Illustration by Alfred Pasleke / Science Source ©
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Screening for chlamydia: Are you doing it? Abstract: This retrospective study evaluates the implications of offering routine chlamydia screenings to women ages 16 to 25 attending a primary care clinical setting. Results found that routine screenings significantly increased the number of women screened, enabling early identification and treatment of affected women and potentially reducing infection rates. By Dyan Den Ouden, DNP, FNP-BC; Anne Derouin, DNP, CPNP; Susan Silva, PhD; and Abdul Khan, MD
hlamydia is one of the most common, curable sexually transmitted infections (STIs) in the United States.1 The CDC estimates that 6.8% of all sexually active women between 14 and 19 years of age have chlamydia.2 In 2011, there were over 1.4 million new cases of chlamydia diagnosed in the United States with an 8% increase in the number of cases per 100,000 people compared with 2010 data.2
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These are significant numbers; however, these numbers are thought to be underreported, as chlamydia is often asymptomatic. Over 75% of women who were newly diagnosed with chlamydia were asymptomatic and did not realize they had the infection.3 When left untreated, chlamydia can cause many long-term health problems for women, including ectopic pregnancies, chronic pelvic pain, pelvic inflammatory disease, and infertility.1
Keywords: chlamydia, routine screening, sexual activity, sexually transmitted infections, urine screening
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Screening for chlamydia is easy and affordable. There are two main ways to screen for chlamydia: cervical swabs or urine tests. In looking at the sensitivity and specificity of urine tests and cervical swabs, these screening methods are comparable in detecting chlamydia.2,4,5 Previous studies have shown that more women will choose to be screened if it is an easy and noninvasive method, making urine screening the screening test of choice.6-8 The United States Preventive Services Task Force (USPSTF) and the CDC both recommend annual screening in sexually active women between 16 and 25 years of age.2 Unfortunately, only 38% of women who are eligible for the screening are actually screened.9 There are two main reasons for the lack of screening. The most common reason for women not getting screened is due to the stigma of an STI.6,10 Many women are embarrassed and afraid of being labeled promiscuous, so they do not inquire about STI screenings. Several studies have looked at ways to increase chlamydia screening rates in the younger population. These studies found that the most successful way to increase screenings is by making them a routine office procedure in which women ages 16 to 25 are offered screenings.7,8,10 By screening all women for chlamydia who fall into this age range, no one is singled out or targeted for the screening. The second reason for the lack of chlamydia screening in women is due to the fact that many routine health screenings may be overlooked by healthcare providers. This lack of screening is a problem throughout the United States. In response to this, the National Committee for Quality Assurance developed a Healthcare Effectiveness Data Information Set (HEDIS) for chlamydia screenings. HEDIS is a
California has a high chlamydia rate. In 2011, there were over 164,000 new cases of chlamydia diagnosed in California.11 In San Joaquin County, where this study was completed, there were over 3,700 new cases diagnosed in 2011, making chlamydia the most common reportable STI in this county.11 With less than half of women being screened for chlamydia and such high infection rates, screening for chlamydia became a priority for all healthcare providers in this region. In order to increase screening rates, a chlamydia screening protocol was created, implemented, and evaluated.
■ Methods This protocol offered chlamydia screening to all women between the ages of 16 to 25 who saw the nurse practitioner (NP) in an internal medicine office located in San Joaquin County, CA. There were three questions to be addressed in the evaluation of the screening protocol: does offering urine chlamydia screening to all women ages 16 to 25 increase the rate of screenings performed by this office; does this routine screening identify women with chlamydia; and what reasons do women give for not being screened for chlamydia? Prior to implementation of the screening protocol, an educational session was held for all office staff. The educational session had two main components. The first component focused on chlamydia. All of the medical assistants (MAs) needed to know what chlamydia was and the importance of this screening. The focus was on how chlamydia was screened for, how to treat it, long-term complications of untreated chlamydia, and the importance of partner notification. These topics were discussed at great length so the MA staff felt comfortable offering the screening to the patients. The second educational component involved how to collect the urine specimen. The office utilized two labs for these screenings, The USPSTF and the CDC recommend which were determined by the patient’s annual screening in sexually active women insurance company. This was imporbetween 16 and 25 years of age. tant to discuss with the MA staff because each lab had different specimen containers that the urine needed to be sent in as well as different requisition forms. The MAs needed tool that a majority of healthcare plans use to measure and to know which lab was preferred for the different insurance monitor providers’ performances on screening practices.3 In companies, as they were responsible for collecting and send2001, prior to the HEDIS measures, only 23.1% of women in ing the specimen and proper paperwork. Unfortunately, if managed-care organizations and 40% of women in Medicaid the urine was in the wrong container or the form was not programs were screened for chlamydia.2 After implementafilled out correctly, the lab would not perform the test. The tion of the HEDIS measures, the number of women screened goal with this second educational piece was to minimize increased. In 2011, 43.1% of women in managed-care orgaand prevent these errors from occurring and to ensure that nizations and 57.5% of women in Medicaid programs were all women who left a sample were screened for chlamydia. screened for chlamydia.2 Despite the rise in the number of A chlamydia screening checklist was also developed women screened after implementing the HEDIS measures, prior to implementation of the protocol. Added to the pathere is still a large portion of “at risk” women who are not tient report sheet, the checklist served as a reminder for both getting screened.
