The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16–29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5–AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference −8.8%; 95% CI −10.5% to −7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference −7.1%; 95% CI −9.6% to −4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was −0.9% (95% CI −3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference −9.5%; 95% CI −11.7% to −7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference −6.4%; 95% CI −8.6% to −4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was −2.6% (95% CI −5.4% to −0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5–AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617

Intensified partner notification and repeat testing can improve the effectiveness of screening in reducing Chlamydia trachomatis prevalence: a mathematical modelling study

BackgroundThe Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a cluster randomised controlled trial designed to assess the effectiveness of annual chlamydia testing through general practice in Australia. The trial showed that testing rates increased among sexually active men and women aged 16–29 years, but after 3 years the estimated chlamydia prevalence did not differ between intervention and control communities. We developed a mathematical model to estimate the potential longer-term impact of chlamydia testing on prevalence in the general population.MethodsWe developed an individual-based model to simulate the transmission of Chlamydia trachomatis in a heterosexual population, calibrated to ACCEPt data. A proportion of the modelled population were tested for chlamydia and treated annually at coverage achieved in the control and intervention arms of ACCEPt. We estimated the reduction in chlamydia prevalence achieved by increasing retesting and by treating the partners of infected individuals up to 9 years after introduction of the intervention.ResultsIncreasing the testing coverage in the general Australian heterosexual population to the level achieved in the ACCEPt intervention arm resulted in reduction in the population-level prevalence of chlamydia from 4.6% to 2.7% in those aged 16–29 years old after 10 years (a relative reduction of 41%). The prevalence reduces to 2.2% if the proportion retested within 4 months of treatment is doubled from the rate achieved in the ACCEPt intervention arm (a relative reduction of 52%), and to 1.9% if the partner treatment rate is increased from 30%, as assumed in the base case, to 50% (a relative reduction of 59%).ConclusionA reduction in C. trachomatis prevalence could be achieved if the level of testing as observed in the ACCEPt intervention arm can be maintained at a population level. More substantial reductions can be achieved with intensified case management comprising retesting of those treated and treatment of partners of infected individuals.

1353. Gonorrhea and Chlamydia Testing and Case Rates Among Women Veterans in the Veterans Health Administration

Background United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans have many risk factors associated with STIs, including high rates of childhood sexual assault, military sexual trauma and intimate partner violence. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans. Methods We performed a retrospective cohort study of all women Veterans in Veterans Health Administration (VHA) care between January 1, 2018 and December 31, 2019 to examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the VHA in 2019. Results Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, predictors of testing in women under age 25 included Black race (aOR: 2.11 CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05 CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (Chlamydia case rate: 265, Gonorrhea case rate: 97/100,000) and those with mental health diagnoses (Chlamydia case rate: 263, Gonorrhea case rate: 72/100,000.) Over a third of chlamydia cases (35.2%) and gonorrhea cases (35.5%) occurred in women who resided in the South Atlantic census division. Chlamydia cases per 100,000 women Veterans seen in VHA (2019) Gonorrhea cases per 100,000 women Veterans seen in VHA (2019) Conclusion Gonorrhea and chlamydia testing remains underutilized among women in the VHA and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates. Disclosures All Authors: No reported disclosures

Preferences for chlamydia testing and management in Hong Kong: a discrete choice experiment

ObjectivesAs most chlamydia cases are asymptomatic, regular testing and timely management may be necessary for control. We aimed to determine the preferences of people living in Hong Kong for chlamydia testing and management services.MethodsAn online panel of sexually active individuals living in Hong Kong completed the survey with two discrete choice experiments (DCEs). The first DCE examined the preferred attributes of a chlamydia testing service (cost, location, appointment time, speed of results, delivery of results and availability of other STI testing). The second DCE examined the preferred attributes of a chlamydia management service (cost, access to patient-delivered partner therapy, location, travel time, type of person consulted and attitude of staff).ResultsIn total, 520 individuals participated: average age 36.8 years (SD 9.9), 40% males and 66% had a bachelor’s degree or higher. Choosing to test was most influenced by cost, followed by speed of results, delivery of results, extra STI testing, appointment available and the least important was the location of testing. Choosing to attend for management was most influenced by staff’s attitude, followed by cost, who they consult, access to patient-delivered partner therapy, travel time and the least important was treatment location.ConclusionTo design effective chlamydia testing and management services, it is vital to respond to patient needs and preferences. For people living in Hong Kong, cost and staff attitude were the most important factors for deciding whether to test or be managed for chlamydia, respectively.

