The author reports no conflict of interest or relevant financial relationships.
Principles & Practice
A Practice Improvement Intervention Increases Chlamydia Screening Among Young Women at a Women's Health Practice
Article first published online: 26 NOV 2012
© 2012 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses
Journal of Obstetric, Gynecologic, & Neonatal Nursing
Volume 42, Issue 1, pages 81–90, January/February 2013
How to Cite
Kettinger, L. D. (2013), A Practice Improvement Intervention Increases Chlamydia Screening Among Young Women at a Women's Health Practice. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 81–90. doi: 10.1111/j.1552-6909.2012.01427.x
- Issue published online: 14 JAN 2013
- Article first published online: 26 NOV 2012
- Manuscript Accepted: SEP 2012
- chlamydia trachomatis;
- practice change;
- quality improvement;
- women's health
Annual chlamydia trachomatis screening of all sexually active women younger than age 26 is a recommended standard practice. Yet most women are not being tested. The author describes a successful practice change intervention to increase routine chlamydia screening rates in a women's health primary care setting. Screening rates increased from 53.4% to 76.1% following the intervention. Results suggest a combination of education, provider feedback, and clinic prompts can influence chlamydia screening behavior among providers.
Chlamydia trachomatis (chlamydia) is the most common curable sexually transmitted infection in the United States. Age is a significant risk factor among women. Chlamydia infection is most prevalent among sexually active adolescent and young women younger than age 26 (Centers for Disease Control [CDC], 2009). Only a small percentage of women with chlamydia infection are symptomatic (CDC, 2010). Without routine testing for chlamydia, many infected women are undetected and untreated, leading to long-term, costly reproductive complications, such as pelvic inflammatory disease, and increased rates of disease transmission.
Chlamydia is easily detected (either with urine or endocervical specimens) and treated; screening is cost-effective (Hu, Hook, & Goldie, 2004). Routine screening potentially preserves reproductive health by preventing pelvic inflammatory disease (PID) and its long-term sequelae of infertility, ectopic pregnancy, and chronic pelvic pain (Maloney & Johnson, 2008). If 90% of eligible young women were screened and treated for chlamydia, 30,000 cases of PID would be prevented each year (National Commission on Prevention Priorities, 2007). Routine annual screening of women younger than age 25 is a top 10 recommendation of the U.S. Preventive Services Task Force, yet less than 60% of women in this age group are screened (CDC, 2011).
Opportunities for screening young women should be greatest when they seek well-woman care, because most preventive visits include a pelvic exam and a Papanicolaou (Pap) test, procedures where cervical specimens for chlamydia testing can be easily obtained. However, in a recent study by Hoover and Tao (2008) using data from nationally representative samples of U.S. hospital outpatient clinics and physicians, very low screening rates were found among women age 15 to 25. Chlamydia testing was conducted at only 16% of preventive visits to obstetrician/gynecologists and at only 23% of those visits that included a Pap test. The American College of Obstetricians and Gynecologists (2010) recommended that women have their first Pap no earlier than age 21 and women in their twenties have a Pap test every 2 years instead of annually. Therefore, fewer females age 25 and younger are receiving pelvic exams at preventative visits. Urine chlamydia testing is an effective method for screening at such visits.
Women's health clinics offer opportunities for recommended annual chlamydia screening, yet many providers are not screening.
Many provider and patient barriers are reported that contribute to the noncompliance of recommended guidelines for chlamydia screening. Providers may not be aware of screening recommendations or the high rates of chlamydia among young women or be knowledgeable about state laws that allow screening without parental consent; they may not be comfortable assessing sexual risks or see chlamydia as a significant medical priority (Hoover & Kent, 2009). Adolescents may not request testing due to costs or confidentiality concerns or may not admit to providers they are sexually active (Shafer et al., 2002). Increasing the number of providers that implement routine chlamydia screening of young women is a primary goal of the CDC and the National Chlamydia Coalition's chlamydia prevention plans (CDC, 2011). Effective strategies and tools are needed to overcome these barriers to screening that are practical, easy to implement, and time efficient for busy primary care settings.