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Screening for chlamydia: Are you doing it?
the MAs and NP to offer the screening to eligible women. The checklist recorded the age of the patient, marital status, chief complaint, and whether the screening was offered, performed, or declined. If the screening was performed, the lab used was listed on the form as well as the results of the screening when they came back. If the screening was declined, the reason for this was noted in narrative on this form. After the designated implementation date, the chlamydia screening was offered to all women ages 16 to 25 that came into the office for an appointment with the NP, regardless of their chief complaint. All eligible women received an informational letter and handout from the CDC when they checked in for their appointment. The printed materials explained what chlamydia is, the screening process, the value of the screening, and treatment options should the test come back positive. The MA who brought the patient to the exam room offered the screening to the patient. If the patient was agreeable, a urine specimen was collected and sent off to the designated lab for testing. If the patient declined the screening at the time of the initial screening request, the NP discussed the screening and answered any further questions they had during the provider visit. If the patient continued to decline the screening, the NP asked why they did not want to be screened. The patient response for declining screening was then noted on the chlamydia checklist. A pre-post design was used to evaluate the effectiveness of the standardized chlamydia screening protocol. Retrospective chart reviews were conducted to assess patient characteristics and the following outcomes during a 3-month pre- and 3-month postimplementation period: the number and percentage of the eligible women offered screenings during the 3-month period; the number and percentage of eligible women who received a screening during the 3-month period; and the chlamydia rates among those women tested. To identify women who were eligible for this project, appointment schedules were examined during the pre- and postimplementation periods. Women were considered eligible for this study if they were between the ages of 16 to 25 years and saw the NP in the office. If women had multiple visits during each time period, the last visit was the only one counted to ensure that each woman was only included once in each time period. Descriptive statistics were used to summarize the clinical characteristics of the women included in the pre- and postimplementation samples. Fisher exact tests were used to test for statistically significant differences in proportions of eligible women in the pre- and postimplementation periods. In addition, the women who refused the screening were analyzed for common themes. Using SAS, nondirectional tests were conducted with the level of significance set at 0.05. www.tnpj.com
Comparison of demographic variables between pre- and postimplementation periods Preimplementation period N = 47
Postimplementation period N = 59
Mean age
20.9 (SD 2.43)
21.2 (SD 2.43)
Number of married women
3 (6.4%)
2 (3.4%)
Number of single women
44 (93.6%)
57 (96.6%)
Number of women sexually active
30 (90.9%)
48 (84.2%)
3 (9.1%)
9 (15.8%)
Number of women not sexually active SD = Standard deviation
Duke Institutional Review Board approval was obtained prior to analysis. ■ Results A total of 106 women were eligible for being offered chlamydia screening. Retrospective chart reviews were completed for each identified woman. Forty-seven or 44% of the women were identified in the preimplementation period, and 59 (or 56%) of the women were in the postimplementation period (See Comparison of demographic variables between pre- and postimplementation periods). Age, marital status, and level of sexual activity were compared on these women to look for commonalities and see if the pre- and postimplementation groups were comparable. The average age of women in the preimplementation period was 20.9 years (SD = 2.43), and in the postimplementation period, the average age was 21.2 years (SD = 2.43). There was no significant difference in ages between the pre- and postimplementation groups (t = 0.58, df = 104, P = 0.56). Upon looking at the marital status of these women, they were classified as either single or married. There was no significant difference in the pre- and postimplementation groups in regards to marital status (Fisher, P = 0.65). Sexual activity was also noted in these women. However, it was not a requirement that the woman be sexually active to be eligible for this screening. In the preimplementation period, 3 (9.1%) women reported they were not sexually active, and 30 (90.9%) women reported they were sexually active. The Nurse Practitioner • April 2014 43
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The postimplementation period had 9 (15.8%) women who reported they were not sexually active, and 48 (84.2%) women reported they were sexually active. Results showed that there was no statistical significance between the groups (Fisher, P = 0.52). The number and percentage of eligible women actually offered chlamydia screenings were evaluated (see Eligible women offered the screenings). In the preimplementation phase, four (8.5%) women were offered chlamydia screening, while 43 (91.5%) women were not offered the screening. In comparison, the postimplementation period had 56 (94.9%) women being offered the screening, and 3 (5.1%) women were not offered the screening. There was a statistically significant difference between the proportion of women in the postimplementation period offered the chlamydia
Eligible women offered the screenings Preimplementation period N = 47
Postimplementation period N = 59
Number of women offered the screening
4 (8.5%)
56 (94.9%)
Number of women not offered the screening
43 (91.5%)
3 (5.1%)
Eligible women who received screenings among those offered Preimplementation Postimplementation period period N = 56 N=4 Not screened for chlamydia
0 (0%)
39 (69.6%)
Screened for chlamydia
4 (100%)
17 (30.4%)
Type of chlamydia screening test Preimplementation period N=4
Postimplementation period N = 17
Urine sample
1 (25%)
12 (70.6%)
Cervical swab
3 (75%)
5 (29.4%)
screening compared with the preimplementation period (Fisher, P < 0.0001). Sixty women in the pre- and postimplementation periods were offered the screening. Twenty-one women were screened in both groups (see Eligible women who received screenings among those offered). The preimplementation period had four women who were offered the screening, and all four women were screened for chlamydia. The postimplementation period had a total of 56 women offered the screening. Seventeen (30.4%) women were screened, and 39 (69.6%) women declined to be screened. Screenings for chlamydia were performed by either a cervical swab done during a Pap smear or a urine test (see Type of chlamydia screening test). A cervical swab can be collected without having a Pap smear done; however, in this study, all cervical swabs were collected during a Pap smear. In the preimplementation period, 1 (25%) of the screenings was done by the urine test, and 3 (75%) were done by cervical swabs. The standard in this office is to offer chlamydia screening during a Pap smear, so these women would have been offered the screening regardless. The fourth woman was there because she was concerned she was exposed to an STI and would have been offered the screening due to the nature of her visit. By implementing this project and offering the urine screenings to all eligible women, 17 out of 59 (or 28.8%) of women in the postimplementation period were screened. Of these women screened, 12 (70.6%) women were screened with the urine sample, while 5 (29.4%) were screened with the cervical swab done during their Pap smear. The number of screenings that identified women with chlamydia was analyzed. There were a total of two positive chlamydia tests throughout this specific time frame (See Chlamydia rates among those screened). Both of these positive tests were diagnosed in the postimplementation period. In the preimplementation period, out of the four women screened for chlamydia, four (100%) women tested negative for chlamydia. In the postimplementation period, 15 (88.2%) women tested negative for chlamydia, and 2 (11.8%) women tested positive for chlamydia. Finally, the reason why women declined to be screened was analyzed for common themes. In the postimplementation period, 39 (69.6%) women declined the screening. (See Reasons for declining screening in postimplementation period.) There were a variety of answers to this question, with the majority of women declining because they had previously been screened and tested negative either during a Pap smear or another screening (17 or 43.6%). The second most common reason was that they had never been sexually active (9 or 23.1%). Other reasons for declining included that they are in a monogamous relationship (8 or 20.5%),
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Screening for chlamydia: Are you doing it?
