Search and Review Outcomes
We reviewed 4566 citations and identified 128 abstracts or articles for further review. Of those, 69 had been identified using previous search terms, 23 were rejected, and 38 met the inclusion criteria (Fig. 1). One study evaluated 2 interventions and another evaluated 4 total interventions. Thus, 42 interventions were summarized alphabetically by author and target population category in Tables 1–4.
Sites of Interventions
Interventions were conducted in the United States (n = 17), Australia (n = 13), United Kingdom (n = 6), New Zealand (n = 2), Scotland (n = 1), Denmark (n = 1), Belgium (n = 1), and Canada (n = 1).
Design of Studies
All of the 42 interventions included in this review compared STD screening or rescreening rates as the main outcome of a RCT (n = 14), a nonrandomized controlled trial (n = 9), an evaluation of a preintervention and postintervention period comparison (n = 18), or a controlled observational study (n = 1).
Of the 42 interventions evaluated, 16 described structural interventions (including staff positions dedicated to STD screening activities) or clinic incentives for screening (Table 1)23–38; 9 evaluated electronic and medical chart reminders (Table 2)30,39–46; 6 evaluated provider-level interventions focusing on education (Table 3)47–52; and 11 evaluated patient-level interventions, one of which described multiple interventions (Table 4).53–60 One article described both a quality improvement program and a chart prompt and is thus listed in Tables 1 and 2.39 One article described 4 patient-level interventions, each of which is listed separately in Table 4.55
Quality of the Studies
Of the 11 randomized controlled studies, 4 studies were rated as high quality,31,32,39,48,54 6 studies were rated as moderate quality25,30,42,47 (multiple),55 and 1 study was of poor quality.52
Target Populations and Outcomes
Of the 42 interventions evaluated, 15 (35.7%) evaluated screening of young women for CT and other STDs 24,25,27,28,30,31,41,42,47–49,51,52,54 and 2 studied screening of pregnant women.26,40 Two (4.5%) interventions targeted young men for STD screening,23,32 and 6 interventions were for both young men and women.29,39,50,53,56,58 A total of 11 interventions targeted MSM (n = 7)36,37,43,45,46,59,60 or HIV-infected MSM (n = 4) 33–35,44 for STD screening. One study targeted both and male and female HIV-infected patients for STD screening.38 There were 5 interventions that targeted CT or GC rescreening among male and female patients after initial diagnosis55,57 and one intervention that targeted repeat syphilis screening among MSM treated for syphilis.45
Outcomes by Intervention Strategy
Of the 42 individual interventions, 16 (38.1%) were rated as highly effective in increasing STD screening and 14 (33.3%) were moderately effective in increasing screening. The remaining 12 (28.6%) interventions did not demonstrate notable or sustainable increases in STD screening as a result of the intervention.
Among 8 structural interventions that included strategic placement of specimen collection materials or automatic collection of urine or blood as part of a routine visit,23,26,28,31–35 7 were highly effective and 1 was moderately effective (Table 1). Among 8 studies that modified EHRs to remind providers to screen, 3 were highly effective and 4 were moderately effective in improving STD screening (Table 2).
Patient-level interventions such as incentives and testing reminders increased screening (Table 4). Of 5 patient-level interventions (including text, telephone, or postcard reminders), 3 were highly effective and 2 were moderately effective in improving STD screening or rescreening.55,57,59,60 Offering free STD testing services in a setting where STD services had previously required payment was moderately effective in improving STD screening.56
Three studies described interventions that included dedicated staff devoted to increasing STD screening24,27,37; all 3 demonstrated improvements in screening, 2 were highly effective, and 1 was moderately effective (Table 2). Both of the studies that described financial incentives for clinics per CT test performed reported an increase in screening25,27 (Table 1). In 1 of these 2 studies, dedicated staff devoted to STD screening was combined with financial incentives to clinics for screening.27
Provider-level interventions had limited success in sustainably increasing STD screening. In this group (n = 6), only 2 of the interventions were categorized as moderately effective.50,52 All 6 provider-level interventions described continuing medical education modules, meetings, simulation videos, workshops, resource packages, or guideline updates (Table 3).
Additional interventions that did not improve STD screening included monetary55 and nonmonetary58 incentives to patients and clinics,25 motivational counseling to patients,54 paper chart reminders,30 and referring patients to an educational Web site.53
Costs for each intervention were estimated or reported as less than $1000 for 28 (66.7%) of the interventions, $1001 to $10,000 for 7 (16.7%), $10,001 to $100,000 for 4 (9.5%), and more than $100,000 for 3 (7.1%) (Tables 1–4). Actual costs associated with intervention implementation were reported for only 5 interventions (12%; Tables 1 and 4).25,27,55,58,59 Each of these 5 interventions included incentives for clinics, providers, or patients.
