Abstract
To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.
Community health centers can serve as a key health care venue for the provision of quality sexual and reproductive health care services for persons in medically underserved communities. They are public or nonprofit, community-directed health care facilities that increase access to care for persons who experience barriers to quality health care, such as their inability to pay, geographic location, or language or cultural differences.1
With increasing closure of sexually transmitted disease (STD) clinics throughout the United States,2 greater provision of STD services in community settings will be important for protecting the sexual and reproductive health of men and women in minority populations with high prevalence of STDs and limited access to care.3,4 An important STD service is chlamydia testing for persons with symptoms or signs of infection and also for all asymptomatic sexually active women aged 25 years or younger annually, as recommended by the Centers for Disease Control and Prevention and other organizations.5–7 An untreated chlamydial infection can result in serious complications, including pelvic inflammatory disease, infertility, or ectopic pregnancy.8–10 We estimated the proportion of visits made by women to community health centers, physician offices, and outpatient clinics with a chlamydia screening or diagnostic test.
METHODS
We analyzed data from the 2006 to 2009 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Methods used in the design, conduct, and analysis of these surveys are fully described elsewhere.11,12 Both surveys collected abstracted visit data from patient medical records. The National Hospital Ambulatory Medical Care Survey response rate was approximately 60%; the National Ambulatory Medical Care Survey response rate was about 80%. Clinics were designated as community health centers according to the Health Resources and Services Administration,1 and outpatient clinics were owned and operated by hospitals.9
We estimated the mean annual number of visits made by nonpregnant women aged 15 to 25 years to community health centers, physician offices, and outpatient clinics during 2006 to 2009 by patient age, race/ethnicity, US geographic region, source of payment, provider or clinic specialty, presence or absence of chlamydial symptoms, and type of reproductive health service. Symptomatic visits were identified with International Classification of Diseases, Ninth Revision, codes13,14 and included visits for pelvic inflammatory disease, cervicitis, vaginitis, vulvitis, endometritis, vaginal discharge or other vaginal symptoms, dyspareunia, pelvic or abdominal pain, postcoital or irregular vaginal bleeding, urinary symptoms, and STD symptoms.6,13 We also estimated the frequency of chlamydia testing at these visits. If too few visits were sampled to provide a robust estimate of chlamydia testing, we calculated it by subtracting the proportion of visits without a test from the total visits. With the χ2 test, a 2-sided P value less than .05 was considered statistically significant in bivariate analyses. Characteristics that were statistically significant in bivariate analyses were included in a multivariate logistic regression analysis of chlamydia testing. All analyses were conducted with SAS version 9.2 (SAS Institute, Cary, NC) and SUDAAN version 10.0.1 (Research Triangle Institute, Research Triangle Park, NC).
RESULTS
During 2006 to 2009, 1.75 million annual visits were made to community health centers, 45.05 million to physician offices, and 7.07 million to outpatient clinics (Table 1). Among visits to community health centers, 63.9% were made by women in minority populations (P < .001). Women with Medicaid made a higher proportion of visits to community health centers (53.7%) and to outpatient clinics (41.2%) than to physician offices (18.8%; P < .001), where patients with private insurance made 65.3% of the visits. A greater proportion of visits were made to community health centers for preventive care (33.2%) than to physician offices (23.2%) or to outpatient clinics (26.8%) (P < .01).
