Impact of cancer- and patient-level factors on provider risk in the Oncology Care Model

e18852

Background: Transferring financial risk from payers to providers to align incentives is central to value-based payment (VBP) reform, including Medicare’s Oncology Care Model (OCM). We simulated the impact of selected cancer- and patient-level factors on providers’ risk in OCM for multiple myeloma (MM), due to its clinical complexity. We hypothesize that risk exposure is sensitive to factors extrinsic to the OCM methodology, including clinical phenotype, disease state and progression rate. Methods: Simulation was used to address omitted variable bias in payer data. We developed 9 key clinical MM scenarios to examine provider risk, based on conceptual frameworks that included patient- and cancer-level factors. The model was parameterized using the Medicare limited data set, research literature and domain knowledge. Twenty factors were varied for each model, e.g. age, autologous stem cell transplant (ASCT). Results: Simulations results showed MM risk for providers depended highly on cancer and patient level factors (see table). For example, high-risk patients were on average $21.5K over target while undergoing ASCT (despite risk adjustment for ASCT) and $18-28K under target for follow on maintenance (maint.) episodes. Conclusions: Provider exposure to risk in OCM is highly sensitive to factors at the cancer and patient level. The distribution of clinical phenotypes, state of disease, and rate of disease progression can significantly impact risk exposure for providers in OCM. New methodologies that model risk in more clinically granular ways are needed to improve VBP in oncology. [Table: see text]

Modeling Medicare’s Oncology Care Model bundles at more clinically granular levels: Evaluating the impact on provider performance

e18854

Background: Aggregating different subtypes of cancers into bundles is an important methodology in oncology payment reform as an alternative to fee for service. However, expected resource utilization can vary significantly across cancer subtypes. We evaluated the impact that modeling Chronic Leukemia into a more clinically granular two part framework of chronic myelogenous leukemia (CML) and chronic lymphocytic leukemia would have on OCM results and the risk that the distribution of clinical subtypes at a practice would influence overall performance in the bundle. Methods: OCM episodes of chronic leukemia initiating between July 2016 and June 2019 were subdivided on the basis of individual ICD-10 coded diagnoses on cancer-related E&M visits. From a total of 4,658 episodes, we randomly sampled with replacement 3,500 episodes from 16 practices using empirical data distributions. Data models and mappings were developed based on clinical knowledge and exploratory data analyses to subdivide the OCM bundle of Chronic Leukemias into CLL and CML. Total cost of care and episode target prices were calculated through implementation of the OCM methodology. The distributional consistencies of episode target, cost, cost above target, and percent above target for the two diseases were evaluated by two-sample Kolmogorov-Smirnov (KS) tests. Results: The CML and CLL subtypes modeled from the aggregate OCM bundle demonstrated significantly different cost distributions relative to each other. As anticipated, treatments used in each subtype varied significantly marking different patterns of expected resource utilization. In our model, CLL episodes were on average 13.7% over target. Average CLL episode costs were $52.2K vs. an average target of $47.6K with 54% of episodes running over target. In contrast, CML episodes were 6.1% under target. Average CML episode costs were $45.2K vs. an average target of $50.3K with 43% of episodes running over target. Conclusions: Value based payment models in oncology such as OCM can be improved by modeling cancer bundles in more clinically granular ways that better reflect expected resource utilization for appropriate, standard of care. Insufficient clinical granularity in bundle construction can lead to provider performance being influenced by the distribution of patient subtypes at the practice. This can lead to inappropriate shifts of risk from payers to providers in value based models. Aggregate vs. subtype episode costs (mean, 5th, and 95th percentiles).[Table: see text]

Evaluating differential cost growth across individual cancers: Insights from Oncology Care Model data

