Diagnosis of genital chlamydia in primary care: an explanation of reasons for variation in chlamydia testing

Infectious Disease and Primary Care Research-What English General Practitioners Say They Need

Background: Infections are one of the most common reasons for patients attending primary care. Antimicrobial resistance (AMR) is perhaps one of the biggest threats to modern medicine; data show that 81% of antibiotics in the UK are prescribed in primary care. Aim: To identify where the perceived gaps in knowledge, skills, guidance and research around infections and antibiotic use lie from the general practitioner (GP) viewpoint. Design and Setting: An online questionnaire survey. Method: The survey, based on questions asked of Royal College of General Practitioners (RCGP) members in 1999, and covering letter were electronically sent to GPs between May and August 2017 via various primary care dissemination routes. Results: Four hundred and twenty-eight GPs responded. Suspected Infection in the elderly, recurrent urinary tract infection (UTI), surveillance of AMR in the community, leg ulcers, persistent cough and cellulitis all fell into the top six conditions ranked in order of importance that require further research, evidence and guidance. Acute sore throat, otitis media and sinusitis were of lower importance than in 1999. Conclusion: This survey will help the NHS, the UK National Institute for Health and Care Excellence (NICE) and researchers to prioritise for the development of guidance and research for chronic conditions highlighted for which there is little evidence base for diagnostic and management guidelines in primary care. In contrast, 20 years of investment into research, guidance and resources for acute respiratory infections have successfully reduced these as priority areas for GPs.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review

Background

Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model.

Methods

Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma).

Conclusions

This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed.

Trial registration

PROSPERO CRD42016041786

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0821-y) contains supplementary material, which is available to authorized users.

Narrative review of the barriers and facilitators to chlamydia testing in general practice

As the cornerstone of Australian primary health care, general practice is a setting well suited for regular chlamydia testing but testing rates remain low. This review examines the barriers and facilitators to chlamydia testing in general practice. Six databases--Medline, PubMed, Meditext, PsycInfo, Scopus and Web of Science--were used to identify peer-reviewed publications that addressed barriers and facilitators to chlamydia testing in general practice using the following terms: 'chlamydia test*', 'STI test*' 'general practice', 'primary care', 'family medicine', 'barriers', 'facilitators' and 'enablers' from 1997 until November 2013. Data about the study design and key findings were extracted from the publications. A framework method was used to manage the data and organise publications into three categories -patient, general practitioner, and general practice. Key findings were then classified as a barrier or facilitator. Sixty-nine publications were included, with 41 quantitative studies, 17 qualitative studies, and 11 using mixed methods. Common barriers identified in all three groups included a lack of knowledge, awareness or training, demands on time and workload, and the social context of testing. Facilitators included the normalisation of testing, the use of nurses and other practice staff, education and incentives. Numerous barriers and facilitators to chlamydia testing in general practice have been identified. While the barriers are well studied, many of the facilitators are not as well researched, and highlight areas for further study.

The added value of chlamydia screening between 2008-2010 in reaching young people in addition to chlamydia testing in regular care; an observational study

Background

Internet-based Chlamydia Screening Implementation (chlamydia screening programme) was introduced in the Netherlands in 2008-2010 to detect and treat asymptomatic infections and to limit ongoing transmission through annual testing and treatment of Chlamydia trachomatis in young people (16-29 years). This population-based screening may be less effective when addressing individuals who are already covered by regular care, instead of addressing a hidden key population without chlamydia testing experience in regular care. This study had two aims: (1) to assess the rate and determinants of newly reached (i.e. not previously tested in 2006-2010) participants in the chlamydia screening programme, and (2) to assess the chlamydia positivity in these newly reached participants.

Methods

This observational matching study included all chlamydia tests performed in subjects aged 16-29 years in eastern South Limburg in the Netherlands (population 16-29 years:41,000) between 2006-2010. Testing was conducted during the systematic chlamydia screening programme (2008-2010), at a sexually transmitted infections clinic (STI clinic), by general practitioners (GPs), and by medical specialists as reported by the medical laboratory serving the region. Data were matched between testing services on individual level. The study population included all participants who were tested at least once for chlamydia by the chlamydia screening programme. Participants were included at their first chlamydia screening participation.

