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The study was performed in family planning clinics (FPC), general practices (GP), and a district general hospital (excluding STI clinic) in rural/semirural area of the United Kingdom.
A review of the records of all patients diagnosed Chlamydia trachomatis positive by ELISA confirmed with MIF between June 1996 and May 1997 was performed. GP records were reviewed by questionnaires to GPs; hospital and family planning records were reviewed by audit coordinator or gynaecology senior house officers.
Data were analysed by using Snap 4 Professional by Mercaptor. The χ2 test was performed with Yates's correction when expected cell values were less than 5.
Of the 3989 chlamydia tests requested (2237 GP, 537 FPC, and 115 hospital), 154 were positive (85 GP, 31 FPC, 38 hospital) giving prevalence rates in those tested of 3.6%, 5.8%, and 3.4% respectively.
Data were available for analysis on 127 patients: 68 GP (64 F, 4M), 21 FPC (21F), and 38 hospital (33F, 5M) (see table 1).
A doctor was more likely to give a positive result than another member of staff in a GP setting than FPC (p<0.05) or hospital (p<0.03). Many patients were not informed of their positive result and this was more likely in hospital (p<0.01) than GP settings with a trend for FPCs (p=0.085). Hospital patients were less likely to be referred to a GUM clinic than FPC attenders (p<0.05), with a trend for GP patients (p=0.068). Only one patient in the study refused referral.
For patients referred to GUM clinics, treatment was more likely to be given for patients from hospital (p=0.05) or GP settings (p<0.01) than from FPCs and was frequently inadequate.
None of the hospital patients referred were advised on abstinence from sexual intercourse.
Thirty seven patients were not referred to GUM clinics and drug therapy was inadequate or not documented in the majority. Similarly, the majority had no partner notification or treatment of partners.
Patients are diagnosed with chlamydia in numerous settings, but audits on their standard of care usually focus on a single settings1–3 and assess intended rather than actual practice.4
The CMO's report recommends screening for C trachomatis in certain groups and advocates referral to GUM clinics for further management, including testing for other sexually transmitted diseases and partner notification.5
However, some have advocated that management of chlamydia should be by those who perform the tests, suggesting high referral rates are unachievable (because of distance or refusal to attend). We have shown patient refusal to be rare and high referral rates can be obtained, similar to results found in a large city where 94.5% of FPC and 52% GP cases were referred.6 The high level of inappropriate treatment is of concern, and consistent with GP studies where only 19–70% of patients would receive an adequate antibiotic regimen.4,7
This is the only study, of which we are aware, that has covered chlamydia management across a whole district and indicates the need for a standardised policy across a whole health authority. As a result of this study, policies have been developed to standardise treatment and referral to GUM clinics across the whole health authority.
National clinical guidelines and standards for the management of genital chlamydia infection have been developed for use in genitourinary medicine8 and it is unethical that patients diagnosed in a non-GUM clinics setting do not have the same standards of care available to them. The most appropriate way to ensure this may be for all cases to be referred to GUM clinics, and the optimal management of chlamydia depends on close links between all healthcare services and the willingness to participate in collaborative audit to ensure standards are met.
Conflict of interest: none. Funding: Clinical audit departments of Chesterfield and North Derbyshire, Royal Hospital NHS Trust, and North Derbyshire Community Trust.
We should like to acknowledge Claire Nash and Dr Karen Price who were involved in data collection, participating general practitioners, and laboratory staff at CNDRH for provision of data.
Contributions: KER, design of study, data analysis, writing of paper; AD, data analysis; SKM, design of study; SS, design of study; RAM, design of study.