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Detection or treatment: which outcome measure?
  1. I Simms1,
  2. H Mallinson2,
  3. J Hopwood3,
  4. A M C Webb4,
  5. K Fenton5,
  6. J Pimenta6
  1. 1Communicable Disease Surveillance Centre
  2. 2Liverpool Public Health Laboratory
  3. 3NHS Chlamydia Screening Pilot
  4. 4North Mersey Community NHS Trust
  5. 5Communicable Disease Surveillance Centre and Department of STDs, Royal Free and University College Medical School
  6. 6Communicable Disease Surveillance Centre
  1. Mr Ian Simms, PHLS Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, UK

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Editor,—The report by Rogstad et al1 is a timely description of the problems associated with the management of patients diagnosed with genital chlamydial infection within and between established healthcare settings. The inappropriate or inadequate treatment, low rates of partner notification, and lack of referral to genitourinary medicine (GUM) clinic described were similar to the observations made in two recent studies. An investigation in Merseyside family planning clinics (FPC) showed that of 80 infected patients identified (n = 958) only 34% were treated within 1 month of diagnosis, 24% had no proof of treatment, and 13% never found out they were infected.2 Similarly, a study of 112 women diagnosed with Chlamydia trachomatis attending FPCs showed that only 48% were known to have been treated 3 months after the test had been carried out.3 If diagnosis does not result in immediate treatment, patients can be lost to follow up. In turn, this can result in poor rates of partner notification, an increased likelihood of further transmission, a reduction in the impact of testing on disease incidence, and an increased risk of complications. In GUM clinics, diagnosis generally results in treatment and consequently surveillance data derived from this setting, the KC60 dataset, can be used as a measure of treatment success. In contrast, the above studies suggest that a proportion of diagnoses made in primary care may not be treated. This questions the validity of using diagnosed infection as an outcome measure for evaluating sexual health intervention in primary care. It also emphasises the significant role of clinical audit in the improvement of the quality of patient management.

Ultimately the effectiveness of intervention should be measured in terms of a reduced prevalence of pelvic inflammatory disease and associated sequelae.4 However, other more pragmatic outcome measures may need to be used. The UK NHS C trachomatis screening pilot is evaluating the feasibility and acceptability of opportunistic screening in primary and secondary healthcare settings in two health authorities.5 Three of the primary outcome measures that are being evaluated are the number of positive diagnoses, the proportion of the positive diagnoses treated, and the rate of patient or provider led partner notification. In the pilot, patient management has been improved by recalling positive patients to a centralised community office staffed by GUM health advisers. Preliminary data indicate that out of 900 positive patients identified through the Wirral arm of the pilot, treatment was not confirmed for 40 (4.4%) patients. Separate studies in Liverpool are also evaluating how patient management could be enhanced by GUM health advisers working in outreach sessions in a community FPC (AMCW) and a department of obstetrics and gynaecology (T Gleave, submitted to British Journal of Family Planning). Results from these studies will provide further evidence to guide the development of patient management and the outcome measures that could be used to assess future intervention strategies.

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