bashh 09 asymptomatic screening audit case notes audit

BASHH 09 Asymptomatic Screening Audit

Case Notes Audit

Recommendations audited against

• Sexually Transmitted Infections: UK National Screening and Testing Guidelines August 2006 http://www.bashh.org/guidelines

• Recommended Tests for Asymptomatic Patients

Case definition

• No symptoms offered on presentation (either on a triage form, or similar form, or on direct questioning by a healthcare worker)

• Seen during a first meeting in a new or re-book episode

Methods

• First 30 consecutive patients seen during 1 January 2009 to 31 March 2009

• Questionnaire designed by NAG, available at: http://www.bashh.org/groups

• Data electronically submitted May to July 2009 using Feedback Server software and downloaded for analysis using Microsoft Access and Excel.

• Pseudonymised data only collected• Data collated and aggregated by Region, and

by NHS Trusts/Clinics within Regions

Results – contribution of cases, N= 4428

• 4428 cases from 157 clinics (~60% of all GU Medicine clinics)

• Regional contribution: 2-17%• London regions: 32% of cases • New cases: 3296 (74%, regional

range 58-94%) • Rebook cases: 1132 (26%, 6-42%)

Results – gender & sexual preference, N= 4428

• Men: 2297 (52%, 43–59%)– Heterosexual: 2078 (47%, 37–

56%)– MSM: 219 (5%, 2–7.5%)

• Women: 2131 (48%, 41–57%)– Pregnant: 14 (0.3%, 0–1.3%)

Results – age distribution, N= 4428

Age group Number %, Regional range%

<16 40 1%, 0–3%

16–18 476 11%, 6–18%

19–24 1756 40%, 32–46%

25–34 1433 32%, 21–42%

35–44 478 11%, 6–16%

45–54 177 4%, 2–7%

55–64 60 1%, 0.3–3%

≥65 8 0.2%, 0–1%

Results – ethnic group, N= 4428Ethnic group Number %, Regional range%

White 3685 83%, 65–97%

Not known 189 4%, 0–30%

Black African 131 3%, 0–7%

Other 130 3%, 0–7%

Black Caribbean 108 2%, 0–8%

Indian 52 1%, 0–4%

Black Other 48 1%, 0–3%

Chinese/South-East Asian 30 0.7%, 0–2%

Pakistani 22 0.5%, 0–2%

Arabic 13 0.3%, 0–1%

Hispanic 11 0.2%, 0–0.7%

Bangladeshi 9 0.2%, 0–1%

Asymptomatic heterosexual men n=2078

Test CEG Recommen

ds

Done n (%, regional range)

Chlamydia(Urine NAAT or urethral NAAT)

Yes 1991 (96%, 81-100%)

Gonorrhoea(Urethral culture* or urine NAAT**)

Yes 1926 (93%, 76-100%)

Syphilis(Any test: EIA, TPPA, cardiolipin test,TPHA)

Yes 1755 (84%, 70-96%)

HIV Yes 1731 (83%, 70-96%)

Hep B (CAb, SAg or SAb)(n=2040, 38 known immune)

No, unless in risk group

476 (23%, 7-60%)

Urethral microscopy No 459 (22%, 0-87%)* Urethral culture only for gonorrhoea: 1194 (58%, 2-98%) ** Recommended if urethral specimen not available

Asymptomatic MSM, n= 219

Test CEG Recommen

ds


Chlamydia(Urine NAAT or urethral NAAT)

Yes 210 (96%, 50-100%)

Gonorrhoea(Urethral culture* or urine NAAT**)

Yes 207 (94%, 80-100%)


Yes 212 (97%, 90-100%)

HIV Yes 207 (94%, 90-100%)


Yes 127 (82%, 54-100%)

Urethral microscopy No 38 (17%, 0-100%)

* Urethral culture only for gonorrhoea: 119 (54%, 9-100%)** Recommended if urethral specimen not available

Asymptomatic MSM: rectal and throat gonorrhoea culture

Test CEG Recommends


Gonorrhoea, rectum Yes, if indicated by sexual hx.

