well. However, a woman might visit her physician for other reproductive health care needs during which a chlamydia tests could be performed. In this study, we estimate the potential effects of new cervical cancer screening guidelines on the annual chlamydia screening rate.

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MATERIALS AND METHODS

We analyzed administrative claims data from the 2007 MarketScan database.14 This claims database included information on patient enrollment and claims for inpatient and outpatient encounters and prescription services for approximately 15 million persons enrolled in health maintenance organizations, preferred provider organizations, point of service plans, or fee-for-service plans. Data are included for patients enrolled in approximately 130 health plans sponsored by approximately 100 large employers. The claims database included patient demographic information, provider specialty, date of service, and International Classification of Disease, Ninth Revision, Clinical Modification diagnostic and Current Procedural Terminology 2007 procedural codes for health care services. Studies using claims data do not require Institutional Review Board review because administrative claims data are from de-identified humans.

We included adolescent girls and young women aged 15 to 25 years who were continuously enrolled for 330 or more days in 2007. A female was classified as sexually active if she had diagnostic or procedural codes at outpatient visits that were associated with one of five reproductive health categories: 1) cervical cancer screening or a pelvic examination; 2) a contraceptive service; 3) a pregnancy-related service; 4) an STD-related service; or 5) an infertility service.15 A female was considered to have been screened for cervical cancer if she had at least one visit in 2007 at which cervical cancer screening was performed. Current Procedural Terminology codes for chlamydial testing were used to identify adolescent girls and young women who were tested for this STD (87110, 87270, 87320, 87490, 87491, 87492, and 87810). We estimated the proportion of adolescent girls and young women who were classified as sexually active by age group. We estimated the proportion of sexually active adolescent girls and young women who were tested for chlamydia overall, by age group, and by whether they were screened for cervical cancer in 2007. We estimated the proportion of visits with cervical cancer screening at which chlamydia screening was also performed. We also estimated the proportion of adolescent girls and young women who had visits for other reproductive health services when a chlamydia test could have been performed. The χ2 test was used to compare proportions of adolescent girls and young women tested for chlamydia between adolescent girls and young women who had cervical cancer screening and those who had no cervical cancer screening in 2007. A two-tailed P<.05 was considered statistically significant.

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RESULTS

A total of 1,573,845 adolescent girls and young women aged 15 to 25 years were enrolled for 330 days or more in 2007 in the MarketScan database. Of these, 68.6% were insured by preferred provider organization plans, 82.2% resided in urban areas (as defined by urban metropolitan statistical area), and 45.4% resided in the South (Table 1). Of the 1,573,845 enrolled adolescent girls and young women, 1,270,007 (80.7%) had at least one medical claim. The characteristics of enrollees with medical claims did not significantly differ from enrollees without a claim by age, type of health plan, urban residence, or region.

Table 1
Table 1
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Of these 1,573,845 adolescent girls and young women, 701,193 (44.6%) were classified as sexually active (Table 2). The proportion of adolescent girls and young women classified as sexually active varied significantly by age group: 34.5% among adolescent girls and young women aged 15 to 20 years and 62.5% among those aged 21 to 25 years. Among sexually active adolescent girls and young women aged 15 to 25 years, 61.7% were screened for cervical cancer during the study period. Similarly, the proportion of sexually active adolescent girls and young women who were screened for cervical cancer in 2007 varied significantly by age: 48.7% among adolescent girls and young women aged 15 to 20 years and 74.4% among those aged 21 to 25 years.

Table 2
Table 2
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Of 701,193 sexually active adolescent girls and young women aged 15 to 25 years, 28.1% had at least one chlamydia test in 2007 (Table 3). The chlamydia testing rates differed significantly by age: 26.1% among adolescent girls and young women aged 15 to 20 years and 30.0% among those aged 21 to 25 years. Adolescent girls and young women who were screened for cervical cancer, compared with those who were not screened, were more likely to be tested for chlamydia: 43.6% compared with 9.5% among adolescent girls and young women aged 15 to 20 years, and 36.1% compared with 12.2% among women aged 21 to 25 years.

