Sexually Transmitted Infection Testing and Screening
in Hospital-Based Primary Care Visits by Women
Jill S. Huppert, MD, MPH, Elizabeth Goodman, MD, Jane Khoury, MS, and Gail Slap, MD, MS
OBJECTIVE: To explore determinants of sexually transmitted
infection screening of asymptomatic women and sexually
transmitted infection testing of women with genitourinary
symptoms, to investigate the effect of specific genitourinary
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symptoms on sexually transmitted infection testing, and to
examine trends in screening.
METHODS: We performed secondary data analysis of na-
tionally representative data from the National Hospital
Ambulatory Medical Care Surveys, using 17,458 visits by
nonpregnant 15- to 44-year-old women seen in primary
care clinics between 1997 and 2000. Point estimates, ad-
justed odds ratios (ORs) and 95% confidence intervals (CIs)
are presented.
RESULTS: Sexually transmitted infection screening was per-
formed in 2.4% of visits by women without genitourinary
symptoms and was more likely among visits for preventive
care (OR 6.9, CI 3.8 –12.5), by nonwhite women (OR 4.3,
CI 2.3–7.9), and in gynecology clinic (OR 3.9, CI 2.5– 6.1).
Sexually transmitted infection testing occurred in 13.2% of
visits by women with genitourinary symptoms and was
associated with Medicaid (OR 2.3, CI 1.4 –3.6), preventive
care (OR 2.0, CI 1.2–3.2), patient age less than 25 years (OR
1.7, CI 1.0 –2.6), and nonwhite race (OR 1.7, CI 1.0 –2.6).
Among symptomatic women, vaginal symptoms (OR 4.8,
CI 2.6 – 8.9) and abdominal/pelvic pain (OR 2.5, CI 1.4 –
4.5) were associated with sexually transmitted infection
testing. Between 1997 and 2000, sexually transmitted infec-
tion screening rates remained stable.
CONCLUSION: Despite national guidelines, sexually trans-
mitted infection testing outpaces screening. Few visits by
From the Division of Adolescent Medicine and the Division of General and
Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio; and the Heller School for Social Policy and Management, Brandeis Univer-
sity, Waltham, Massachusetts.
Supported by the National Research Service Award Fellowship Program (grant
1T32PE10027), a W. T. Grant Scholars Award from the William T. Grant
Foundation, and the Leadership in Adolescent Health Program, Maternal and
Child Health Bureau (grant MCJ 964).
Preliminary findings were presented in part at the Society of Adolescent Medicine
Annual Clinical Meeting, Seattle, Washington, March 21, 2003 (abstract pub-
lished in J Adolesc Health 2003;32:128 –129), and at the Annual Clinical
Meeting of The American College of Obstetricians and Gynecologists, New Orleans,
Louisiana, April 30, 2003.
VOL. 105, NO. 2, FEBRUARY 2005
390 © 2005 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
asymptomatic women under age 25 result in screening.
Strategies to improve screening in primary care should
target nongynecology settings and non–preventive care vis-
its. (Obstet Gynecol 2005;105:390 – 6. © 2005 by The
American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: III
Laboratory methods that can be used to identify individ-
uals who have sexually transmitted infections can be
employed for either screening or diagnosis. In epidemi-
ologic terms, screening accomplishes secondary preven-
tion of disease by detecting infection in asymptomatic
individuals. Diagnostic testing allows accurate diagnosis
and treatment of an established disease (tertiary preven-
tion). Both screening and testing are necessary compo-
nents of sexually transmitted infection control. Because
the majority of these infections are asymptomatic in
women, since 1996 national guidelines have recom-
mended annual screening for sexually transmitted infec-
tions in all sexually active women under the age of 25,
regardless of race/ethnicity or symptoms.1–3 In addition,
the Centers for Disease Prevention and Control (CDC)
recommend diagnostic sexually transmitted infection
testing for sexually active women with genitourinary
symptoms such as vaginal discharge, dysuria, dyspareu-
nia, abnormal bleeding, or signs of upper genital tract
disease.4,5
Despite the scientific evidence that drives these guide-
lines, adherence appears to be inadequate. Recent sur-
veys of primary care physicians in the United States
indicate that only 29 –54% routinely screen asymptom-
atic sexually active young women for Chlamydia trachoma-
tis, the most common sexually transmitted infection.6 – 8
In contrast, up to 97% of providers report testing symp-
tomatic young women.8 In the past, the need for a pelvic
examination was a barrier to sexually transmitted infec-
tion screening. Development of urine-based sexually
transmitted infection detection methods in the late 1990s
may have increased screening rates by eliminating the
need for a pelvic examination.