TABLE 1—
Mean Annual Visits to Community Health Centers, Physician Offices, and Outpatient Clinics by Nonpregnant US Women Aged 15–25 Years: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2006–2009
| Characteristic | Community Health Centers, No.a (%) | Physician Offices, No.a (%) | Outpatient Clinics, No.a (%) | P |
| Total | 1 751 800 | 45 046 200 | 7 066 000 | |
| Age, y | ||||
| 15–19 | 674 920 (38.5) | 21 023 080 (46.7) | 3 164 220 (44.8) | <.05 |
| 20–25 | 1 076 880 (61.5) | 24 023 120 (53.3) | 3 901 780 (55.2) | |
| Race/ethnicity | ||||
| White, non-Hispanic | 633 150 (36.1) | 31 478 060 (69.9) | 3 897 810 (55.2) | <.001 |
| Black, non-Hispanic | 453 270 (25.9) | 5 745 010 (12.8) | 1 693 640 (24.0) | |
| Hispanic | 558 690 (31.9) | 5 660 210 (12.6) | 1 158 320 (16.4) | |
| Otherb | 106 700 (6.1) | 2 162 920 (4.8) | 316 230 (4.5) | |
| Geographic region | ||||
| Northeast | 508 290 (29.0) | 8 354 890 (18.5) | 1 833 330 (25.9) | <.001 |
| Midwest | 309 360 (17.7) | 9 500 750 (21.1) | 2 363 910 (33.5) | |
| South | 440 650 (25.1) | 18 082 900 (40.1) | 1 985 700 (28.1) | |
| West | 493 500 (28.2) | 9 107 660 (20.2) | 883 070 (12.5) | |
| Source of payment | ||||
| Private insurance | 218 360 (12.5) | 29 424 900 (65.3) | 2 544 770 (36.0) | <.001 |
| Medicaid/SCHIP | 940 060 (53.7) | 8 454 450 (18.8) | 2 914 490 (41.2) | |
| Uninsuredc | 309 890 (17.7) | 2 948 340 (6.5) | 861 720 (12.2) | |
| Otherd | 283 500 (16.2) | 4 218 500 (9.4) | 745 020 (10.5) | |
| Provider specialty | ||||
| Primary care | 1 266 300 (72.3) | 23 888 540 (53.0) | 4 431 030 (62.7) | <.001 |
| Gynecology | 448 630 (25.6) | 8 693 320 (19.3) | 1 666 880 (23.6) | |
| Other | 36 870e (2.1) | 12 464 340 (27.7) | 968 100 (13.7) | |
| Chlamydia symptomsf | ||||
| Yes | 281 300 (16.1) | 5 997 940 (13.3) | 977 750 (13.8) | .44 |
| No | 1 470 500 (83.9) | 39 048 260 (86.7) | 6 088 250 (86.2) | |
| Pelvic examination | ||||
| Yes | 298 200 (17.0) | 6 463 380 (14.3) | 1 008 060 (14.3) | .60 |
| No | 1 453 600 (83.0) | 38 583 830 (85.7) | 6 057 950 (85.7) | |
| Papanicolaou test | ||||
| Yes | 168 330 (9.6) | 3 780 490 (8.4) | 556 410 (7.9) | .59 |
| No | 1 583 470 (90.4) | 41 265 710 (91.6) | 6 509 590 (92.1) | |
| Urinalysis | ||||
| Yes | 267 270 (15.3) | 4 861 360 (10.8) | 1 056 670 (15.0) | <.01 |
| No | 1 484 530 (84.7) | 40 184 840 (89.2) | 6 009 330 (85.0) | |
| Chlamydia test | ||||
| Yes | 105 270 (6.0) | 1 443 470 (3.2) | 386 340 (5.5) | <.001 |
| No | 1 646 530 (94.0) | 43 602 730 (96.8) | 6 679 660 (94.5) |
Note. SCHIP = State Children’s Health Insurance Program.
Weighted for the probability of selection, nonresponse rate, and population ratio.
Asian, Hawaiian/Pacific Islander, American Indian/Alaskan Native, and multiple races.
Self-pay or no charge for visit.
Medicare, worker’s compensation, and other or unknown.
Estimate based on < 30 records or with a relative SE > 30%.
Mucopurulent cervicitis, pelvic inflammatory disease, abnormal vaginal discharge, dyspareunia, postcoital bleeding, abnormal vaginal bleeding, or dysuria.
Diagnostic chlamydia testing rates were 16.4% at symptomatic visits to community health centers, 14.9% at outpatient clinics, and 8.8% at physician offices (P < .05; Table 2). At asymptomatic visits, 4.0% were tested in community health centers, 2.3% in physician offices, and 3.9% in outpatient clinics (P < .05). Black, non-Hispanic women were more likely to be tested at visits to community health centers (8.9%) and outpatient clinics (8.0%) than at physician offices (3.7%; P < .05). At a visit when a Papanicolaou test was performed, chlamydia screening was also done at 36.5% of visits to community health centers, 24.9% of visits to physician offices, and 35.7% of visits to outpatient clinics (P < .05). Screening rates were higher at visits to gynecology providers than at visits to primary care or other providers. After we controlled for several variables, including women’s race/ethnicity, chlamydia testing was more likely at visits to outpatient clinics (Table 3).