or they are not currently sexually active (4 or 10.3%). Two patients were given lab slips to get the screening done; however, they never got screened. ■ Discussion These two groups of women were similar in regards to age, marital status, and report of sexual activity; there was no statistically significant difference between these groups. However, there were missing data regarding the sexual activity of these women. In the preimplementation period, there were 14 women whose level of sexual activity was unknown, as it was not included in the chart. This occurred in two women in the postimplementation group. This was not a concern, as this was not a requirement to be offered the screening. Sexual activity was not a requirement for this screening based on several studies looking at increasing screening rates. These studies showed that if the screening was offered to everyone within the age category and did not focus on sexual activity or history, more women would be willing to be screened.7,8,10 There was a statistically significant difference in the proportion of women offered chlamydia screening in the postimplementation period compared with the preimplementation period. In the postimplementation phase, only three women were not offered the screening. All other eligible women who came into the office during that time period were offered the screenings. In the preimplementation phase, 4 women were offered the screening, leaving 43 women unscreened. Of the women who were offered the screening, a statistically significant proportion of women were screened in the postimplementation period compared with the preimplementation period. By offering routine screenings, 12 additional women were screened who would not have been screened prior to implementation of this protocol. During the postimplementation phase, the screening was offered to 56 women, and 17 of these women were screened. This left 39 women who declined to be screened. When looking into reasons why these women declined the screening, it was encouraging to see that the majority of women were declining because they had recently been screened and tested negative (17 out of 39 or 43.6%). Many of these women stated that the screening was performed through their last Pap smear (13 out of 39 or 33.3%). This could show that other providers are taking the initiative and offering screenings to these women. Other reasons for declining include that they are in a monogamous relationship (8 out of 39 or 20.5%), they have never been sexually active (9 out of 39 or 23%), or they are not currently sexually active (3 out of 39 or 7.7%). This is clinically significant, as half of the woman who declined screening with the reasoning of monogamy, abstinence, or denial of initiating sexual activity may actually have been exposed to chlamydia without their knowledge. The women who were not currently www.tnpj.com
Chlamydia rates among those screened Preimplementation period N=4
Postimplementation period N = 17
Negative chlamydia screening
4 (100%)
15 (88.2%)
Positive chlamydia screenings
0 (0%)
2 (22.8%)
Reasons for declining screening in postimplementation period Postimplementation period N = 39 Screened during last Pap smear
13 (33.3%)
Recently screened
4 (10.3%)
Never been sexually active
9 (23.1%)
In a monogamous relationship
8 (20.5%)
Not currently sexually active
3 (7.7%)
Given lab slip to complete at a later date
2 (5.1%)
sexually active or in a monogamous relationship should ideally be tested because of their previous sexual activity. Two women agreed to be screened for chlamydia; however, they were unable to leave a urine sample in the office and stated that they would return at a later date to complete the screening. To encourage them to be screened, a lab slip was given to them to take to a lab and be tested at a later time. Neither of these women completed the testing during the study period, which demonstrates the importance of collecting the sample while the patient is in the office. Out of all the chlamydia screenings that were completed in both the pre- and postimplementation periods, there were two positive tests. Both of these positive tests were found in the postimplementation period. One positive result was determined during a routine well-woman exam; the other was for a sick visit. The woman who was getting a Pap smear would probably have been tested for chlamydia, as that was the standard protocol in the office at that time. However, the second woman would not have been offered chlamydia screening without the screening protocol in place. It is important to note that neither of these women had symptoms of the disease, and both were shocked to learn that they The Nurse Practitioner • April 2014 45
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had it. This demonstrates the point that chlamydia is often asymptomatic and that many women have no idea that they may have it.3 Fortunately, these women were diagnosed and treated for chlamydia. Each woman was only counted once in this study, so if they had multiple visits to the clinic during the study time period, only the last visit was counted. This is important to note because the second woman who tested positive during the routine screening was seen twice in the office during the postimplementation period. She was offered the screening at both visits and was screened at both visits; she tested positive both times. Her positive test was only counted once because each woman was counted once. As this patient was adherent to treatment, having her test positive twice really shows that partner notification and treatment are essential to protecting women from reinfection. ■ Implications for practice Overall, implementation of a chlamydia screening protocol was successful. By making chlamydia screening a routine protocol, not only was this office able to offer the chlamydia screenings to more women, but through these screenings, two women who were asymptomatic were identified and treated for chlamydia. This allowed for early intervention, education, and may have prevented any long-term complications that can arise from chlamydia. Project planning was critical to the success of this study. Including clinical staff in the planning phase of this project was important to create buy-in and support for this project. The educational session was extremely valuable for the office staff. The second component that focused on the specimen collection and lab paperwork was a success in that no specimens were left unscreened. All women who left a sample had their urine tested. The protocol was easy to implement, with staff turnover being the major barrier to implementation. During the postimplementation period, several MAs left the practice leaving the office short-handed and forced the remaining staff to pick up extra responsibilities. Once new staff members were hired, focus on proper training of their overall responsibilities as well as the screening protocol was paramount. MA turnover and new-staff training hindered the ability of consistency in offering the screening to patients resulting in the NP to ensure that each eligible woman was offered the screening. This project was a small pilot study that focused only on women in the selected age range who were seen by the NP. The universal screening protocol with ongoing evaluation can easily be expanded to include men in this same age range as well as patients of all providers in the office. Furthermore, with the success of implementing the chlamydia protocol, additional noninvasive STI screening may also be considered.
