Possible Unintended Consequence of an Evidence-Based Clinical Policy Change
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* Kurt S. Stange

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 Comments: Submit a response.”) You can find discussion questions and more information online at: [http://www.AnnFamMed.org/site/AJC/](http://www.AnnFamMed.org/site/AJC/).

## CURRENT SELECTION

### Article for Discussion

 Ursu A, Sen A, Ruffin MT. The impact of cervical cancer screening guidelines on chlamydia screening. Ann Fam Med. 2015; 13( 4): xxx- xxx.

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:
    
    1.  How patients were selected, excluded, or lost to follow-up?
    
    2.  Temporal changes in screening rates due to factors other than the cervical cancer screening guideline change?
    
    3.  How the main variables were measured?
    
    4.  Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
    
    5.  Chance?
    
    6.  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?

*   © 2015 Annals of Family Medicine, Inc.

## References

1.  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](http://annfammed.org/content/4/3/196).
    
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