Opt-out Testing to Improve Chlamydia Screening in Primary Care

Source: Sukhija-Cohen AC, Grewal AK, Vu J, et al. Outcomes of an opt-out chlamydia testing program across 21 northern California pediatric clinics. J Adolesc Health. 2026;78(6):949-951; doi: 10.1016/j.jadohealth.2026.01.022.Investigators from Sutter Health, Sacramento, CA, conducted a retrospective study to assess the effect of implementation of an opt-out chlamydia testing program on rates of testing and diagnosis of chlamydia in adolescent and young adult females. Study participants were females 16–24 years old who were active patients in a large health care system and had ≥1 visit at 1 of 21 general pediatric clinics in Northern California during the period 2023–2024. In 2024, the health care system implemented a policy of routinely collecting a urine specimen for chlamydia testing during ambulatory visits as standard care for all patients 16–24 years old, unless declined. The policy was instituted because, prior to this time, rates of testing were considered sub-optimal. For the study, participants were classified as having received chlamydia testing if there was a record of a chlamydia test within 10 days of an ambulatory visit. In addition to test results, demographic data were collected on study participants. Rates of chlamydia testing in female patients in the pre-implementation (2023) and post-implementation period (2024) were compared.Data were analyzed on 10,540 females with a visit in pre-implementation period and 11,120 after opt-out chlamydia testing was implemented in 2024. Rates of testing increased from 12.9% of visits to 31.7% post-implementation (P <0.001). There were a total of 22 (1.6%) chlamydia diagnoses in the pre-implementation period and 30 (0.9%) in the opt-out period. Among adolescent females 16 years old, the rate of testing increased from 8.9% pre-implementation to 22.9% post-implementation; for those 17 years old, rates increased from 12.4% to 35.6%; for young women 18–24 years old, rates increased from 18.8% to 39.1%. Chlamydia testing increased after implementation of an opt-out policy among participants from all assessed racial and ethnic groups, with the biggest increases noted in Hispanic/Latino females (17.4% to 38.1%) and non-Hispanic Asians (10.1% to 37.4%). The increase in testing from the pre- to post-implementation period was significantly greater among those with private insurance (12.9% to 36.3%) than in females who were publicly insured (18.1% to 39.2%; P = 0.01).The authors conclude that implementation of a policy of opt-out chlamydia testing at ambulatory visits was associated with a substantial increase in the rate of testing in female patients 16–24 years old.Dr Raphael has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Chlamydia is the most prevalent reportable bacterial sexually transmitted infection (STI) in adolescents and young adults (AYA) in the United States.1 Despite recommendations for annual chlamydia screening in sexually active females <25 years old, nationally, only about half of this eligible population is appropriately screened.1,2 Infrequent preventive care visits among AYA, lack of disclosure of sexual activity, incomplete sexual history taking, other health care priorities, and provider bias may contribute to this screening gap. (See AAP Grand Rounds. 2024;52[6]:68.)3,4 Opt-out testing is one potential strategy to address this.The current study investigators were able to demonstrate more than a two-fold increase in chlamydia screening through an optout approach. This was a large multisite study, and it provides a real-world example of system-level change. The success of such opt-out chlamydia screening initiatives has been demonstrated in other primary care settings as well.3,5 In one similar study, reduction in testing inequity related to insurance status, language preference, and race also was demonstrated.5 While the current study investigators were not able to analyze the rate at which participants opted out, or if missed screening was due to participant-related factors or issues with intervention fidelity, the increase in screening rates demonstrates overall acceptability. Consistent with this finding, a survey of AYA conducted within a large primary care network found that youths overwhelmingly preferred an opt-out approach to risk-based testing (93% vs 6%), as they associated opt-out testing with less STI stigma.6However, one important consideration is the cost of universal opt-out screening to the health care system. If testing cost is offset by increased chlamydia detection, decreased transmission, and decreased complications, then these downstream benefits could outweigh upfront efforts. Model-based cost effectiveness analysis indicates that even if there is a modest reduction in significant sequelae such as pelvic inflammatory disease, opt-out testing is more cost-effective than risk-based testing. This is particularly the case when baseline chlamydia prevalence and likelihood of sequelae is high.7 However, direct cost-effectiveness data from implementation trials are lacking. This is an important area of future study, as it could help identify settings in which opt-out chlamydia screening would be most beneficial.Opt-out chlamydia screening, successfully implemented in pediatric primary care, has the potential to enhance STI prevention in AYA.