Combining Effect and Cost
Interventions that included the automatic collection of specimens as part of a routine or follow-up visit (Table 1),23,26,28,31–35 use of EHR reminders (Table 2),39–46 or the use of patient reminders (Table 4)55,57,59,60 had the greatest improvements in STD screening at the lowest cost (Fig. 2). Dedicating staff to improve STD screening was associated with the largest improvement in screening at the highest estimated cost (Table 1).24,27,37
Case Finding and Positivity
Of the 42 interventions in this review, 18 (43%) included before-and-after data on case finding, 9 (21.4%) or the percent of attendees that were positive, 9 (21.4%). Of the 9 interventions that reported on percent of tests that were positive, 3 reported no change,42,46,58 4 reported an increase in percent positive,41,43,56,60 and 2 reported a decrease50,57 after the intervention. Of the 9 interventions that included case identification, 8 reported an absolute increase in STD cases identified,23,26,28,31,33–35,39 and 1 reported an absolute decrease in cases identified29 after the intervention (Tables 1–4).
We systematically reviewed clinic-based interventions developed to improve CT, GC, and syphilis screening. Interventions evaluated in this review incorporated systems-level programs, EHR reminders, and patient- and provider-level activities to improve STD screening. Effects varied by type of intervention, but improvements in screening were consistent for interventions that incorporated the automatic collection of STD specimens in association with a routine or follow-up visit. The EHR reminders also led to notable improvements in STD screening. Patient reminders for testing or retesting were effective in improving screening, whereas motivational counseling and interviewing showed minimal improvement. Overall, patient and provider education was of limited benefit in improving STD screening. Cost estimates varied depending on the intervention but were lower for interventions that included the universal collection of STD testing specimens or the use of EHR reminders and were greater for those where dedicated staff was assigned to improve STD screening or incentives were provided for screening.
Increasing screening through program and protocol development (with or without assignment of a dedicated staff) was often done using the automatic collection of specimens in association with a patient visit, usually before the patient saw the provider.23,26,28,31–35 Others strategically placed specimen collection kits such that providers would remember to perform the test along with other tests due at that appointment. Routinizing collection of specimens at a variety of visit types (even visits for unrelated issues) for patient in target age group/demographic reduces missed opportunities and standardizes an effective approach to STD screening at a lower cost. Quality improvement efforts that placed dedicated staff members to facilitate STD screening also demonstrated increases in STD screening,24,27,37 albeit at a much higher cost.
Reminders in EHRs were effective at increasing STD screening39–46 and have been used to improve performance of other routine screening measures in different clinical settings.61,62 With the increase in use of EHR in community clinics and primary care settings, this may be an opportune time for clinical and public health programs to focus on EHR reminders especially for screening that has been recommended by the US Preventive Services Task Force9 such as CT screening among adolescent girls and young women. Many EHR platforms have programmable provider reminders that can be tailored to correspond to health screening recommendations.39–46,61,62
Direct provider education related to appropriate management of health conditions remains a mainstay of efforts to advance medical knowledge and clinical practice. These efforts are often the easiest to put in place, are an accepted method of acquiring information about a medical topic, and can be done quickly at a reasonable cost. However, studies we reviewed found education led to limited improvements in STD screening.53–60 These findings suggest that provider education should be considered only in combination with other highly successful methods such as EHR reminders or clinic-based protocol development.
Patient-level interventions that used incentives and motivational interviewing had little success at increasing STD screening or rescreening. Patient reminders via telephone call, text messaging, or letter increased STD screening and rescreening at a relatively low cost.55,57,59,60 The use of texting to communicate health reminders with youth has been evaluated in other clinical settings63,64 but would require knowing the patient's cell phone number and may be most appropriate for rescreening or for frequent screening of high-risk persons.
Costs are often a major component of choosing and implementing an intervention. However, few of these publications reported costs associated with implementation. Many of the multilevel interventions involved the systematic collection of STD testing specimens from eligible clients before, or as a part of, a clinician encounter. Those interventions could be done at minimal cost by changing clinic policy. Similarly, programming clinical reminders into EHRs may be done with limited additional cost and those reminders may be adapted or expanded to address local STD epidemiology. Patient reminders, some of which used cellular messaging technologies or other accessible reminder systems, were low-cost strategies that could be adapted in community clinic settings. Clinic-level advocacy for opportunistic STD screening as a standard of care for eligible patients according to national guidelines2,9 may be needed in some clinical settings to improve screening performance even in the absence of concern for cost.
