Distribution and characteristics of sexual health service provision in primary and community care in England

Management of chlamydia and gonorrhoea infections diagnosed in primary care using a centralised nurse-led telephone-based service: mixed methods evaluation

BACKGROUND

Up to 18% of genital Chlamydia infections and 9% of Gonorrhoea infections in England are diagnosed in Primary Care. Evidence suggests that a substantial proportion of these cases are not managed appropriately in line with national guidelines. With the increase in sexually transmitted infections and the emergence of antimicrobial resistance, their timely and appropriate treatment is a priority. We investigated feasibility and acceptability of extending the National Chlamydia Screening Programme's centralised, nurse-led, telephone management (NLTM) as an option for management of all cases of chlamydia and gonorrhoea diagnosed in Primary Care.

METHODS

Randomised feasibility trial in 11 practices in Bristol with nested qualitative study. In intervention practices patients and health care providers (HCPs) had the option of choosing NLTM or usual care for all patients tested for Chlamydia and Gonorrhoea. In control practices patients received usual care.

RESULTS

One thousand one hundred fifty-four Chlamydia/gonorrhoea tests took place during the 6-month study, with a chlamydia positivity rate of 2.6% and gonorrhoea positivity rate of 0.8%. The NLTM managed 335 patients. Interviews were conducted with sixteen HCPs (11 GPs, 5 nurses) and 12 patients (8 female). HCPs were positive about the NLTM, welcomed the partner notification service, though requested more timely feedback on the management of their patients. Explaining the NLTM to patients didn't negatively impact on consultations. Patients found the NLTM acceptable, more convenient and provided greater anonymity than usual care. Patients appreciated getting a text message regarding a negative result and valued talking to a sexual health specialist about positive results.

CONCLUSION

Extension of this established NLTM intervention to a greater proportion of patients was both feasible and acceptable to both patients and HCP, could provide a better service for patients, whilst decreasing primacy care workload. The study provides evidence to support the wider implementation of this NLTM approach to managing chlamydia and gonorrhoea diagnosed in primary care.

The epidemiology of sexually transmitted infections in the UK: impact of behavior, services and interventions

Sexually transmitted infections (STIs) are a major public health concern. The UK has some of the most advanced STI surveillance systems globally. This article uses national surveillance data to describe remarkable changes in STI epidemiology in the UK over the last century and explores the behavioral and demographic shifts that may explain these trends. The past 10 years have seen considerable improvements in STI service provision and the introduction of national public health interventions. However, sexual health inequalities persist and men who have sex with men, young adults and black ethnic minorities remain a priority for interventions. Technological advances in testing and a shift in sexual health service commissioning arrangements will present both opportunities and challenges in future.

Diagnosis and treatment of chlamydia and gonorrhoea in general practice in England 2000-2011: a population-based study using data from the UK Clinical Practice Research Datalink

OBJECTIVES

To determine the relative contribution of general practices (GPs) to the diagnosis of chlamydia and gonorrhoea in England and whether treatment complied with national guidelines.

DESIGN

Analysis of longitudinal electronic health records in the Clinical Practice Research Datalink (CPRD) and national sexually transmitted infection (STI) surveillance databases, England, 2000-2011.

SETTING

GPs, and community and specialist STI services.

PARTICIPANTS

Patients diagnosed with chlamydia (n=1,386,169) and gonorrhoea (n=232,720) at CPRD GPs, and community and specialist STI Services from 2000-2011.

MAIN OUTCOME MEASURES

Numbers and rates of chlamydia and gonorrhoea diagnoses; percentages of patients diagnosed by GPs relative to other services; percentage of GP patients treated and antimicrobials used; percentage of GP patients referred.

