Hospital-Based Clinic Visits by Women Seldom Include Routine Screening for STDs
Routine STD screening of sexually active women aged 15–24, although recommended in federal guidelines, is uncommon in primary care visits at hospital-based clinics: In 1997–2000, only 4% of such visits by women in this age-group who had no genitourinary symptoms included testing for an STD.1 Even when women of reproductive age report symptoms that could signal the presence of an STD, testing is infrequent; diagnostic tests were conducted in 13% of visits made by women reporting symptoms. Regardless of whether women were symptomatic, the likelihood of testing was elevated if the visit was for preventive care, if the woman was nonwhite and if the woman was younger than 25.
To assess rates of and factors associated with testing for STDs other than HIV, researchers analyzed data from a national probability sample of visits to outpatient clinics at the nearly 500 federal hospitals that participate in the National Hospital Ambulatory Medical Care Survey. They conducted separate analyses for screening of asymptomatic women and diagnostic testing of women with symptoms for which federal guidelines recommend STD testing (vaginal or urinary symptoms, abnormal vaginal bleeding, and abdominal or pelvic pain). The analyses are based on data for 17,458 primary care visits by nonpregnant 15–44-year-old women.
Complaints of genitourinary symptoms were recorded during 11% of visits. Urinary symptoms were the most common complaints (reported in 27% of visits by symptomatic women), and abdominal or pelvic pain the least common (17%). Compared with visits in which no symptoms were reported, visits that included complaints of symptoms more frequently were by nonwhite women (32% vs. 23%) and Medicaid participants (30% vs. 25%); they more often were to a gynecology clinic (40% vs. 15%), but less often were for preventive care (11% vs. 21%). Three in 10 visits by both symptomatic and asymptomatic women were made by 15–24-year-olds.
Overall, 4% of visits included an STD test; this rate included 13% of visits by women with genitourinary symptoms and 2% of visits by asymptomatic women. Diagnostic testing rates varied by type of symptom reported; the highest rate was 29%, for visits in which the woman complained about vaginal symptoms, and the lowest was 8%, for those in which urinary symptoms were reported. The highest screening rate was 10%, for visits to a gynecology clinic; 7% of preventive care visits and 4% of visits by women aged 15–24 included screening. By applying national data on sexual activity among young people to the screening rate observed in their study, the analysts estimate that only 12% of asymptomatic sexually active 15–24-year-old women who make primary care visits are screened for STDs.
Results of chi-square analysis revealed that rates of both screening and diagnostic testing were elevated if the woman was younger than 25, nonwhite or covered by Medicaid; they were higher at gynecology clinics than at general medicine or pediatric clinics, and higher if the purpose of the visit was preventive care than otherwise. Logistic regression analyses controlling simultaneously for all of these factors confirmed most of the associations. The odds of diagnostic testing were elevated in visits made by nonwhite women (odds ratio, 1.7), 15–24-year-olds (1.7) and Medicaid recipients (2.3); they also were raised in preventive care visits (2.0), but not in visits to a gynecology clinic. The odds of STD screening were elevated in preventive visits (6.9), visits to a gynecology clinic (3.9), and visits by nonwhite women (4.3) and women aged 15–24 (1.2); Medicaid receipt was not associated with the odds of screening. Notably, preventive care visits by nonwhite women were significantly less likely than such visits made by white women to include an STD screening test (0.3).
Summing up their findings, the researchers note that "screening rates were influenced more heavily by type of visit, race, and clinic specialty than by age, the only factor for which screening recommendations exist." However, this is not the only area in which STD testing in hospital-based primary care visits is lacking: Many women with genitourinary symptoms that warrant diagnostic testing are not receiving it. Thus, while the researchers urge health professionals who see sexually active young women "to consider every health care visit as an opportunity for sexually transmitted infection screening," they also press for interventions that will reinforce guidelines for screening asymptomatic women who obtain nonpreventive care from a variety of types of providers.
1. Huppert JS et al., Sexually transmitted infection testing and screening in hospital-based primary care visits by women, Obstetrics & Gynecology, 2005, 105(2): 390– 396.