Clinical Practice Intervention May Increase Chlamydia Screening in Teen Girls

Laurie Barclay, MD

June 01, 2009

June 1, 2009 — A clinical practice intervention (CPI) significantly improved the proportion of adolescent girls screened for chlamydia during urgent care, according to the results of a randomized controlled trial reported in the June issue of Archives of Pediatrics & Adolescent Medicine.

"Untreated CT [Chlamydia trachomatis] infections can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility," write Kathleen P. Tebb, PhD, from University of California-San Francisco, and colleagues. "Since most of these infections have no symptoms, routine screening is the only way to detect the majority of CT cases. Despite recommendations for at least annual screening for CT among all sexually active adolescents and young adults younger than 26 years, screening rates remain low."

The goal of this study was to design and assess an intervention to increase screening for Chlamydia trachomatis in sexually active adolescent girls seen during pediatric urgent care.

At a large health maintenance organization (HMO) in northern California, 10 pediatric clinics offering urgent care services to adolescent girls aged 14 to 18 years were randomly assigned to an intervention group (5 clinics) or to a control group (5 clinics). The intervention consisted of a monthly meeting in which a team of providers and clinic staff met to redesign their clinic system with the goal of improving chlamydia screening during urgent care. Clinics in the control group received an informational lecture on chlamydia screening.

From April 2005 to September 2006, the investigators estimated the clinic-specific proportions of sexually active girls screened for chlamydia, which was the main endpoint of the study.

Compared with the control group, the intervention group had significantly greater change with time in clinic-specific chlamydia screening rates in urgent care (likelihood ratio, χ2 (1) = 18.7; P < .001). The proportion of girls screened for chlamydia increased by 15.93% in the intervention group from baseline to the fifth intervention period, whereas it decreased by 2.13% in the comparison clinics.

"The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care," the study authors write. "Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year."

Limitations of this study include possible lack of generalizability beyond large HMO systems. In addition, few clinics fully adopted all of the intervention components, and significant labor and management issues prevented 1 clinic from implementing the intervention as it was intended.

"To address the CT epidemic among our adolescent and young adult populations, attention needs to be given to the urgent care setting, the setting in which many adolescents and young adults, especially those at high risk for CT, interface with the health care system," the study authors write. "Targeting interventions for this setting is challenging and will only be effective to the extent that as many of the steps involved in the CT screening process can be redirected to other support staff and the patients themselves. It will be important to also investigate the extent to which intervention effects can be sustained over time, especially in urgent care given the constraints in this setting."

In an accompanying editorial, Diane Blake, from University of Massachusetts Medical School in Worcester, recommends assuring ongoing access to chlamydia screening in nonclinical settings with proven success as well as further exploration of novel settings for screening.

"The more possibilities there are for an adolescent to 'bump into' a screening opportunity, the fewer holes there will be in the patchwork of screening options, which will increase the probability of approaching 100% chlamydia screening of sexually active adolescents," Dr. Blake writes. "This is a lofty goal, but one well worth pursuing. The study by Tebb and colleagues moves us a step closer to this goal."

The Centers for Disease Control and Prevention Agency for Healthcare Research and Quality and the Kaiser Garfield Memorial Fund supported this study. One of the study authors was also supported in part by a grant from the Maternal and Child Health Bureau. The other study authors have disclosed no relevant financial relationships.

Dr. Blake previously conducted a chlamydia-screening cost-effectiveness analysis funded by a grant from GenProbe, Inc, and was paid as a consultant by Johns Hopkins School of Medicine.

Arch Pediatr Adolesc Med. 2009;163:559-564, 585-586.

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