■ A routine test Offering the noninvasive chlamydia screening to eligible women was easy to implement, cost-effective for the clinical setting, and patient responses were encouraging. Many were happy to be asked about the screening and eagerly participated. Results of this study support the evidence that women are willing to be screened for chlamydia, especially if a noninvasive urine screening is available and that it is seen as a “routine” test done in clinical settings. By making this screening a routine office procedure regardless of patient report of sexual activity, relationship status or last Pap smear could also easily increase the number of patients screened for chlamydia. This would improve identification and treatment, enabling NPs to improve surveillance rates to the standardized goals and reduce chlamydia rates, especially in regions like San Joaquin County that have high infection rates. REFERENCES 1. Centers for Disease Control and Prevention. Chlamydia, sexually transmitted diseases surveillance. http://www.cdc.gov/std/stats11/chlamydia.htm. 2. Centers for Disease Control and Prevention. Incidence, prevalence, and cost of sexually transmitted infections in the United States. www.cdc.gov/std/stats/ sti-estimates-fact-sheet-feb-2013.pdf. 3. Douglas J, Berman S, Walsh C. Improving chlamydia screening strategies from top performing health plan. National Committee for Quality Assurance; 2007. 4. Watson EJ, Templeton A, Russel I, et al. The accuracy and efficacy of screening tests for Chlamydia trachomatis: A systematic review. Journal of Medical Microbiology. 2013;51(12):1021-31. 5. Haughland S, Thune T, Fosse B, Wentzel-Larsen T, Hjelmevoll S, Myrmel H. Comparing urine samples and cervical swabs for Chlamydia testing in a female population by means of Strand Displacement Assay (SDA). BMC Women’s Health. 2010;10:(9). 6. Pavlin NL, Gunn JM, Parker R, Fairley CK, Hocking J. Implementing chlamydia screening: What do women think? A systematic review of the literature. BMC Public Health. 2006;6(1):221. 7. 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 Infectious Diseases. 2011;11(1):211 8. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking J. Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice. BMC Infectious Diseases. 2008;8:62. 9. American Congress of Obstetricians and Gynecologists. Chlamydia screening rates too low, reinfection rates too high. www.acog.org/About_ACOG/News_ Room/News_releases/2012/Chlamydia_Screening_Rates_Too_Low. 10. Balfe M, Brugha R, O’Donovan D, O’Connell E, Vaughan D. Young women’s decisions to accept chlamydia screening: influences of stigma and doctorpatient interactions. BMC Public Health. 2010;10:425. 11. California Department of Public Health. Chlamydia, Cases and Rates, California Counties and Selected City Health Jurisdictions, 2007–2011 Provisional Data. http://www.cdph.ca.gov/data/statistics/Documents/STD-Data-ChlamydiaProvisional-Tables.pdf. Dyan Den Ouden is a family nurse practitioner with the city and county of San Francisco, Calif. Anne Derouin is an assistant professor at Duke University School of Nursing, Durham, N.C. Susan Silva is an associate research professor at Duke University School of Nursing, Durham, N.C. Dr. Abdul Khan is a physician in Manteca, Calif. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000444649.28067.3e
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SPOTLIGHT ON
MSN to DNP degree Two broadly defined doctoral pathways are available to nurses: a research-oriented degree (usually a PhD; sometimes a DNS, DSN, or DNSc), or a practice-oriented degree. For the latter, the Doctor of Nursing Practice (DNP) is now the most commonly held degree and has replaced the original Doctor of Nursing (ND) degree first offered in 1979. In 2004, the American Association of Colleges of Nursing (AACN) recommended that “preparation for specialization in nursing should occur at the doctoral level by 2015.” In 2010, the Institute of Medicine, recommended doubling the number of nurses holding doctoral degrees by 2020. If you are already practicing with a master’s degree, you are not required to obtain a DNP to continue practicing at the advanced level. But should you pursue a DNP anyway? Consider these commonly cited benefits of a DNP degree: Increased knowledge and skill. The AACN notes that as healthcare becomes increasingly complex and preventable errors continue to occur at unacceptable rates, nurses need the latest scientific and practical expertise to bring about the best patient outcomes. Parity with other fields. Existing MSN programs already require as many credits as doctoral degrees in some healthcare fields. Attaining a DNP is a way to achieve increased recognition for your expertise. Greater influence on healthcare. Whether you decide to go into administration, policy-making, or education, your DNP degree will enhance your ability to improve the healthcare field. Many DNP programs have an online component. Most important for nurses with master’s degrees: Many DNP programs offer an MSN-to-DNP pathway and allow transfer of credits earned for master’s level clinical practice hours. A DNP degree requires at least 1000 practice hours and, for master’s-prepared nurses, requires a year or two to complete. If you want to go into graduate teaching, you’ll need to take additional coursework in educational methodology (possibly while acquiring your DNP degree). DNP programs culminate in a student-designed capstone project. For now, the choice of whether to pursue a DNP degree is a personal one. Nurses with master’s degrees and specialized advance practice certifications already bring sophisticated knowledge and clinical expertise to their work. Earning a doctorate, though, can only increase your strengths as an advanced practice nurse.
