Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia

Study Summary:
This study focused on the effects of screening for Chlamydia in the outpatient setting in relation to Cervical Cancer Screening guideline changes in 2009.

Discussion:
Initially we were surprised by the actual number for the rate of Chlamydia in the U.S. and just how prevalent it has become. Immediately we then agreed that it was made clear the importance and magnitude of the research done in the article for providers today. As a group, we did agree that having some of the epidemiology of other STIs, such as gonorrhea, HIV, and syphilis, might put that Chlamydia rate in better context. For background sake, we did like that the "more likely" provider was described when it came to screening in outpatient. However, there was some discussion as to why discussion related to obstetrician-gynecologists was mentioned as well since it appeared the focus of the paper was on family medicine care. We were undecided on how useful comparing the two practices was for this particular study since it was not a scope of the project. Members agreed the connection to cervical cancer screening was appropriate in content and length to end the introduction.

Regarding methods, we thought it was a robust study population. Strengths of the study included the researchers' use of five different sites and using a cross-sectional approach. We discussed the researchers' age cutoff for the study and concluded in discussion that having the age cut off in the study be lower than what is recommended to screen for in Chlamydia is likely related to cervical cancer screening being recommended at age 21. Including demographics would have been extremely useful to increase generalizability of the study results. Specifically, if the study's purpose is to examine how changes in guidelines impact providers' screening practices we would also be interested in level of sexual activity and other factors per guideline recommendation. The biggest point of discussion related to the methodology was uncertainty to how screening for Chlamydia (i.e. swab vs. urine collection) was conducted. We believed that screening patterns may vary greatly if the provider was to ask a patient to urinate in a collection cup versus have an invasive pelvic swab for a routine visit. Also the current research shows that there is significant difference between screening Chlamydia in the Medicaid population versus the commercial health insurance population. So to prevent any confounding effect, having that demographic information would have been helpful.

Regarding the results, we discussed the major drop off in Chlamydia screens before and after the guideline changes. Before the guideline changes, there were 191 Chlamydia screenings unrelated to the Papanicolaou, but after there were just 33. We wondered if other factors could be attributed to the results. The group discussed some limitations to the paper. We would have liked more details related to the methodology or citation to an accompanying paper if published for more details. The journal club members were unsure if the results could be generalized to the population they are exposed to in clinical training. Members explored examining how well we were screening for Chlamydia in terms of national goals (e.g. Health People 2020) instead of pre- and post-guideline changes. We agreed that overall, the paper sufficiently examined and reported on the pre- vs. post-guideline change effects for the Papanicolaou and Chlamydia screening, but we hope our discussion may spearhead other opportunities to explore this area of research further.

Competing interests: None declared