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Background: Analyzing cost growth in oncology often faces significant challenges, including fragmentation of data for infused vs. oral agents and ascertaining the cost of inpatient care. How differential cost growth at the individual cancer level contributes to aggregate cost growth in oncology is often opaque. We leverage the integrated claims data provided by Medicare for its Oncology Care Model (OCM) pilot to analyze variations across individual cancers with respect to cost growth. Methods: OCM’s innovative methodology creates a natural experiment where costs are compared against a counterfactual comprised of Medicare patients seen in non-OCM practices. Leveraging this differential counterfactual provides an opportunity to gain insight into cost growth for individual cancers compared to oncology as a whole. Specifically, cost growth is measured each Performance Period (PP) with respect to the Baseline Period, from 2012 to 2015. We analytically decomposed and remodeled key quantitative factors in OCM associated with cost dynamics in oncology, including the Trend Factor (TF), which represents non-OCM cost growth. From 124,896 episodes, we sampled with replacement 19,191 episodes from 17 practices between PP1 and PP6 using empirical data distributions. We assumed neutral novel therapy and experience adjustments and then compared the overall TF to the remodeled cancer-level TF, reaggregated from the individual episodes. Results: Reallocating the TF reveals that cost growth among cancer types is highly variable in the broader Medicare population. Cost growth at the individual cancer level varied from +99.3% to -14.3%. Of the 21 OCM cancers, 18 have TFs greater than zero, indicating cost growth in the non-OCM Medicare population since the Baseline Period. Four have a TF greater than 50%. Three cancer types show decreasing costs relative to the baseline period: intestinal cancer, MDS, and CNS tumor. Conclusions: Significant variation exists across individual cancer subtypes in terms of cost growth. Aggregate analyses of cancer at large have insufficient specificity to rationalize payment mechanisms. Payment reform efforts within cancer care should directly address dynamics at the individual cancer or cancer subtype level in order to provide more valid considerations for expected resource utilization, including in future payment policies. [Table: see text]

The use of quasi-experimental design methods to evaluate and improve the impact of acute care centers on oncologic emergencies

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Background: Reducing avoidable hospital and emergency department (ED) use are national priorities in cancer care. Acute care centers (ACCs) that expand access for patients with oncologic emergencies are increasingly implemented as alternatives to inpatient and ED care. The impact of these ACCs is uncertain. Additionally, how to rigorously evaluate these interventions and to iteratively improve their effectiveness remains unclear as infrastructure interventions such as ACCs are not amenable to experimental manipulation. Methods: We are developing a novel quasi-experimental framework for evaluating and improving the effectiveness of an ACC intervention at the Simmons Comprehensive Cancer Center (SCCC) of the University of Texas Southwestern. SCCC covers one of the largest geographic regions of any academic medical center in the country, creating challenges addressing access to care. Drawing on the Andersen model for healthcare utilization we hypothesize that ACC effectiveness is mediated through enabling factors, particularly distance. Our initial evaluation framework draws on an untreated control group design with multiple pretest and post-test samples. The control group is comprised of patients living in zip codes farther away from the ACC. Additional analytic work will assess the feasibility of adding a matching cohort group structure based on factors such as onset of illness and matching individual patient episodes based on risk adjustment parameters. If the ACC is later expanded to other sites, the design can be further developed by adding a switching replications methodology to augment the quasi-experiment. Data collection draws on claims data provided through SCCC’s participation in Medicare’s Oncology Care Model (OCM). Results: Over OCM’s initial four performance periods (each six months long), all-cause risk adjusted hospitalization rates for SCCC patients ranged from 25.2% to 27.2%. All-cause risk adjusted OCM ED use ranged from 28.1 to 29.9%. Seeking to improve performance for both, SCCC leadership initially implemented a temporary urgent care clinic in August 2018. This initial prototype clinic was formalized into an operational ACC in August 2020. Evaluation of the impact of this ACC intervention is ongoing. Conclusions: ACCs represent potentially important means to reduce avoidable hospital and ED use. However, complex infrastructure interventions are not amenable to experimental evaluations assessing their impact, and it remains difficult to gain insights into how to tailor services through these interventions to support patients with oncologic urgencies and emergencies. Quasi-experimental approaches when integrated alongside ACC interventions represent promising mechanisms of evaluation and continuous quality improvement.

