Transcript Document

BASHH 2009
Asymptomatic Screening Audit
in
UK GUM Clinics
~ Case Notes Audit ~
BASHH 2009 Asymptomatic
Screening Audit
•
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•
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Audit methods
Results (selected)
Limitations
Conclusions
Recommendations for practice change

Recommendations audited
against
• BASHH Clinical Effectiveness Group:
Sexually Transmitted Infections: UK
National Screening and Testing
Guidelines August 2006*
*http://www.bashh.org/guidelines
Asymptomatic case
definition
• No symptoms offered on presentation
(either on a triage form, or similar
form, or on direct questioning by a
healthcare worker)
• New or re-book
Methods
• First 30 consecutive patients January to
March 2009
• Questionnaire designed by NAG, available at:
http://www.bashh.org/groups
• Electronically data submission using Feedback
Server software and downloaded for analysis
using Microsoft Access and Excel.
• Data collated and aggregated by
– Clinics: regional aggregates
– Regions: national aggregate
Results …
Main messages
1.
HIV, syphilis, chlamydia – good testing
performance against BASHH first line
recommended tests
2. Gonorrhoea: good testing performance only
when culture plus NAATs included
3. Throat and rectal gonorrhoea screening common
practice for MSM
– Especially when sexual history documented
Contribution of cases, N= 4428
• 4428 cases from 157 clinics
(~60% of all GU Medicine clinics)
• Regional contribution: 2-17%
Gender & sexual preference, N= 4428
• Men: 2297 (52%, 43–59%)
– Heterosexual: 2078 (47%, 37–56%)
– MSM: 219 (5%, 2–8%)
• Women: 2131 (48%, 41–57%)
Results: specific infection
screening in asymptomatic groups
HIV & syphilis screening …
HIV screening in asymptomatic groups
“All patients attending the GUM clinic should be offered an HIV test, according to the
National Strategy for Sexual Health and HIV ” Testing uptake standard 60%
Group
Done n (%, regional range)
MSM
n= 219
207 (94%, 90-100%)
Heterosexual men
n=2078
1731 (83%, 70-96%)
Women
n=2131
1716 (81%, 66-98%)
HIV testing in women (n=2131)
HIV testing in MSM (n=219)
Syphilis screening* in asymptomatic groups
“Screening is recommended for all asymptomatic patients attending a UK GU clinic”
Group
MSM
n= 219
Heterosexual men
n=2078
Women
n=2131
Done n (%, regional
range)
212 (97%, 90-100%)
1755 (84%, 70-96%)
1735 (81%, 69-98%)
*Any test for syphilis: EIA, TPPA, VDRL/RPR,TPHA
Chlamydia screening …
Chlamydial screening
Group
CEG Test of choice
Done n (%, regional
range)
MSM
n= 219
Het men
n=2078
Urine NAAT or
urethral NAAT
210 (96%, 50-100%)
Urine NAAT or
urethral NAAT
1991 (96%, 81-100%)
Women
n=2131
Cx NAAT, VV NAAT,
or urine NAAT
Women
n=2131
1987 (93%, 73-100%)
Urine NAAT
233 (11%, 0-37%)
VV NAAT
347 (16%, 0-40%)
Gonorrhoea screening …
MSM, n= 219
CEG test of choice: culture for invasive sampling
Tests for gonorrhoea
Urethral culture only
Urethral culture or urine NAAT*
* Recommended if urethral specimen not available
Done n (%, regional
range)
119 (54%, 9-100%)
207 (94%, 80-100%)
Heterosexual men, n=2078
CEG test of choice: culture for invasive sampling
Tests for gonorrhoea
Urethral culture only
Urethral culture or urine NAAT*
* Recommended if urethral specimen not available
Done n (%, regional
range)
1194 (58%, 2-98%)
1926 (93%, 76-100%)
Women, n=2131
CEG test of choice: culture for invasive sampling
Tests
Done n (%, regional
range)
Cx culture
1393 (65%, 26-94%)
Cx culture
+ Cx NAAT, VV NAAT
1770 (83%, 53-99%)
Cx culture
+ Cx NAAT, VV NAAT
+ Urine NAAT, urth NAAT, urth cult
1981 (93%, 83-100%)
Throat and rectal screening
