Clinical Audit - Sexual health checks in younger males

Published: July, 2024 | Review date: July, 2027

Audit focus

This audit identifies younger male patients, who are less likely to present to primary care, to assess whether they have been offered a sexual health check within the past 12 months. This audit also provides an opportunity to check the HPV vaccination status of these patients and offer vaccination where appropriate.

Background

Rates of sexually transmitted infections (STIs) are high in New Zealand. Chlamydia is the most commonly reported bacterial STI.¹ Small increases in the number of infectious syphilis and gonorrhoea cases have been reported recently; both of which disproportionately affect men who have sex with men (MSM).¹ Genital warts are more common in males, but overall diagnoses continue to decrease following inclusion of the human papillomavirus (HPV) vaccination (Gardasil 9) in the National Immunisation Schedule in 2008.¹

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 or concurrent sexual partners, condomless sex. 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, MSM.

STI testing rates are typically lower for males than females. Younger males in particular may rarely attend primary care, 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.

^*HPV vaccination is recommended and funded for all people aged 9 – 26 years. The vaccine can be administered (not funded) to people aged 27 years and over if they have not been vaccinated before and are likely to benefit, e.g. MSM, those with HIV infection or people who are newly sexually active.

References:

1. The Institute of Environmental Science and Research Ltd (ESR). Sexually transmitted infections in New Zealand: supplementary annual surveillance report 2022. 2023. Available from: https://www.esr.cri.nz/digital-library/sexually-transmitted-infections-annual-surveillance-report-2022/ (Accessed Jul, 2024).

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

For latest recommendations on testing, see: sti.guidelines.org.nz/sexual-health-check/

For guidance on antibiotic management of chlamydia, gonorrhoea, Mycoplasma genitalium and syphilis infections in primary care, see: bpac.org.nz/antibiotics/guide.aspx

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

Audit Plan

Summary

This audit identifies male patients aged 16 – 30 years who have presented to primary care in the past 12 months to assess whether they have been offered a sexual health check or had appropriate STI testing. They should also have a record of a completed HPV vaccination course or an offer of immunisation to those who are eligible but have not yet been vaccinated or completed the course.

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 appropriate 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 a completed HPV vaccination course 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. Also consider offering HPV vaccination to patients aged 27 years and over if they have not been vaccinated before and are likely to benefit (however, this would not be funded).

Alternatively, consider a “working audit” where the data sheet is filled in over time opportunistically during consultations for any reason with an eligible patient until the required number of patients has been reached. If conducting a “working audit” and there is no record of a recent sexual health check or a discussion regarding HPV vaccination in the patient’s clinical notes, this should be undertaken at the time, or a future appointment booked.

Audit Data

Eligible patients

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

Identifying patients

For the conventional audit, you will need to have a system in place that allows you to identify eligible patients and audit their clinical notes. Many practices will be able to do this by running a ‘query’ through their PMS to find all male patients aged 16 – 30 years. The notes of identified patients will need to be reviewed and those who have attended a primary care consultation within the past 12 months selected for the audit.

If conducting a “working audit” fill in the data sheet when you have a consultation for any reason with an eligible patient until the required number of patients has been reached.

N.B. To increase vaccination uptake in this key population, consider running a separate PMS ‘query’ to identify all male patients aged 16 – 30 years enrolled in the practice who have not yet received HPV vaccination (or completed the course) and flag for discussion at the next appointment.

Sample size

The number of eligible patients will vary according to your practice demographic. A sample size of 30 patients is sufficient for this audit; a smaller sample size may be necessary if conducting a working audit.

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

Criteria for a positive outcome

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

• Record of a discussion offering a sexual health check or a record of recommended STI testing for their clinical circumstances in the past 12 months; AND
• Record of completed HPV vaccination course or an offer of vaccination at any time

Data analysis

Use the sheet provided to record your data.

In the conventional audit (Data sheet A), 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 appropriate STI testing in the past 12 months and a record of HPV vaccination or a discussion offering vaccination to those in whom it is recommended, 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.

In the working audit (Data sheet B), aim to carry out a sexual health check for as many eligible patients as possible. HPV vaccination should also be offered to all patients in whom vaccination is recommended but they have not yet received it or completed the course.

Using clinical audits for improving practice and patient outcomes

Clinical audits can be an important tool to identify where gaps exist between expected and actual performance. Once completed, they can provide ideas on how to change practice and improve patient outcomes. General practitioners are encouraged to discuss the suitability and relevance of their proposed audit with their practice or peer group prior to commencement to ensure the relevance of the audit. Outcomes of the audit should also be discussed with the practice or peer group; this may be recorded as a learning activity reflection if suitable.

The Plan, Do, Study, Act (PDSA) model is recommended by the Royal New Zealand College of General Practitioners (RNZCGP) as a framework for assessing whether a clinical audit is relevant to your practice. This model has been widely used in healthcare settings since 2000. It consists of two parts, the framework and the PDSA cycle itself, as shown in Figure 1.

Figure 1. The PDSA model for improvement.

Source: Plan, Do, Study, Act (PDSA) cycles and the model for improvement

1. The framework

This consists of three questions that help define the “what” and “how” of an improvement project (in this case an audit). The questions are:

• "What are we trying to accomplish?" – the aim
• "How will we know that a change is an improvement?" – what measures of success will be used?
• "What changes can we make that will result in improvement?" – the concept to be tested

2. The PDSA cycle

This is often referred to as the “engine” for creating, testing and carrying out the proposed changes. More than one cycle is usually required; each one is intended to be short, rapid and frequent, with the results used to inform and refine the next. This allows an ongoing process of continuous learning and improvement.

Each PDSA cycle includes four stages:

• Plan – decide what the change to be tested is and how this will be done
• Do – carry out the plan and collect the data
• Study – analyse the data, assess the impact of the change and reflect on what was learned
• Act – plan the next cycle or implement the changes from your plan