Results

In the chlamydia screening programme, 80.7% (4298/5323) of participants were newly reached, others were previously tested by the STI clinic (5.7%, n=304), GPs (6.2%, n=328), medical specialists (3.5%, n=187) or a combination of providers (3.9%, n=206). Chlamydia prevalence was similar in newly reached participants (4.8%, 204/4298) and participants previously tested (4.5%, 46/1025, P=0.82). Independent determinants for being a newly reached participant were male gender (men OR 2.9; 95% CI 2.5-3.4) and young age <21 years (versus 25-29 years OR 1.8; 95% CI 1.5-2.2).

Conclusions

The majority of the chlamydia screening programme participants have not been tested by regular care, and show similar chlamydia prevalence as those previously tested. Thereby population-based chlamydia screening adds to the existing regular care by testing young individuals hidden to current regular care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0612-2) contains supplementary material, which is available to authorized users.

Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities

BACKGROUND

Laboratory tests are extensively used for diagnosis and monitoring in UK primary care. Test usage by GPs, and associated costs, have grown substantially in recent years.

AIM

This study aimed to quantify temporal growth and geographic variation in utilisation of laboratory tests.

DESIGN AND SETTING

Retrospective cohort study using data from general practices in the UK.

METHOD

Data from the General Practice Research Database, including patient demographics, clinical details, and laboratory test results, were used to estimate rates of change in utilisation between 2005 and 2009, and identify tests with greatest inter-regional variation, by fitting random-effects Poisson regression models. The study also investigated indications for test requests, using diagnoses and symptoms recorded in the 2 weeks before each test.

RESULTS

Around 660 000 tests were recorded in 230 000 person-years of follow-up. Test use increased by 24.2%, from 23 872 to 29 644 tests per 10 000 person-years, between 2005 and 2009. Tests with the largest increases were faecal occult blood (121%) and C-reactive protein (86%). There was substantial geographic variation in test utilisation; GPs in some regions requested tests such as plasma viscosity and cardiac enzymes at a rate more than three times the national average.

CONCLUSION

Increases in the use of laboratory tests have substantial resource implications. Rapid increases in particular tests may be supported by evidence-based guidelines, but these are often vague about who should be tested, how often, and for how long. Substantial regional variation in test use may reflect uncertainty about diagnostic accuracy and appropriate indications for the laboratory test. There is a need for further research on the diagnostic accuracy, therapeutic impact, and effect on patient health outcomes of the most rapidly increasing and geographically variable tests.

Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain

Objectives

Rates of sexually transmitted infections (STIs) in UK young people remain high in men and women. However, the National Chlamydia Screening Programme has had limited success in reaching men. The authors explored the acceptability of various medical, recreational and sports venues as settings to access self-collected testing kits for STIs and HIV among men in the general population and those who participate in sport.

Methods

A stratified random probability survey of 411 (weighted n=632) men in Great Britain aged 18–35 years using computer-assisted personal and self-interviews.

Results

Young men engaged well with healthcare with 93.5% registered with, and 75.3% having seen, a general practitioner in the last year. 28.7% and 19.8% had previously screened for STIs and HIV, respectively. Willingness to access self-collected tests for STIs (85.1%) and HIV (86.9%) was high. The most acceptable pick-up points for testing kits were general practice 79.9%, GUM 66.8% and pharmacy 65.4%. There was a low acceptability of sport venues as pick-up points in men as a whole (11.7%), but this was greater among those who participated in sport (53.9%).

Conclusions

Healthcare settings were the most acceptable places for accessing STI and HIV self-testing kits. Although young men frequently access general practice, currently little STI screening occurs in this setting. There is considerable potential to screen large numbers of men and find high rates of infection through screening in general practice. While non-clinical settings are acceptable to a minority of men, more research is needed to understand how these venues could be used most effectively.