RESULTS

The diagnosis rate (95% CI) per 100,000 population of chlamydia in GP increased from 22.8 (22.4-23.2) in 2000 to 29.3 (28.8-29.7) in 2011 (p<0.001), while the proportion treated increased from 59.5% to 78.4% (p=0.001). Over 90% were prescribed a recommended antimicrobial. Over the same period, the diagnosis rate (95% CI) per 100,000 population of gonorrhoea in GP ranged between 3.2 (3-3.3) and 2.4 (2.2-2.5; p=0.607), and the proportion treated ranged between 32.7% and 53.6% (p=0.262). Despite being discontinued as a recommended therapy for gonorrhoea in 2005, ciprofloxacin accounted for 42% of prescriptions in 2007 and 20% in 2011. Over the study period, GPs diagnosed between 9% and 16% of chlamydia cases and between 6% and 9% of gonorrhoea cases in England.

CONCLUSIONS

GP makes an important contribution to the diagnosis and treatment of bacterial STIs in England. While most patients diagnosed with chlamydia were managed appropriately, many of those treated for gonorrhoea received antimicrobials no longer recommended for use. Given the global threat of antimicrobial resistance, GPs should remain abreast of national treatment guidelines and alert to treatment failure in their patients.

Improving surveillance of sexually transmitted infections using mandatory electronic clinical reporting: the genitourinary medicine clinic activity dataset, England, 2009 to 2013

A new electronic surveillance system for sexually transmitted infections (STIs) was introduced in England in 2009. The genitourinary medicine clinic activity dataset (GUMCAD) is a mandatory, disaggregated, pseudo-anonymised data return submitted by all STI clinics across England. The dataset includes information on all STI diagnoses made and services provided alongside demographic characteristics for every patient attendance at a clinic. The new system enables the timely analysis and publication of routine STI data, detailed analyses of risk groups and longitudinal analyses of clinic attendees. The system offers flexibility so new codes can be introduced to help monitor outbreaks or unusual STI activity. From January 2009 to December 2013 inclusive, over twenty-five million records from a total of 6,668,648 patients of STI clinics have been submitted. This article describes the successful implementation of this new surveillance system and the types of epidemiological outputs and analyses that GUMCAD enables. The challenges faced are discussed and forthcoming developments in STI surveillance in England are described.

Declining genital Warts in young women in england associated with HPV 16/18 vaccination: an ecological study

Background. Diagnoses of genital warts (GW) in genitourinary medicine (GUM) clinics have been increasing in England for many years. In 2008, an HPV immunization program began with a bivalent vaccine (Cervarix). This was expected to markedly reduce infections and disease due to human papillomavirus (HPV) 16/18 but not HPV 6/11 infections or disease. However, from 2009 to 2011 there were decreases in reported diagnoses of GW in young females at GUM clinics.

Methods. Using data from GUM clinics and a sample of general practices (GPs) throughout England, we analyzed rates of GW diagnoses by age, year of diagnosis, and estimated immunization coverage.

Results. The overall reduction in GW diagnoses at GUM clinics between 2008 and 2011 was 13.3% among 16- to 19-year-old females, with the greatest decline of 20.8% in 17-year-olds. Declines were positively associated with estimated immunization coverage. A similar pattern was seen in GP diagnoses, but not among older women, and for other GUM consultations.

Conclusions. Several factors might contribute to declines in GW. However, the size and pattern of the declines strongly suggest that we are observing an unexpected, moderately protective effect of HPV 16/18 vaccination against GW.

Factors associated with travel to non-local genitourinary medicine clinics for gonorrhoea: an analysis of patients diagnosed in London, 2009-10

We analysed factors associated with travelling to non-local genitourinary medicine clinics for gonorrhoea care in London. We used surveillance data on London residents attending genitourinary medicine clinics in 2009-10 and calculated distances between patients' areas of residence and both the nearest genitourinary medicine clinic and the clinic attended. Non-local clinics were attended by 5408 (46.7%) patients. Men having sex with men attended non-local services more than heterosexuals (OR 3.83, p < 0.001). Among heterosexual men, black Africans and black Caribbeans were more likely, and South Asians less likely, to attend non-local services compared to whites (OR [95%CI] 1.33 [1.04-1.72], 1.36 [1.11-1.67] and 0.46 [0.31-0.70] respectively). Similar associations, although not statistically significant, were found in women. People were more likely to attend local services if their local clinic provided walk-in and young people's services, weekend consultations and long opening hours. These findings could help design services meeting local population needs and facilitate prompt and equitable access to care.