Our knowledge of individual provider sexually trans-
mitted infection screening and testing practice is limited.
0029-7844/05/$30.00
doi:10.1097/01.AOG.0000151129.47746.be
Prior studies are small, use unvalidated survey instru-
ments, and are limited by biases inherent in provider
self-reports. Although providers report that they are
more likely to obtain sexually transmitted infection tests
for symptomatic subjects, published studies do not de-
scribe whether specific symptoms (ie, those mentioned in
the CDC guidelines) prompt sexually transmitted infection
testing. Finally, no published studies have examined trends
in screening practices by specialty since the introduction of
noninvasive, urine-based laboratory methods.
The National Hospital Ambulatory Medical Care Sur-
vey (NHAMCS) database is a publicly available data set
that allows us to examine patient characteristics, symp-
toms, provider specialty, and whether a sexually trans-
mitted infection test is ordered or performed. Because
NHAMCS is an encounter-based survey, recall bias is
reduced and errors in documentation should be nondif-
ferential. Therefore, we are able to link actual provider
practice to patient characteristics and specific symptoms.
In addition, we are able to compare trends in sexually
transmitted infection screening by specialty and year.
The aim of this project is to explore determinants of
sexually transmitted infection screening of asymptom-
atic women and sexually transmitted infection testing of
women with genitourinary symptoms, to investigate the
effect of specific genitourinary symptoms on sexually
transmitted infection testing, and to examine trends in
sexually transmitted infection screening over time.
MATERIALS AND METHODS
We performed a secondary data analysis of 4 years
(1997–2000) of data collected by the U.S. National Cen-
ter for Health Statistics as part of the National Hospital
Ambulatory Medical Care Survey. The survey design
has been described in detail elsewhere.9,10 In short, a
complex 4-stage sampling frame is used to select a na-
tional probability sample of visits to the outpatient and
emergency departments of non-Federal, short-stay, and
general U.S. hospitals. The same set of approximately
485 hospitals participates each year, and about one half
of those have outpatient departments. Services may be
provided by physicians, nurse practitioners, midwives,
or residents, but all visits must be supervised by a
physician. Radiology and laboratories are not included
as clinic sites. Each outpatient department supplies ap-
proximately 150 records during a 4-week reporting pe-
riod. These reporting periods are determined by
NHAMCS and are distributed across the calendar year
to allow for seasonal variations in visit patterns. Staff
members of participating hospitals are trained to abstract
patient visit records by using a standard data collection
form to record information such as patient demograph-
VOL. 105, NO. 2, FEBRUARY 2005
ics, payment sources, patient complaints and reason for
visit codes, physician diagnoses, and diagnostic and
screening services provided at the visit. Individual iden-
tifying data are not included in the record. To improve
information on women’s health services, the survey has
included items for pregnancy status, Papanicolaou test,
and pelvic examination since 1997. Thus, we used the
outpatient portion of the NHAMCS data sets collected
and available for analysis from 1997 to the most recent
year with available data (2000).
Our analysis sample included visits by reproductive-
aged women, defined as ages 15– 44 years. Visits by
pregnant women were excluded because sexually trans-
mitted infection screening is a standard component of
prenatal care. The sample was also restricted to visits
made to clinics defined by NHAMCS as primary care:
general medicine clinics, pediatric clinics, and gynecol-
ogy clinics. In addition, these 3 types of clinic accounted
for 79% of visits and 97% of sexually transmitted infec-
tion tests ordered in the full data set. Thus, our sample
included 17,458 records of outpatient visits to primary
care clinics made by women aged 15– 44 who were not
pregnant and were of black, white, and Hispanic race/
ethnicity. Because of the weighted design of NHAMCS,
this sample represents an estimated 49.9 million visits
nationwide.
