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Clinical Audit: Sexual health checks in younger males

Increasing the uptake of opportunistic testing is essential to help reduce the high rates of sexually transmitted infections (STIs) in New Zealand. This audit aims to identify younger male patients, a group who are less likely to present routinely to general practice, to assess whether they have been offered a sexual health check within the past 12 months, with the overall objective of increasing the uptake of STI testing. This audit also provides an opportunity to check the HPV vaccination status of these young male patients.

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Rates of STIs are high in New Zealand. Chlamydia is the most commonly reported bacterial STI, however, there is evidence that rates of Mycoplasma genitalium infection are nearly as high as chlamydia in some groups. There has also been a marked increase in the number of infectious syphilis cases in recent years. The rate of genital warts diagnoses has dramatically decreased following inclusion of the human papillomavirus (HPV) vaccination (Gardisil 9) in the National Immunisation Schedule in 2008, however, genital warts remain a common STI in New Zealand.

The highest rates of STIs are typically reported in younger adults and adolescents, due to an increased prevalence of higher risk sexual behaviours, e.g. frequently changing sexual partners, having sex under the influence of alcohol or illicit drugs. As these infections can be asymptomatic, increased testing is essential to prevent complications developing and transmission of infections to others by enabling prompt treatment. Annual STI testing is recommended for all sexually active people aged < 30 years; more frequent testing may be indicated for certain groups, e.g. people who have multiple sexual partners, men who have sex with men (MSM).

STI testing rates are significantly lower for males than females. Younger males in particular may rarely attend general practice, therefore, any consultation should be considered as a potential opportunity to initiate a discussion about sexual health and offer STI testing as appropriate. This is also an opportunity to check HPV vaccination status and discuss vaccination with those who are eligible* but have not been immunised, e.g. those who missed out on the school-based programme.

* Males aged nine to 26 years have been eligible to receive the HPV vaccine fully subsidised since January, 2017; vaccination may be beneficial to certain groups aged 27 years and older, e.g. MSM, those with HIV infection or those with little previous exposure to HPV, however it is not subsidised.

For further information on how to perform a sexual health check, see: www.bpac.org.nz/BPJ/2013/April/how-to-guide-sexual-health.aspx

For updates on managing chlamydia, gonorrhoea, Mycoplasma genitalium and syphilis infections in primary care, see: www.bpac.org.nz/2019/chlamydia-gonorrhoea.aspx

For further information on HPV vaccination, including the vaccination schedule and groups eligible for fully subsidised vaccination, see: www.bpac.org.nz/2019/hpv.aspx

Summary

This audit identifies male patients aged 16–30 years who have presented in the past 12 months to assess whether they have been offered a sexual health check or had STI testing and have a record of HPV vaccination or an offer of immunisation to those who are eligible.

Recommended audit standards

Ideally, all male patients aged 16–30 years should have documented evidence in their patient record of having been offered a sexual health check or had STI testing in the previous 12 months. Any patients who do not have the recommended information in their clinical notes should be flagged for review. They should also have a record of HPV vaccination or an offer of vaccination at any time. Any patients who do not have the recommended information in their clinical notes and are eligible for vaccination, i.e. aged 26 years and under, should be flagged for review, e.g. a discussion about vaccination at their next appointment or a recall letter.

Identifying eligible patients

All male patients within the practice who are aged 16–30 years and have attended for any reason in the past 12 months are eligible for this audit.

You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to identify patients by running a ‘query’ through their PMS, e.g. by age and sex. Once eligible patients have been identified, review the patient’s clinical notes to identify whether they have been offered a sexual health check or had STI testing in the past 12 months and whether there is a record of HPV vaccination or vaccination has been offered at any time.

Sample size

The number of eligible patients will vary according to your practice demographic. A sample size of 20–30 patients is sufficient for this audit.

N.B. the timeframe of the audit can be extended beyond 12 months if an insufficient number of patients are identified.

Criteria for a positive result

For a positive result for the audit, the patient’s clinical notes should contain both of the following:

  • A record of a discussion offering a sexual health check or a record of STI testing in the past 12 months
  • A record of HPV vaccination or a discussion offering vaccination to those who are eligible, i.e. aged 26 years or under, at any time

Data analysis

Use the data sheet provided to record your data. A positive result is any patient who has documented evidence in their notes of an offer of a sexual health check or a record of STI testing in the past 12 months and a record of HPV vaccination or a discussion offering vaccination to those who are eligible, at any time. The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that the doctor completes the first part of the Audit of Medical Practice summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Continuing Professional Development (CPD)

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement – CQI) for allocation of CPD credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current CPD programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section. From the drop down menu select “Approved practice/PHO audit” and record the audit name.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).

Published: 4 July 2018 | Updated:

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