Evidence suggests the most effective strategies to change clinical practice for several health prevention areas involve a multifaceted systems approach to overcome provider-level barriers such as reminder prompts and provider education combined with performance measurement and feedback (Maciosek et al., 2006; Shafer et al., 2002). Studies suggest that interventions to increase chlamydia screening rates among sexually active women younger than age 26 can be effective in primary care settings, including women's health primary care settings (Guy et al., 2011). Interventions that involve changing clinic procedures (e.g., exam room reminders, use of urine tests), use of clinic “champions” or screening facilitators, and a team-based quality improvement approach appear to have a greater impact on increasing screening rates.
For example, an obstetrics and gynecology (OB/GYN) department of a large managed care organization increased its chlamydia screening rate of women age 15 to 26 from 55% to 72% by implementing a simple, systems-level policy to place an endocervical swab alongside a Pap test in the examination room (Burstein et al., 2005). In comparison, primary care clinics in the organization received only provider training and recommended screening guidelines and did not see significant increases in the proportion of young women screened (30%–32%).
Armstrong, Kinn, Scoular, and Willson (2003) found the introduction of a health adviser whose role was to raise awareness of chlamydia and to train staff on chlamydia screening guidelines increased the number of chlamydia tests during the period the advisor was present (n = 335) compared to the preceding year (n = 152). However, much of the increase was in patients older than age 24 (46%), and only 11% of the increase was in patients age 15 to 19. McNulty, Freeman, Oliver, Ford-Young, and Randall (2008) used semistructured telephone interviews to explore strategies to increase chlamydia screening in general practice. Their findings suggested a key factor determining high screening rates within a practice was a designated screening coordinator who advances the screening process and maintains motivation of other practice staff.
In a randomized case-control study by Shafer et al. (2002), an adolescent pediatric clinic adopted multicomponent strategies found effective in changing clinical practice. They tested a clinical practice improvement intervention designed to increase chlamydia screening by using urine-based tests for sexually active adolescent girls during routine checkups at pediatric clinics in a large health maintenance organization (HMO). Intervention clinics increased chlamydia screening among girls age 14 to 18 from 47% to 65%, compared to an increase of only 17% to 21% in the control clinics. The intervention included a skills-building workshop for all clinic staff, implementation of a quality improvement change model, and the development of a practice toolkit. The tools included a customized clinic flowchart, exit polls, and patient education/campaign materials.
The North Carolina Blue Cross Blue Shield organization piloted a systems-level, quality improvement approach in three large OB/GYN practices in 2004 to increase chlamydia screening rates (BlueCross BlueShield of North Carolina [BCBSNC], 2006). A quality improvement team incorporated similar strategies described in the above-published studies including determining baseline screening rates, disseminating national screening guidelines to all clinicians, selecting a physician champion to lead discussions at staff meetings, identifying barriers and solutions and setting screening target goals, developing and sharing a screening policy, placing chlamydia specimen collection items next to Pap test collection kits, providing patient education materials to young women on chlamydia and routine testing recommendations, and measuring progress and providing feedback. Program evaluation found an overall 138% increase in routine chlamydia screening rates after one year. The average chlamydia screening rate among the intervention practices was 53% compared to 22% among three comparison practices.
These studies and the North Carolina BlueCross BlueShield report suggest systems-level interventions can increase chlamydia screening rates in clinic and office practices. The studies conducted in large HMOs (Burstein et al., 2005; Shafer et al., 2002) may not be generalized to other settings, such as smaller office practices or hospital-based clinics. These authors did not explore (or report) reasons why women did not get screened, for example, were the reasons provider based, patient based, or systems based, such as cost of testing or third-party payment issues? These insights can be helpful to guide researchers and practitioners in designing intervention strategies and setting realistic target screening goals.