Practice transformation at scale through a microsystems quality improvement (QI) approach

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Background: How oncology providers should implement practice transformation for value-based care is unclear, particularly at scale. Organizational size enables efficient “top down” approaches, but also presents challenges such as physician engagement. Dis-economies of scale can be acute in oncology due to physician autonomy and coordination costs. We hypothesized that organizational change based in sense-making models that enhance physician engagement and use a decentralized, iterative microsystems approach will enable practice transformation to scale. Methods: Florida Cancer Specialists & Research Institute (FCS) is a physician led 250-oncologist statewide practice, with regional variation in disease state/mix, patient cohort, etc., making a purely top-down approach to organizational change infeasible. FCS prototyped a transformation strategy starting in June 2017 based on sharing interpreted data with physician and executive leadership. Later implementation directly engaged physicians in a microsystems quality QI strategy focused on regional performance. Interventions targeted disease, health service utilization, location, and individual physicians. Performance was evaluated using data from Medicare’s Oncology Care Model (OCM) and assessed using the one-sided risk target (4% below benchmark). We analyzed 70,239 performance period (PP) episodes at FCS across 35,116 patients. Results: In the pre- intervention period (90% of PP1 episodes, completed by June 2017), FCS was 5.8% above target. Performance was 10.9% above target for the remainder of PP1 (10% of PP1 episodes), then improved to 0.3% above target in PP2 and PP3, and below target by 0.9%, 0.8%, and 0.75% in PP4, PP5, and PP6. Early QI efforts focused on performance in lung cancer, which was 2.5% over target in PP1; it improved to 2.1% under target in PP6. Later regional QI sessions targeted cancer, utilization and providers. Pre-intervention, all 18 regions were above target; by PP6, 11 out of 19 regions were below target. Relative to the pre-intervention period, per-episode inpatient costs increased by 12.1% for the remainder of PP1 and increased by 4.3% and 1.3% in PP2 and PP6; inpatient costs decreased in PP3, PP4, and PP5 by 3.8%, 2.4% and 4.8%. Conclusions: Practice transformation in oncology can achieve scale through models of organizational change that foster physician engagement. Data, when clinically contextualized, is a foundational tool in the sense-making process. Scale can develop through an additive microsystems approach in which QI units are de-centralized, accountability is defined, and iteration becomes part of organizational culture. [Table: see text]

Bundling cancer subtypes in value-based care: A pilot analysis of lymphoma episodes in the Oncology Care Model

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Background: Value based models (VBMs) in which cancers are bundled are a growing alternative to fee for service, as in the Oncology Care Model (OCM). However, bundles in OCM may not capture the clinical granularity needed to predict resource utilization for cancer subtypes. One such bundle is lymphoma, which groups highly heterogeneous diseases with distinct treatments and differing intensity of care. Here, we compare OCM predicted episode costs (targets) to actual episode costs by lymphoma subtype. Methods: Our cohort study used OCM data from a large academic medical center (AMC) and large community oncology practice (COP). Six-month episodes of lymphoma beginning between July 2016 and June 2019 were categorized based on ICD-10 diagnoses on antineoplastic infusions and E&M visits, as well as disease and data modeling. Episodes were subdivided into follicular (FL), diffuse large B (DLBCL), small B (SBCL), mantle (MCL), Hodgkin (HL), Waldenstrom macroglobulinemia (WM), mature T/NK (T/NK), and Other. The distributional consistency of episode costs and targets for each subtype relative to the rest of the episodes was evaluated by Kolmogorov-Smirnov tests. We also compared the proportion of subtypes contributing to episodes in the AMC vs. COP. Results: A total of 1801 lymphoma episodes were identified (44% in AMC, 56% in COP). The most common subtypes (DLBCL and FL) contributed a larger proportion of episodes in the COP, while less frequent subtypes (T/NK, WM) were more prevalent at the AMC. Further, episode costs are significantly different across individual subtypes. Target variance was significantly lower than cost variance across subtypes. For example, the average target for WM was $50.4K, average costs were $40.2K, with 26% of episodes over target. In contrast, the average target for T/NK was $55.9K, average costs were $72.7K, with 64% of episodes over target. Conclusions: VBMs such as OCM currently aggregate cancer types and lack clinical granularity. Our evaluation of OCM episodes at an AMC and COP found considerable differences in lymphoma populations and in costs by subtype. Failure to account for clinical features (i.e. lymphoma history) could lead to inappropriate shifts of risk from payers to providers in VBMs.[Table: see text]

P1489An audit of 215,000 patients on primary care registers using novel electronic searches to identify patients with heart failure requiring treatment optimisation and complex device therapies

INTRODUCTION

 Patients with heart failure (HF) may not routinely receive review from a HF specialist and understanding of which patients may benefit from specialist therapies is not widely appreciated by non-specialists.  Therefore, there may be frequent missed opportunities for patients under non-specialist care to access prognostically important therapies. 

