Only 16% of female teenagers and 2% of male teenagers participating in a managed care program in the Baltimore-Washington area were tested for chlamydia during 1998 and 1999. More than 60% of young women classified as sexually active were tested for chlamydia. Among the young people tested, 15% were infected with chlamydia--14% of females tested and 19% of males. Young people who tested positive were given a prescription for antibiotics, and two-thirds were retested at least a month after their initial positive test; of these, 16% had a repeat chlamydia infection.1
In the United States, chlamydia infection rates are highest among 15-19-year-old females. Since most chlamydia infections produce no symptoms, screening asymptomatic young women is one of the only ways for such infections to be detected and treated. Similarly, a substantial number of young males with chlamydia have no symptoms, and their infection will likely go undetected in the absence of screening. The Centers for Disease Control and Prevention recommends that all sexually active women younger than 20 be tested for chlamydia when they receive a pelvic exam, and national guidelines recommend that managed care organizations screen all sexually active women between the ages of 15 and 25 for chlamydia.
To examine the extent to which chlamydia screening has become part of standard care for young people covered by a large nonprofit managed care organization (Kaiser Permanente Mid-Atlantic States), a group of investigators studied patient care records from the plan's 21 clinic sites in Baltimore; Washington, D.C.; and surrounding suburban areas of Maryland and Virginia.
Among the more than 500,000 members receiving services annually at these sites, about 15% are teenagers. The researchers gathered data on all patient visits by 12-19-year-olds who were enrolled in the plan for at least 11 months of a calendar year during the period January 1998--December 1999. Over the two-year study period, approximately 43,000 females and 44,000 males aged 12-19 were enrolled in the plan for at least 11 months. Fifty-seven percent were aged 15-19, and 80% attended one of the clinic sites in suburban Maryland or northern Virginia.
Overall, 16% of females and 2% of males were tested for chlamydia; males were significantly more likely than females to test positive (19% vs. 14%). Young people aged 12-14 were less likely than 15-19-year-olds to have been tested (1% vs. 15%) and to have tested positive (9% vs. 15%). Members visiting sites in Washington were more likely to have been tested (16%) than were youth at other locations (6-9%). Moreover, those tested at a Washington clinic site were somewhat more likely to have received a chlamydia diagnosis (21%) than were those tested in Baltimore and suburban Maryland (15%) or in northern Virginia (10%).
Results regarding chlamydia testing were similar when the investigators restricted their analyses to young people who were actively receiving health care services during that year. Among plan members who made at least one clinic visit during that year, 17% of females and 1% of males were tested for chlamydia, as were 1% of 12-14-year-olds and 15% of participants aged 15-19.
Using records of services provided, the investigators identified 36% of the more than 24,000 adolescent females served in 1999 as being sexually active (because they had had a Pap smear or a pelvic exam, had been prescribed contraceptives, had received pregnancy-related services, or had been screened or treated for other sexually transmitted diseases). Women aged 15-19 were much more likely to be identified as sexually active (51%) than were 12-14-year-olds (10%), and those attending sites in Baltimore and Washington were more likely to be so identified (47%) than were those visiting a site in suburban Maryland or northern Virginia (34%).
Sixty-three percent of the young women identified as sexually active were tested for chlamydia in 1999. Young women visiting an obstetrics and gynecology clinic had significantly higher odds of having been tested than those visiting only a primary care clinic (odds ratios, 3.9 for 15-19-year-olds and 5.6 for younger teenagers).
Moreover, 72% of female adolescents who had a Pap smear in 1999 were tested for chlamydia. While there were no significant differences by age-group, young women who had Pap smears at a facility in Washington were much more likely to have been tested for chlamydia (92%) than were those in Baltimore (70%), suburban Maryland (77%) or northern Virginia (60%).
Among the adolescent managed care patients who tested positive for chlamydia during 1998 and 1999, two-thirds were tested again more than 30 days after the initial test; young women were much more likely than young men to have been retested (74% vs. 31%). Sixteen percent tested positive again. The median length of time between the first and second positive tests was about six months; 25% of repeat infections were diagnosed within three months.
The researchers comment that the "limited chlamydia testing" found among adolescent clients of the managed care plan studied presumably "reflects provider practices more than member access to care." In general, they contend that managed care organizations should be able to increase the accessibility of reproductive health services for teenagers, because they offer greater confidentiality than traditional insurance plans. (They add that new urine-based diagnostic tests--which avoid the need for an invasive exam, are easy to perform and may be more acceptable to young people--should further enhance managed care organizations' ability to provide sexually transmitted disease services to teenagers.) The researchers recommend that managed care plans use their own operational data "to develop protocols that identify and test all at-risk adolescent members."--M. Klitsch
1. Burstein GR et al., Adolescent chlamydia testing practices and diagnosed infections in a large managed care organization, Sexually Transmitted Diseases, 2001, 28(8): 477-483.