A quality improvement process was used to evaluate providers’ practice of offering routine chlamydia screening among sexually active women younger than age 26 who are receiving annual preventive care services in a women's health practice setting. This article describes a quality improvement process to evaluate an intervention designed to increase providers’ adherence to recommended chlamydia screening guidelines. The question guiding this study was “Will a tailored, multicomponent practice intervention result in increased routine chlamydia screening for eligible women?” Although this population is also at risk for gonorrhea and other sexually transmitted infections (STIs) this intervention focused on chlamydia based on known low screening rates in the clinic and high prevalence rates among young women.
Successfully changing practice behavior involves a team effort among providers and clinic staff, flexibility and willingness to change, and interventions tailored to each practice (Dietrich, Woodruff, & Carney, 1994; Goodwin et al., 2001). The preventive care-focused goal setting/assessment/plan/start-up (GAPS) model incorporates these concepts (Dietrich et al.) and has been successfully applied to develop a practice-based intervention to increase breast and cervical cancer screening services (Backer, Geske, McIlvain, Dodendorf, & Minier, 2005). The approach is a four-step continuous quality improvement method: goal setting regarding preventive care, assessment of current preventive care processes and level of goal attainment, planning to modify existing routines and to implement improved routines that support preventive care, and starting and maintaining the improved practices. The GAPS approach was applied to increase routine chlamydia screening. Providers and nursing staff at a women's health clinic were engaged in each step: goal setting to achieve routine chlamydia screening, assessing current screening rates and clinic processes, planning to modify existing screening practices, and providing support for providers’ improved practices.
Routine chlamydia screening rates increased 42.7% during the 5 months after the intervention, 45.5% more women were tested, and more infections were detected.
This preintervention/postintervention quality improvement project was based on quantitative data from medical records to measure changes in the practice's chlamydia screening rates from baseline and at 5 months following the intervention. The study protocol was approved by the Medical University of South Carolina Institutional Review Board.
The study site was a university faculty outpatient women's health clinical practice in the southern region of the United States between July 2011 and March 2012. The faculty practice sees patients with private insurance and self-pay (a separate resident clinic sees Medicaid patients, not included in this study). An average of 125 patients younger than age 26 is seen per month, of which 22% present for annual or preventive visits. A preliminary assessment with practice site providers to determine their interest in participating was conducted prior to program implementation. Initial inquiries with medical staff indicated most providers were not implementing routine chlamydia screening for young women. Some providers were unaware of national guidelines for routine chlamydia testing in young women, whereas other providers expressed that because the majority of patients at the clinic have private insurance, they did not believe that the young women seen at this particular clinic were at high risk for chlamydia infection and therefore did not believe annual testing was worth the extra cost to the patient. The clinic included 10 providers (seven physicians and three certified nurse-midwives), two registered nurses, three licensed practical nurses, and three certified nursing aides. The author was the study coordinator and led the planning and delivery of the intervention and conducted postintervention monitoring and feedback with providers.
The target study population for chlamydia screening was selected based on the CDC's national guidelines for chlamydia screening. The specific inclusion criterion for screening included sexually active females age 25 and younger seeking annual preventive and routine reproductive care services at the practice. Women were excluded as eligible for screening if they were age 26 or older, or were not sexually active. Pregnant women or those who intended to become pregnant were also excluded from this study. Sexual activity was defined as currently or having ever in the past engaged in vaginal, oral, or anal intercourse.
Data were collected via retroactive chart review to assess the practice's preintervention chlamydia screening rates of females younger than age 26. An initial meeting with medical and nursing staff was held to describe the purpose of the study, examine the current screening practices, and identify issues of concern specific to the practice and potential solutions. Barriers to chlamydia screening at the clinic were identified, and a plan to address and resolve barriers was discussed. Training needs were also determined. The clinic's nurse manager was selected as the liaison-champion and was responsible for scheduling training and implementation meetings and providing feedback on screening progress and barriers.
Providers received a 1-hour educational in-service where the recommended guidelines for chlamydia screening were reviewed, the rationale and feasibility of routine screening were discussed, as well as current screening practices and potential barriers. Study materials were provided that included screening guidelines, a practice-specific screening procedure and flowchart, and information on several different chlamydia testing methods.
