Provider and contract referral for bacterial STIs: two sides of the same coin? Exploring the clinical practice and attitudes of sexual health advisers Merle Symonds on behalf of Spread the Word team

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Provider and contract referral for bacterial
STIs two sides of the same coin?Exploring the
clinical practice and attitudes of sexual health
advisersMerle Symondson behalf of Spread the
Word team
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Partner Notification in UK

• Partner notification a core element in STI
  control
• Shift in STI testing and management from GUM to
  primary care settings
• Emphasis on ensuring that all services offering
  STI screening are competent in all aspects of
  patient/partner management
• Growing body of research exploring efficacy and
  cost effectiveness of partner management
  strategies

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Why commission research on PN?

• The National Chlamydia Screening Programme (NCSP)
  was identifying a new population requiring PN
• Recent NICE guidelines on one-to-one
  interventions for sexual health identified need
  to enable PN in community settings
• Evidence review for NICE on partner notification
• Emergence of new technologies may reduce efficacy
  of existing PN practices or offer scope for
  improvement
• HTA call (07/43) with outline submission in
  summer 2007, for a randomised controlled trial of
  partner notification (contact tracing) in primary
  care

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The brief from HTA
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Spread The Word

• Three arm, randomised controlled trial(RCT) of PN
  among patients diagnosed with Chlamydia in
  general practice.
• Routine (patient),
• Provider
• Contract referral
• Webtool linking participating GP study sites with
  a central research health adviser (RHA) office
• RHA conducts standardised PN activity relating
  to patients and partners according to trial arms.
  
• Outcomes measured include total partners
  notified, diagnosed, treated, reinfection rates,
  economic evaluation

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Spread The Word
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Partner notification (PN) is accepted as an
essential element of STI control.

• Index patient benefits

• Public health benefits

• Reduces index case risk of complications due to
  reinfection (chlamydia)

• Reduction of onward transmission
• Targeted testing has high yield
• 50 chlamydia contacts, 65 gonorrhoea contacts
  will test positive
• By contrast, 3 of a population sample will test
  positive

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Partner Notification

• Patient, partner, passive or self-referral
• Provider or active referral
• Conditional, contract or negotiated referral
• Faldon.C et al. The Manual For Sexual Health
  Advisers
• (SSHA 2004)

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Patient, partner, passive or self-referral

• Denotes when the index patient with the infection
  informs sexual partners. They are encouraged to
  notify partner(s) of their possible infection
  without the direct involvement of a health
  adviser. The patient may
• Provide the partner with information
• Accompany the partner to the clinic
• Hand over a contact slip
• The health adviser may help a patient to
  establish the information to be passed on to a
  partner and the methods of providing it.

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Provider or active referral

• A health care worker notifies a patients
  partner(s). In the UK health advisers in GUM
  clinics almost exclusively perform this.
• The index patient provides information on
  partner(s) to a health adviser, who then
  confidentially traces and notifies the partner(s)
  directly.

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Conditional, contract or negotiated referral

• A hybrid approach may be employed where an
  initial patient referral is followed up by a
  provider referral after an agreed period of time,
  if the contact has not attended.

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What the SSHA Manual doesnt tell us.

• How are these partner notification models
  operationalised in clinical services in the UK?
• What is the role of contract referral in current
  practice?
• Need for greater clarity in order to develop
  distinct, operational trial arms

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Developing Spread the Word trial interventions

• Pragmatic PN study
• Trial interventions should be representative of
  current PN practice
• Reproducible in clinical practice
• Individuals experienced in conducting PN should
  be able to distinguish clearly between the three
  trial arms

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Questions to be answered

• Are the three PN methods clear to HAs from a
  variety of service types?
• Are the three PN methods feasible and
  operational?
• What are the patterns of use for each arm?
• Are there conflict between theory and practice,
  and if so, how can they be resolved in a
  standardised intervention?

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Engaging the experts

• Capture the experience and attitudes of health
  care workers conducting PN in a range of service
  settings
• Ascertain a clearer picture of how partner
  notification models are operationalised in
  clinical practice
• Seek health adviser views on the proposed trial
  arm PN models

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Methods

• Email invitations to 12 sexual health
  advisers/health practitioners to participate in a
  one day focus group
• Participants sought on basis on diversity of
  role/service setting
• Metropolitan GUM clinic
• Rural GUM clinic,
• Integrated CASH/GUM/CSO,
• Community health adviser
• Acute teaching trust, Acute trust, PCT

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Methods

• Participants completed an online questionnaire
  prior to the focus group to establish baseline
  information on
• Experience
• Service setting
• Establishment
• Responsibility for PN
• Local PN policy/standard operating procedures
• Use of patient/provider/contract PN
• Training/education/competency measurement

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Methods

• Focus-groups
• participatory approach, utilising role play of
  commonly occurring clinical scenarios with actors
  playing the role of patients diagnosed with
  infections, observed by participants and
  facilitated by study team
• Facilitated discussion of experience of partner
  notification in clinical practice
• Trialling of trial interventions/proposed models
• Data collection 7 hours of audiotaped material
  transcribed and thematically analysed

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Participants

• Ten sexual health advisers/practitioners from
  nine services from across England (5
  metropolitan, 5 non-metropolitan)
• Six female participants, four male
• Participant experience of delivering PN ranged
  from two years to in excess of twenty
• Five participants had current/previous experience
  in senior/management roles, including
  training/supervising PN practice

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General approaches to PN

• Highly individualised
• Negotiated process
• Variable parameters include infection type,
  relationship nature and duration, sexual
  orientation of patients, contact detail type and
  motivation to contact partner/s
• Some patterns identifiable re practitioners
  offer of PN choices