TABLE 2—
Chlamydia Testing Rates of Symptomatic and Asymptomatic US Women Aged 15–25 Years at Community Health Centers, Physician Offices, and Outpatient Clinics: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2006–2009
| Community Health Centers |
Physician Offices |
Outpatient Clinics |
|||||
| Characteristic | Visitsa | Chlamydia Test,a No. (%) | Visitsa | Chlamydia Test,a No. (%) | Visitsa | Chlamydia Test,a No. (%) | P |
| Symptomaticb visits | |||||||
| Subtotal | 281 300 | 46 230 (16.4) | 5 997 940 | 530 130 (8.8) | 977 750 | 145 150 (14.9) | <.05 |
| Reproductive health care servicec | 39 580 | 25 630 (64.8) | 968 120 | 290 130 (30.0) | 140 890 | 58 700 (41.7) | .11 |
| Asymptomatic visits | |||||||
| Subtotal | 1 470 500 | 59 040 (4.0) | 39 048 260 | 913 340 (2.3) | 6 088 250 | 241 200 (4.0) | <.05 |
| Race/ethnicity | |||||||
| White, non-Hispanic | 568 610 | 3210 (0.6) | 27 340 070 | 539 070 (2.0) | 3 408 400 | 70 730 (2.1) | .07 |
| Black, non-Hispanic | 350 400 | 31 140 (8.9) | 4 912 890 | 182 960 (3.7) | 1 398 150 | 111 550 (8.0) | <.05 |
| Hispanic | 459 960 | 22 520 (4.9) | 4 823 250 | 134 630 (2.8) | 995 100 | 35 980 (3.6) | .62 |
| Other | 91 540d | 2160 (2.4) | 1 972 050 | 56 690 (2.9) | 286 600 | 22 940 (8.0) | .09 |
| Provider specialty | |||||||
| Primary care | 1 068 930 | 21 700 (2.0) | 20 640 170 | 331 620 (1.6) | 3 810 110 | 87 750 (2.3) | .45 |
| Gynecology | 373 940 | 37 340 (10.0) | 6 459 870 | 581 720 (9.0) | 1 338 290 | 153 250 (11.5) | .51 |
| Other | 27 630d | 0 (0) | 11 948 230 | 0 (0) | 939 850 | 200 (0.02) | .38 |
| Reproductive health care servicec | |||||||
| Pelvic examination | 213 420 | 47 310 (22.2) | 4 352 380 | 670 180 (15.4) | 697 380 | 154 960 (22.2) | .09 |
| Papanicolaou test | 128 760 | 46 960 (36.5) | 2 812 370 | 699 380 (24.9) | 415 520 | 148 400 (35.7) | <.05 |
| Urinalysis | 168 610 | 25 220 (15.0) | 3 285 220 | 333 410 (10.1) | 704 210 | 106 230 (15.1) | .38 |
Weighted for the probability of selection, nonresponse rate, and population ratio.
Mucopurulent cervicitis, pelvic inflammatory disease, abnormal vaginal discharge, dyspareunia, postcoital bleeding, abnormal vaginal bleeding, or dysuria.
Pelvic examination, Papanicolaou test, or urinalysis.
Estimates based on < 30 records or with a relative SE > 30%.
TABLE 3—
Multivariate Logistic Regression Analysis of Chlamydia Testing of US Women Aged 15–25 Years at Visits to Community Health Centers, Physician Offices, and Outpatient Clinics: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2006–2009
| Characteristic | Visits With a Chlamydia Test,a % | AOR (95% CI) |
| Symptomaticb visits | ||
| Yes | 9.9 | 3.09 (2.03, 4.70) |
| No (Ref) | 2.6 | 1.00 |
| Race/ethnicity | ||
| White, non-Hispanic (Ref) | 2.6 | 1.00 |
| Black, non-Hispanic | 7.2 | 2.25 (1.41, 3.57) |
| Hispanic | 4.4 | 1.59 (1.00, 2.53) |
| Other | 4.7 | 2.14 (1.03, 4.46) |
| Papanicolaou test | ||
| Yes | 28.2 | 25.63 (17.35, 37.87) |
| No (Ref) | 1.4 | 1.00 |
| Health care venue | ||
| Physician office (Ref) | 3.2 | 1.00 |
| Community health center | 6.0 | 1.61 (0.93, 2.80) |
| Outpatient clinic | 5.5 | 1.82 (1.33, 4.46) |
Note. AOR = adjusted odds ratio; CI = confidence interval.
Weighted for the probability of selection, nonresponse rate, and population ratio.
Mucopurulent cervicitis, pelvic inflammatory disease, abnormal vaginal discharge, dyspareunia, postcoital bleeding, abnormal vaginal bleeding, or dysuria
DISCUSSION
Chlamydia testing can prevent pelvic inflammatory disease in young women,9,10 but too few women are tested.13,15–17 Our findings of suboptimal testing rates confirmed the results of other studies that found underuse of chlamydia testing in women with symptoms or signs of chlamydial infection and in asymptomatic women. Compared with physician offices, community health centers and outpatient clinics had higher rates of both diagnostic testing and asymptomatic screening for chlamydia during gynecological procedures, but these rates also were too low. Achieving recommended testing coverage of all sexually active young women is challenging, and interventions are needed to improve implementation of this important reproductive health preventive service.
Providers in community health centers are poised to serve the health care needs of an increasing number of men and women. The community health center is a health care setting that is expected to double its capacity to serve 40 million patients over the next several years.18 Community health centers provide quality primary and preventive health care services for medically underserved areas and populations that have historically had poor access to care.1,18,19 Community health centers will likely become an increasingly important health care setting for provision of sexual and reproductive health care services and will play a more important role in STD prevention and control by serving populations that were previously uninsured and populations that have high rates of reported STD morbidity.
Human Participant Protection
Survey protocols were approved by the Centers for Disease Control and Prevention’s National Center for Health Statistics Research Ethics Review Board.
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