Postal survey of management of cervical Chlamydia trachomatis infection in English and Welsh general practices

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND

Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patient's behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system.

OBJECTIVE

We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice.

DESIGN

Cluster randomised controlled trial.

SETTING

General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system.

INTERVENTIONS

Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral.

MAIN OUTCOME MEASURES

(1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months.

RESULTS

As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions.

CONCLUSIONS

External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24160819.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.

Sex difference in partner notification: results from three population based surveys in France

OBJECTIVES

To estimate the proportion of individuals in the general population who did not notify their sexual partners at the time of an STD diagnosis, according to the sex of the patient and the type of partner.

METHODS

We analysed behaviour at the time of diagnosis of a self reported STD, using data from three large French national population based surveys of adults (ACSF, Barométre Santé) and adolescents (ACSJ). Univariate and multivariate analyses took into account the complex sampling design.

RESULTS

In the ACSF, 14% (95% CI: 4% to 24%) of men reported that they had not informed their main sexual partner compared with only 2% (95% CI: 0% to 5%) of women (p = 0.03). This sex difference was independent of the nature of the STD, the patient's age, level of education, and number of partners. Similarly, in the ACSJ, 51% (95% CI: 21% to 81%) of boys reported that they had not talked about this STD with their current sexual partner compared with only 9% (95% CI: 0% to 26%) of girls (p = 0.04). Notification by a sexual partner had led to discovery of the STD more frequently in male subjects than in female subjects, both in adults (32% of men compared with 4% of women (p=0.04)), and adolescents (36% of boys compared with 12% of girls). Most subjects, irrespective of sex, had not informed partners other than their main or current partner: 73% (95% CI: 62% to 84%) of adults and 86% (95% CI: 77% to 95%) of adolescents.

CONCLUSIONS

Procedures must be developed urgently to improve the notification of sexual partners, particularly female partners and adolescents, who are unlikely to be tested early without such notification.

Sexually transmitted infections in primary care: a need for education

General practitioners and practice nurses require the clinical skills that will enable them to detect sexually transmitted infections in the context of a shift to having no, or insidious symptoms. They need to be able to confirm the diagnosis and have clear models for management and referral. Primary care and genitourinary medicine need to work more closely together to increase mutual understanding and clarify the issues which surround referral and attendance. Sexual health risk assessment through the investigation of sexual history is a helpful way forward in both differential diagnosis and in targeting sexual health promotion and care. Many aspects of these clinical skills are specific to the primary care context. There is a need for improved undergraduate, postgraduate, and in-service training. Multidisciplinary educational approaches are ideal for the subject of sexual health. Primary care groups offer a potential way forward to help develop quality in primary care and some are developing health improvement programmes that aim to address sexual health issues.

Chlamydia trachomatis in primary care: knowledge and practice in Glasgow

A recent Department of Health report recommended the establishment of a selective screening programme for Chlamydia trachomatis infection. We report a survey which suggests that primary care clinicians may not yet be prepared for this task.

The impact of a quasi-market on sexually transmitted disease services in the UK

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.

A collaborative approach to management of chlamydial infection among teenagers seeking contraceptive care in a community setting

OBJECTIVES

To develop and assess a coordinated model of care for effective management of genital chlamydial infection in young women, identified through a selective screening programme in a community based teenage health clinic.

METHODS

Selective screening for genital Chlamydia trachomatis was undertaken among young women aged 13-19 years who were having a routine cervical smear test, being referred for termination of pregnancy, or who reported behavioural risk factors, for, and/or symptoms of, genital infection. Collaboration among family planning, genitourinary medicine (GUM), and public health staff was used to enhance management of infected individuals, with particular focus on partner notification.

RESULTS

94 young women had confirmed genital chlamydial infection, representing 11% of those tested. All index patients received appropriate antibiotic therapy and follow up; 93 (99%) of these were counselled by a health adviser, of whom 62 (66%) were able to provide sufficient details for partner notification, resulting in treatment of male partners associated with 51 (82%) of these young women. Younger age (< or = 16 years) was significantly associated with delay in attending for treatment.

CONCLUSIONS

Effective management of genital chlamydial infection is achievable in settings outside GUM clinics using a collaborative approach which incorporates cross referencing between community based services and GUM clinics.

Are postal questionnaire surveys of reported activity valid? An exploration using general practitioner management of hypertension in older people

BACKGROUND

Postal questionnaire surveys are commonly used in general practice and often ask about self-reported activity. The validity of this approach is unknown.

AIM

To explore the criterion validity of questions asking about self-reported activity in a self-completion questionnaire.

