Implementing a centralised nurse-led telephone-based service to manage chlamydia and gonorrhoea infections diagnosed in primary care: mixed methods evaluation

Problem

Chlamydia trachomatis and Neisseria gonorrhoeae are the two most commonly diagnosed bacterial sexually transmitted infections in England, with 218,095 and 56,259 diagnoses reported in 2018, a 6% and 26% increase since 2017. Chlamydia, which is commonly asymptomatic, causes a substantial burden of disease, in women particularly, including chronic pelvic pain, ectopic pregnancy and infertility. Gonorrhoea treatment is threatened by the emergence of antimicrobial resistance, which is now a global public health priority. Up to 18% of Chlamydia infections and 9% of Gonorrhoea infections in England are diagnosed in Primary Care. However, evidence suggests that a substantial proportion of these cases are not managed appropriately in line with national guidelines.

Approach

We investigated feasibility and acceptability of extending the National Chlamydia Screening Programme’s centralised, nurse-led, telephone management (NLTM) as an option for management of cases of chlamydia and gonorrhoea diagnosed in Primary Care. Randomised feasibility trial in 11 practices in Bristol and North Somerset with nested qualitative study. In intervention practices patients and health care providers (HCPs) had the option of choosing NLTM or usual care for all patients tested for Chlamydia and Gonorrhoea. In control practices patients received usual care. Interviews were conducted with patients and HCP, purposively sampled to capture maximum variation in views and experiences of NLTM. Interviews were digitally recorded, transcribed verbatim and analysed thematically supported by NVivo11.

Findings

1154 Chlamydia/gonorrhoea tests took place during the 6-month study, with a chlamydia positivity rate of 2.6% and gonorrhoea positivity rate of 0.8%. The majority of eligible patients in intervention practices were managed via NLTM (n=335). Interviews were conducted with sixteen HCPs (11 GPs, 5 nurses) and 12 patients. Patients perceived benefits of NLTM to be a faster and a more proactive approach to communicating test results. The convenience and greater anonymity of telephone consultations and being managed by a sexual health specialist was welcomed. HCPs expected the impact of NLTM on workload to be positive and to provide benefits for patients in relation to better and timely follow-up - particularly with regards to partner notification. Findings identified a need for improved clarity of NLTM pathway process for both patients and HCPs, and for timely HCP notification of actions taken by the NLTM. Without such feedback, HCPs often felt obligated to follow up positive test results themselves.

Consequences

Extension of this established NLTM intervention to a greater proportion of patients was both feasible and acceptable. NLTM could both provide a better service for patients whilst decreasing primacy care workload and contribute to better use of clinical resources and better patient outcomes. The study provides evidence to support the wider implementation of this NLTM approach to managing chlamydia and gonorrhoea diagnosed in primary care.