in
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Screening for chlamydia: Are you doing it? Abstract: This retrospective study evaluates the implications of offering routine chlamydia screenings to women ages 16 to 25 attending a primary care clinical setting. Results found that routine screenings significantly increased the number of women screened, enabling early identification and treatment of affected women and potentially reducing infection rates. By Dyan Den Ouden, DNP, FNP-BC; Anne Derouin, DNP, CPNP; Susan Silva, PhD; and Abdul Khan, MD
hlamydia is one of the most common, curable sexually transmitted infections (STIs) in the United States.1 The CDC estimates that 6.8% of all sexually active women between 14 and 19 years of age have chlamydia.2 In 2011, there were over 1.4 million new cases of chlamydia diagnosed in the United States with an 8% increase in the number of cases per 100,000 people compared with 2010 data.2
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These are significant numbers; however, these numbers are thought to be underreported, as chlamydia is often asymptomatic. Over 75% of women who were newly diagnosed with chlamydia were asymptomatic and did not realize they had the infection.3 When left untreated, chlamydia can cause many long-term health problems for women, including ectopic pregnancies, chronic pelvic pain, pelvic inflammatory disease, and infertility.1
Keywords: chlamydia, routine screening, sexual activity, sexually transmitted infections, urine screening
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Screening for chlamydia is easy and affordable. There are two main ways to screen for chlamydia: cervical swabs or urine tests. In looking at the sensitivity and specificity of urine tests and cervical swabs, these screening methods are comparable in detecting chlamydia.2,4,5 Previous studies have shown that more women will choose to be screened if it is an easy and noninvasive method, making urine screening the screening test of choice.6-8 The United States Preventive Services Task Force (USPSTF) and the CDC both recommend annual screening in sexually active women between 16 and 25 years of age.2 Unfortunately, only 38% of women who are eligible for the screening are actually screened.9 There are two main reasons for the lack of screening. The most common reason for women not getting screened is due to the stigma of an STI.6,10 Many women are embarrassed and afraid of being labeled promiscuous, so they do not inquire about STI screenings. Several studies have looked at ways to increase chlamydia screening rates in the younger population. These studies found that the most successful way to increase screenings is by making them a routine office procedure in which women ages 16 to 25 are offered screenings.7,8,10 By screening all women for chlamydia who fall into this age range, no one is singled out or targeted for the screening. The second reason for the lack of chlamydia screening in women is due to the fact that many routine health screenings may be overlooked by healthcare providers. This lack of screening is a problem throughout the United States. In response to this, the National Committee for Quality Assurance developed a Healthcare Effectiveness Data Information Set (HEDIS) for chlamydia screenings. HEDIS is a
California has a high chlamydia rate. In 2011, there were over 164,000 new cases of chlamydia diagnosed in California.11 In San Joaquin County, where this study was completed, there were over 3,700 new cases diagnosed in 2011, making chlamydia the most common reportable STI in this county.11 With less than half of women being screened for chlamydia and such high infection rates, screening for chlamydia became a priority for all healthcare providers in this region. In order to increase screening rates, a chlamydia screening protocol was created, implemented, and evaluated.
■ Methods This protocol offered chlamydia screening to all women between the ages of 16 to 25 who saw the nurse practitioner (NP) in an internal medicine office located in San Joaquin County, CA. There were three questions to be addressed in the evaluation of the screening protocol: does offering urine chlamydia screening to all women ages 16 to 25 increase the rate of screenings performed by this office; does this routine screening identify women with chlamydia; and what reasons do women give for not being screened for chlamydia? Prior to implementation of the screening protocol, an educational session was held for all office staff. The educational session had two main components. The first component focused on chlamydia. All of the medical assistants (MAs) needed to know what chlamydia was and the importance of this screening. The focus was on how chlamydia was screened for, how to treat it, long-term complications of untreated chlamydia, and the importance of partner notification. These topics were discussed at great length so the MA staff felt comfortable offering the screening to the patients. The second educational component involved how to collect the urine specimen. The office utilized two labs for these screenings, The USPSTF and the CDC recommend which were determined by the patient’s annual screening in sexually active women insurance company. This was imporbetween 16 and 25 years of age. tant to discuss with the MA staff because each lab had different specimen containers that the urine needed to be sent in as well as different requisition forms. The MAs needed tool that a majority of healthcare plans use to measure and to know which lab was preferred for the different insurance monitor providers’ performances on screening practices.3 In companies, as they were responsible for collecting and send2001, prior to the HEDIS measures, only 23.1% of women in ing the specimen and proper paperwork. Unfortunately, if managed-care organizations and 40% of women in Medicaid the urine was in the wrong container or the form was not programs were screened for chlamydia.2 After implementafilled out correctly, the lab would not perform the test. The tion of the HEDIS measures, the number of women screened goal with this second educational piece was to minimize increased. In 2011, 43.1% of women in managed-care orgaand prevent these errors from occurring and to ensure that nizations and 57.5% of women in Medicaid programs were all women who left a sample were screened for chlamydia. screened for chlamydia.2 Despite the rise in the number of A chlamydia screening checklist was also developed women screened after implementing the HEDIS measures, prior to implementation of the protocol. Added to the pathere is still a large portion of “at risk” women who are not tient report sheet, the checklist served as a reminder for both getting screened.
