bluuebunny/crossref_metadata_2025_split huggingface dataset:
Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey
Authors: Paddison Charlotte , Elliott Marc , Parker Richard , Staetsky Laura , Lyratzopoulos Georgios , Campbell John L , Roland Martin 
Published: May 2012

ObjectivesUncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care.Design/settingSecondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects.Main outcome measuresPrimary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services.ResultsDepending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors.ConclusionsWhile its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would ‘cream-skim’ by not enrolling patients from vulnerable socio-demographic groups.
O10 Should sexual health services participate in the HPV vaccination programme? A national survey assessing HPV vaccination uptake in young GUM attendees
Authors: Sacks R , Robinson A , Wilkinson D 
Published: May 2012

BackgroundIn 2008, a schools-based HPV vaccination programme was introduced for girls aged 12–13, with an accelerated catch up programme for those aged 14–18. A significant impact on cervical cancer rates requires 80% uptake of three vaccinations, however in England the completion rate was 58% in 2009/10.AimTo compare HPV vaccination outcomes and prevalence of risk factors, associated with HPV acquisition and cervical cancer development, in young women attending GUM clinics with national data.MethodAn anonymous questionnaire was given to 13–19 y/old women attending 19 participating GUM clinics from March to August 2011. Data were analysed using multivariate linear regression in SPSS.Results2247 questionnaires were completed (median respondent age 17). Compared to national data, respondents were more likely to be smokers (48% vs 12% of 15 y/olds), have had coitarche aged <16 (52% vs 26%), have had an STI previously (29% vs 13% for <16 coitarche) or not be in education, employment or training (NEET) (8% vs 2% of 16 y/olds). Of the 74% offered the vaccination, 81% accepted. Of those accepting the vaccination, 81% had all three injections. Of those who had <3 doses, 65% reported no active recall. Overall, 47% of all respondents had received all three vaccine doses. Completion rates were lower in London, non-white ethnicities, 17–19 y/olds, NEETs, smokers and those with previous Chlamydia (all p<0.0001).DiscussionThe study population exhibited lower HPV vaccination completion rates than the national average, demonstrating that GUM attendees are a harder-to-reach group through current PCT delivery programmes. This population also exhibited higher rates of risk factors for HPV acquisition, highlighting GUM attendees as a priority target group for HPV vaccination. This data demonstrates the potential role of GUM clinics as supplementary HPV vaccination delivery sites, in targeting at-risk young women with low uptake of the HPV vaccination.
O12 HSV-1 counselling what actually happens in consulting rooms? A qualitative evaluation of practice using mystery shopping in English level 3 GUM clinics
Authors: Munday L , Foley E , Lamb T , Green J , Evans C , Barton SE , Patel R 
Published: May 2012

BackgroundGuidelines indicate best practice for HSV management and topics that should be covered during counselling. Consultations can be difficult, since many complex issues must be explained carefully, and there is opportunity to confuse HSV-1 and HSV-2.AimsTo evaluate the quality, accuracy and differences in advice given by staff (doctors (D), nurses (N) and health advisors (HA)) in Level 3 sexual health clinics (L3SH) on an initial consultation for HSV-1 infection recently diagnosed elsewhere. To assess whether a professional patient mystery shopping approach provides useful information for L3SH.MethodsA prospective qualitative evaluation of 20 consultations was performed. Clinical leads within each unit gave permission for participation; details of the exact nature or time of visit were not shared. A professional patient visited each unit as a patient new to the area seeking advice for a standard complex scenario –various probes gauged management of different clinical scenarios. Field notes were made immediately following each consultation in the form of a written transcript and audio notes. Anonymised written transcripts were provided to a panel of clinicians to classify overall and specific aspects of care as ACCEPTABLE (A), UNACCEPTABLE (U) or a CAUSE FOR CONCERN.ResultsConsultations were supported well with written information (not HSV-1 specific). Staff frequently declined to give prognostic information and some confused HSV-1 and HSV-2 guidance. Although many centres are quick to offer patient-initiated therapy this was virtually always at doses that have been superseded in current guidance. The majority of N-led consultations were A with only limited trends in favour of D-provided consultations. HA did not always provide A consultations.ConclusionPPMS appears to be feasible for assessing some aspects of L3SH care which may otherwise be difficult to gauge. Some aspects of HSV-1 management are well handled but most units do not provide convenient patient-initiated therapy, or support consultations with disease-specific information.
O13 HIV incidence in an open national cohort of MSM attending GUM clinics in England
Authors: Desai S , Nardone A , Hughes G , Delpech V , Burns F , Hart G , Gill ON 
Published: May 2012