Young people’s perceptions of accessing a community pharmacy for a chlamydia testing kit: a qualitative study based in North East England

ObjectivesChlamydia testing among young people in community pharmacies in North East England has been low compared with other remote settings offering testing for the past few years. To understand why this may be, to maximise service provision, the perceptions of young men and women about pharmacy testing and possible chlamydia treatment were gathered and interpreted.DesignIndepth, semistructured interviews.SettingFour youth centres in North East England.ParticipantsThe study included 26 young people aged 16–23. The sample of participants comprised those with a history of chlamydia testing as well as those never tested.InterviewsFace-to-face interviews were conducted between October 2018 and May 2019. The interview schedule covered young people’s perceptions of sexually transmitted infections, provision of pharmacy sexual and reproductive health and chlamydia testing, and potential chlamydia treatment. Data from the interviews were subjected to thematic analysis.ResultsThe geographical accessibility and long opening times of community pharmacies in North East England were perceived benefits of the service. However, young people had concerns about being judged by pharmacy staff or overheard by customers when requesting the test. Men did not want to be seen by their peers accessing the pharmacy. These barriers were associated with a perceived stigma of chlamydia. Despite this, young people thought that pharmacist advice on the test kit would be important to ensure they complete it correctly. Those never tested favoured how the kit could be taken home to complete the urine sample. The option of including chlamydia treatment was reported to be convenient and comforting.ConclusionSupporting pharmacies in North East England to offer a confidential chlamydia testing service is necessary to overcome young people’s perceived barriers to testing. Delivering testing as an integrated sexual health package with other pharmacy services, together with treatment where suitable, will increase acceptance for testing and timely access to treatment.

A chlamydia education and training program for general practice nurses: reporting the effect on chlamydia testing uptake

The long-term health consequences of untreated chlamydia are an increased risk of pelvic inflammatory disease, ectopic pregnancies and infertility among women. To support increased chlamydia testing, and as part of a randomised controlled trial of a chlamydia intervention in general practice, a chlamydia education and training program for general practice nurses (GPN) was developed. The training aimed to increase GPNs’ chlamydia knowledge and management skills. We compared the difference in chlamydia testing between general practices where GPNs received training to those who didn’t and evaluated acceptability. Testing rates increased in all general practices over time. Where GPNs had training, chlamydia testing rates increased (from 8.3% to 19.9% (difference=11.6%; 95% CI 9.4–13.8)) and where GPNs did not have training (from 7.4% to 18.0% (difference=10.6%; 95% CI 7.6–13.6)). By year 2, significantly higher testing rates were seen in practices where GPNs had training (treatment effect=4.9% (1.1 – 8.7)), but this difference was not maintained in year 3 (treatment effect=1.2% (−2.5 – 4.9)). Results suggest a GPN chlamydia education and training program can increase chlamydia testing up to 2 years; however, further training is required to sustain the increase beyond that time.

Who Is Best to Test? A Systematic Review of Chlamydia Infections in Switzerland

In many countries, community pharmacies provide sexual-health-related services to limit the spread of sexually transmitted infections (STIs), including chlamydia testing. To identify suitable target groups for pharmacy-based chlamydia testing in Switzerland, we aimed to assess chlamydia prevalence, identify risk groups, and delineate screening strategies. We conducted a systematic literature search up to December 2019 in PubMed, EMBASE, and Web of Science, according to the PRISMA guidelines, using as keywords “chlamydia”, “screening”, and “Switzerland”. Two researchers screened the title, abstract, and full-text article and assessed the methodological quality. The literature search generated 108 hits, and nine studies were included. Chlamydia prevalence ranged between 0.8 and 12.8%. Most frequently affected were undocumented women undergoing voluntary termination of pregnancy (12.8%, 95% CI: 8.4–18.9), HIV-positive men who have sex with men (10.9%, 95% CI: 9.2–17.6), and adult offenders (6.5%, 95% CI: 3.2–9.0). Systematic screening was suggested for the first two risk groups and women suffering a miscarriage. To conclude, chlamydia infections are prevalent in Switzerland, but the identified risk groups are difficult to reach for a pharmacy-based testing service. More studies are needed to identify suitable target groups, including customers seeking sexual health services, particularly emergency contraception users who already receive counselling for STIs at community pharmacies.