The primary outcome variable was derived from the
survey item “other STD test,” defined by NHAMCS as
any sexually transmitted infection test ordered or per-
formed at the visit, excluding human immunodeficiency
virus (HIV) serology and Papanicolaou tests. For this
analysis, the outcome was defined as a sexually transmitted
infection screen when ordered or performed in the absence
of genitourinary symptoms and as a sexually transmitted
infection test when performed in the presence of genitouri-
nary symptoms. Six other variables were explored for
their associations with sexually transmitted infection
screening and testing: patient age, race/ethnicity, pay-
ment source, clinic type, visit type, and genitourinary
symptoms. These were abstracted from the medical
record by the NHAMCS record abstractor.
Age was calculated from the date of visit and date of
birth recorded on the NHAMCS patient record form.
Because published guidelines recommend sexually
transmitted infection screening for women under age 25,
age was dichotomized as 15–24 years versus 25– 44
years. Race categories were recorded as white, black,
Asian/Pacific Islander, and American Indian/Eskimo/
Aleut, but low cell size precluded inclusion of races other
than black or white. Ethnicity was recorded as Hispanic
or not Hispanic. The race and ethnicity variables were
further condensed to a dichotomous variable of non-
Hispanic white versus nonwhite after analyses demon-
Huppert et al Screening for Sexually Transmitted Infection 391
strated no significant difference in the rates of sexually
transmitted infection screening or testing between black
and Hispanic patients. Payment source was recorded as
a dichotomous variable of Medicaid and non-Medicaid.
Up to 3 patient complaints or symptoms were coded
on the NHAMCS patient record form according to the
Reason For Visit (RFV) Classification for Ambulatory
Care.11 Genitourinary symptoms (RFV codes S640 –
S829) were defined by NHAMCS as any urinary, men-
strual, vaginal, vulvar, pelvic, menopausal, breast, and
infertility complaints. To be consistent with other
NHAMCS-reported data,12 we used this definition to
stratify our data set into symptomatic and asymptomatic
visit samples.
Genitourinary symptoms were further subdivided by
the investigators to compare 4 specific symptoms that are
often associated with sexually transmitted infections and
for which the CDC recommends additional sexually
transmitted infection testing. Vaginal symptoms were de-
fined as vaginal discharge, pain, infection, vulvar itching,
pain, lump, or ulcer (RFV codes S760 –S770.3). Urinary
symptoms were defined as frequency, urgency, dysuria
hematuria, incontinence, bladder or kidney pain, uri-
nary or kidney infection (RFV codes S640-S682.9). Ab-
normal bleeding was defined as irregular or heavy menses,
breakthrough bleeding, or postcoital bleeding (RFV
codes S735–740.3, 755.0 –755.3). Abdominal/pelvic pain
included pelvic pain, pressure, infection, dyspareunia,
stomach or abdominal pain or cramps, or upper, lower,
and periumbilical abdominal pain (RFV codes S775.0 –
775.3, S825, and S545–S550.2). Thus, these specific
symptom groups represent a different range of symp-
toms than those included in the NHAMCS-defined gen-
itourinary symptoms category. Specifically, stomach or ab-
dominal pain or cramps and upper, lower, and
periumbilical abdominal pain were not included in the
NHAMCS-defined genitourinary symptoms. Each class
of symptoms was dichotomized as present versus absent.
Because routine screening may differ in a preventive
care visit from that in an acute care visit, type of visit was
examined as preventive care versus other care. Preventive
care, as defined by NHAMCS, included visits for general
medical and gynecological examinations, as well as visits
for family planning, diagnostic testing, and immuniza-
tions (RFV codes X100 –X599). Visits in which a pre-
ventive-care code was not included as one of the 3 RFVs
were coded as other care. Type of primary care clinic was
recorded as general medicine, pediatrics, and gynecol-
ogy. Clinic type was dichotomized as gynecology versus
other because small cell size precluded reliable statistical
estimates.
