What does validation of cases in electronic record databases mean? The potential contribution of free text

Electronic health records are increasingly used for research. The definition of cases or endpoints often relies on the use of coded diagnostic data, using a pre-selected group of codes. Validation of these cases, as ‘true’ cases of the disease, is crucial. There are, however, ambiguities in what is meant by validation in the context of electronic records. Validation usually implies comparison of a definition against a gold standard of diagnosis and the ability to identify false negatives (‘true’ cases which were not detected) as well as false positives (detected cases which did not have the condition). We argue that two separate concepts of validation are often conflated in existing studies. Firstly, whether the GP thought the patient was suffering from a particular condition (which we term confirmation or internal validation) and secondly, whether the patient really had the condition (external validation). Few studies have the ability to detect false negatives who have not received a diagnostic code. Natural language processing is likely to open up the use of free text within the electronic record which will facilitate both the validation of the coded diagnosis and searching for false negatives

The public health importance of scabies in community domiciliary care settings: an exploratory cross-sectional survey of health protection teams in England

Scabies is a contagious skin infection commonly occurring in institutions such as care homes. However, a large proportion of vulnerable people in England receive domiciliary care in the community and their experience of scabies has not been described. We undertook a pragmatic cross-sectional survey of Health Protection Teams (HPTs) in England to determine the burden of scabies related to domiciliary care. Fifteen cases or outbreaks were notified to HPTs between January 2013 and December 2017. Although a relatively uncommon event for individual HPTs, they were complex to manage and required the co-ordination of multiple stakeholders. Diagnosis was often delayed and required several clinical consultations. A lack of guidance led to difficulties establishing stakeholder roles and responsibilities and sources of funding for treatment. The stigmatisation of scabies sometimes affected the quality of care provided to patients, such as use of excessive personal protective equipment. Our study demonstrates that scabies is an issue of public health importance for domiciliary care service providers and users, and research is required to better understand the impacts of the disease and to develop evidence-based guidance. More generally, there is a need for simpler treatment regimens and methods of diagnosing scabies

Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review

Objective: To examine the effectiveness of methods to improve partner notification by patient referral (index patient has responsibility for informing sex partners of their exposure to a sexually transmitted infection). Design: Systematic review of randomised trials of any intervention to supplement simple patient referral. Data sources: Seven electronic databases searched (January 1990 to December 2005) without language restriction, and reference lists of retrieved articles. Review methods: Selection of trials, data extraction, and quality assessment were done by two independent reviewers. The primary outcome was a reduction of incidence or prevalence of sexually transmitted infections in index patients. If this was not reported data were extracted according to a hierarchy of secondary outcomes: number of partners treated; number of partners tested or testing positive; and number of partners notified, located, or elicited. Random effects meta-analysis was carried out when appropriate. Results: 14 trials were included with 12 389 women and men diagnosed as having gonorrhoea, chlamydia, non-gonococcal urethritis, trichomoniasis, or a sexually transmitted infection syndrome. All studies had methodological weaknesses that could have biased their results. Three strategies were used. Six trials examined patient delivered partner therapy. Meta-analysis of five of these showed a reduced risk of persistent or recurrent infection in patients with chlamydia or gonorrhoea (summary risk ratio 0.73, 95% confidence interval 0.57 to 0.93). Supplementing patient referral with information for partners was as effective as patient delivered partner therapy. Neither strategy was effective in women with trichomoniasis. Two trials found that providing index patients with chlamydia with sampling kits for their partners increased the number of partners who got treated. Conclusions: Involving index patients in shared responsibility for the management of sexual partners improves outcomes. Health professionals should consider the following strategies for the management of individual patients: patient delivered partner therapy, home sampling for partners, and providing additional information for partners

Scabies outbreaks in care homes for the elderly – authors' reply

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How and why do South Asians attend GUM clinics? Evidence from contrasting GUM clinics across England

Background: Improving access to sexual healthcare is a priority in the UK, especially for ethnic minorities. Though South Asians in the UK report low levels of sexual ill health, few data exist regarding their use of genitourinary medicine (GUM) services. Objectives: To describe reasons for attendance at GUM clinics among individuals of South Asian origin relative to patients of other ethnicities. Methods: 4600 new attendees (5% South Asian; n=226) at seven sociodemographically and geographically contrasting GUM clinics across England completed a questionnaire between October 2004 and March 2005, which were linked to routine clinical data. Results: South Asians were more likely than other groups to be signposted to the GUM clinic by another health service-for example, in women 14% versus 8% respectively (p=0.005) reported doing so from a family planning clinic. These women also reported that they would be less likely to go to the clinic if their symptoms resolved spontaneously compared with other women (51% vs 31%, p=0.024). However, relative to other clinic attendees, no differences in the proportions of South Asians who had acute STI(s) diagnosed at clinic were noted. Furthermore, South Asian men were more likely to report as their reason for attendance that they wanted an HIV test (23.4% vs 14.8%, p=0.005). Conclusion: Despite having similar STI care needs to attendees from other ethnic groups, South Asians, especially women, may be reluctant to seek care from GUM clinics, especially if their symptoms resolve. Sexual health services need to develop locally-delivered and culturally-appropriate initiatives to improve care pathways

The implementation of chlamydia screening: a cross-sectional study in the south east of England