There are several limitations related to the interpretation of these data. Our search did not include abstracts, meeting proceedings, or other “gray” literature; thus, unpublished studies that reported negative results are likely underrepresented. Effectiveness categories were chosen to identify high- and low-performing interventions. Programs should carefully consider moderately effective interventions in relation to their clinical care setting and patient population. The effects of the interventions we studied may be different in other clinical settings. Some multilevel interventions demonstrated significant improvements in STD screening; however, it was not possible to discern which element of the intervention was responsible in part or in full for the improvement. Cutoff values for categories of effectiveness were determined by the authors and may not reflect patient or population-level impact. For example, we did not fully account for baseline screening performance when calculating changes, so sites with low baseline screening had a greater opportunity to increase screening compared with clinics where baseline screening was already high. Interventions were not weighted or stratified based on rigor of the study methods. Our cost estimates may underestimate or overestimate the true costs of the interventions; only 5 studies reported actual costs. We did not include ancillary costs of screening such as staff time associated with collection of STD specimens in our estimates. Also, we did not include estimates of insurance reimbursement to the clinics. Thus, cost categories used in this review should be viewed as general estimates and not specific values. There were only 4 high-quality RCTs in our systematic review; therefore, our conclusions about effectiveness are largely based on observational data. Finally, although case identification is the ultimate goal of screening, we assessed the number of tests done; STD case identification, or positivity, was reported for less than half of the interventions in this review.
Screening in clinics improved the most when interventions used protocols for the universal collection of specimens or strategic placement of collection kits, electronic health reminders for providers, or reminders for patients to improve STD screening and rescreening. These interventions might be implemented in clinical settings at a minimal cost, but often require clinic- and provider-level advocacy, protocol development, and feedback on performance. Only research studies were included in our review, so it will be important for programs that implement these interventions in real-world settings evaluate and share their experience. The ability of STD programs to influence clinics to implement successful interventions depends on collaborative partnerships. Establishing those partnerships is a new task for many STD programs, one that also requires study.
1. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis 2013; 40: 197–201.
2. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2010. MMWR 2010; 59: 44–45.
3. Haggerty CL, Gottlieb SL, Taylor BD, et al. Risk of sequelae after Chlamydia trachomatis
infection genital infection in women. J Infect Dis 2010; 201: s134–s155.
4. Scholes D, Stergachis A, Heidrick FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydia infection. N Engl J Med 1996; 334: 1362–1366.
5. Anschuetz GL, Asbel L, Spain CV, et al. Association between enhanced screening for Chlamydia trachomatis
and Neisseria gonorrhoeae
and reductions in sequelae among women. J Adolesc Health 2012; 51: 80–85.
6. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted disease to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3–17.
7. Sexton J, Garnett G, Rottingen JA. Meta-analysis and metaregression in interpreting study variability in the impact of sexually transmitted disease to sexual transmission on susceptibility to HIV infection. Sex Transm Dis 2005; 32: 351–357.
8. Chesson HW, Bernstein KT, Gift TL, et al. The cost-effectiveness of screening men who have sex with men for rectal chlamydial and gonococcal infection to prevent HIV Infection. Sex Transm Dis 2013; 40: 366–371.
10. Tao G, Hoover KW, Kent CK. 2009 cervical cytology guidelines and chlamydia testing among sexually active young women. Obstet Gynecol 2010; 116: 1319–1323.
11. Tao G, Hoover KW, Kent CK. Chlamydia testing patterns for commercially insured women, 2008. Am J Prev Med 2012; 42: 337–341.
12. Christiansen-Lindquist L, Tao G, Hoover K, et al. Chlamydia screening of young sexually active, Medicaid-insured women by race and ethnicity, 2002–2005. Sex Transm Dis 2009; 36: 642–646.
13. Hoover KW, Tao G, Nye MB, et al. Suboptimal adherence to repeat testing recommendations for men and women with positive chlamydia tests in the United States, 2008–2010. Clin Infect Dis 2013; 56: 51–57.
14. Hoover KW, Butler M, Workowski K, et al. STD screening of HIV-infected MSM in HIV clinics. Sex Transm Dis 2010; 37: 771–776.
17. Atherly A, Blake SC. Efforts by commercial health plans to increase Chlamydia trachomatis
screening among their members. Sex Transm Dis 2013; 40: 55–60.