Chi-squared testing was used to assess the associations
of sexually transmitted infection screening and testing
392 Huppert et al Screening for Sexually Transmitted Infection
with age, race/ethnicity, payment source, clinic type, and
visit type. To highlight the differences between screening
and testing for sexually transmitted infections, we strat-
ified our analyses by the presence or absence of genito-
urinary symptoms. To estimate independent correlates
of sexually transmitted infection screening and testing,
those variables associated with sexually transmitted in-
fection testing at P ⬍ .05 in bivariate analyses were
entered into a logistic regression model. After analyzing
main effects, we evaluated all possible 2-way interactions
between variables. Those interaction terms that were
significant at P ⬍ .05 were added to the main effects
model. A ␹2 test of trend was performed to compare
differences in sexually transmitted infection screening
rates over time between specialties in the sample of visits
by asymptomatic women.13
Sampling weights were applied to provide national
estimates and to account for the complex sampling de-
sign. The SUDAAN statistical program (Research Tri-
angle Institute, Research Triangle Park, NC) was used to
calculate confidence intervals to adjust for the complex
survey design of NHAMCS and calculate robust stan-
dard errors.
RESULTS
Of the 17,458 visits in our sample, 1,871 (10.6%) in-
cluded reports of genitourinary symptoms and consti-
tuted our symptomatic sample. The remaining 15,587
comprised our asymptomatic sample. A description of
the visits is shown in Table 1. Visits by women reporting
genitourinary symptoms included a higher proportion of
visits by nonwhite women, those with Medicaid insur-
ance, and those attending a gynecology clinic than did
visits by women without genitourinary symptoms. Gy-
necology clinics accounted for only 17.3% of visits,
whereas the remainder occurred in general medicine or
pediatric clinics.
Table 2 summarizes the weighted rates of sexually
transmitted infection testing per 100 visits by visit char-
acteristics, stratified by the presence or absence of geni-
tourinary symptoms. Overall, between 1997 and 2000,
669 visits (3.6%) included a sexually transmitted infec-
tion test. The proportion of visits with sexually transmit-
ted infection testing was higher for visits by women with
genitourinary symptoms (13.2%) than that for visits by
asymptomatic women (2.4%, P ⬍ .001). In both the
symptomatic and asymptomatic groups, the proportion
of visits with a sexually transmitted infection test was
higher for women who were younger, nonwhite, insured
by Medicaid, or seen in gynecology clinics. Although
visits with any genitourinary symptom were associated
with increased likelihood of having a sexually transmit-
OBSTETRICS & GYNECOLOGY
Table 1. Characteristics of Outpatient Visits to Hospital-Based Primary Care Clinics by Nonpregnant Women of Black,
White, and Hispanic Race/Ethnicity
Visits With Genitourinary Visits Without Genitourinary
Symptoms Symptoms
(N ⫽ 1,871) (N ⫽ 15,587) P*
Age (15–24 y) 563 (30.4) 4,614 (27.6) .16
Nonwhite race 639 (32.3) 4,129 (23.1) ⬍ .001
Medicaid 616 (29.8) 4,656 (24.8) .01
Gynecology Clinic 817 (40.3) 2,858 (14.6) ⬍ .001
Preventive Care Visit 216 (10.7) 3,681(21.0) ⬍ .001
Specific genitourinary symptoms
Urinary symptoms 501 (26.8) 0
Abnormal bleeding 414 (22.6) 0
Vaginal symptoms 418 (20.3) 0
Abdominal/pelvic pain 291 (16.7) 624 (4.0)
Data are expressed as n (%); percentages are weighted to account for sampling.
* P value of the difference between visits with and those without genitourinary symptoms.

ted infection test performed, the highest unadjusted test- old asymptomatic females, the annual rate of sexually
ing rate was in those visits in which the patient reported transmitted infection screening in our study was 3.8 per
vaginal symptoms (28.9%). Among asymptomatic visits, 100 visits.
nearly 1 in 10 visits to a gynecology clinic (9.8%) resulted For the symptomatic and asymptomatic samples, mul-
in sexually transmitted infection screening, and 7.4% of tivariable logistic regression models were developed to
visits for preventive care, regardless of the provider, simultaneously adjust for all variables found significant
included such screening. Among visits by 15- to 24-year- in the unadjusted analysis. Table 3 shows adjusted odds
ratios (ORs) and confidence intervals (CIs) for correlates
Table 2. Percentage of Visits With Sexually Transmitted of sexually transmitted infection testing and screening.