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Patient referral

• Most of participants agree common first approach
  for majority of patients.
• May include preparatory discussions to help with
  managing difficult issues around disclosure and
  implications especially around issues such as
  infidelity
• Individual views on what is best for the
  patient may also influence PN negotiation

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• I suppose on the first offering its about
  reading how they feel about letting someone know,
  really, and getting a feel. But I would like to
  give people the opportunity to refer themselves
  patient referral. I think the outcome is
  better for them

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Provider referral

• All participants use provider referral, but how
  and when offered is variable
• Many participants reported making calls to
  partners as soon as information is received from
  patients, sometimes within the team, sometimes
  with negotiation with external clinics
• Some participants choose to offer provider
  referral on basis of perceived improved outcomes

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• The PN we offer is very much dependant upon the
  condition diagnosis of the patient. Mostly we
  favour a provider referral just to take on
  ourselves and hopefully its going to get a better
  outcome as a resultIndex patient referral, we
  generally try not toand that generally seems to
  be the better one that the staff and patients
  prefer

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Provider referral

• Participants highlighted that infection and
  patient types are significant in whether provider
  referral is offered or not.

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• The provider referrals, I think are by farthis
  is also an urban metropolitan clinic, so by far
  the preferredI actually tend to do those more
  for the blood borne infections, particularly with
  MSM. HIV is one that Im much more likely to
  engage that.

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Provider referral

• Some participants articulated the conducting
  provider referral resulted in an improved sense
  of satisfaction with ones work/role

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• I wouldnt say that the culture of my clinic was
  necessarily provider referral. Thats for
  me.because I know that I can get everything
  done. Having done the gay mens clinic for quite
  some time in various long spells, and thats
  where the vast majority of provider referrals
  come from. Youre talking 20 or 30 people per
  patient. And its me. Yeah, it becomes a
  mission, actually. I start making charts of them
  all. So yeah, theres some personal difference
  and I think thats experience."

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Contract referral

• Participants accounts of contract referral use
  in clinical settings, and their own experience
  was variable

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• The only time I know thats been used in my
  clinic has been around HIV patients and usually
  that process has begun as generated by the HIV
  team staff, so everyone has got a hand in it

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• We do when there's a fragility, a psychological
  vulnerability around the impact of that
  diagnosis. But I can sense that actually it's
  important that they do tell their partner, they
  want to tell their partner but... just can't
  quite work it out at this point and they need
  more time to absorb it and think about it.... you
  can see that they're processing something and
  it's not the same as they're being resistant but
  actually just trying to work out how they're
  going to navigate it and negotiate it. So often
  I will say to them, 'Well, why don't we set a
  timeframe here and maybe buy like two or three
  weeks. If I follow you up, maybe by that point
  you'll have got to this stage,' and then I follow
  them up,

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Ambiguity in PN

• Participant interpretations of what constitutes
  contact referral varies
• The notion of contract referral being an implicit
  part of the PN process rather than something
  formally agreed between clinician and patient was
  highlighted by a number of participants
• For others participants this is not considered as
  Contract referral but part of routine follow up
  care

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• I think if they rang back and they were...I know
  we talked about Provider referral, but I think I
  would prefer to do an Index patient one, then I
  would say, 'That's fine.' And I'd asked them
  what had made them change their mind... and then
  I would probably turn them over to maybe a
  Contract and say, 'I'll give you two weeks. See
  how you get on and then I'll give you a call,'
  and frame it that I was just checking to see how
  they were getting on. And then if they'd been
  able to do it, then good. If not, then I think I
  would say maybe, 'It's not too late to go back to
  a Provider.

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• ...we tell all our patients that we will call
  them in a couple of weeks' time just to see how
  they are and we wrap it round saying, 'Did you
  have any problems after the tablets? Were you
  okay?' ...But we always tell them in advance
  and say, 'And then we can see how you're getting
  on with telling your partners.' So, in a way,
  the Contract referrals are implicit in the normal
  way that we work because of the checking we do at
  two weeks. If they haven't been able to do it
  then, then we'll offer Provider referral.

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• You usually know quite soon if they're happy to
  let an individual know. Or they might be happy
  to let one know and not quite sure about another
  one. So for me, it's one to one with that
  individual. And also you kind of know if they're
  telling the truth to me and so everyone would be
  followed up and it's on that follow-up call for,
  say, Chlamydia, two weeks down the line, to
  actually talk to them and...re-assess the
  situation. If then they've had problems you do
  Provider referral

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Negotiated referral

• A number of participants took partner names as a
  basis to aid follow up, no participants routinely
  documented contact details for partners at
  initial consultation
• A theme of negotiated referral emerged from
  participants, giving patients time to think or
  weigh up options re patient referral.
• Within this an offer of delayed provider referral
  as part of a follow up call within a negotiated
  timeframe, with partner contact details being
  taken at follow up, if the patient was
  unsuccessful in contacting partners

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Implications for the Spread the Word trial

• Outcomes from the focus group show only two
  distinct models of PN
• Patient referral
• Provider referral
• Two arm RCT
• Recalculated sites/index patients

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Implications for PN practice

• PN models are in practice fluid though the
  process of PN
• High degree of variability in how PN is
  operationalised
• Existing guidance though widely recognised, is
  ambiguous and confused in its interpretation and
  may well need to be amended to reflect difference
  in practice between bacterial and blood borne
  infections

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Implications for PN practice

• Absence of any qualitative operational research
  of PN practice
• Data shows demonstrates a rich and dynamic
  process between professional and patient
• However this needs to be more clearly articulated
  to enable reproducibility and measurement of
  competency