18. Ginige S, Fairley CK, Hocking JS, et al. Interventions for increasing chlamydia screening in primary care: A review. BMC Public Health 2007; 7: 95.
19. Guy R, Hocking J, Low N, et al. Interventions to increase rescreening for repeat chlamydial infection. Sex Transm Dis 2012; 39: 136–146.
20. Guy RJ, Ali H, Liu B, et al. Efficacy of interventions to increase the uptake of chlamydia screening in primary care: A systematic review. BMC Infect Dis 2011; 11: 211.
21. Zou H, Fairley CK, Guy R, et al. The efficacy of clinic-based interventions aimed at increasing screening for bacterial sexually transmitted infections among men who have sex with men: a systematic review. Sex Transm Dis 2012; 39: 382–387.
22. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996; 17: 1–12.
23. Andersen B, Eidner PO, Hagensen D, et al. Opportunistic screening of young men for urogenital chlamydia trachomatis infection in general practice. Scand J Infect Dis 2005; 37: 35–39.
24. Armstrong B, Kinn S, Scoular A, et al. Shared care in the management of genital Chlamydia trachomatis
infection in primary care. Sex Transm Infect 2003; 79: 369–371.
25. Bilardi JE, Fairley CK, Temple-Smith MJ, et al. Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: A pilot cluster randomized controlled trial. BMC Public Health 2010; 10: 70.
26. Burstein GR, Snyder MH, Conley D, et al. Chlamydia screening in a Health Plan before and after a national performance measure introduction. Obstet Gynecol 2005; 106: 327–334.
27. Kalwij S, French S, Mugezi R, et al. Using educational outreach and a financial incentive to increase general practices' contribution to chlamydia screening in South-East London. BMC Public Health 2012; 12: 802.
28. Kettinger LD. A practice improvement intervention increases chlamydia screening among young women at a women's health practice. J Obstet Gynecol Neonatal Nurs 2013; 42: 81–90.
29. Lawton BA, Rose SB, Elley CR, et al. Increasing the uptake of opportunistic chlamydia screening: A pilot study in general practice. J Prim Health Care 2010; 2: 199–207.
30. Scholes D, Grothaus L, McClure J, et al. A randomized trial of strategies to increase chlamydia screening in young women. Prev Med 2006; 43: 343–350.
31. Shafer MA, Tebb KP, Pantell RH, et al. Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls. JAMA 2002; 288: 2846–2852.
32. Tebb KP, Pantell RH, Wibbelsman CJ, et al. Screening sexually active adolescents for Chlamydia trachomatis
: What about the boys? Am J Public Health 2005; 95: 1806.
33. Bissessor M, Fairley CK, Leslie D, et al. Frequent screening for syphilis as part of HIV monitoring increases the detection of early asymptomatic syphilis among HIV-positive homosexual men. J AIDS 2010; 55: 211–216.
34. Botes LP, McAllister J, Ribbons E, Jin F, et al. Significant increase in testing rates of sexually transmissible infections following the introduction of an anal cytological screening program, targeting HIV-positive men who have sex with men. Sexual Health 2011; 8: 76–78.
35. Cohen CE, Winston A, Asboe D, et al. Increasing detection of asymptomatic syphilis in HIV patients. Sex Transm Infect 2005; 81: 217–219.
36. Ryder N, Bourne C, Rohrsheim R, et al. Clinical audit: Adherence to sexually transmitted infection screening guidelines for men who have sex with men. Int J STD AIDS 2005; 16: 446–449.
37. Snow AF, Vodstrcil LA, Fairley CK, et al. Introduction of a sexual health practice nurse is associated with increased STI testing of men who have sex with men. BMC Infect Dis 2013; 13: 298.
38. Tu D, Belda P, Littlejohn D, et al. Adoption of the chronic care model to improve HIV care: In a marginalized, largely aboriginal population. Can Fam Physician 2013; 59: 650–657.
39. McNulty CA, Hogan AH, Ricketts EJ, et al. Increasing chlamydia screening tests in general practice: A modified Zelen prospective Cluster Randomized Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour. Sex Transm Infect 2014; 90: 188–194.
40. Riley M, Galang S, Green LA, et al. The impact of clinical reminders on prenatal care. Fam Med 2011; 43: 560–565.
41. Rudd S, Gemelas J, Reilley B, et al. Integrating clinical decision support to increase HIV and chlamydia screening. Prev Med 2013; 57: 908–909.