Nursing Staff Education
A separate in-service and meeting was held for the clinic nursing staff. Topics included current recommended screening guidelines, how to overcome screening barriers, how to identify the target population based on age, sexual activity, and risk behaviors, and feasible testing methods (e.g., urine or endocervical swab) based on the patient, in-house procedures, and the type of office visit. Patient education strategies and materials were provided. The study champion, who was the clinic's nurse manager, was introduced and her role explained. Methods of how to remind or encourage providers to include a chlamydia test with the routine pelvic exam or to utilize the urine-based chlamydia test when pelvic exams were not performed were determined and implemented.
Site Screening Policy
A screening policy was put in place to flag women younger than age 26 and to assess chlamydia risks and screening inclusion criteria (Figure 1). The policy stated that all sexually active females age 25 and younger seeking annual or preventive clinical services including oral contraceptive evaluation, Pap smears, or routine testing for STIs meet the screening inclusion criteria and should be tested for chlamydia during the office visit. Screening packets were placed at each of the nursing vitals stations, where women were taken prior to entering the examination room. Packets included a neon orange note to flag providers, lab requisition form for the genital swab testing kit and urine specimen collection, and the most recent CDC chlamydia fact sheet (provided by the CDC). Nurses identified eligible women based on age and visit type upon check-in and screening packets with the flag were placed outside the door of the examination room to notify providers prior to entering the room. Nursing staff provided patients with educational materials and discussed chlamydia risks and testing procedures. The testing method was selected based on the reason for the office visit; for example, for women having a vaginal examination the nurse placed a chlamydia swab for specimen collection next to Pap test kits, and if a vaginal examination was not indicated during the visit, a urine specimen was collected.
Follow-up meetings with the study liaison/nurse manager and clinic staff occurred at 6, 10, and 14 weeks following the intervention to provide feedback on screening rates and discuss successes or problems with screening implementation. Screening barriers were identified through observation and dialogues with providers and clinic staff. Weekly visits were made during Weeks 12 to 17 postintervention to observe screening progress and meet with providers individually to provide additional education on guidelines, urine testing procedures, and discuss screening costs.
Measures and Data Collection
The primary outcome measure was the proportion of total eligible women who were offered routine chlamydia screening by all providers. Secondary measures included the proportion of women who declined a chlamydia test when offered and the proportion of women with a positive test. Data from the medical record were used pre- and postintervention to determine the patient's eligibility, including age and sexual activity. Chlamydia screening was counted if there was documentation that the test had been ordered or if the provider had recommended the test but the patient had declined.
Preintervention chlamydia screening data collection was obtained by retrospective chart review of all females younger than age 26 seen at the clinic practice for preventive services from March 1, 2011 to July 31, 2011. A report was generated of all women younger than age 26 seen at the practice during the 5-month preintervention period. Charts were then reviewed to filter patients by type of visit: annual preventive maintenance exams (APME), new gynecologic visits to establish care, initiation of family planning services, and routine contraception counseling visits were included as preventive care visits. All obstetrical visits and problem visits were excluded. Additional data collected included: age/date of birth, date of service, past history of chlamydia infection, type of test (urine/endocervical swab), test results (positive/negative), and the provider seen at the visit. If documented in the medical record, those who requested testing, declined testing, and marital/relationship status were obtained.
The launch of the intervention took place in late September 2011 and was completed by mid-October 2011. The data collection period for post-intervention screening was from mid-October 2011 to mid-March 2012. Postintervention data were collected by chart review of all women younger than age 26 served by all providers during the postintervention period following the same steps as preintervention data collection. The author conducted chart reviews and collected the pre- and postintervention data.
The screening rate was calculated as the number of patients offered chlamydia screening (numerator) and the number of eligible sexually active women younger than age 26 seen at the practice (denominator) for the specific time intervals of study. Pre- and postintervention chlamydia screening rates were statistically analyzed to determine change in clinical practice and adherence to recommended chlamydia screening guidelines. Screening rates were also analyzed by age to determine differences among adolescents and young adult women, as providers’ perceptions of barriers related to cost, confidentiality, and insurance coverage status could influence their screening practices. The statistical significance of differences in the estimates of the pre- and postintervention screening rates was compared using chi-squared. All tests of significance were evaluated at the p < .05 level. Analyses were conducted using SPSS (Version 20.0.1) for Windows.