BackgroundEndemic HIV transmission in men who have sex with men (MSM) is a major concern in England. Since 2008, a new national anonymised genitourinary medicine (GUM) clinic reporting system provides follow-up data on clinic attendees.ObjectiveTo calculate HIV seroconversion rates and identify predictors of acquisition in MSM clinic attendees to inform the development of further HIV prevention initiatives.MethodsNational cohort of MSM who tested HIV negative at a GUM clinic in England in 2009 and had a follow-up test within 1 year were included in these analyses. HIV seroconversion rates (per 100 person-years (py)) with 95% CI were calculated by subgroups and risk markers. HR with 95% CI are reported for significant (p<0.05) predictors of HIV seroconversion identified using Cox regression analyses. Population attributable risk was calculated to estimate the importance of each predictor for HIV infection.ResultsAmong the 15 500 men who attended in 2009, there were 277 seroconversions, giving an overall incidence of 2.7/100 py (95% CI 2.4 to 3.1). Incidence was higher among MSM aged 35–49 years (3.4/100 py), of black ethnicity (4.1/100 py) and with a previous gonorrhoea or chlamydia infection (8.6/100 py and 9/100 py, respectively). In multivariable analysis, risk of acquiring HIV was higher among MSM with a previous gonorrhoea (HR: 2.4, 95% CI 1.4 to 4.1) or chlamydia infection (HR: 3.0, 95% CI 2.0 to 4.7) or who received treatment as a STI contact (HR: 1.8, 95% CI 1.1 to 2.9). Age predicted HIV acquisition in 30% of new infections and clinical risk markers from the previous year another 10%.ConclusionsAnnual HIV incidence among MSM re-attending GUM clinics is very high at almost 3%. None of the clinical risk factors were important predictors of HIV acquisition. Therefore more discriminatory behavioural information is required to identify MSM at higher risk of HIV and facilitate better triaging of HIV prevention measures in GUM clinics.
O15 Primary HIV infection: lack of knowledge among men who have sex with men (MSM)
Authors: Conway K , Jack D , Dew C , Johnson S , Cooper V , Waters L , Fisher M 
Published: May 2012

IntroductionPrimary HIV infection (PHI) is commonly symptomatic, offers an opportunity for early diagnosis and is important for individual health and preventing transmission. At risk populations should be aware of PHI symptoms.AimTo ascertain PHI knowledge among UK MSM.MethodsOnline anonymous survey conducted by the National AIDS Trust using the GaydarTM website between 31 March 2011 and 6 April 2011. Questions were asked about likelihood/nature of PHI symptoms and transmission risk. Data on recent HIV testing, HIV status and response to symptoms was collected. Analysis was done using χ2tests.Results8561 men responded: 76% had tested for HIV (16% positive), 21% were untested and 3% did not disclose. 5159/8548 (60%) believed PHI to be asymptomatic and 799/8548 (9%) correctly answered that 70%–90% would have symptoms; HIV+ MSM were significantly more likely to be aware of this than HIV-/untested MSM (14.9% vs 8.2%, p<0.0001) and MSM who had tested were more likely to be aware than never testers (10.2% vs 5.8%, p<0.0001). 2926/8267 (35.4%) identified the fever/sore throat/rash triad as the most common presentation of PHI. MSM who had never HIV tested were less likely to correctly identify these symptoms than those who had (29.3% vs 37.0%, p<0.0001). 2964/8450 (35.1%) believed it is hard to transmit HIV in early infection; the remainder recognised PHI as highly infectious. HIV+ MSM were more likely to recognise this than HIV-/untested MSM (76.8% vs 62.5%, p<0.0001) and untested MSM were less likely to recognise this than those who had tested (60.4% vs 66%, p<0.0001). 4220/6918 (61%) of HIV-/untested MSM would seek medical advice if symptomatic; the remainder would ignore symptoms or await resolution. Of those who would seek advice 54.1% would attend GP/NHS walk-in centre and 34.6% would attend GU clinic or take community HIV test.DiscussionThis survey illustrates a concerning lack of knowledge among MSM regarding PHI symptoms and the urgent need for ongoing health promotion and education.
O18 Sexual behaviour, partnership patterns and STI diagnoses among HIV positive MSM: implications for HIV/STIs transmission and partner notification
Authors: Wayal S , Hart G , Copas A , Edwards S , Cassell JA 
Published: May 2012

