Penney G C, Brace V, Cameron S, Tucker J
Scottish Programme for Clinical Effectiveness in Reproductive Health, University of Edinburgh, Edinburgh, UK.
Public Health. 2005 Nov;119(11):1031-8. doi: 10.1016/j.puhe.2005.02.005. Epub 2005 Aug 9.
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.
Clinical audit against standards developed from a national clinical guideline.
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.
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).
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.
作为对洛锡安郡一项由政府资助的健康示范项目“健康尊重”进行评估的一部分，比较苏格兰洛锡安郡和格兰扁地区与生殖道沙眼衣原体感染检测及管理相关的临床实践。
对照依据国家临床指南制定的标准进行临床审计。
对照依据国家临床指南（苏格兰校际指南网络指南42）制定的优质护理标准，评估与生殖道沙眼衣原体感染检测及管理相关的临床实践。审计方法包括：对基层医疗临床医生进行邮政调查；审查从基层医疗转诊至二级医疗的转诊信；审查基层医疗和二级医疗的患者病历。比较洛锡安郡和格兰扁地区的调查结果。
洛锡安郡的167名基层医疗临床医生和格兰扁地区的96名基层医疗临床医生回复了问卷。在以下方面，洛锡安郡和格兰扁地区的临床医生给出了相似的答复：有症状患者的检测（87%对88%）；为无症状年轻患者提供检测（55%对55%）；抗衣原体药物的选择（47%对42%选择阿奇霉素作为一线用药）；以及随访策略（50%对51%在基层医疗提供随访）。洛锡安郡的临床医生更有可能参与性伴侣通知工作（57%对44%；P = 0.04），并且更认同反映在衣原体相关护理中“感知自我效能”的陈述（57%对48%；P = 0.006）。审查了洛锡安郡31名有生殖器症状女性和格兰扁地区28名有生殖器症状女性从基层医疗转诊至二级医疗的转诊信。洛锡安郡更多女性在转诊前接受了衣原体检测（65%对39%；差异不显著）。审查了年轻人（洛锡安郡调查145例；格兰扁地区调查203例）基层医疗咨询记录，结果显示格兰扁地区衣原体检测水平更高（洛锡安郡为14%；格兰扁地区为34%；P<0.0001）。然而，审查二级医疗记录（n = 39）显示，洛锡安郡的检测水平要高得多（洛锡安郡为75%；格兰扁地区为9%；P<0.0001）。审查与经证实衣原体阳性女性相关的二级医疗记录（n = 159）表明，在确保抗生素治疗方面，洛锡安郡的护理更好（洛锡安郡为91%；格兰扁地区为74%；P = 0.004），且在使用首选抗生素阿奇霉素方面也是如此（洛锡安郡为78%；格兰扁地区为37%；P<0.0001）。然而，格兰扁地区记录的转诊至健康顾问处的情况似乎更好（洛锡安郡为32%；格兰扁地区为48%；P = 0.048）。
在“健康尊重”示范项目开展期间，未发现洛锡安郡和格兰扁地区的临床医生在衣原体相关实践方面存在明显差异。在两个地区，临床医生似乎都非常清楚有必要对有相关症状的患者进行衣原体检测，但为无特定症状的年轻患者提供机会性检测的可能性较小。这些发现表明，洛锡安郡的“健康尊重”项目对临床医生影响甚微。然而，这些发现必须在更广泛的评估背景下加以考虑，值得注意的是，所发现的少数显著差异往往表明洛锡安郡的实践更好。