A combination of tailored education, monitoring and feedback, and leadership efforts involving office nurses can effectively change screening practices in women's health clinics.
There were 133 medical records for the preintervention analysis and 130 for the postintervention (Table 1). During the preintervention period 53.4% (71) of 133 eligible females were screened for chlamydia versus 76.1% (99) of 130 eligible in the postintervention period (p = .021). During the preintervention period 44.4% (59/133) received testing and 9% (12/133) declined testing (Figure 2). The postintervention testing rate was 64.6% (84/130) with 11.5% (15/130) that declined. The chlamydia infection rate in the preintervention group was 3.4% (two positive test results out of 59 tests). In contrast, the infection rate was 7.1% in the postintervention group (six positive test results out of 84 patients that received testing).
|Patients seen by age (years)|
|Screened by age (years)|
|Screened in age (years) group|
|History of chlamydia infection||9||6.8||9||6.9|
|% Not screened in relationship||22||35.5||15||48.3|
The statistical analysis reflects the overall clinic's screening practice change among all providers. Assessing practices by individual provider may be useful for follow-up efforts. Although not statistically analyzed, of the nine providers that were present during pre- and postintervention only one provider had no increase in screening rates (six improved rates postintervention and two had 100% screening rates before and after intervention). Age characteristics of women screened remained fairly consistent for pre- and postintervention with the highest percentage of those screened between age 22 and 23 for both groups (Figure 3). The 24- to 25-year-old group makes up the largest percentage of those seen for annual or preventive services at the practice (41% during preintervention and 40% during postintervention). Although not significant (p = >.05), the screening rates did increase in this age group with 31.3% in postintervention versus 26.8% in preintervention.
For nearly two decades, routine chlamydia screening of young women has been a priority intervention to prevent serious reproductive health consequences if untreated. Many free resources and toolkits exist to educate and guide providers on how to integrate screening in their practice (Maloney & Johnson, 2008; National Committee for Quality Assurance [NCQA], 2007). Despite national guidelines and available practice resources, providers are not routinely screening women. This study confirms results of previous studies demonstrating that a multicomponent intervention applied using a quality improvement process can be effective in changing practice behavior related to preventive services in general (Backer et al., 2005; Deitrich et al., 1994) and specifically chlamydia screening in women's health care settings (Burstein et al., 2005; Guy et al., 2011). Overall, routine chlamydia screening rates increased 42.7% during the 5 months after the intervention, 45.5% more women were tested, and more infections were detected and treated. The proportion of women screened (76.1%) in this women's health practice setting is similar to postintervention rates achieved in other studies occurring in similar clinics (e.g., BCBSNC, 2006; Burstein et al.).
Although provider education alone may not be sufficient to change practice, education is a key component in group sessions and individual meetings to tailor the screening protocol and address barriers or misconceptions. For example, with recent changes in national guideline recommendations to defer Pap tests in women until age 21, providers need to be aware of the benefits and ease of use of urine chlamydia testing. Yet many providers are either unaware of urine testing or are skeptical about the sensitivity and specificity of this method, including some providers in this study. After educating providers about the urine test, the use of urine testing increased from 8.5% (5/59) in the preintervention to 17.9% (15/84) in the postintervention period; however, only three of 10 providers were utilizing this method in the postintervention period (compared to one in the preintervention).
A designated staff person needs to provide ongoing monitoring and feedback to identify gaps and adjust study screening criteria or obtain additional information. For example, females age 24 to 25 comprised the majority of women younger than age 26 seen for annual or preventative services at the practice but also represented the largest cohort of missed opportunities for screening in the pre- and postintervention periods. Why were providers not screening this age group? In this study, women younger than age 26 qualified for screening according to the CDC's national guidelines. However, the U.S. Preventive Services Task Force recommended chlamydia screening for women age 24 years and younger. It is possible that these differing recommendations create inconsistent screening practices among women age 24 to 25, or perhaps providers do not find this age at high risk for infection. In this study, women age 24 to 25 represented 58.1% (36/62) of those not screened preintervention and 67.7% (21/31) postintervention. Feedback to providers can result in modifying the age protocol to address this discrepancy.