AimsIn the UK, HIV+ve men who have sex with men (MSM) are disproportionately affected with sexually transmitted infections (STIs). STIs can enhance HIV transmission. We examined factors associated with STIs diagnoses and partner notification, and explored preferred methods for STIs notification among HIV+ve MSM.Methods429 HIV+ve MSM attending a central London HIV clinic completed a computer-assisted survey (May–September 2010). Multivariate logistic regression analyses were conducted.Results86% men (368/429) were sexually active in the last year. Of these sexually active men, 84% (305/362) had tested for STIs. Among men who tested for STIs, 57% (174/305) reported engaging in unprotected anal intercourse (UAI) and 32% (98/305) were diagnosed with STIs. UAI, particularly non-concordant unprotected anal intercourse, age <35 years, concurrent sexual partnerships were independently associated with STIs diagnoses. 58% men had notified ¡Ý1 partner following STIs diagnosis. Being employed, born in the UK, concerns about breach of HIV confidentiality were negatively associated; while clinic advice and support were positively associated with partner notification following STIs diagnosis. 79% (339/429) men reported willingness to notify partners of STIs in the future. Of these, 76% men were willing to notify a boyfriend themselves. 11% men expressed preference for provider referral. Most men were willing to notify regular partners by phone. Men expressed willingness to notify casual partners by phone, text message, or anonymous provider-led methods.ConclusionsThe high level of risky sexual behaviour, STIs diagnosis and its association with non-concordant unprotected anal intercourse among HIV+ve MSM suggests that partner notification provides opportunities for HIV and STIs case-finding and treatment. The offer of a choice of notification methods to HIV+ve MSM, particularly young men and men with multiple/concurrent, casual partners, may override personal, partnership, and structural barriers to partner notification.
O19 Sexual partnership patterns and sexually transmitted infections in HIV positive men who have sex with men: implications for partner notification
Authors: Wayal S , Cassell J A , Edwards S , Hart G 
Published: May 2012

AimsIt is essential to understand the implications of sexual partnerships, sexual networks and type of sexually transmitted infections (STIs) on partner notification to maximise its effectiveness. We examined the relationship of these factors with HIV+ve men who have sex with men's (MSM) attitudes towards partner notification.Methods24 purposively selected men participated in semi-structured interviews (May 2010–February 2011). Piloted vignettes about different types of STIs diagnosis and sexual partners were used to facilitate discussion. Framework analysis was conducted.ResultsMen perceived the personal and public health benefits of HIV/STIs notification. However, HIV was perceived as a “fatal illness” and partner notification as “imperative” to facilitate partners' access to antiretroviral treatment. Some men preferred immediate HIV partner notification to allow post-exposure prophylaxis; others preferred to wait due to their own emotional burden of HIV diagnosis. Men perceived HIV notification with greater fear of stigma and “blame culture” than STIs notification. Concerns regarding breach of confidentiality and long-term relationships were perceived barriers to HIV partner notification, while clinic advice and support was favoured. Men who intentionally engaged in bareback sex perceived STIs partner notification as “the norm”. However, some men emphasised their and partners' “personal responsibility” to test for STIs regularly. Men favoured notifying a boyfriend and regular partners personally, especially for non-curable STIs like Hepatitis C (HCV). However, fear of being blamed or blaming group/casual sex partners, especially for HCV, were barriers to STIs notification. Provider-led or anonymous-notification methods were preferred in such cases.ConclusionsHIV+ve MSM should be offered clinic support for patient-led HIV notification, provider-led methods for HCV notification, and notifying group/casual sex partners to improve partner notification.
O5 Partner notification for gonorrhoea: analysis of outcomes using surveillance data
Authors: Savage E , Marsh K , Lowndes C M , Duffell S , Zaman A , Hughes G 
Published: May 2012