Infection Testing or Screening Performed for Non- Among visits by symptomatic women, 4 independent
pregnant Women in Hospital-Based Primary Care correlates of sexually transmitted infection testing were
Clinics found: age 25 years or less, nonwhite race, Medicaid
Visits With Visits Without insurance, and visits for preventive care. For visits by
Genitourinary Genitourinary women without genitourinary symptoms, attending a
Symptoms Symptoms
(N ⫽ 1,871) (N ⫽ 15,587) preventive care visit was associated with a 6-fold increase
in the likelihood of sexually transmitted infection screen-
%* P† %* P†
ing. Other correlates of sexually transmitted infection
Age (y) screening were nonwhite race, attending a gynecology
15–24 17.7 .03 3.8 ⬍ .001
25–44 11.2 1.9
clinic, and younger age. The significant interaction term
Race for nonwhite race and preventive visit (OR 0.29, CI
White, non-Hispanic 11.0 .02 1.7 ⬍ .001 0.15– 0.56) suggests there is a racial disparity in sexually
Black or Hispanic 18.0 4.8 transmitted infection screening in preventive care visits;
Payment source preventive care visits for nonwhite women are less likely
Medicaid 22.2 ⬍ .001 4.6 .008
Other 9.4 1.7 to result in sexually transmitted infection screening than
Clinic preventive care visits by white women.
Gynecology 17.4 .05 9.8 ⬍ .001 Among visits by women with genitourinary symp-
Medicine/pediatric 10.0 1.2 toms, we examined the effect of specific genitourinary
Reason for visit
symptoms on the odds of sexually transmitted infection
Preventive care 23.6 .02 7.4 ⬍ .001
Other care 12.0 1.1 testing. After controlling for age, race, Medicaid, and
Genitourinary symptoms clinic type, the symptoms most strongly associated with
Urinary symptoms 7.5 sexually transmitted infection testing were vaginal symp-
Abnormal bleeding 13.6 toms (OR 4.81, CI 2.6 – 8.9) and abdominal/pelvic pain
Vaginal symptoms 28.9
(OR 2.52, CI 1.4 – 4.52). Urinary symptoms (OR 1.11,
Abdominal/pelvic pain 19.4 6.2
CI 0.6 –2.1) and abnormal bleeding (OR 1.4, CI 0.82–
* Percentage of total visits, weighted to account for sampling.
†
P value of the difference in sexually transmitted infection test rate 2.5) were not associated with significant increases in
by characteristic. sexually transmitted infection testing. No 2-way interac-

VOL. 105, NO. 2, FEBRUARY 2005 Huppert et al Screening for Sexually Transmitted Infection 393
Table 3. Adjusted Odds Ratios for Sexually Transmitted Infection Testing and Screening in Visits by Nonpregnant Women
in Primary Care Clinics
Referent Category
Main effect
Preventive care Other care
Nonwhite White
Gynecology clinic Other
Age 15–24 y Age 25—44 y
Medicaid Non-Medicaid
Interaction term
Nonwhite race and preventive visit
STI, sexually transmitted infection.
Data are expressed as odds ratio (95% confidence interval).
tions were detected between specific genitourinary
symptoms or between genitourinary symptoms and
other variables.
We did not find any trends in sexually transmitted
infection testing and screening by clinic type. Between
1997 and 2000, for visits by symptomatic women, the
proportion of visits that resulted in sexually transmitted
infection testing remained steady in gynecology (17%)
and nongynecology clinics (10%). Among asymptomatic
women, the proportion of total visits to gynecology
clinics (14.5% of all visits) and the proportion of gyne-
cology visits that resulted in a sexually transmitted infec-
tion test (9.8%) remained stable. We were unable to test
for trend in nongynecology clinics because the small cell
size in 1997 precluded reliable statistical estimates.
DISCUSSION
This encounter-based survey documents very low rates
of sexually transmitted infection screening and testing by
providers in hospital-based primary care clinics. Both
sexually transmitted infection screening and testing are
influenced by patient characteristics, including race, age,
and visit type. Sexually transmitted infection screening is
occurring in the context of preventive care and gynecol-
ogy clinics, which conforms to the standard of care.