PURPOSE

To identify high-risk patients in primary care with HF and left ventricular systolic dysfunction (LVSD) that require optimisation and consideration for complex device therapy.

METHODS

15 general practitioner (GP) practices across Cornwall were audited between between July 2018 and August 2019 with a total population of 215,114 patients. The total combined HF register in these practices was 2,925. A further 2,238 patients were identified using the case finder element of GRASP-HF, an electronic search tool, to identify patients with HF +/- LVSD not coded correctly in GP records. Electronic records were manually reviewed and selected patients, potentially benefitting from further optimisation, were electronically reviewed by a Consultant Cardiologists for final screening before being invited into a specialist HF clinic at their local GP practice. All patients received an up to date ECG prior to specialist review. Outcomes of each patient clinical review were followed-up for a minimum of 1 month.

RESULTS

From 5,163 patients audited, 157 underwent clinic review with a Consultant Cardiologist at their local GP practice and are described below.

Patient characteristics

Mean age was 75 years, 78% were male, 51% had ischaemic cardiomyopathy and 27% had AF. 66% had severe LVSD (EF <35%), 48% had broad QRS (>120ms) and only 44% were deemed to be on optimal medical therapy. Of 88 patients not fully optimised, the proportion requiring optimisation of ACEi/ARB, beta-blocker, MRA, sacubitril-valsartan and ivabradine were 57%, 30%, 36%, 7% and 1%, respectively.  

Patient outcomes

Median follow up period was 7 months (range 2-15).  65% of all patients required further imaging of LV function to help determine onward management.  48% were potential candidates for device therapy and 3 patients (2%) were listed directly for device therapy while 5 patients (3%) declined.  In total, following complete assessment, 18 patients (11%) received device implantation (12 CRT-P, 2 CRT-D, 2 ICD and 1 loop recorder) and 25 patients (16%) received sacubitril-valsartan.  A change in patient clinical management was instituted in 64% of patients following specialist review.

CONCLUSION

This comprehensive audit of GP registers demonstrates a significant burden of patients with HF and LVSD who are not appropriately coded.  This audit also identifies frequent opportunities to intensify 1st and 2nd line medical therapies and patients that may benefit from specialist therapies including complex devices.  Primary care teams would benefit from regular review of their HF registers and from specialist outreach initiatives.

Who is coming back for more chlamydia testing within non-specialist health services and where do they go? England, 2013-2016

OBJECTIVES

To investigate patient demographics and venue type preferences within community settings associated with re-attendance for chlamydia testing.

STUDY DESIGN

Data used for this analysis were obtained from the English National Chlamydia Screening Programme (NCSP) which focuses on prevention, control and treatment of chlamydia in sexually active under-25 year olds. A greater understanding of how young adults attend services helps to inform commissioners regarding where to focus resources within community settings.

METHODS

Data from the Chlamydia surveillance system (CTAD) were used to count patient attendances at non-specialist sexual health services (SHSs) among 15-24-year-olds and monitor re-attendance for chlamydia testing within and between community services between 6 and 18 months of their first visit.

RESULTS

From January 2013 to December 2016, 866,847 young people underwent 1,041,245 tests for chlamydia. Re-attendance for chlamydia testing was 20.1% (174,398/866,847). Re-attendance rate was 28.5% after a positive test and 19.5% after a negative test. For re-attenders, 64.2% used the same venue type for both visits. General practice (GP) and sexual and reproductive health services (SRH) were the most commonly re-attended services (31.0% and 30.6% respectively).

CONCLUSIONS

Only one in five re-attended for chlamydia testing. Re-attendance was associated with having a positive result, accessibility and convenience. Patients are likely to return for testing to services they know. This should be considered by commissioners implementing new re-attendance guidance based on the NCSP.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

OBJECTIVES

Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response.

METHODS

HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated.

RESULTS

New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007).

CONCLUSIONS

The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.

The role of frequent HIV testing in diagnosing HIV in men who have sex with men

OBJECTIVES

In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing.

METHODS

Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported.

RESULTS

Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17).

CONCLUSIONS

The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM.

