Should young people be paid for getting tested? A national comparative study to evaluate patient financial incentives for chlamydia screening.

BACKGROUND: Patient financial incentives ("incentives") have been widely used to promote chlamydia screening uptake amongst 15-24 year olds in England, but there is scarce evidence of their effectiveness. The objectives of the study were to describe incentives used to promote chlamydia screening in Primary Care Trusts (PCTs) in England and to evaluate their impact on coverage and positivity rate. METHODS: PCTs that had used incentives between 1/1/2007 and 30/6/2009 (exposed) were matched by socio-demographic profile and initial screening coverage with PCTs that had not (unexposed). For each PCT, percentage point change in chlamydia screening coverage and positivity for the period before and during the incentive was calculated. Differences in average change of coverage and positivity rate between exposed and unexposed PCTs were compared using linear regression to adjust for matching and potential confounders. RESULTS: Incentives had a significant effect in increasing average coverage in exposed PCTs (0.43%, CI 0.04%-0.82%). The effect for voucher schemes (2.35%) was larger than for prize draws (0.16%). The difference was greater in females (0.73%) than males (0.14%). The effect on positivity rates was not significant (0.07%, CI -1.53% to 1.67%). CONCLUSIONS: Vouchers, but not prize draws, led to a small absolute but large relative increase in chlamydia screening coverage. Incentives increased coverage more in females than males but had no impact on reported positivity rates. These findings support recommendations not to use prize draws to promote chlamydia screening and contribute to the evidence base of the operational effectiveness of using patient incentives in encouraging public health action.

Who is being tested by the English National Chlamydia Screening Programme? A comparison with national probability survey data.

OBJECTIVES: We compare data collected by England's National Chlamydia Screening Programme (NCSP) with national probability survey data to examine demographic and behavioural differences that may be important in understanding who the NCSP is reaching and interpreting chlamydia positivity. METHODS: Data for 538,119 men and women aged 16-24 years who were screened in 2008 and data collected from 2180 interviewees in Britain's second National Survey of Sexual Attitudes and Lifestyles 1999-2001 (Natsal-2), of whom 644 were tested for chlamydia, were compared using the χ2 statistic and logistic regression. RESULTS: Compared with Natsal-2, the NCSP tested more women (67% vs. 49%). NCSP participants were more likely to be younger: 29% were 16-17 years versus 16% of men and 15% of women in Natsal-2; from ethnic minority groups: 17% of men and 14% of women versus 8% and 6%, respectively, in Natsal-2; not to have used condoms at last sex: 66% of men and 68% of women versus 48% and 63%, respectively, in Natsal-2: and more likely to report two or more partners in the last year: 62% of men and 47% of women versus 47% and 30%, respectively, in Natsal-2. In multivariate analyses, higher AOR of chlamydia positivity were found for those reporting non-use of condoms and for those reporting multiple partners in both the NCSP and Natsal-2. CONCLUSIONS: The NCSP is testing young people at increased risk of chlamydia. The impact of this testing bias on the effectiveness of the programme should be evaluated.

Will chlamydia screening reach young people in deprived areas in England? Baseline analysis of the English National Chlamydia Screening Programme delivery in 2008.

BACKGROUND: The National Chlamydia Screening Programme (NCSP) was established in England to control chlamydia in people <25 years. This study examined variations in NCSP delivery in 2008, its first full year of national coverage, by comparing the distribution of screening venues and coverage with the risk of testing positive in men and women by socioeconomic circumstances (SEC) and age. METHODS: A total of 550,000 NCSP screening records from 2008 were linked to the Index of Multiple Deprivation 2007. NCSP provision (venues/1000 population aged 13-24 years) was examined by SEC. NCSP coverage (tests/target population) and chlamydial positivity (positive results/[positive + negative results]) were examined separately in men and women by SEC and age. Odds ratios for positivity were calculated, adjusted for socioeconomic quintile, age, ethnicity, behavior, and screening provider. RESULTS: NCSP coverage was just 4.1% (95% confidence interval [CI]: 4.0-4.1) in men and 9.6% (95% CI: 9.5-9.6) in women. Screening provision and coverage were highest in more socioeconomically deprived areas where chlamydia positivity was also highest. The adjusted odds for testing positive in the most deprived areas was 1.4 (95% CI: 1.3-1.5) times higher in men and 1.4 (95% CI: 1.4-1.5) times higher in women than the least deprived areas. CONCLUSIONS: In the first year in which all areas delivered screening, the NCSP's total coverage was low, particularly in men. However, coverage was higher in deprived populations, who were also at increased risk of testing positive for infection. This analysis provides a baseline by which to monitor social variations in NCSP delivery as coverage expands.

The English National Chlamydia Screening Programme: variations in positivity in 2007/2008.

