The chlamydia care cascade of young people attending Australian general practices; a descriptive study to assess gaps in care

Introduction

Chlamydia infection is the most frequently notified sexually transmissible infection (STI) in Australia, and notification rates have been increasing from 368.8 per 100 000 people in 2015 to 434.5 per 100 000 in 2019.¹ Chlamydia infection can result in serious reproductive health complications, including pelvic inflammatory disease (which can cause fallopian tube scarring, ectopic pregnancy, infertility and chronic pelvic pain) in women and epididymo-orchitis in men.^2–4 Timely diagnosis and treatment have the potential to prevent these complications.

The ‘care cascade’ concept was developed to identify gaps in HIV care⁵ and has been adapted to other infections, including chlamydia.⁶ For chlamydia infection, the care cascade consists of three steps: (1) testing, (2) treatment and (3) re-testing. Royal Australian College of General Practitioners guidelines⁷ recommend opportunistic testing for all sexually active people under 30 years old. Re-testing at 3 months following treatment is also recommended² because of the risk of re-infection.^8,9 In most situations, a test of cure or re-testing within 4 weeks after treatment is not recommended, as it may result in false positive results from the remnants of a previous infection.^2,10

Sexual health care in Australia is provided predominantly through primary care services. These include specialist services, such as sexual health clinics and family planning clinics, and general practice clinics. General practice is Australia’s mainstream primary healthcare setting, and it is here that the majority of chlamydia tests and infections are diagnosed.^1,11 The youngest legal age for consensual sex in Australia is 16 years,¹² and clinical guidelines recommend that general practitioners (GPs) conduct opportunistic testing for those under 30 years of age who are sexually active,⁷ as two-thirds of chlamydia diagnoses occur in this group.¹ Understanding chlamydia management of this at-risk population attending general practices is an important step to strengthen chlamydia care in Australia. Hence, we explored the chlamydia care cascade for 16–29-year-olds attending Australian general practices. Given the impact that COVID-19 had on general practice attendance and the lower STI notification data,¹ we also took the opportunity to explore the impact that COVID-19 had on chlamydia care in 2020.

Methods

GPs are often the first point of contact in the Australian health system, and approximately 80% of Australians saw a GP between 2018 and 2020.¹³ There were over 37 000 GPs working across 8147 general practices in Australia¹⁴ and approximately 1874 clinics were in Victoria.^15–20

We undertook a descriptive study to explore the testing, treatment and re-testing steps of the chlamydia care cascade in general practice. We used routinely collected general practice data that included 220 909 clinical episodes of care for 137, 358 individuals aged 16–29-years attending 70 general practices (69 were in the state of Victoria) between 1 January 2018 and 31 December 2020.

Results

Discussion

We found substantial gaps in chlamydia management for 16–29-year-olds attending Australian general practice during 2018–2020. The most significant gaps related to testing and re-testing, with only one-tenth of patients tested and one-fifth of positive cases re-tested within recommended timeframes. The main barriers to performing chlamydia testing in GP clinics include a lack of time to discuss testing and conduct a follow-up, a lack of a formal recall and reminder system, and a patient’s embarrassment and lack of knowledge about chlamydia.²⁶ Although most chlamydia cases had appropriate antibiotic prescriptions recorded within 31 days of their diagnosis, we found that most of those who did not have an antibiotic prescription recorded did re-attend their clinic following the positive diagnosis, suggesting that treatment either did not occur, was not recorded or occurred elsewhere.

Our findings showed that fewer individuals attended general practices and a lower proportion tested in 2020 during the first year of the COVID-19 pandemic compared to 2018 and 2019. A recent study showed a significant reduction in the number of patients attending a sexual health clinic in Melbourne, Australia, in 2020 due to the COVID-19 pandemic,²⁷ and the lower chlamydia testing proportion in 2020 may have been related to COVID-19 pandemic restrictions. However, we found that the proportion of positive tests was similar in 2020 to 2018 and 2019, which contrasts with the data reported by the Kirby Institute.¹ This is likely due to the difference in data source; the Kirby Institute analysed nation-wide data whereas our study analysed general practice data, for which most practices were in Victoria.

We identified an important intervention gap in chlamydia re-testing where one-third of young people with chlamydia infections re-attending the general practices within 4 months were not re-tested. An earlier Australian study²⁸ identified similar missed opportunities for re-testing, in which 32% of young people re-attended the general practices within 4 months of treatment but were not re-tested between 2008 and 2009.²⁸ Chlamydia re-infection substantially increases a woman’s risk of developing pelvic inflammatory disease by up to 20% for each repeated infection,²⁹ and optimising the re-testing aspect of chlamydia management is important to detect re-infection in a timely manner. Over 97% of Australian general practices use an electronic medical software to record their clinical consultations.^30,31 Pop-up alert computerised clinical decision support system have been shown to increase chlamydia and syphilis testing,^32,33 and pop-up alerts integrated within the medical software can offer a mechanism to prompt GPs to discuss and organise chlamydia re-testing at the point of care, thereby reducing the proportion missed for re-testing.

We found that males were less likely to be tested for chlamydia but were more likely to be diagnosed upon testing than females. The higher testing proportion in females may be due to differences in health-seeking behaviour. For example, females are more likely to participate in preventative health screening activities, such as an annual health check and seeking lifestyle advice from medical practitioners to optimise their health.³⁴ In addition, GPs also have more opportunities to perform chlamydia testing in females while discussing reproductive health issues, such as contraception, cervical cancer screening or antenatal care. These findings also suggest that chlamydia testing in males may have been targeted at high-risk groups. One example of an at-risk male group is men who have sex with men (MSM). Current guidelines² recommend a 3-monthly STI screening for MSM. Regular targeted STI screening in these male groups may result in an increased proportion being diagnosed with chlamydia. We were not able to explore this as our data did not have patient’s sexual practice. The role of general practice in providing sexual health care to MSM could be further explored.

There are several limitations to our study. The majority of general practices in our study were in the state of Victoria, Australia; hence, results may not be generalised nationally. In addition, regional and rural GP clinics may be underrepresented; hence, comparisons between clinic location should be interpreted cautiously. We may also have underestimated the proportion appropriately treated, as individuals who did not have doxycycline or azithromycin medication may have been provided with a handwritten prescription or may have been prescribed another antibiotic due to a medication allergy. Lastly, we were not able to identify individuals who attended different clinics for their antibiotic treatment and re-testing, so we potentially overestimated treatment and re-testing gaps.

Our study strengths included the large sample size and the use of routinely collected general practice clinic data, which provided an insight into a real-world scenario of chlamydia STI care delivery in general practices. The ICC provided may also inform the design of future cluster-based studies in primary care.²⁵

This study demonstrated the value of utilising routinely collected general practice data in a research setting, highlighting testing and re-testing as major gaps in chlamydia care and missed opportunities for re-testing. Digital interventions integrated within the EHR can be utilised as a possible intervention strategy to reduce gaps in chlamydia care, and the routinely collected clinical data can be utilised to explore the effectiveness of further intervention strategies on chlamydia management.

Supplementary material

Supplementary material is available online.