Using null models to infer microbial co-occurrence networks

Although microbial communities are ubiquitous in nature, relatively little is known about the structural and functional roles of their constituent organisms' underlying interactions. A common approach to study such questions begins with extracting a network of statistically significant pairwise co-occurrences from a matrix of observed operational taxonomic unit (OTU) abundances across sites. The structure of this network is assumed to encode information about ecological interactions and processes, resistance to perturbation, and the identity of keystone species. However, common methods for identifying these pairwise interactions can contaminate the network with spurious patterns that obscure true ecological signals. Here, we describe this problem in detail and develop a solution that incorporates null models to distinguish ecological signals from statistical noise. We apply these methods to the initial OTU abundance matrix and to the extracted network. We demonstrate this approach by applying it to a large soil microbiome data set and show that many previously reported patterns for these data are statistical artifacts. In contrast, we find the frequency of three-way interactions among microbial OTUs to be highly statistically significant. These results demonstrate the importance of using appropriate null models when studying observational microbiome data, and suggest that extracting and characterizing three-way interactions among OTUs is a promising direction for unraveling the structure and function of microbial ecosystems.

Managing the risk of iatrogenic transmission of Creutzfeldt-Jakob disease in the UK

BACKGROUND

With the emergence of bovine spongiform encephalopathy (BSE) and variant Creutzfeldt-Jakob disease (CJD) in the UK, there is concern about iatrogenic transmission, and the approach to managing this risk is unique.

AIM

To describe and review CJD incident management and the notification of individuals 'at increased risk' as a strategy for reducing iatrogenic transmission.

METHODS

A description of iatrogenic CJD transmission, the CJD Incidents Panel's role, the number and nature of CJD incidents reported and the individuals considered 'at increased risk' by mid-2012.

FINDINGS

Seventy-seven UK cases of CJD are likely to have resulted from iatrogenic transmission, among recipients of human-derived growth hormone (64 cases), dura mater grafts (eight cases), blood transfusions (four cases) and plasma products (one case). To limit transmission, the Panel reviewed 490 incidents and advised on look-backs, recalls of blood and plasma products, and quarantining and disposing of surgical instruments. Additionally, on Panel advice, around 6000 asymptomatic individuals have been informed they are at increased risk of CJD and have been asked to follow public health precautions.

CONCLUSION

The strategy to reduce iatrogenic transmission of CJD has been developed in a context of scientific uncertainty. The rarity of transmission events could indicate that incident-related exposures present negligible transmission risks, or--given the prolonged incubation and subclinical phenotypes of CJD--infections could be yet to occur or have been undetected. Scientific developments, including better estimates of infection prevalence, a screening test, or improvements in decontaminating surgical instruments, may change future risk management.

Ecology of speciation in the genus Bacillus

Microbial ecologists and systematists are challenged to discover the early ecological changes that drive the splitting of one bacterial population into two ecologically distinct populations. We have aimed to identify newly divergent lineages ("ecotypes") bearing the dynamic properties attributed to species, with the rationale that discovering their ecological differences would reveal the ecological dimensions of speciation. To this end, we have sampled bacteria from the Bacillus subtilis-Bacillus licheniformis clade from sites differing in solar exposure and soil texture within a Death Valley canyon. Within this clade, we hypothesized ecotype demarcations based on DNA sequence diversity, through analysis of the clade's evolutionary history by Ecotype Simulation (ES) and AdaptML. Ecotypes so demarcated were found to be significantly different in their associations with solar exposure and soil texture, suggesting that these and covarying environmental parameters are among the dimensions of ecological divergence for newly divergent Bacillus ecotypes. Fatty acid composition appeared to contribute to ecotype differences in temperature adaptation, since those ecotypes with more warm-adapting fatty acids were isolated more frequently from sites with greater solar exposure. The recognized species and subspecies of the B. subtilis-B. licheniformis clade were found to be nearly identical to the ecotypes demarcated by ES, with a few exceptions where a recognized taxon is split at most into three putative ecotypes. Nevertheless, the taxa recognized do not appear to encompass the full ecological diversity of the B. subtilis-B. licheniformis clade: ES and AdaptML identified several newly discovered clades as ecotypes that are distinct from any recognized taxon.