However, 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.
The CDC and other national organizations list age
less than 25 years as the number one risk factor for
sexually transmitted infections in sexually active females
and thus recommend routine annual sexually transmit-
ted infection screening in this group, regardless of race,
symptoms, or other risk factors.2,5 Because of these
recommendations, we had expected to find higher sexu-
ally transmitted infection screening rates among visits by
women aged 15–24 years. The annual rate of screening
394 Huppert et al Screening for Sexually Transmitted Infection
STI Test Visits With STI Screen Visits Without
Genitourinary Symptoms Genitourinary Symptoms
(N ⫽ 1,871) (N ⫽ 15,587)
1.95 (1.17–3.25) 6.89 (3.81–12.45)
1.74 (1.02–2.65) 4.26 (2.30–7.89)
1.31 (0.83–2.07) 3.90 (2.48–6.13)
1.66 (1.04–2.65) 1.62 (1.18–2.22)
2.27 (1.43–3.60) 1.23 (0.78–1.93)
0.29 (0.15–0.56)
for visits by 15- to 24-year-old females in our study was
3.8 per 100 visits. National estimates show that 70% of
patients in this age-sex group are sexually active14 –16 and
that each patient averages 2.2 visits to primary care
yearly.12 Given this, the sexually transmitted infection
screening rate we found (3.8 per 100 visits) suggests that
annual sexually transmitted infection screening was
achieved in only 12% of asymptomatic sexually active
15- to 24-year-old females who made primary care visits.
Furthermore, although the CDC data shows that 70% of
all C trachomatis infections in females occur in those aged
15–24 years,3 our analyses indicate that only 27.8% of all
sexually transmitted infection tests were done in this age
group. These findings demonstrate an inadequate
screening of the age-sex group at highest risk for sexually
transmitted infections and a disproportionately high rate
of screening among women at lower risk.
Our analysis of actual practice confirms previous pro-
vider self-reports of low screening of adolescents and
young women. For example, Torkko et al8 reported that
only 12% of providers surveyed reported annual sexu-
ally transmitted infection screening of asymptomatic ad-
olescent females. In a survey of North Carolina provid-
ers, only 29% reported routinely screening adolescent
females for C trachomatis, and the likelihood of screening
was increased when the providers reported serving a
larger proportion of minority patients.17 The overall
provider reluctance to screen adolescents in our study
and others contributes to the barriers that adolescents
face when they need sexually transmitted infection test-
ing. Even after they access health care, they are not
targeted for increased screening.
This study also showed that physicians are 5 times
more likely to provide sexually transmitted infection
tests in visits by women with genitourinary symptoms
than asymptomatic women. The majority of sexually
transmitted infection tests provided in this sample oc-
OBSTETRICS & GYNECOLOGY
curred in the 10% of visits by women who report geni-
tourinary symptoms, primarily vaginal symptoms. Even
among visits by symptomatic women, physicians do not
appear to follow CDC guidelines for sexually transmit-
ted infection testing. Many women with such symptoms
see a health care provider but do not receive sexually
transmitted infection testing. Only 13.2 of every 100
visits by symptomatic reproductive-aged women re-
sulted in a sexually transmitted infection test. Of the
genitourinary symptoms for which the CDC recom-
mends interim sexually transmitted infection testing
(vaginal discharge, dysuria, dyspareunia, abnormal
bleeding, or signs of upper genital tract disease),4,5 we
showed that visits with reports of vaginal symptoms and
abdominal/pelvic pain were highly associated with sexu-
ally transmitted infection testing. However, neither uri-
nary symptoms nor abnormal bleeding were associated
with receiving such testing.
Despite CDC guidelines for sexually transmitted in-
fection testing, the evidence for any associations between
specific genitourinary symptoms and the most common
sexually transmitted infections is weak. In a large pro-
spective study, vaginal discharge, itching, and odor were
negatively associated with C trachomatis or Neisseria gonor-
rhea.18 Urinary symptoms have been associated with an
increase in C trachomatis, N gonorrhea, and Trichomonas
vaginalis, although this increase is modest (less than
2-fold).19 –21 In a recent prevalence study, the prevalence
of C trachomatis was lower in women with vaginal dis-
charge (0.93% versus 4.27%) and similar in those with
and without dysuria (6.1% versus 4.0%).22 Lower ab-
dominal pain and abnormal bleeding are both consid-
ered to be symptoms of upper genital tract infections,
but, in a large prospective study by Ryan et al,18 these
symptoms did not predict C trachomatis or N gonorrhea.