Relationship status is also a factor that may have influenced provider screening practices at this clinical practice, especially among women age 24 to 25. The proportion of women in a stable relationship or married who were not screened was 35.5% (22/62) in the preintervention period and 48.3% (15/31) postintervention. Further, of all women not screened during postintervention, 67.7% (21/31) were between age 24 to 25 and 61.9% (13/21) reported themselves as either married or in a stable relationship. National guidelines recommend routine chlamydia screening for all women younger than age 26 regardless of relationship status. Providers may consider women who are either married or in stable relationships at low risk of chlamydia infection. Specific training on how providers can inform women of the need for screening regardless of relationship status needs to be incorporated.
Another factor influencing chlamydia screening at this practice was related to patient copay amounts under different insurance plans and self-pay costs, and the need for providers to know test costs when communicating with patients. Although the Medicaid-eligible population has coverage for chlamydia screening recommended in national guidelines, women with private insurance may not have coverage or may be unable or unwilling to pay the copay for preventative services. Providers did not know the various copay costs, thus to sustain practice changes, staff should prepare cost information so providers can better inform women of test costs in order for them to decide to accept or decline the test.
The positive results in this study may not be generalizable to other settings, such as smaller practices or those in rural areas. In addition, though the increased change in the overall screening rate was statistically significant, there was a relatively small sample size and only a 5-month postintervention period. It is unknown if these initial increased rates will be sustained over time. Finally, the increased results reflect screening behaviors of the entire practice. Of the nine providers present during the pre- and postintervention time period, only one provider did not improve screening rates. Insufficient sample size for each provider did not allow for statistical analysis to determine if there was a significant increase to reflect differences in individual provider behavior postintervention. There were 10 providers providing services in each period; whereas nine providers were consistent, one left the practice and a new provider was hired during the study period. Opportunity to offer routine screening was not equal between providers, as they all work various schedules; some worked 3 days a week and some only 1 day. A longer evaluation period and greater sample size is needed to evaluate individual provider change in screening practice, which could facilitate follow-up feedback and education to address barriers for individual providers.
This project offers several implications and insights for other practices desiring to increase chlamydia screening rates. This project applied the GAPS model, a type of quality assurance process, beginning with an assessment of how the practice was doing with respect to recommended routine chlamydia screening; setting a goal for improved screening; assessing existing routines; identifying and alleviating barriers to increase screening rates; and providing support for these improvements. The practice set a general goal of “improving rates” given the short duration for measuring postintervention change. Other practices may set smaller, more specific goals in time increments over a longer period of time, which may be important for sustaining higher screening rates.
Studies suggest the key role of an office champion/provider leader to effect change (e.g., McNulty et al., 2008). This was a key component in this study and suggests that nurse practitioners or nurses interested in changing provider practice should “seize” the opportunity where leaders exist to implement recommended chlamydia screening practices. The role of the champion was shared between the study coordinator, who led the planning and evaluation process, and the clinic nurse manager, who provided support scheduling initial meetings and ensured nurses “cued” eligible patients for chlamydia screening by flagging charts and placing the chlamydia swab next to the Pap test kit or placing urine testing materials out for providers.
This study highlights the role of nurses in the collaborative effort to change clinical practice with providers, nursing, and office staff. In addition to being a “champion,” nurses can facilitate change by keeping up with current clinical practice guidelines most applicable to their patient population. They should feel comfortable discussing with providers the current practices and potential changes that can improve the quality of care of their patients. Nurses can help identify young sexually active women at the beginning of the visit and remind providers that they should be screened for chlamydia.
Finally, though a detailed cost analysis of the intervention was not conducted, this intervention did not involve significant costs to the practice other than time for initial education and planning meetings, and time to review charts and monitor and provide feedback regarding progress toward meeting the screening goal. Patient education materials were obtained free from the CDC. Guidelines for providers to implement screening are also available free from the National Chlamydia Coalition.