Identifying the fundamental units of bacterial diversity: a paradigm shift to incorporate ecology into bacterial systematics

The central questions of bacterial ecology and evolution require a method to consistently demarcate, from the vast and diverse set of bacterial cells within a natural community, the groups playing ecologically distinct roles (ecotypes). Because of a lack of theory-based guidelines, current methods in bacterial systematics fail to divide the bacterial domain of life into meaningful units of ecology and evolution. We introduce a sequence-based approach ("ecotype simulation") to model the evolutionary dynamics of bacterial populations and to identify ecotypes within a natural community, focusing here on two Bacillus clades surveyed from the "Evolution Canyons" of Israel. This approach has identified multiple ecotypes within traditional species, with each predicted to be an ecologically distinct lineage; many such ecotypes were confirmed to be ecologically distinct, with specialization to different canyon slopes with different solar exposures. Ecotype simulation provides a long-needed natural foundation for microbial ecology and systematics.

Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis

OBJECTIVE

Antenatal screening for syphilis is well established in the United Kingdom. The prevalence of syphilis is now very low, prompting the question as to whether this screening programme is still necessary. This paper aims at identifying possible screening strategy options for the programme and comparing their effectiveness and cost effectiveness.

METHODS

The cost of the screening programme in the United Kingdom was estimated. This was based on the cost of screening tests, treatment, and follow up of infected women and their infants. This information was obtained from laboratories, antenatal clinics, and genitourinary medicine clinics. Epidemiological data from a survey of women treated for syphilis in pregnancy were analysed to identify groups at increased risk of syphilis. Strategic options for the screening programme were then identified. The effectiveness, number needed to treat, and cost effectiveness of these options were compared.

RESULTS

Antenatal screening in the United Kingdom detected at least 40 pregnant women who need treatment for syphilis every year. This means that 18602 women are screened for every woman detected who needs treatment for syphilis. The marginal annual cost of this screening programme in the United Kingdom is 672366 pounds sterling. This is equivalent to 90p per woman screened, or 16670 pounds sterling to detect one woman who needs treatment for syphilis. The screening programme could be targeted geographically at pregnant women in the Thames regions. This option has the potential to save 482185 pounds sterling. Other strategic options are to target pregnant women in non-white ethnic groups, or those born outside the United Kingdom. These targeted options would each detect between 70% and 77% of women needing treatment for syphilis. These options could potentially save 592938 pounds sterling and 562691 pounds sterling respectively.

CONCLUSIONS

Targeting or stopping the screening programme would save relatively little money. Although selectively screening groups by country of birth or by ethnic group could detect at least 70% of cases, this would be politically and practically difficult. Targeting by region would facts and the changing international epidemiology of syphilis lead us to recommend that the current universal antenatal screening for syphilis should continue.

Survey of how public health doctors in the United Kingdom and Republic of Ireland investigate the effects of long-term exposure to point sources of chemicals

Public health departments may need to investigate the health effects of long term exposures to chemicals from sources such as landfill sites and factories. Public health consultants responsible for communicable disease and environmental health and directors of public health in all health authorities and health boards in the United Kingdom and the Republic of Ireland were surveyed on behalf of a Faculty of Public Health Medicine guideline development group. The survey achieved a response rate of over 80%. Most public health doctors had investigated the health effects of long term exposure to chemicals, but many found it difficult to conduct effective and appropriate investigations in the face of community and political pressure. Most doctors acknowledged that they were responsible for investigating these problems, but wanted more epidemiological support, training, and guidance.

Syphilis in pregnant women and their children in the United Kingdom: results from national clinician reporting surveys 1994-7

OBJECTIVE

To measure the incidence of syphilis detected in pregnancy and congenital syphilis in the United Kingdom.

DESIGN

Surveys through consultants in genitourinary medicine and paediatricians with active surveillance.

SETTING

United Kingdom, 1994-7.

SUBJECTS

Women treated for syphilis in pregnancy, and children with early congenital syphilis born in the United Kingdom.

RESULTS

Over 3 years 139 women were diagnosed with and treated for syphilis in pregnancy; 121 were detected through antenatal screening. Thirty one had confirmed or probable congenitally transmissible syphilis, putting their pregnancies at risk. These were minimum figures but are compatible with the 90 to 100 women newly diagnosed annually as having infectious or early latent syphilis. A universal screening policy would require 18 600 and 55 700 women (maximum numbers) to be screened, respectively, to detect one woman needing treatment and to prevent one case of congenital syphilis. Nine presumptive cases of children with congenital syphilis born in the United Kingdom were reported. Mothers requiring treatment for syphilis were found in almost every health region but were more prevalent in London and the south east. Being born abroad and belonging to an ethnic minority group were strong risk factors, but 14% (19 of 121) of cases treated and six of 31 definite or probably transmissible cases occurred in white women born in the United Kingdom.