The lack of correlation between patient complaints and
sexually transmitted infections results in symptom algo-
rithms that have low sensitivity and positive predictive
values for cervical infections of C trachomatis and N gonor-
rhea.23 Thus, the finding that vaginal symptoms were
more strongly associated with sexually transmitted infec-
tion testing than other symptoms that may better predict
presence of C trachomatis and N gonorrhea is concerning. It
is unclear whether the high rate of sexually transmitted
infection testing in visits by women with vaginal symp-
toms results from lack of provider awareness of the
prevalence of asymptomatic disease or from patient con-
cern and requests for sexually transmitted infection test-
ing in the presence of vaginal symptoms.
Regardless of the specific symptom, testing does not
occur uniformly among symptomatic women. Visits by
symptomatic nonwhite women and those with Medicaid
are more likely to result in a sexually transmitted infec-
VOL. 105, NO. 2, FEBRUARY 2005
tion test. This is consistent with other provider surveys
which found that serving a higher proportion of minority
or African-American patients was associated with in-
creased rates of sexually transmitted infection screen-
ing.6,17 Our study shows increased sexually transmitted
infection screening rates by patient race, but interest-
ingly, reveals that preventive care visits by nonwhite
women were less likely to include sexually transmitted
infection screening than preventive care visits by white
women. Thus, provider practices in relation to screening
and testing may be influencing our knowledge of sexu-
ally transmitted infection prevalence. Racial differences
in sexually transmitted infection rates are apparent for
many sexually transmitted infections, such as C trachoma-
tis, N gonorrhea, and syphilis.24 Because there is no bio-
logic explanation for these apparent racial differences, a
common explanation for these differences is that race is a
marker for disparities in risk behaviors or access to
health services. Our data suggest that, even with access
to heath service, differences in provider screening and
testing practices may account for some of the racial
disparities in sexually transmitted infections.
The strengths of this study include the large sample
that is nationally representative and an encounter-based
reporting survey that limits recall and reporting bias.
The most important limitation is the lack of data on
sexual activity and sexual risk behaviors. However, by
age 25, sexual activity is nearly universal (⬎ 95%), and
racial differences in sexual activity rates disappear by age
20.16 The type of sexually transmitted infection test
performed or ordered is not recorded, and test rates
reported are per visit, not per patient. Finally, an esti-
mated 80% of outpatient visits by 15- to 44-year-old
women in the United States are made to private physi-
cian offices, not to the hospital-based clinics represented
by this sample. However, in the database that examines
outpatient visits to private physician offices (National
Ambulatory Medical Care Survey), the proportion of
sexually transmitted infection tests in a similarly con-
structed sample was less than 1%, precluding statistical
evaluation (data not shown).
To meet the Healthy People 2010 goals for sexually
transmitted infection screening of high-risk young
women, we will need to consider every health care visit
as an opportunity for sexually transmitted infection
screening. Each year, only a small proportion of visits
made by reproductive-aged women are made to gynecol-
ogy clinics or for preventive care. To make the largest
public health impact on the epidemic of sexually trans-
mitted infections in the United States, we need to design
interventions that reinforce current recommended
guidelines for screening asymptomatic women seen
in nongynecology clinics, women appearing for non–
Huppert et al Screening for Sexually Transmitted Infection 395
preventive care visits, and patients in private practice
settings.
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rationale. U.S. Preventive Services Task Force. Am J Prev
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Address reprint requests to: Jill S. Huppert, MD, MPH, Divi-
sion of Adolescent Medicine, Cincinnati Children’s Hospital
Medical Center, 3333 Burnet Avenue, ML 4000, Cincinnati,
OH 45229 –3039; e-mail: jill.huppert@cchmc.org.
Received July 29, 2004. Received in revised form September 17, 2004.
Accepted September 23, 2004.
OBSTETRICS & GYNECOLOGY