Background England's National Chlamydia Screening Programme (NCSP) provides opportunistic testing for under 25 year-olds in healthcare and non-healthcare settings. The authors aimed to explore relationships between coverage and positivity in relation to demographic characteristics or setting, in order to inform efficient and sustainable implementation of the NCSP. Methods The authors analysed mapped NCSP testing data from the South East region of England between April 2006 and March 2007 inclusive to population characteristics. Coverage was estimated by sex, demographic characteristics and service characteristics, and variation in positivity by setting and population group. Results Coverage in females was lower in the least deprived areas compared with the most deprived areas (OR 0.48; 95% CI 0.45 to 0.50). Testing rates were lower in 20 1324-year-olds compared with 15 1319-year-olds (OR 0.69; 95% CI 0.67 to 0.72 for females and OR 0.67; 95% CI 0.64 to 0.71 for males), but positivity was higher in older males. Females were tested most often in healthcare services, which also identified the most positives. The greatest proportions of male tests were in university (27%) and military (19%) settings which only identified a total of 11% and 13% of total male positives respectively. More chlamydia-positive males were identified through healthcare services despite fewer numbers of tests. Conclusions Testing of males focused on institutional settings where there is a low yield of positives, and limited capacity for expansion. By contrast, the testing of females, especially in urban environments, was mainly through established healthcare services. Future strategies should prioritise increasing male testing in healthcare settings

Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005

Objectives: To provide nationally representative data on trends in HIV testing in primary care and to estimate the proportion of diagnosed HIV positive individuals known to general practitioners (GPs). Methods: We undertook a retrospective cohort study between 1995 and 2005 of all general practices contributing data to the UK General Practice Research Database (GPRD), and data on persons accessing HIV care (Survey of Prevalent HIV Infections Diagnosed). We identified all practice-registered patients where an HIV test or HIV positive status is recorded in their general practice records. HIV testing in primary care and prevalence of recorded HIV positive status in primary care were estimated. Results: Despite 11-fold increases in male testing and 19-fold increases in non-pregnant female testing between 1995 and 2005, HIV testing rates remained low in 2005 at 71.3 and 61.2 tests per 100 000 person years for males and females, respectively, peaking at 162.5 and 173.8 per 100 000 person years at 25–34 years of age. Inclusion of antenatal tests yielded a 129-fold increase in women over the 10-year period. In 2005, 50.7% of HIV positive individuals had their diagnosis recorded with a lower proportion in London (41.8%) than outside the capital (60.1%). Conclusion: HIV testing rates in primary care remain low. Normalisation of HIV testing and recording in primary care in antenatal testing has not been accompanied by a step change in wider HIV testing practice. Recording of HIV positive status by GPs remains low and GPs may be unaware of HIV-related morbidity or potential drug interactions

Exploring the costs and outcomes of sexually transmitted infection (STI) screening interventions targeting men in football club settings: preliminary cost-consequence analysis of the SPORTSMART pilot randomised controlled trial

Background: The objective of this study was to compare the costs and outcomes of two sexually transmitted infection (STI) screening interventions targeted at men in football club settings in England, including screening promoted by team captains. Methods: A comparison of costs and outcomes was undertaken alongside a pilot cluster randomised control trial involving three trial arms: (1) captain-led and poster STI screening promotion; (2) sexual health advisor-led and poster STI screening promotion and (3) poster-only STI screening promotion (control/comparator). For all study arms, resource use and cost data were collected prospectively. Results: There was considerable variation in uptake rates between clubs, but results were broadly comparable across study arms with 50% of men accepting the screening offer in the captain-led arm, 67% in the sexual health advisor-led arm and 61% in the poster-only control arm. The overall costs associated with the intervention arms were similar. The average cost per player tested was comparable, with the average cost per player tested for the captain-led promotion estimated to be £88.99 compared with £88.33 for the sexual health advisor-led promotion and £81.87 for the poster-only (control) arm. Conclusions: Costs and outcomes were similar across intervention arms. The target sample size was not achieved, and we found a greater than anticipated variability between clubs in the acceptability of screening, which limited our ability to estimate acceptability for intervention arms. Further evidence is needed about the public health benefits associated with screening interventions in non-clinical settings so that their cost-effectiveness can be fully evaluated

How much do delayed health care seeking, delayed care provision and diversion from primary care contribute to the transmission of STIs

Objectives: To explore the changing pattern of condom use from 1990 to 2000; to identify sociodemographic and behavioural factors associated with condom use; and reasons for condom use in 2000. Methods: Large probability sample surveys administered among those resident in Britain aged 16–44 (n = 13 765 in 1990, n = 11 161 in 2000). Face to face interviews with self completion components collected sociodemographic, behavioural, and attitudinal data. Results: Condom use in the past year among sexually active 16–24 year old men increased from 61.0% in 1990 to 82.1% in 2000 (p<0.0001), and from 42.0% to 63.2% (p<0.0001) among women of the same age, with smaller increases among older age groups. Among individuals reporting at least two partners in the previous 4 week period, approximately two thirds reported inconsistent or no condom use (63.1% (95% CI 55.9% to 69.8%) of the men and 68.5% (95% CI 57.6% to 77.7%) of the women). Conclusions: Rates of condom use increased substantially between 1990 and 2000, particularly among young people. However, inconsistent condom use by individuals with high rates of partner acquisition may contribute significantly to the recent resurgence in STIs. This group is an important target for intensive and specific sexual health interventions