CONCLUSIONS

Congenitally transmissible syphilis continues to occur among pregnant women in the United Kingdom. Cases would be missed and stillbirths and congenitally infected babies would occur if antenatal screening was abandoned.

Behavioural and demographic characteristics of attenders at two genitourinary medicine clinics in England

OBJECTIVES

To investigate how attenders with sexually transmitted disease (STD) differ from the general population with respect to sexual behaviour, and to identify which attenders at genitourinary medicine (GUM) clinics are at particular behavioural risk for acquiring STD.

DESIGN

Multicentre cross sectional survey.

SETTING

Two genitourinary medicine clinics, one in London and one in Sheffield

SUBJECTS

20,516 patients attending the two clinics over an 18 month period.

MAIN OUTCOME MEASURES

Behavioural and demographic characteristics and clinical diagnoses were recorded for each patient.

RESULTS

8862 patients, in whom 12,506 diagnoses were made, were seen in the Sheffield clinic, and 11,654 patients, in whom 20,243 diagnoses were made, were seen in the London clinic. When compared with the reported results from a general population survey, there were higher proportions of clinic attenders reporting two or more sexual partners in the preceding 12 months (p < 0.001), and a higher proportion of males reporting homosexual contact (13% compared with 1%, p < 0.001). Only age and number of sexual partners in the past 12 months were significantly associated with acute STDs for each sex in each clinic. Acute STDs tended to occur with greater frequency in the younger age groups, peaking among 16-19 year olds, particularly among females.

CONCLUSIONS

The results have confirmed that patients with STDs exhibit higher risk sexual behaviour than the general population, and have highlighted the problem of continuing high risk behaviour among younger attenders, particularly younger homosexual men. This study has demonstrated that among GUM clinic attenders age and number of sexual partners are key risk factors for the acquisition of an acute STD. The results of this survey also indicate, however, that half of the females and more than one quarter of males with acute STDs reported only one sexual partner in the past 12 months, suggesting that health education messages should point out that it is not only those who have multiple recent sexual partners, or who have recently changed sexual partner, that are at risk of STD, including HIV.

Sexually transmitted diseases among teenagers in England and Wales

A profile of sexually transmitted diseases (STDs) and HIV infections among teenagers in England and Wales was obtained from reports of newly diagnosed STDs among teenagers attending genitourinary medicine (GUM) clinics in 1995, laboratory reports of newly diagnosed HIV infections between 1985 when reporting began and the end of 1995, and the prevalence of HIV (unlinked anonymous programme) among teenagers attending genitourinary medicine clinics and antenatal clinics in 1994 and 1995. STD reports were analysed by sex, age group, and place of residence of patients--whether in the NHS Thames regions or elsewhere in England and Wales. High rates of STDs were reported in teenagers, particularly in girls. The incidences of gonorrhoea, chlamydia infection, and first attack genital wart infections were higher in teenage girls than in any other age group. Boys under 16 years of age had substantially higher rates of infection with all STDs in the Thames regions than elsewhere. Rates of gonorrhoea in teenagers of both sexes in the Thames regions were more than twice those in the rest of the country. Infection rates for genital herpes, and chlamydia in girls, were also higher in the Thames regions, although the geographical differences were less marked. The seroprevalence of HIV among heterosexual teenagers was very low. In contrast, 226 HIV infections among teenage boys had probably been acquired through sexual intercourse with other males. Unlinked anonymous testing revealed HIV antibody in 7.5% of routinely collected serology specimens taken from teenage homosexual or bisexual males attending GUM clinics in London. The high rates of STDs among teenage girls and all teenagers in the Thames regions make these groups a high priority for sexual health promotion, with special consideration given to homo/bisexual male teenagers. Detailed surveillance of risk factors for STDs, and further studies of teenage sexual behaviour will help to effectively target resources to improve the sexual health of teenagers in England and Wales.