METHOD

A comparison was made between (a) the self-reported actions of all general practitioner (GP) principals in 51 general practices randomly selected within the nine family health services authorities of the former northern regional health authority, and (b) the contents of the medical records (case notes and computerized records) of patients classified as hypertensive from a 1 in 7 random sample of all patients registered in these practices and aged between 65 and 80. Data were gathered from the GPs by self-completion postal questionnaires. Six comparisons were made for two groups of items: first, target and achieved blood pressure; secondly, patient's weight, smoking status, alcohol consumption, exercise and salt intake. The frequency with which the data items were recorded in patient records was compared with the GPs' self-reported frequency of performing the actions.

RESULTS

No relationship was found between achieved blood pressure and stated target levels. For each of the other actions, more than half of the responders reported that they usually or always performed the activity. For four of these (smoking, weight, alcohol and exercise), a significant association was noted, but the size of this varied considerably.

CONCLUSIONS

There is a variable relationship between what responders report that they do in self-completion questionnaires, and what they actually do as judged by the contents of their patients' medical records. In the absence of prior, knowledge of the validity of questions on reported activity, or of concurrent attempts to establish their validity, the questions should not be asked.

Detection of male genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae using an automated multiplex PCR system (Cobas Amplicor)

We evaluated Cobas Amplicor, a highly automated polymerase chain reaction (PCR) system, to test first-void urine (FVU) and urethral swab specimens for Chlamydia trachomatis and Neisseria gonorrhoeae in men attending a sexually transmitted infection (STI) clinic. Results were compared against an in-house radioimmune dot blot (DB) test for C. trachomatis and selective culture for N. gonorrhoeae. Three hundred and ninety sets of specimens were obtained from 378 consecutive new and returned-new patients. Gonorrhoea prevalence was 9.49%, with no significant difference in sensitivity or specificity between culture and PCR. Chlamydia prevalence was 15.4%, with sensitivities of: DB 55%, PCR of FVU 86.7%, urethral swab PCR 90%. The specificity of PCR on FVU and urethral swabs was 100%. We have shown that Cobas Amplicor PCR is highly sensitive and specific in the diagnosis of chlamydia and gonorrhoea in men attending an STI clinic. Further economic and scientific studies are needed to determine the cost-effectiveness of this technique for screening in primary care settings.

Azithromycin. A pharmacoeconomic review of its use as a single-dose regimen in the treatment of uncomplicated urogenital Chlamydia trachomatis infections in women

In women, Chlamydia trachomatis infection often occurs in the urethra or cervix, with up to 70% of infections associated with few or no symptoms. Inadequate treatment may lead to infection of the upper genital tract and subsequent pelvic inflammatory disease (PID) in 10 to 40% of patients. PID causes an increased relative risk of ectopic pregnancy of 2.5 to 7.9 and PID may also lead to tubal infertility in about 17% of patients. 60% of infants born of mothers with C. trachomatis infection may become infected, leading to conjunctivitis in 23% and pneumonia in 21%. All of these sequelae of C. trachomatis infection may require in- or outpatient treatment. With > 4 million infections estimated to occur each year in the US, C. trachomatis is one of the most common and costly of the sexually transmitted pathogens. Treatment options for uncomplicated C. trachomatis infections in nonpregnant women include single-dose azithromycin 1000 mg or doxycycline 100 mg twice daily for 7 days orally. In clinical trials, the bacteriological cure rate of single dose azithromycin 1000 mg (95 to 100%) was similar to that of oral doxycycline 200 mg/day for 7 days (88 to 100%) in nonpregnant women. Azithromycin was at least as well tolerated as doxycycline and was associated with mainly mild gastrointestinal adverse effects including diarrhoea, nausea and abdominal pain. Pharmacoeconomic analyses have sought to determine if the 2.7- to 12-fold higher acquisition costs of azithromycin in comparison with doxycycline are offset by its simple single-dose regimen which is likely to aid patient compliance and so optimise drug efficacy. All analyses were retrospective cost-effectiveness decision-tree models and mainly considered direct costs. All models incorporated an estimate of noncompliance with doxycycline and its influence on efficacy. For the treatment of confirmed C. trachomatis infection, azithromycin saved around $US1200 per major outcome avoided (1993 values; third-party payer perspective in the US) or US$3502 per case of PID avoided (1993 values; US healthcare system perspective) compared with doxycycline. If infection was treated empirically, azithromycin was more costly than doxycycline by $US792 (1993 values), but the result was sensitive to changes of some parameters of the model. Azithromycin was more costly than doxycycline from the perspective of a public health clinic which paid for the treatment of initial infection and acute sequelae only. Thus, pharmacoeconomic data from the US support the use of azithromycin in the treatment of nonpregnant women with confirmed C. trachomatis urogenital infections from the perspective of the healthcare system or third-party payer; however, from the perspective of a public clinic, doxycycline is the less costly option. Decreases in doxycycline compliance or azithromycin acquisition cost are factors that favour azithromycin.