Factors associated with appropriate physician management of sexually transmitted diseases in an urban Canadian center

The antibiotic management of gonorrhoea in Ontario, Canada following multiple changes in guidelines: an interrupted time-series analysis

OBJECTIVE

This study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance.

METHODS

We used interrupted times-series analyses to analyse treatment data for cases of uncomplicated gonorrhoea reported in Ontario, Canada, between January 2006 and May 2014. We assessed adherence with first-line treatment according to the guidelines in place at the time and the use of specific antibiotics over time. We used the introduction of new recommendations in the Canadian Guidelines for Sexually Transmitted Infections in 2008 and 2011 and the release of the province of Ontario's Guidelines for the Treatment and Management of Gonococcal Infections in Ontario in 2013 as interruptions in the time-series analysis.

RESULTS

Overall, 34 287 gonorrhoea cases were reported between 1 January 2006 and 31 May 2014. Treatment data were available for 32 312 (94.2%). Our analysis included 32 272 (94.1%) cases without either a conjunctival or disseminated infection. Following the release of the 2011 recommendations, adherence with first-line recommendations immediately decreased to below 30%. Adherence slowly increased but did not reach baseline levels before the 2013 guidelines were released. Following release of the 2013 guidelines, adherence again decreased; adherence is slowly recovering but by May 2014, was only approximately 60%.

CONCLUSIONS

Due to concerns about antibiotic resistance, gonorrhoea treatment guidelines need to be updated regularly and rapidly adopted in practice. Our study showed poor adherence following dissemination of updated guidelines. Over a year after the latest Ontario guidelines were released, 40% of patients did not receive first-line treatment, putting them at risk of treatment failure and potentially promoting further drug resistance. Greater attention should be devoted to dissemination and implementation of new guidelines.

STD and HIV counseling practices of British Columbia primary care physicians

This study evaluated British Columbian primary care physicians' use of sexually transmitted disease (STD) and HIV counseling guidelines. The authors sought to assess barriers to integrated HIV and STD testing and counseling, with the objective of developing and revising practice guidelines to meet the needs of primary care physicians in diverse settings. The BC College of Physicians and Surgeons membership of general practice/family medicine practitioners was stratified by practitioner location; 1200 physicians were randomly selected to receive a mailed self-administered questionnaire. Four hundred seven completed questionnaires were returned. Female physicians reported better adherence to practice guidelines on many items than their male counterparts. A minority of primary care physicians routinely integrated HIV and STD testing and counseling. Physicians in nonurban areas were more likely to report that they lacked sufficient information on HIV and STD risk and prevention. Although male primary care physicians in British Columbia were more likely to provide care for people with HIV infection, female physicians were more likely to undertake ongoing screening for sexual risk behavior and sexually transmitted infections (STIs) among their HIV-positive patients. Clinical practice guidelines are theoretically equally available to all physicians, but they are not universally used. Physicians may not receive adequate training in sexual health during their medical education; continuing education opportunities may be limited to physicians outside of urban centres. Accessible and relevant continuing medical education in novel formats are needed to address the gap between ideal and actual practice in HIV and STD prevention, treatment, and care in Canada.

Treatment of Sexually Transmitted Diseases in Estonia

BACKGROUND

Estonia is among those Eastern European countries that have witnessed an explosive intravenous drug use-driven HIV epidemic. Early sexually transmitted disease (STD) diagnosis and appropriate treatment is essential to prevent an STD-driven HIV epidemic.

OBJECTIVES

The objectives of this study were to define the schedule of antibiotic treatment doctors in Estonia used to treat STDs, and to determine if the treatments used correspond to evidence-based medicine treatment principles.

STUDY DESIGN

Using an administrative database of the Estonian Health Insurance Fund on pharmaceuticals reimbursement, we obtained information on: drug (ATC 1998) prescribed with an STD diagnosis (International Classification of Diseases and Related Health Problems, syphilis, gonorrhea, genital Chlamydia trachomatis and Trichomonas vaginalis infections, and genital herpes), prescribing physician specialty, and patient demographics (date of birth, gender). To evaluate the correspondence of STD treatment to evidence-based medicine principles, the therapeutic regimens used were compared with recommendations from the European Sexually Transmitted Infections Management Guidelines.

RESULTS

In 2001 and 2002, physicians ordered 17,077 prescriptions for systemic antibacterial medications to treat STDs in 12,823 different individuals: 2942 men (mean age, 31.8 years) and 9880 women (mean age, 29.5 years). The majority of STD treatments were prescribed by gynecologists (60%) or dermatovenerologists (29%); general practitioners treated 8% of STDs. In 11% of treatment episodes, the drug prescribed was inconsistent with guideline recommendations; additionally, in 9% of episodes, the recommended drug was chosen but the prescribed dose was too low. At least 20% of treatment episodes could therefore be considered inappropriate.

CONCLUSIONS

Educational efforts are needed to increase physician awareness of evidence-based approaches for STD management and treatment to assure effective STD care.

Sexually transmitted diseases in Manitoba: evaluation of physician treatment practices, STD drug utilization, and compliance with screening and treatment guidelines

BACKGROUND AND GOAL

There is little information in Manitoba on the utilization of drugs for sexually transmitted disease (STD) treatment and the extent to which physicians comply with STD screening and treatment guidelines. This study was undertaken to provide such information to inform policy and program development.

METHODS

Physicians providing STD care were asked to complete a simple record for each new STD index client or contact seen. This information was subsequently linked with data from provincial diagnostic and treatment databases.

RESULTS

Between October 1997 and September 1998, there were 2535 reports of STD treatments. Only about 25% of drugs provided by the provincial health department to physicians for STD treatment could be accounted for on the basis of the treatment reports received. Seventy-four percent of all treatments provided were presumptive ones for urethral or cervical infection or pelvic inflammatory disease (PID), and 14.4% of these were associated with subsequent positive tests for Chlamydia trachomatis or Neisseria gonorrhoeae. About three quarters of presumptive treatments were in compliance with provincial guidelines, as were most etiology-based treatments for chlamydial infection and 72% of etiology-based treatments for gonorrhea. Noncompliance with guidelines was commonly due to presumptive treatment that covered only C trachomatis, nonrecommended treatment for N gonorrhoeae, and incorrect treatment of PID. Only about 25% of women and 4% of men aged 15 to 24 years who visited a physician in 1997 were tested for C trachomatis.

CONCLUSION

Increased educational efforts are required to improve physician compliance with STD screening and treatment guidelines, as well as ensure the appropriate use of STD drugs provided. Opportunities are being missed for screening for C trachomatis among young people, the majority of whom are seen regularly by a physician.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts

BACKGROUND

Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested.

GOAL

To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

STUDY DESIGN

Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment.

RESULTS

Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae.

CONCLUSION

Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.