for gonorrhoea by culture
Asymptomatic MSM:
rectal and throat gonorrhoea culture, n= 219
Site of test for
gonorrhoea
Rectum
CEG Recommends
Done n (%, regional
range)
100%, if indicated by
sexual history
153 (70%)
Receptive anal sex documented
n=141
119 (84%, 67-100%)
Receptive anal sex not documented
n= 78
34 (44%, 0-100%)
Throat
100%, if indicated by
sexual history
175 (80%)
Receptive oral sex documented
n=156
134 (86%, 75-100%)
Receptive oral sex not documented
n= 63
41 (65%, 0-100%)
NAATs for gonorrhoea screening
Group
Urine
Urethra
Cervical
Rectal
Throat
Done n (%,
regional range)
Done n (%,
regional
range)
Done n (%,
regional
range)
Done n (%,
regional
range)
Done n (%,
regional range)
751
84
(36%, 0-100%)
(4%, 0-16%)
98
37
(45%, 0-100%)
(17%, 0-60%)
Women
209
33
n=2131
(10%, 0-36%)
(2%, 0-13%)
Het men
n=2078
MSM
n=219
-
-
-
33
20
(15%, 0-44%)
9%, 0-30%)
250
5
5
(12%, 0-44%)
(0.2%,0- 1.1%)
(0.2%, 0-2.3%)
-
Urine NAATs for Gc in MSM
• Conclusions and recommendations
Limitations- not known:
• Patient, clinician or systems preferences
influencing choice of
– Invasive/non-invasive sampling
– NAATs/culture
• Positive NAATs for gonorrhoea
– Culture confirmation
– Repeat testing with different NAAT target
to avoid false positives
Main messages
1.
HIV, syphilis, chlamydia – good testing
performance against BASHH first line
recommended tests
2. Gonorrhoea: good testing performance only
when NAATs included
–
Urine GC NAATs: often used, including 45% MSM
–
Especially when sexual history documented
3. Throat and rectal gonorrhoea screening common
practice for MSM
Suggested Areas for Practice
Improvement/Interventions- 1
• Increased documentation of discussion
about oral and anal sex
– Recommended in the BASHH Guideline
on sexual history taking
– Identifies anatomical sites for sampling
Suggested Areas for Practice
Improvement/Interventions- 2
• Culture needed in every clinic?
• Regional strategies? …
… balance NAATs with culture testing for
gonorrhoea to monitor antibiotic sensitivity
(Gonococcal Resistance to Antimicrobials
Surveillance Programme)
• Detailed data and PowerPoint
presentation on:
www.bashh.org/committees/nag/index.htm
• Late 2010: DH-funded audit of BASHH
STI Management Standards
… the end
ACKNOWLEDGEMENTS
The work done by all NHS staff who submitted data and supported the Audit is gratefully
acknowledged. The work done by those running the pre-pilot and pilot phases is gratefully
acknowledged.
The work done by the Regional Chairs and staff in NHS Trusts/Clinics is gratefully
acknowledged.
Membership of National Audit Group, October 2008: Chris Carne (Chair), David Daniels
(Vice-Chair), Hugo McClean (Hon Sec), Anatole Menon-Johansson (Director of
Development), Raymond Maw (N.Ireland and BCCG chair), Ed Wilkins/Alison Rodger
(BHIVA Representative), TC Harry (Anglia), Gail Crowe (Essex), Ravindra Gokhale
(Merseyside), Ann Sullivan (N Thames), Eva Jungmann (N Thames), Sarup Tayal
(Northern), Ashish Sukthankar (North-West), Adil Isaac (Oxford), Steve Baguley
(Scotland), Arnold Fernandes (South-West), Cindy Sethi (SE Thames), Steven
Estreich (SW Thames), Jyoti Dhar (Trent), Helen Bailey (Wales), Sarah McAndrew
(Wales), Reena Mani (Wessex), Kaveh Manavi (West Midlands), Amy Tobin-Mammen
(Yorkshire), Paul Bunting (Co-opted Member), Irene Vaughan (Co-opted Member), Mike
Walzman (Co-opted Member),Nicola Low (Co-opted Member).
The advice and support of Hilary Curtis in designing the on-line questionnaires and in
collecting, processing and tabulating the audit data into a national aggregate and regional
aggregates is gratefully acknowledged.