BACKGROUND: The purpose of this study was to examine variation in positivity within the English National Chlamydia Screening Programme during 2007/2008. METHODS: Data were analyzed using multivariable logistic regression. The outcome measure was positivity. Funnel plots were used to explore variation in positivity according to screening volume. RESULTS: Three hundred and thirty-four thousand nine hundred and two screening tests were done, 29% of which were in men. Overall positivity was 7.6% in men and 9.3% in women. For men, positivity increased rapidly to plateau from ages 19 to 24. For women, rates peaked at 18 years-those aged 21 being at the same risk of chlamydial infection as 16-year-olds. For men and women, positivity was generally higher for those of black or mixed ethnicity compared with whites, whereas Asians were at lower risk. Similarly, risk of infection for men and women varied by screening venue. Multivariable analysis showed that, for men and women positivity varied significantly with age, ethnicity, screening venue attended, whether the young people had had a new sexual partner in the past 3 months, and whether the patient had had 2 or more sexual partners in the past year. Positivity did not vary significantly with implementation phase. CONCLUSIONS: This is the largest description of testing for Chlamydia trachomatis in healthcare and nonhealthcare settings outside Genitourinary Medicine clinics in England and allowed a detailed analysis of positivity by age and ethnic group. Considerable heterogeneity exists and local health service commissioners need to ensure that the implementation of chlamydial screening reflects these differences.

Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study.

OBJECTIVE: To provide perinatal mortality and congenital anomaly rates for babies born to women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland. DESIGN: National population based pregnancy cohort. SETTING: 231 maternity units in England, Wales, and Northern Ireland. PARTICIPANTS: 2359 pregnancies to women with type 1 or type 2 diabetes who delivered between 1 March 2002 and 28 February 2003. MAIN OUTCOME MEASURES: Stillbirth rates; perinatal and neonatal mortality; prevalence of congenital anomalies. RESULTS: Of 2359 women with diabetes, 652 had type 2 diabetes and 1707 had type 1 diabetes. Women with type 2 diabetes were more likely to come from a Black, Asian, or other ethnic minority group (type 2, 48.8%; type 1, 9.1%) and from a deprived area (type 2, 46.3% in most deprived fifth; type 1, 22.8%). Perinatal mortality in babies of women with diabetes was 31.8/1000 births. Perinatal mortality was comparable in babies of women with type 1 (31.7/1000 births) and type 2 diabetes (32.3/1000) and was nearly four times higher than that in the general maternity population. 141 major congenital anomalies were confirmed in 109 offspring. The prevalence of major congenital anomaly was 46/1000 births in women with diabetes (48/1000 births for type 1 diabetes; 43/1000 for type 2 diabetes), more than double that expected. This increase was driven by anomalies of the nervous system, notably neural tube defects (4.2-fold), and congenital heart disease (3.4-fold). Anomalies in 71/109 (65%) offspring were diagnosed antenatally. Congenital heart disease was diagnosed antenatally in 23/42 (54.8%) offspring; anomalies other than congenital heart disease were diagnosed antenatally in 48/67 (71.6%) offspring. CONCLUSION: Perinatal mortality and prevalence of congenital anomalies are high in the babies of women with type 1 or type 2 diabetes. The rates do not seem to differ between the two types of diabetes.

Project 27/28: inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland.

OBJECTIVE: To identify variations in standards of neonatal care in the first week of life that might have contributed to deaths in infants who were born at 27 and 28 weeks' gestation. METHODS: A case-control study was conducted of infants who were born at 27 and 28 weeks' gestation in England, Wales, and Northern Ireland during a 2-year period. Cases were neonatal deaths; control subjects were randomly selected survivors at day 28. Main outcome measures were failures of prespecified standards of care or deficiencies in care reported by regional panels assessing anonymized medical records. RESULTS: Failures of standards of care relating to ventilatory support (adjusted odds ratio [OR]: 3.29; 95% confidence interval [CI]: 1.97-5.49), cardiovascular support (OR: 2.37; 95% CI :1.36-4.13), and thermal care (OR: 1.71; 95% CI: 1.21-2.43) were associated with neonatal death. Frequencies of unmet resuscitation standards (range: 3%-46%) and of delays in surfactant administration (range: 38%-40%) were similar in cases and control subjects. Panels identified significantly more deficiencies in all aspects of neonatal care in cases with the exception of the management of infection. Stratification by clinical condition of infants at birth showed a stronger association between overall standard of care and death when infants were in a good condition at birth. CONCLUSIONS: Our findings suggest an association between quality of neonatal care and neonatal deaths, most marked for early thermal care and ventilatory and cardiovascular support. Poor overall quality of care was more strongly associated with deaths when the infant was in a good condition at birth.