Receptive anal sex documented n=141

119 (84%, 67-100%)

Receptive anal sex NOT documented n=78

34 (44%, 0-100%)

Gonorrhoea, throat Yes, if indicated by sexual hx.

Receptive oral sex documented n=156 134 (86%, 75-100%)

Receptive oral sex NOT documented n=63

41 (65%, 0-100%)

Asymptomatic women n=2131Test CEG

Recommends


Chlamydia (Cx, v/vagina, urethra or urine* NAAT)

Yes 1996 (93%, 73-100%)

Gonorrhoea(Cervical culture)

Yes 1393 (65%, 26-94%)


Yes 1735 (81%, 69-98%)

HIV Yes 1716 (81%, 66-98%)


No, unless in risk group

475 (23%, 8-59%)

Cervical microscopy No 248 (12%, 0-42%) * recommended if urethral specimen not available Chlamydia: any of cx NAAT, vv NAAT, urine NAAT, ur NAAT, ur cult, cx cult,vv cult: 2082 (98%, 94-100%)Gonorrhoea: any of cx culture, cx NAAT, vv NAAT: 1770 (83%, 53-99%)Gonorrhoea: any of cx NAAT, cx cult, vv NAAT, urine NAAT, ur NAAT and ur cult: 1981 (93%, 83-100%)

Asymptomatic women: rectal and throat gonorrhoea culture

Test CEG Recommends


Gonorrhoea, rectum Yes, if indicated by sexual hx.

Receptive anal sex documented n=93 11 (12%,0-100%)

Receptive anal sex NOT documented n=2038

27 (1%, 0-13%)

Gonorrhoea, throat Yes, if indicated by sexual hx.

Receptive oral sex documented n=549 65 (12%, 0-30%)

Receptive oral sex NOT documented n=1582

15 (1%, 0-6%)

NAAT testing for gonorrhoeaGroup Urine


CervicalDone n

(%, regional range)

RectalDone n (%, regional range)

Het menn=2078

751 (36%, 0-100%)

N/A N/A

MSM n=219

98 (45%, 0-100%)

N/AAnal sex doc: 23/141 (16%, 0-67%)

Anal sex not doc: 10/78 (13%, 0-

50%)

Womenn=2131

209 (10%, 0-36%)

250 (12%, 0-

44%)

Anal sex doc 4/93 (4%, 0-25%)

Anal sex not doc 1/2038 (0.05%, 0-

1%)

HIV testing* overall N=4428

*EIA, point of care or oral fluid tests (n=3)Nationally, any HIV test done: 248 of 287 (86%, 0-100%)

HIV testing in Black Ethnic Groups (n=287)

HIV testing in heterosexual men (n=2078)

HIV testing in MSM (n=219)

HIV testing in women (n=2131)

Hepatitis C antibody testing

• 566 of 4420 cases (13%, 4-57%) tested (8 known to have hep C antibody)

• MSM: 89 of 219 MSM (41%, 0-100%) tested

(none known to have hep C antibody)

Conclusions

• High overall rates of testing with BASHH CEG first line recommended tests for chlamydia, syphilis and HIV

• High overall rates of testing for gonorrhoea in women when NAATs included

• Important number of cases having N. gonorrhoeae NAATs, including urine GC NAATs (45% MSM)

• Urethral microscopy ~ 20% men• Cervical microscopy ~ 10%• Most MSM tested for HepB (80%)• Predominance of hepatitis C testing in MSM

Suggested Areas for Practice Improvement/Interventions

• Increased documentation of discussion about oral and anal sex, as recommended in the BASHH recommendations on sexual history taking to identify which anatomical sites need to be sampled for infection

• Regional strategies should be considered to balance nucleic acid amplification testing for gonorrhoea with culture testing to monitor antibiotic sensitivity

• Increased screening for hepatitis B in MSM is needed in some regions.

• Increased screening for HIV is needed in some regions, particularly for women

ACKNOWLEDGEMENTSThe 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 (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.

bashh 09 asymptomatic screening audit case notes audit

Documents

cases new cases

results contribution

rebook cases

rebook episode slide

regional range

results age distribution

asymptomatic patients

pseudonymised data