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Screening for chlamydia: Are you doing it?
the MAs and NP to offer the screening to eligible women. The checklist recorded the age of the patient, marital status, chief complaint, and whether the screening was offered, performed, or declined. If the screening was performed, the lab used was listed on the form as well as the results of the screening when they came back. If the screening was declined, the reason for this was noted in narrative on this form. After the designated implementation date, the chlamydia screening was offered to all women ages 16 to 25 that came into the office for an appointment with the NP, regardless of their chief complaint. All eligible women received an informational letter and handout from the CDC when they checked in for their appointment. The printed materials explained what chlamydia is, the screening process, the value of the screening, and treatment options should the test come back positive. The MA who brought the patient to the exam room offered the screening to the patient. If the patient was agreeable, a urine specimen was collected and sent off to the designated lab for testing. If the patient declined the screening at the time of the initial screening request, the NP discussed the screening and answered any further questions they had during the provider visit. If the patient continued to decline the screening, the NP asked why they did not want to be screened. The patient response for declining screening was then noted on the chlamydia checklist. A pre-post design was used to evaluate the effectiveness of the standardized chlamydia screening protocol. Retrospective chart reviews were conducted to assess patient characteristics and the following outcomes during a 3-month pre- and 3-month postimplementation period: the number and percentage of the eligible women offered screenings during the 3-month period; the number and percentage of eligible women who received a screening during the 3-month period; and the chlamydia rates among those women tested. To identify women who were eligible for this project, appointment schedules were examined during the pre- and postimplementation periods. Women were considered eligible for this study if they were between the ages of 16 to 25 years and saw the NP in the office. If women had multiple visits during each time period, the last visit was the only one counted to ensure that each woman was only included once in each time period. Descriptive statistics were used to summarize the clinical characteristics of the women included in the pre- and postimplementation samples. Fisher exact tests were used to test for statistically significant differences in proportions of eligible women in the pre- and postimplementation periods. In addition, the women who refused the screening were analyzed for common themes. Using SAS, nondirectional tests were conducted with the level of significance set at 0.05. www.tnpj.com
Comparison of demographic variables between pre- and postimplementation periods Preimplementation period N = 47
Postimplementation period N = 59
Mean age
20.9 (SD 2.43)
21.2 (SD 2.43)
Number of married women
3 (6.4%)
2 (3.4%)
Number of single women
44 (93.6%)
57 (96.6%)
Number of women sexually active
30 (90.9%)
48 (84.2%)
3 (9.1%)
9 (15.8%)
Number of women not sexually active SD = Standard deviation
Duke Institutional Review Board approval was obtained prior to analysis. ■ Results A total of 106 women were eligible for being offered chlamydia screening. Retrospective chart reviews were completed for each identified woman. Forty-seven or 44% of the women were identified in the preimplementation period, and 59 (or 56%) of the women were in the postimplementation period (See Comparison of demographic variables between pre- and postimplementation periods). Age, marital status, and level of sexual activity were compared on these women to look for commonalities and see if the pre- and postimplementation groups were comparable. The average age of women in the preimplementation period was 20.9 years (SD = 2.43), and in the postimplementation period, the average age was 21.2 years (SD = 2.43). There was no significant difference in ages between the pre- and postimplementation groups (t = 0.58, df = 104, P = 0.56). Upon looking at the marital status of these women, they were classified as either single or married. There was no significant difference in the pre- and postimplementation groups in regards to marital status (Fisher, P = 0.65). Sexual activity was also noted in these women. However, it was not a requirement that the woman be sexually active to be eligible for this screening. In the preimplementation period, 3 (9.1%) women reported they were not sexually active, and 30 (90.9%) women reported they were sexually active. The Nurse Practitioner • April 2014 43
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S E LE C TE D CA P S T O N E PROJ E C T
The postimplementation period had 9 (15.8%) women who reported they were not sexually active, and 48 (84.2%) women reported they were sexually active. Results showed that there was no statistical significance between the groups (Fisher, P = 0.52). The number and percentage of eligible women actually offered chlamydia screenings were evaluated (see Eligible women offered the screenings). In the preimplementation phase, four (8.5%) women were offered chlamydia screening, while 43 (91.5%) women were not offered the screening. In comparison, the postimplementation period had 56 (94.9%) women being offered the screening, and 3 (5.1%) women were not offered the screening. There was a statistically significant difference between the proportion of women in the postimplementation period offered the chlamydia
Eligible women offered the screenings Preimplementation period N = 47
Postimplementation period N = 59
Number of women offered the screening
4 (8.5%)
56 (94.9%)
Number of women not offered the screening
43 (91.5%)
3 (5.1%)
Eligible women who received screenings among those offered Preimplementation Postimplementation period period N = 56 N=4 Not screened for chlamydia
0 (0%)
39 (69.6%)
Screened for chlamydia
4 (100%)
17 (30.4%)
Type of chlamydia screening test Preimplementation period N=4
Postimplementation period N = 17
Urine sample
1 (25%)
12 (70.6%)
Cervical swab
3 (75%)
5 (29.4%)
screening compared with the preimplementation period (Fisher, P < 0.0001). Sixty women in the pre- and postimplementation periods were offered the screening. Twenty-one women were screened in both groups (see Eligible women who received screenings among those offered). The preimplementation period had four women who were offered the screening, and all four women were screened for chlamydia. The postimplementation period had a total of 56 women offered the screening. Seventeen (30.4%) women were screened, and 39 (69.6%) women declined to be screened. Screenings for chlamydia were performed by either a cervical swab done during a Pap smear or a urine test (see Type of chlamydia screening test). A cervical swab can be collected without having a Pap smear done; however, in this study, all cervical swabs were collected during a Pap smear. In the preimplementation period, 1 (25%) of the screenings was done by the urine test, and 3 (75%) were done by cervical swabs. The standard in this office is to offer chlamydia screening during a Pap smear, so these women would have been offered the screening regardless. The fourth woman was there because she was concerned she was exposed to an STI and would have been offered the screening due to the nature of her visit. By implementing this project and offering the urine screenings to all eligible women, 17 out of 59 (or 28.8%) of women in the postimplementation period were screened. Of these women screened, 12 (70.6%) women were screened with the urine sample, while 5 (29.4%) were screened with the cervical swab done during their Pap smear. The number of screenings that identified women with chlamydia was analyzed. There were a total of two positive chlamydia tests throughout this specific time frame (See Chlamydia rates among those screened). Both of these positive tests were diagnosed in the postimplementation period. In the preimplementation period, out of the four women screened for chlamydia, four (100%) women tested negative for chlamydia. In the postimplementation period, 15 (88.2%) women tested negative for chlamydia, and 2 (11.8%) women tested positive for chlamydia. Finally, the reason why women declined to be screened was analyzed for common themes. In the postimplementation period, 39 (69.6%) women declined the screening. (See Reasons for declining screening in postimplementation period.) There were a variety of answers to this question, with the majority of women declining because they had previously been screened and tested negative either during a Pap smear or another screening (17 or 43.6%). The second most common reason was that they had never been sexually active (9 or 23.1%). Other reasons for declining included that they are in a monogamous relationship (8 or 20.5%),
44 The Nurse Practitioner • Vol. 39, No. 4
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Screening for chlamydia: Are you doing it?
