Missed Opportunities: The Health Adviser as a link between Genitourinary Medicine and Primary Care in the management of Chlamydia Bruce Armstrong, Sue Kinn, Anne Scoular and Phil Wilson
Dec 26, 2015
Missed Opportunities:The Health Adviser as a link
between Genitourinary Medicine and Primary Care
in the management of Chlamydia
Bruce Armstrong, Sue Kinn,
Anne Scoular and Phil WilsonThis study was funded by a grant from the Research and Development
Department of Greater Glasgow Primary Care NHS Trust
Background
• Rising incidence of genital Chlamydia
• Debate about a screening programme
• Under 25’s most at risk
• This group make poor use of existing sexual health services
Background
• Primary care is likely to be a common setting for screening
• For any screening programme to work there must be good links between primary care and GUM
• Current links are quite passive
Study Aims
• To investigate a model for collaboration between primary care and GUM and to answer the research question:
• “Does the presence of a health adviser, in a general practice setting, improve the awareness, diagnosis and treatment of Chlamydia at the community level?”
Outcome Measures
Primary measures
• Screening rate for Chlamydia in under 25 year olds
• Screening rate for Chlamydia in under 20 year olds
• Partner notification outcomes
Outcome Measures
Secondary measures
• Screening rates for other STI’s
• Knowledge and understanding among professionals and patients
Methods
• Controlled before-and-after intervention study
• Set in area of high deprivation
• 2 large urban health centres
Demography and Population
Population GPs Practice Nurses Practices
Health Centre A 24,566 25 9 8
Health Centre B 32,822 24 8 6
Intervention
Health adviser in health centre 6 months:
• Training and support for staff
• Development of administrative systems for partner notification
• Outreach work
Data Collected
• Laboratory computer systems• Questionnaires
– Professionals– Patients
• Case note review– Reasons for test– Partner notification outcomes
• Qualitative data– Researcher field notes– Interviews
Screening Rates
In Health Centre A
• 11% of the total increase was in <20s
• 43% of the total increase was in 20-24s
• 46% of the total increase was in >24s
• 79% of tests were done by practice nurses
• 90% of <20s were seen by GPs
Positive Results
• Health centre A– In 2000: 16 of 152 = 10%– In 2001: 24 of 335 = 7%
• In health centre B– In 2000: 17 of 336 = 5%– In 2001: 21 of 374 = 5%
Partner Notification Outcomes
21 of 24 case notes for positive tests were available:
Partner notification discussed 17
1 partner treated 11
1 partner positive 3
Declined partner notification 1
>1 partner declared 0
Knowledge and Attitudes
Patient questionnaires117 of 335 completed a pre-test questionnaire asking about reasons for testing:
– Doctor/nurse advised me to 85– I asked for a test 17– Information from poster/leaflet 14– Discussion with friends 11– Information from magazine/newspaper 4– Partner has infection 2– Information from tv/radio 1– Lesson at school 0
– Other 6
Knowledge and Attitudes
• 75% of respondents had heard of Chlamydia before having the test
• 97% reported that the doctor or nurse had discussed the condition with them
Knowledge and Attitudes
Patients’ Comments
"I agree that screening should be available on request/randomly”
"I think it should be a regular test for both men and women by their GPs”
" I am pleased the nurse mentioned the test because I wouldn't have thought about it otherwise”
" I would never have thought about getting a test for Chlamydia"
Knowledge and Attitudes
Staff questionnaires• Distributed pre- and post-intervention in
both health centres
• Response rate:
2000 2001
HCA 38% 49%
HCB 24% 26%
Qualitative Data
Major themes
• Time constraints
• Skills for sexual health work
• Staff and patient’s agendas
• Practicality of guidelines
Time Constraints
“… If I'm running late and a 25 year old comes in for a repeat prescription of the pill, so I know they’re sexually active, I think thank god, quick blood pressure, pill and out … in an ideal world I would love to sit there with time to spend with every one of them. It’s painfully hard, it just can’t happen.”
Skills for Sexual Health Work
“I don’t have a particular problem about (discussing sexual health with patients). I just think … I’m already running fifteen minutes late, am I going to open up a whole can of worms here?”
Staff and Patients’ Agendas
“Patients sometimes come in to me quite disgruntled because they’ve come to the general practitioner with a sore throat and ended up with a cervical smear”
Practicality of Clinical Guidelines
“ Thank god they’re not something we have to adhere to rigidly, because if they were we’d be here twenty-four hours a day!”
Practicality of Clinical Guidelines
“Probably general practice wasn’t considered (when the SIGN guidelines were written).”
Why the Decrease in Percentage of Positive
Results?
• Increase in testing activity
• Largest proportion of increase was in patients at low risk
• Small increase in patients under 20 years
Possible Reasons - 1
Practice nurses were more likely to:
• Attend training
• Use the health adviser as a resource
• Carry out testing
Possible Reasons - 1
Therefore the staff best equipped to carry out opportunistic testing were least likely to see the patients most at risk.
Possible Reasons - 2
• Practice nurses offer opportunistic testing to patients attending for cervical screening (i.e. female patients over 20 years)
• Other methods of introducing opportunistic testing are less well developed
What Are the Constraints on Opportunistic Testing?
General practitioners
• Time constraints
• Multiple, competing priorities
What Are the Constraints on Opportunistic Testing?
Practice nurses
• Time constraints (but more likely to offer testing than GPs)
• Less likely to see patients under 20 years
What Are the Constraints on Opportunistic Testing?
Treatment room nurses
• See patients in the age group most at risk
• But do not have authority to initiate opportunistic testing
Partner Notification
Passive, despite the presence of a health adviser in the health centre, due to:• Time constraints• Some practices having no follow up
systems• Under recording of sensitive discussions• Lack of information about partners from
other practices
Conclusions
Training and support from a health adviser does not improve detection rates for Chlamydia trachomatis in the absence of changes to constraining factors. These include:
• Lack of time for opportunistic sexual health consultations
• Lack of robust systems for sexual health work