An evaluation of the impact of a national health demonstration project on testing and management for Chlamydia trachomatis infections in two regions of Scotland

OBJECTIVES: To compare clinical practice relating to testing for, and management of, genital Chlamydia trachomatis infection in the Lothian and Grampian regions of Scotland as part of an evaluation of a Government-funded health demonstration project in Lothian, Healthy Respect. STUDY DESIGN: Clinical audit against standards developed from a national clinical guideline. METHODS: Clinical practice relating to testing for, and management of, genital C. trachomatis infection was assessed against standards for good quality care developed from a national clinical guideline (Scottish Intercollegiate Guidelines Network Guideline 42). Audit methods comprised: postal survey of primary care clinicians; review of referral letters from primary to secondary care; and review of primary and secondary care patient case records. Findings from Lothian and Grampian were compared. RESULTS: Questionnaires were returned by 167 primary care clinicians in Lothian and 96 in Grampian. Clinicians in Lothian and Grampian gave similar responses relating to: testing of symptomatic patients (87 vs 88%); offer of testing for asymptomatic young patients (55 vs 55%); choice of antichlamydial agent (47 vs 42% azithromycin as first line); and follow-up strategies (50 vs 51% offer follow-up in primary care). Clinicians in Lothian were significantly more likely to participate in partner notification work (57 vs 44%; P=0.04) and to agree with statements reflecting 'perceived self-efficacy' in chlamydia-related care (57 vs 48%; P=0.006). Referral letters from primary to secondary care were reviewed for 31 women with genital symptoms in Lothian and 28 in Grampian. More women in Lothian were tested for chlamydia prior to referral (65 vs 39%; difference not significant). Review of primary care records for consultations in young people (145 in Lothian; 203 in Grampian) showed a higher level of chlamydia testing in Grampian (Lothian, 14%; Grampian, 34%; P<0.0001). However, review of secondary care records (n=39) showed a much higher level of testing in Lothian (Lothian, 75%; Grampian, 9%; P<0.0001). Review of secondary care records relating to proven chlamydia-positive women (n=159) suggested better care in Lothian in relation to ensuring antibiotic treatment (Lothian, 91%; Grampian, 74%; P=0.004), and use of the preferred antibiotic, azithromycin (Lothian, 78%; Grampian, 37%; P<0.0001). However, documented referral to a health adviser appeared to be better in Grampian (Lothian, 32%; Grampian, 48%; P=0.048). CONCLUSIONS: During the period of activity of the Healthy Respect demonstration project, few differences were detected between clinicians in Lothian and Grampian with regard to chlamydia-related practice. In both regions, clinicians appeared to be very aware of the need to test for chlamydia in patients with relevant symptoms, but were less likely to offer opportunistic testing to young patients without specific symptoms. These findings suggest that Healthy Respect in Lothian has had little impact on clinicians. However, these findings must be considered within the context of a broader evaluation, and it is noteworthy that the few significant differences that were detected tended to suggest better practice in Lothian.