Not so different after all? Comparing patients attending general practice-based locally enhanced services for sexual health with patients attending genitourinary medicine

We did a cross-sectional survey of patients attending genitourinary (GU) medicine clinics (n = 933) and general practice-based Locally Enhanced Services for Sexual Health (GP-LESSH, n = 111) in Cornwall, England, in 2009/2010, to compare patients' characteristics and experiences. Patients completed a pen-and-paper questionnaire that was then linked to an extract of their clinical data. GP-LESSH patients took longer both to seek and to receive care: medians of nine and seven days, respectively, versus GU medicine patients: medians of seven and one day, respectively. GP-LESSH patients were less likely than GU medicine patients to report symptoms (19.6% versus 30.6%) and sexual risk behaviours (33.3% versus 44.7% reported new partners) since recognizing needing to seek care; 5.0% versus 10.2% were men who have sex with men). However, they were equally likely to have sexually transmitted infections (STIs) diagnosed (23.3% versus 24.8%). As GP-LESSH may operate infrequently, local services must work collaboratively to ensure that those seeking care for suspected STIs receive it promptly. Failing to do so facilitates avoidable STI transmission.

Assessing user preferences for sexually transmitted infection testing services: a discrete choice experiment

OBJECTIVE

To assess user preferences for different aspects of sexually transmitted infection (STI) testing services.

DESIGN

A discrete choice experiment.

SETTING

14 centres offering tests for STIs in East Sussex, England.

PARTICIPANTS

People testing for STIs.

MAIN OUTCOME MEASURE

(Adjusted) ORs in relation to preferred service characteristics.

RESULTS

3358 questionnaires were returned; mean age 26 (SD 9.4) years. 70% (2366) were recruited from genitourinary medicine (GUM) clinics. The analysis suggested that the most important characteristics to users were whether 'staff had specialist STI knowledge' compared with 'staff without it' (OR 2.55; 95% CI 2.47 to 2.63) and whether 'tests for all STIs' were offered rather than 'some' (OR 2.19; 95% CI 2.12 to 2.25). They remained the most important two service characteristics despite stratifying the analysis by variables such as age and sex. Staff levels of expertise were viewed as particularly important by people attending CASH centres, women and non-men who have sex with men. A 'text or call to a mobile phone' and 'dropping in and waiting' were generally the preferred methods of results reporting and appointment system, respectively.

CONCLUSIONS

This study suggests that people testing for STIs place particular importance on testing for all infections rather than some and staff with specialist STI knowledge. Thus, targets based purely on waiting up to 48 h for an appointment are misguided from a user perspective.

Genital warts and cost of care in England

Objectives

To estimate the total number of cases of, and cost of care for, genital warts (GWs) in England, to inform economic evaluations of human papillomavirus vaccination.

Methods

The number of GW cases seen in general practices (GPs) and in genitourinary medicine (GUM) clinics was estimated using the General Practice Research Database and the GUM Clinic Activity Dataset. The overlap in care of cases in the two settings was estimated. The calculated costs of care in GP and hospitals were added to the costs of care in GUM clinics (estimated elsewhere) to estimate the cost of care for GWs in England.

Results

In England, in 2008, GP and GUM saw 80 531 new (157/100 000 population) and 68 259 recurrent (133/100 000 population) episodes, giving a total of 148 790 episodes of care of GWs (289/100 000 population). Seventy-three per cent of cases were seen only in GUM clinics, 22% were seen by a GP before being referred to GUM, and 5% by GPs only. Hospital care was given in 1.3% of cases and contributed 8% of the costs. The average cost of care per episode was £113, and the estimated annual cost of care in England was £16.8 million.

Conclusions

This study provides a fairly comprehensive measure of GW frequency and care in England. GWs exert a considerable impact on health services, a large proportion of which could be prevented through immunisation using the quadrivalent human papillomavirus vaccine.