Article Figures & Data
Tables
Characteristic Pre–Guideline Change Groupa (n=1,626) Post–Guideline Change Groupa (n=1,846) Total visits, No. 4,847 5,005 Age, mean (SD), y 17.7 (1.6) 17.8 (1.7) Visits per patient, mean (SD) [range], No. 3.0 (2.9) [1–28] 2.7 (2.5) [1–23] Total Pap tests, No. 394 73 Total chlamydia screens, No. 502 37 Total chlamydia screens when Pap tested, No. 311 4 Pap=Papanicolaou.
↵a Refers to patients seen before vs after the 2009 change in cervical cancer screening guidelines.
Both Groups Pre–Guideline Change Groupa Post–Guideline Change Groupa Predictor Odds Ratio (95% CI) P Value Odds Ratio (95% CI) P Value Odds Ratio (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 test 73.43 (54.27–99.36) <.001 90.83 (65.09–126.73) <.001 12.25 (3.78–39.66) <.001 Pap=Papanicolaou.
↵a Refers to patients seen before vs after the 2009 change in cervical cancer screening guidelines.
Additional Files
The Article in Brief
Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia
Mack T. Ruffin, IV , and colleagues
Background In 2009, a guideline change postponed cervical cancer screening to age 21. (Previously, the American College of Obstetrics and Gynecologists recommended beginning screening three years after first sexual intercourse or by age 21, whichever occurred first.) This study assesses if the guideline change had an effect on rates of chlamydia screening in women aged 15-21 years in primary care clinics.
What This Study Found Following the guideline change, there was a dramatic decrease in chlamydia screening among women aged 15 to 21 years. Women had higher odds of being screened for chlamydia before the guideline change compared to after. There was no corresponding decrease in office visits which could explain the reduced screening rates.
Implications
- The American College of Physicians recently recommended against performing screening pelvic examinations in nonpregnant, asymptomatic women. This recommendation, the authors warn, may affect chlamydia screening rates in a way similar to that of the change in cervical cancer guidelines. They conclude that chlamydia, pelvic examinations and cervical cancer screening need to be uncoupled and new screening opportunities should be identified.
Annals Journal Club
Jul/Aug: Possible Unintended Consequence of an Evidence-Based Clinical Policy Change
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
Ursu A, Sen A, Ruffin MT. Impact of cervical cancer screening guidelines on screening for chlamydia. Ann Fam Med. 2015;13(4):361-363.
Discussion Tips
This article provides a chance to consider an unintended consequence from a well-meaning and evidence-based clinical guideline change.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question? What alternative study designs might be possible?
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- Temporal changes in screening rates due to factors other than the cervical cancer screening guideline change?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- How the findings were interpreted?
- What are the main study findings?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- What contextual factors are important for interpreting the findings?
- How might this study change your practice? Policy? Education? Research?
- What are the implications of the study, and of urine tests and primary care office staffing and roles, for screening for sexually transmitted diseases?
- Who are the constituencies for the findings, and how might they be engaged in interpreting or using the findings?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.