Table 3
Table 3
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Of 230,599 chlamydia tests performed during the study period among 196,680 sexually active adolescent girls and young women aged 15 to 25 years, 66.2% were performed during the same visit as cervical cancer screening. Of 701,193 sexually active adolescent girls and young women aged 15 to 25 years identified by the current methodology, 90.5% would be identified as sexually active if only contraceptive services, pregnancy-related services, STD-related services, and infertility services were used to identify sexual activity. Similarly, of 504,513 sexually active adolescent girls and young women aged 15 to 25 years identified by our methodology who had no chlamydia test in 2007, 85.4% would be identified as sexually active if only contraceptive services, pregnancy-related services, STD-related services, and infertility services were used to identify sexual activity. However, if visits with cervical cancer screening were excluded, only 75.1% of the 701,193 adolescent girls and young women and 74.9% of the 504,513 adolescent girls and young women would be identified as sexually active.

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DISCUSSION

Although annual chlamydia screening of sexually active adolescent girls and young women aged 25 years and younger has been recommended by several health organizations for several years, our study found that only 28.1% of sexually active adolescent girls and young women aged 15 to 25 years were tested for chlamydia in 2007. Further, we found that adolescent girls and young women were more likely to be tested for chlamydia if they were also screened for cervical cancer. We estimated how chlamydia screening rates might decrease if providers comply with the new recommendations for less frequent cervical cancer screening of adolescent girls and young women and do not change their current STD screening practices. The chlamydia screening rates could potentially decrease from 26.1% to 9.5% for all sexually active adolescent girls and young women aged 15 to 20 years, and from 36.1% to 12.2% to 30.0% for most sexually active women aged 21 to 25 years, depending on the frequency of cervical cancer screening. Visits for STD counseling and screening, as well as for other reproductive health needs such as contraception and pregnancy planning, are recommended to continue annually.

Our study found that among adolescent girls and young women who were identified as sexually active in the administrative claims database, approximately 91% received other reproductive health services except cervical cancer screening. Because the recommendations in the 2009 American College of Obstetricians and Gynecologists Practice Bulletin might potentially further decrease already low chlamydia testing rates, interventions are needed to increase chlamydia testing during encounters without cervical cancer screening. A vaginal swab specimen can be collected if a speculum examination is not performed, either by the provider or by the patient. Vaginal swabs have been found to have similar sensitivity as endocervical swabs in detecting chlamydia, and the sensitivity and specificity of provider-collected swabs are comparable to the sensitivity and specificity of patient-collected swabs.16 Although a urine specimen is not quite as sensitive for the diagnosis of chlamydia as an endocervical or vaginal swab,17 it is an option for chlamydia testing of adolescent girls and young women who otherwise might not be tested. A recent study found that most sexually active adolescents prefer to be screened for STD with a urine specimen, followed by a self-collected vaginal swab, and they least preferred the provider-collected endocervical swabs.18 Another study demonstrated that the chlamydia screening rate could be increased among sexually active adolescent girls and young women during routine check-ups by using urine-based tests.19 Targeted provider education is needed to increase awareness of the options of vaginal swab and urine tests that do not require a pelvic examination, especially for obstetrician-gynecologists and family physicians, because they provide most reproductive health services for sexually active adolescent girls and young women.20

A strength of our study is that it included more than 1 million adolescent girls and young women with various types of commercial insurance. A limitation is that the administrative claims database did not include laboratory data that have procedures and results, so we likely underestimated the chlamydia testing rate and were unable to assess chlamydia positivity. A previous study found that the inclusion of laboratory data would increase the chlamydia screening rate significantly because not all chlamydia tests were documented in the outpatient claims data.21 Another limitation is that the database used in our study is not representative of other populations, such as Medicaid or uninsured populations, who might have different patterns of health service utilization and different prevalence of chlamydial infection from commercially insured populations. Our methodology likely resulted in an underestimation of the number of sexually activity adolescent girls and young women given that approximately 20% of those enrolled in health plans had no medical claims during the study period.22

Routine chlamydia screening is an important strategy to decrease chlamydia prevalence in the United States. Because the recently published American College of Obstetricians and Gynecologists Practice Bulletin could result not only in less frequent cervical cancer screening but also in less frequent chlamydia screening, health care providers should be aware of alternatives to cervical swabs for specimen collection, such as patient-collected vaginal swabs or urine specimens. These specimens can be easily collected at visits when adolescent girls and young women might seek other reproductive health services. In addition, simple and sustainable structural interventions to increase chlamydia screening should be implemented and evaluated, such as electronic health record prompts to remind providers of the need for chlamydia screening and physician pay-for-performance to reward appropriate chlamydia screening practices.