Individualized practice interventions can be implemented in women's health practices that influence providers’ compliance with recommended chlamydia screening of young women. This study showed rapid improvement during 5 months following a multicomponent intervention. This type of practice improvement is most likely to be successful if the overall practice is motivated and receptive to changing screening practices, a local clinic facilitator serves as an advocate to monitor and provide feedback with individual providers, and a team approach is used.
The author thanks Sharon Bond, PhD, CNM and Lynda Kettinger, MPH.
- American College of Obstetricians and Gynecologists. (2010). Cervical cancer in adolescents: Screening, evaluation, and management. Committee Opinion No. 463. Obstetrics & Gynecology, 116, 469–472.
- 2003). Shared care in the management of genital chlamydia trachomatis infection in primary care. Sexually Transmitted Infections, 79(5), 369–370. , , , & (
- 2005). Improving female preventive health care delivery through practice change: An every woman matters study. Journal of American Board of Family Medicine, 18, 401–408. , , , , & (
- BlueCross BlueShield of North Carolina. (2006). Evidence-based steps for increasing chlamydia screening at your practice. Retrieved from http://www.bcbsnc.com
- 2005). Chlamydia screening in a health plan before and after a national performance measure introduction. Obstetrics & Gynecology, 106, 327–334. , , , , , , & (
- Centers for Disease Control and Prevention (CDC). (2009). Sexually transmitted diseases surveillance, 2009: Table 10. Retrieved from http://www.cdc.gov/std/stats09/tables/10.htm
- Centers for Disease Control and Prevention (CDC). (2010). Sexually transmitted diseases treatment guidelines. Morbidly and Mortality Weekly Report, 59(12), 1–116.
- Centers for Disease Control and Prevention (CDC). (2011). CDC grand rounds: Chlamydia prevention: Challenges and strategies for reducing disease burden and sequelae. Morbidly and Mortality Weekly Report, 60(12), 370–373.
- 1994). Changing office routines to enhance preventive care: The preventive GAPS approach. Archives of Family Medicine, 3, 176–183. , , & (
- 2001). A clinical trial of tailored office systems for preventive service delivery: The study to enhance prevention by understanding practice (STEP-UP). American Journal of Preventive Medicine, 21, 20–28. , , , , , , … (
- 2011). Efficacy of interventions to increase the uptake of chlamydia screening in primary care: A systematic review. BMC Infectious Diseases, 11, 211. , , , , , , … (
- 2009). Missed opportunities for chlamydia screening. The Female Patient, 34(2), 10–11. , & (
- 2008). Missed opportunities for chlamydia screening of young women in the United States. Obstetrics & Gynecology, 111(5), 1097–1102. , & (
- 2004). Screening for chlamydia trachomatis in women 15 to 29 years of age: A cost-effectiveness analysis. Annals of Internal Medicine, 141(7), 501–513. , , & (
- 2006). Priorities among effective clinical preventive services: Results of a systematic review and analysis. American Journal of Preventive Medicine, 31, 52–61. , , , , , & (
- 2008). Why screen for chlamydia? An implementation guide for healthcare providers. Washington, DC: Partnership for Prevention. Retrieved from http://www.prevent.org/data/files/ncc/whyscreenforchlamydia_web25_8-13-10.pdf , & (
- 2008). Strategies used to increase chlamydia screening in general practice: A qualitative study. Public Health, 122(9), 845–856. , , , , & (
- National Commission on Prevention Priorities. (2007). Preventive care: A national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention. Retrieved from http://www.prevent.org/data/files/initiatives/ncpppreventivecare report.pdf
- National Committee for Quality Assurance. (2007). Improving chlamydia screening: Strategies from top performing health plans. Retrieved from http://www.ncqa.org/Portals/0/Publications/Resource%20Library/Improving_Chlamydia_Screening_08.pdf
- 2002). Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls. Journal of the American Medical Association, 288(22), 2846–2852. , , , , , , … (