or they are not currently sexually active (4 or 10.3%). Two patients were given lab slips to get the screening done; however, they never got screened. ■ Discussion These two groups of women were similar in regards to age, marital status, and report of sexual activity; there was no statistically significant difference between these groups. However, there were missing data regarding the sexual activity of these women. In the preimplementation period, there were 14 women whose level of sexual activity was unknown, as it was not included in the chart. This occurred in two women in the postimplementation group. This was not a concern, as this was not a requirement to be offered the screening. Sexual activity was not a requirement for this screening based on several studies looking at increasing screening rates. These studies showed that if the screening was offered to everyone within the age category and did not focus on sexual activity or history, more women would be willing to be screened.7,8,10 There was a statistically significant difference in the proportion of women offered chlamydia screening in the postimplementation period compared with the preimplementation period. In the postimplementation phase, only three women were not offered the screening. All other eligible women who came into the office during that time period were offered the screenings. In the preimplementation phase, 4 women were offered the screening, leaving 43 women unscreened. Of the women who were offered the screening, a statistically significant proportion of women were screened in the postimplementation period compared with the preimplementation period. By offering routine screenings, 12 additional women were screened who would not have been screened prior to implementation of this protocol. During the postimplementation phase, the screening was offered to 56 women, and 17 of these women were screened. This left 39 women who declined to be screened. When looking into reasons why these women declined the screening, it was encouraging to see that the majority of women were declining because they had recently been screened and tested negative (17 out of 39 or 43.6%). Many of these women stated that the screening was performed through their last Pap smear (13 out of 39 or 33.3%). This could show that other providers are taking the initiative and offering screenings to these women. Other reasons for declining include that they are in a monogamous relationship (8 out of 39 or 20.5%), they have never been sexually active (9 out of 39 or 23%), or they are not currently sexually active (3 out of 39 or 7.7%). This is clinically significant, as half of the woman who declined screening with the reasoning of monogamy, abstinence, or denial of initiating sexual activity may actually have been exposed to chlamydia without their knowledge. The women who were not currently www.tnpj.com
Chlamydia rates among those screened Preimplementation period N=4
Postimplementation period N = 17
Negative chlamydia screening
4 (100%)
15 (88.2%)
Positive chlamydia screenings
0 (0%)
2 (22.8%)
Reasons for declining screening in postimplementation period Postimplementation period N = 39 Screened during last Pap smear
13 (33.3%)
Recently screened
4 (10.3%)
Never been sexually active
9 (23.1%)
In a monogamous relationship
8 (20.5%)
Not currently sexually active
3 (7.7%)
Given lab slip to complete at a later date
2 (5.1%)
sexually active or in a monogamous relationship should ideally be tested because of their previous sexual activity. Two women agreed to be screened for chlamydia; however, they were unable to leave a urine sample in the office and stated that they would return at a later date to complete the screening. To encourage them to be screened, a lab slip was given to them to take to a lab and be tested at a later time. Neither of these women completed the testing during the study period, which demonstrates the importance of collecting the sample while the patient is in the office. Out of all the chlamydia screenings that were completed in both the pre- and postimplementation periods, there were two positive tests. Both of these positive tests were found in the postimplementation period. One positive result was determined during a routine well-woman exam; the other was for a sick visit. The woman who was getting a Pap smear would probably have been tested for chlamydia, as that was the standard protocol in the office at that time. However, the second woman would not have been offered chlamydia screening without the screening protocol in place. It is important to note that neither of these women had symptoms of the disease, and both were shocked to learn that they The Nurse Practitioner • April 2014 45
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S E LE C TE D CA P S T O N E PROJ E C T
had it. This demonstrates the point that chlamydia is often asymptomatic and that many women have no idea that they may have it.3 Fortunately, these women were diagnosed and treated for chlamydia. Each woman was only counted once in this study, so if they had multiple visits to the clinic during the study time period, only the last visit was counted. This is important to note because the second woman who tested positive during the routine screening was seen twice in the office during the postimplementation period. She was offered the screening at both visits and was screened at both visits; she tested positive both times. Her positive test was only counted once because each woman was counted once. As this patient was adherent to treatment, having her test positive twice really shows that partner notification and treatment are essential to protecting women from reinfection. ■ Implications for practice Overall, implementation of a chlamydia screening protocol was successful. By making chlamydia screening a routine protocol, not only was this office able to offer the chlamydia screenings to more women, but through these screenings, two women who were asymptomatic were identified and treated for chlamydia. This allowed for early intervention, education, and may have prevented any long-term complications that can arise from chlamydia. Project planning was critical to the success of this study. Including clinical staff in the planning phase of this project was important to create buy-in and support for this project. The educational session was extremely valuable for the office staff. The second component that focused on the specimen collection and lab paperwork was a success in that no specimens were left unscreened. All women who left a sample had their urine tested. The protocol was easy to implement, with staff turnover being the major barrier to implementation. During the postimplementation period, several MAs left the practice leaving the office short-handed and forced the remaining staff to pick up extra responsibilities. Once new staff members were hired, focus on proper training of their overall responsibilities as well as the screening protocol was paramount. MA turnover and new-staff training hindered the ability of consistency in offering the screening to patients resulting in the NP to ensure that each eligible woman was offered the screening. This project was a small pilot study that focused only on women in the selected age range who were seen by the NP. The universal screening protocol with ongoing evaluation can easily be expanded to include men in this same age range as well as patients of all providers in the office. Furthermore, with the success of implementing the chlamydia protocol, additional noninvasive STI screening may also be considered.