42. Walker J, Fairley CK, Walker SM, et al. Computer reminders for chlamydia screening in general practice: A randomized controlled trial. Sex Transm Dis 2010; 37: 445–450.
43. Bissessor M, Fairley CK, Leslie D, et al. Use of a computer alert increases detection of early, asymptomatic syphilis among higher-risk men who have sex with men. Clin Infect Dis 2011; 53: 57–58.
44. Callander D, Baker D, Chen M, et al. Including syphilis testing as partner of standard HIV management checks and improved syphilis screening in primary care. Sex Trans Dis 2013; 40: 338–340.
45. Hotton AL, Gratzer B, Pohl D, et al. Factors associated with repeat syphilis testing at a large urban LGBT health clinic: Chicago, IL 2002–2008. Sex Transm Dis 2011; 38: 205–209.
46. Lister NA, Smith A, Fairley CK, et al. an STD clinic, the Melbourne Sexual Health Centre, Australia. Sex Health 2005; 2: 241–244.
47. Allison JJ, Kiefe CI, Wall T, et al. Multicomponent Internet continuing medical education to promote chlamydia screening. Am J Prev Med 2005; 28: 285–290.
48. Bowden FJ, Currie MJ, Toyne H, et al. Screening for Chlamydia trachomatis
at the time of routine Pap smear in general practice: A cluster randomized controlled trial. Med J Aust 2008; 188: 76–80.
49. Gooding HC, Blood EA, Sharma N, et al. An educational intervention to increase internists' confidence with provision of preventive services to adolescents and young adults. Teach Learn Med 2012; 24: 321–326.
50. Kelly C, Johnston J, Carey F, et al. Evaluation of a partnership between primary and secondary care providing an accessible level 1 sexual health service in the community. Int J STD AIDS 2014; 25: 751–757.
51. Merritt TD, Durrheim DN, Hope K, et al. General practice intervention to increase opportunistic screening for chlamydia. Sex Health 2007; 4: 249–251.
52. Verhoeven V, Avonts D, Vermeire E, et al. A short educational intervention on communications skills improves the quality of screening for chlamydia in GPs in Belgium: A cluster randomized controlled trial. Patient Educ Couns 2005; 57: 101–105.
53. Bilardi JE, Sanci LA, Fairley CK, et al. The experience of providing young people attending general practice with an online risk assessment tool to assess their own sexual health risk. BMC Infect Dis 2009; 9: 29.
54. Chacko MR, Wiemann CM, Kozinetz CA, et al. Efficacy of a motivational behavioral intervention to promote chlamydia and gonorrhea screening in young women: A randomized controlled trial. J Adolesc Health 2010; 46: 152.
55. Malotte CK, Ledsky R, Hogben M, et al. Comparison of methods to increase repeat testing in persons treatment for gonorrhea and/or chlamydia at public sexually transmitted disease clinics. Sex Transm Dis 2004; 31: 637–642.
56. Morgan J, Haar J. General practice funding to improve provision of adolescent primary sexual health care in New Zealand: Results from an observational intervention. Sex Health 2009; 6: 203–207.
57. Paneth-Pollak R, Klingler EJ, Blank S, et al. The elephant never forgets: Piloting a chlamydia and gonorrhea retesting reminder postcard in an STD clinic setting. Sex Transm Dis 2010; 37: 365–368.
58. Zenner D, Molinar D, Nichols T, et al. Should young people be paid for getting tested? A national comparative study to evaluate patient financial incentives for chlamydia screening. BMC Pubic Health 2012; 12: 261.
59. Bourne C, Knight V, Guy R, et al. Short message service reminder intervention doubles sexually transmitted infection/HIV re-testing rates among men who have sex with men. Sex Transm Infect 2011; 87: 229–231.
60. Zou H, Fairley CK, Guy R, et al. Automated, computer generated reminders and increased detection of gonorrhea, chlamydia and syphilis in men who have sex with men. PLoS One 2013; 8: e61972.
61. Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc 2005; 12: 431–437.
62. Holt TA, Thorogood M, Griffiths F, et al. Changing clinical practice through patient specific reminders available at the time of the clinical encounter: Systematic review and meta-analysis. J Gen Int Med 2012; 27: 974–984.
63. Matheson EC, Derouin A, Gagliano M, et al. Increasing HPV vaccination series completion rates via text message reminders. J Pediatr Health Care 2014; 28: e35–e39.
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64. Stockwell MS, Kharbanda EO, Martinez RA, et al. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: A randomized controlled trial. JAMA 2012; 307: 1702–1708.