BackgroundPartner notification (PN) is an essential component of STI control but can be difficult where index cases have multiple casual partners. Guidelines recommend that for gonorrhoea, a minimum of 0.4 contacts/case in large conurbations, and 0.6 contacts/case elsewhere, should be screened. We investigated the effectiveness of newly introduced surveillance codes for monitoring standards of PN in England.ObjectivesTo investigate the relationship between PN ratios for gonorrhoea and patient socio-demographic characteristics.MethodsData on PN from the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) were analysed.ResultsReporting on PN began on a rolling basis in 207 GUM clinics during 2011. Provisional data on PN were available from 171 clinics reporting data covering 951 clinic months in total, during which there were 7423 cases and 2749 contacts. In this period, the overall PN ratio for gonorrhoea was 0.37 contacts/case. PN ratios were highest for clinics in non-urban areas (0.42 vs 0.36 in urban areas) but there was no difference between PN ratios in London and the rest of England. PN was most successful for female partners of heterosexual male index cases (0.44 contacts/case). Of those attending as a contact 26% (707/2749) tested positive for gonorrhoea; 31% of females, 22% of heterosexual males and 24% of MSM.ConclusionsProvisional data suggest that, on average, contact to index case ratios for gonorrhoea are below recommended standards but these are likely to vary considerably by clinic. The high prevalence of gonorrhoea among contacts emphasises the importance of PN for case finding and reducing transmission. Further analysis to better understand the strengths and limitations of these data is warranted.
O7 The diagnosis and treatment of chlamydia and gonorrhoea in general practice in England: analysis of electronic health records and surveillance data
Authors: Wetten S , Yung M , Mercer C , Cassell J , Hughes G 
Published: May 2012

BackgroundPrimary care has become increasingly important in STI management in England but data on diagnosis and treatment in this setting are not routinely analysed.AimsTo investigate and assess the diagnosis and treatment of bacterial STIs in general practice (GP).MethodsWe calculated age and gender standardised estimates of the incidence of diagnoses of chlamydia and gonorrhoea in GP using data from the GP Research Database and national population statistics for the years 2003–2008. Since diagnoses made and treated elsewhere can be recorded in primary care notes, we estimated cases treated in primary care using an algorithm to identify appropriate prescriptions within defined window periods, accounting for other possible treatment indications. We estimated the proportion of all cases reported in England which were treated in GP, relative to other providers of sexual health services.ResultsAn estimated 21 423 diagnoses of chlamydia (42.3/100 000 registered population) and 1494 diagnoses of gonorrhoea (2.96/100 000) were made in GP in England/annum between 2003 and 2008. 35% of chlamydia diagnoses were in those over 25 years. 70% of chlamydia and 36% of gonorrhoea diagnoses recorded in GP were treated, comprising respectively 12% and 3% of all cases diagnosed in England. Doxycycline and azithromycin were most commonly prescribed drugs for chlamydia. Despite revision of gonorrhoea treatment guidelines in 2005, quinolones remained most commonly prescribed for gonorrhoea (42% in 2006–2008), although the proportion treated with cephalosporins rose gradually over the study period (29% in 2006–2008). The algorithm identified 12% and 30% more treated cases of chlamydia and gonorrhoea compared with including same-day prescriptions only.ConclusionsGeneral practice makes an important contribution to the diagnosis and treatment of bacterial STIs. Efforts to ensure GPs are aware of and use recommended treatment guidelines are needed.
C3 An old friend, a new face: primary syphilis presenting as a bubo with balanitis and lymphocoele
Authors: Nori A , Goh B T 
Published: May 2012