■ A routine test Offering the noninvasive chlamydia screening to eligible women was easy to implement, cost-effective for the clinical setting, and patient responses were encouraging. Many were happy to be asked about the screening and eagerly participated. Results of this study support the evidence that women are willing to be screened for chlamydia, especially if a noninvasive urine screening is available and that it is seen as a “routine” test done in clinical settings. By making this screening a routine office procedure regardless of patient report of sexual activity, relationship status or last Pap smear could also easily increase the number of patients screened for chlamydia. This would improve identification and treatment, enabling NPs to improve surveillance rates to the standardized goals and reduce chlamydia rates, especially in regions like San Joaquin County that have high infection rates. REFERENCES 1. Centers for Disease Control and Prevention. Chlamydia, sexually transmitted diseases surveillance. http://www.cdc.gov/std/stats11/chlamydia.htm. 2. Centers for Disease Control and Prevention. Incidence, prevalence, and cost of sexually transmitted infections in the United States. www.cdc.gov/std/stats/ sti-estimates-fact-sheet-feb-2013.pdf. 3. Douglas J, Berman S, Walsh C. Improving chlamydia screening strategies from top performing health plan. National Committee for Quality Assurance; 2007. 4. Watson EJ, Templeton A, Russel I, et al. The accuracy and efficacy of screening tests for Chlamydia trachomatis: A systematic review. Journal of Medical Microbiology. 2013;51(12):1021-31. 5. Haughland S, Thune T, Fosse B, Wentzel-Larsen T, Hjelmevoll S, Myrmel H. Comparing urine samples and cervical swabs for Chlamydia testing in a female population by means of Strand Displacement Assay (SDA). BMC Women’s Health. 2010;10:(9). 6. Pavlin NL, Gunn JM, Parker R, Fairley CK, Hocking J. Implementing chlamydia screening: What do women think? A systematic review of the literature. BMC Public Health. 2006;6(1):221. 7. 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 Infectious Diseases. 2011;11(1):211 8. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking J. Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice. BMC Infectious Diseases. 2008;8:62. 9. American Congress of Obstetricians and Gynecologists. Chlamydia screening rates too low, reinfection rates too high. www.acog.org/About_ACOG/News_ Room/News_releases/2012/Chlamydia_Screening_Rates_Too_Low. 10. Balfe M, Brugha R, O’Donovan D, O’Connell E, Vaughan D. Young women’s decisions to accept chlamydia screening: influences of stigma and doctorpatient interactions. BMC Public Health. 2010;10:425. 11. California Department of Public Health. Chlamydia, Cases and Rates, California Counties and Selected City Health Jurisdictions, 2007–2011 Provisional Data. http://www.cdph.ca.gov/data/statistics/Documents/STD-Data-ChlamydiaProvisional-Tables.pdf. Dyan Den Ouden is a family nurse practitioner with the city and county of San Francisco, Calif. Anne Derouin is an assistant professor at Duke University School of Nursing, Durham, N.C. Susan Silva is an associate research professor at Duke University School of Nursing, Durham, N.C. Dr. Abdul Khan is a physician in Manteca, Calif. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000444649.28067.3e
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SPOTLIGHT ON
MSN to DNP degree Two broadly defined doctoral pathways are available to nurses: a research-oriented degree (usually a PhD; sometimes a DNS, DSN, or DNSc), or a practice-oriented degree. For the latter, the Doctor of Nursing Practice (DNP) is now the most commonly held degree and has replaced the original Doctor of Nursing (ND) degree first offered in 1979. In 2004, the American Association of Colleges of Nursing (AACN) recommended that “preparation for specialization in nursing should occur at the doctoral level by 2015.” In 2010, the Institute of Medicine, recommended doubling the number of nurses holding doctoral degrees by 2020. If you are already practicing with a master’s degree, you are not required to obtain a DNP to continue practicing at the advanced level. But should you pursue a DNP anyway? Consider these commonly cited benefits of a DNP degree: Increased knowledge and skill. The AACN notes that as healthcare becomes increasingly complex and preventable errors continue to occur at unacceptable rates, nurses need the latest scientific and practical expertise to bring about the best patient outcomes. Parity with other fields. Existing MSN programs already require as many credits as doctoral degrees in some healthcare fields. Attaining a DNP is a way to achieve increased recognition for your expertise. Greater influence on healthcare. Whether you decide to go into administration, policy-making, or education, your DNP degree will enhance your ability to improve the healthcare field. Many DNP programs have an online component. Most important for nurses with master’s degrees: Many DNP programs offer an MSN-to-DNP pathway and allow transfer of credits earned for master’s level clinical practice hours. A DNP degree requires at least 1000 practice hours and, for master’s-prepared nurses, requires a year or two to complete. If you want to go into graduate teaching, you’ll need to take additional coursework in educational methodology (possibly while acquiring your DNP degree). DNP programs culminate in a student-designed capstone project. For now, the choice of whether to pursue a DNP degree is a personal one. Nurses with master’s degrees and specialized advance practice certifications already bring sophisticated knowledge and clinical expertise to their work. Earning a doctorate, though, can only increase your strengths as an advanced practice nurse.
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