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REFERENCES

1. Cervical cytology screening. ACOG Practice Bulletin No. 109. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1409–20.

2. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55(RR-11):1–94.

3. U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2007;147:128–34.

4. Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 357. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1615–22.

5. Sexually transmitted diseases in adolescents. ACOG Committee Opinion No. 301. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:891–8.

6. American College of Obstetricians and Gynecologists. Well-woman care. Guidelines for women's health care, a resource manual. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007. p. 201.

7. Forhan SE, Gottlieb SL, Sternberg MR, Xu F, Datta SD, McQuillan GM, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009;124:1505–12.

8. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2006. Atlanta (GA): U.S. Department of Health and Human Services; 2007.

9. Datta SD, Sternberg M, Johnson RE, Berman S, Papp JR, McQuillan G, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med 2007;147:89–96.

10. Burstein GR, Snyder MH, Conley D, Newman DR, Walsh CM, Tao G, et al. Chlamydia screening in a Health Plan before and after a national performance measure introduction. Obstet Gynecol 2005;106:327–34.

11. Hoover K, Tao G. Missed opportunities for Chlamydia screening of young women in the United States. Obstet Gynecol 2008;111:1097–102.

12. 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;112:891–8.

13. Tao G, Walsh CM, Anderson LA, Irwin KL. Avenues to combat the silent epidemic of Chlamydia infection in managed care organizations: an analysis of the HEDIS measure on screening for Chlamydia trachomatis. Prev Med Managed Care 2000;1:177–83.

14. Thomson Reuters (Healthcare) Inc. MarketScan research databases, user guide and database dictionary. Available at: http://home.thomsonhealthcare.com/marketscanuniversity/index.aspx?page=product. Retrieved May 26, 2010.

15. National Committee for Quality Assurance. Chlamydia screening in women. HEDIS 2010: Technical specifications, volume two. Washington, DC: National Committee for Quality Assurance; 2009. p. 89–92.

16. Schachter J, Chernesky MA, Willis DE, Fine PM, Martin DH, Fuller D, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis 2005;32:725–8.

17. Johnson RE, Newhall WJ, Papp JR, Knapp JS, Black CM, Gift TL, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep 2002;51(RR-15):1–38.

18. Serlin M, Shafer MA, Tebb K, Gyamfi AA, Moncada J, Schachter J, et al. What sexually transmitted disease screening method does the adolescent prefer? Adolescents' attitudes toward first-void urine, self-collected vaginal swab, and pelvic examination. Arch Pediatr Adolesc Med 2002;156:588–91.

19. Shafer MA, Tebb KP, Pantell RH, Wibbelsman CJ, Neuhaus JM, Tipton AC, et al. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA 2002;288:2846–52.

20. Hoover KW, Tao G, Berman S, Kent CK. Utilization of health services in physician offices and outpatient clinics by adolescents and young women in the United States: implications for improving access to reproductive health services. J Adolesc Health 2010;46:324–30.

21. Douglas JM, S.M. B, Walsh C. A word about chlamydia screening in managed care organizations in the prevention of sexually transmitted diseases. Available at: http://www.ncqa.org/Portals/0/Publications/Resource%20Library/Improving_Chlamydia_Screening_08.pdf. Retrieved May 26, 2010.

22. Tao G, Walsh CM, Anderson LA, Irwin KL. Understanding sexual activity defined in the HEDIS measure of screening young women for Chlamydia trachomatis. Jt Comm J Qual Improv 2002;28:435–40.

© 2010 The American College of Obstetricians and Gynecologists

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