BackgroundFollman balanitis as an initial presentation of primary syphilis is well described and syphilis is a known cause of lymphocoele. Inguinal buboes are commonly seen in chancroid and lymphogranuloma venereum but not in syphilis. We report an unusual case of syphilis presenting with balanitis, lymphocoele and bubo together.Case reportA 24-year-old man presented with a painless lump in the right groin for 2 weeks and a swelling and red spot on the glans penis for 2 days. He had three casual male partners all within the UK in the preceding 3 months and had an episode of unprotected insertive anal intercourse 2 months before, with no episodes of vigorous intercourse or masturbation. There was a 2 cm fluctuant non-tender lymph node in the right groin, a non-tender cord-like swelling under the coronal sulcus on the same side and a well defined erythematous patch with an infiltrated base on the glans. No other local or systemic signs. A dark field microscopy preparation from the balanitis was negative; one from the lymph node aspirate showed characteristic motile spirochaetes typical ofTreponema pallidum; a positive Treponemal EIA-IgM and RPR (titre of 1:4) confirmed a diagnosis of syphilitic bubo with Follman balanitis and lymphocoele. The lymph node aspirate on gram staining showed pus cells. Chlamydia NAAT (SDA) was negative from the balanitis and lymph node aspirate. The rest of the STI screen including HIV serology was negative. He was treated with Benzathine penicillin 2.4 m IU IM weekly for 2 weeks with clinical resolution. All three contacts had been informed.Discussion(1) Balanitis is a common presentation in GUM clinics and this case highlights the importance of including syphilis in the differential diagnosis. (2) Early syphilis can cause lymphocoele and inguinal bubo. (3) Aspiration of lymph nodes for dark field microscopy examination enabled point of care diagnosis and facilitates early treatment and partner notification.
C4 A case of the great and little imitator
Authors: MacDonald R , Fox R 
Published: May 2012

We present a case of Acute Intermittent Porphyria (AIP) exacerbated by HAART and review the complications of managing these two conditions. Only one previous case of these two conditions has been published. AB is a middle aged man who was diagnosed with HIV with baseline CD4 of 518. He was well until 2011 when he was admitted to our department with severe abdominal pain, hypotension and a penile ulcer. CT, MRCP, OGD and ultrasound were normal but syphilis serology was positive. He was treated with benzathine, his pain reduced and was discharged. He was then started on Atripla with a CD4 of 162. After 3 weeks he developed severe abdominal pain, hypertension and complained of ‘bloody’ urine but no blood on analysis. Biochemistry showed a sodium of 117. With these new symptoms urinary porphyrins were requested which were elevated at 4002 nmol/l representing an acute episode of AIP. It was felt this second admission was triggered by HAART which was stopped and he was treated with haem arginate and his symptoms improved. On further discussion with AB he admitted to taking a ‘legal high’ prior to the first admission which may have triggered this episode. There have been no reported cases of AIP due to syphilis. AIP is a disorder of the haem pathway and is known as the Little Imitator in contrast to syphilis the Great Imitator as it is often misdiagnosed. While it is a rare condition its importance with HIV is that it is triggered by most drugs needed in managing HIV. Drugs which induce cytochrome p450, anti PCP, TB and fungal agents have all been implicated. NRTI's are thought to be safe while Saquinavir is the only PI recommended for use and there is no evidence of newer HIV agents. AB was started on Truvada and boosted Saquinavir and 4 months on his symptoms are controlled with no further AIP attacks and viral load is 42 c/ml. Reports such as this are important in increasing the limited knowledge of safely co-treating HIV and AIP.Correction noticeThis article has been corrected since it was published. The text has had minor edits made to protect patient anonymity.