Usefulness of primary care electronic networks to assess the incidence of chlamydia, diagnosed by general practitioners

Background

Chlamydia is the most common curable sexually transmitted infection (STI) in the Netherlands. The majority of chlamydia diagnoses are made by general practitioners (GPs). Baseline data from primary care will facilitate the future evaluation of the ongoing large population-based screening in the Netherlands. The aim of this study was to assess the usefulness of electronic medical records for monitoring the incidence of chlamydia cases diagnosed in primary care in the Netherlands.

Methods

In the electronic records of two regional and two national networks, we identified chlamydia diagnoses by means of ICPC codes (International Classification of Primary Care), laboratory results in free text and the prescription of antibiotics. The year of study was 2007 for the two regional networks and one national network, for the other national network the year of study was 2005. We calculated the incidence of diagnosed chlamydia cases per sex, age group and degree of urbanization.

Results

A large diversity was observed in the way chlamydia episodes were coded in the four different GP networks and how easily information concerning chlamydia diagnoses could be extracted. The overall incidence ranged from 103.2/100,000 to 590.2/100,000. Differences were partly related to differences between patient populations. Nevertheless, we observed similar trends in the incidence of chlamydia diagnoses in all networks and findings were in line with earlier reports.

Conclusions

Electronic patient records, originally intended for individual patient care in general practice, can be an additional source of data for monitoring chlamydia incidence in primary care and can be of use in assessing the future impact of population-based chlamydia screening programs. To increase the usefulness of data we recommend more efforts to standardize registration by (specific) ICPC code and laboratory results across the existing GP networks.

STD/HIV risk among adults in the primary care setting: are we adequately addressing our patients' needs?

BACKGROUND

Risk behavior surveys often target sexually transmitted disease (STD) clinic populations, but few studies address risk behaviors in primary care settings.

METHODS

This cross-sectional study performed at a university adult primary care clinic evaluated risk behaviors using an anonymous, self-administered survey. The following data were collected: demographics, sexual history, condom use, and confidence discussing STDs.

RESULTS

A total of 718 surveys were completed: 69% by females and 67% black. A total of 44% had never been asked about sexual health by their primary care provider and 18% reported they had never had a gender-specific genital examination. Among 394 sexually active individuals in the past 3 months, 58% reported never using a condom, and 33% stated they would not use a condom for their next sexual encounter. About one-third of the sample had never been tested for HIV and was not aware of their partner's HIV status. One-third reported history of STD, and 32% reported feeling uncomfortable discussing STDs with primary care provider.

CONCLUSIONS

Our data demonstrate that sexual health is infrequently addressed despite high rates of previous STDs and low condom use in this population. Identifying barriers to determining sexual risk behaviors in the primary care setting will help to expand testing strategies for HIV and other STDs.

Interactive workshops increase chlamydia testing in primary care--a controlled study

BACKGROUND

Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately.

OBJECTIVES

To determine if interactive workshops and modified laboratory request forms could increase testing and case detection.

STUDY DESIGN

Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate.

STUDY POPULATION

82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington.

INTERVENTION

Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study.

RESULTS

Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75).

CONCLUSIONS

Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Strategies used to increase chlamydia screening in general practice: a qualitative study

OBJECTIVES

To explore strategies used by chlamydia screening co-ordinators and practice staff to implement genital chlamydia screening within general practices.

METHODS

Qualitative phenomenological study using individual semi-structured telephone interviews. Screening co-ordinators were selected purposively in Phase 1 and 2 areas of the Department of Health National Chlamydia Screening Programme in England, where there was significant screening in general practice. Open questions were asked about: the factors that determined high chlamydia screening rates; maintaining motivation for screening; and strategies to increase screening in general practices.

RESULTS

Co-ordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalized screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time-saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. Chlamydia screening was sustained through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the 'at-risk' population from the screening team. Co-ordinators' enthusiasm and project management skills were as important as sexual health experience. Co-ordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public.

CONCLUSIONS

All practice staff need to be encouraged to become champions of the chlamydia screening programme through education, especially aimed at older clinicians and receptionists. The National Health Service should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.