Cancer diagnostic service use in people living with HIV in South Africa: A cross-sectional study.

OBJECTIVE: The objective of this study was to map place of cancer diagnosis in relation to Human Immunodeficiency Virus (HIV) care centre among people living with HIV (PLHIV) within South Africa (SA) using national laboratory database. DESIGN: We linked HIV and cancer laboratory data from 2004-2014 using supervised machine-learning algorithms. We performed a cross-sectional analysis comparing province where individuals accessed their HIV care versus where they had their cancer diagnosis. SETTING: We used laboratory test records related to HIV diagnostics and care, such as CD4 cell counts and percentages, rapid tests, qualitative Polymerase Chain Reaction (PCR), antibody and antigen tests for HIV data that was documented as HIV positive and laboratory diagnosed cancer records from SA. STUDY POPULATION: Our study population consisted of HIV records from the National Health Laboratory Service (NHLS) that linked to cancer record at the National Cancer Registry (NCR) between 2004-2014. PRIMARY AND SECONDARY OUTCOMES: We linked HIV records from NHLS to cancer records at NCR in order to study the inherent characteristics of the population with both HIV and cancer. RESULTS: The study population was 68,284 individuals with cancer and documented HIV related laboratory test. The median age at cancer diagnosis was 40 [IQR, 33-48] years for the study population with most cancers in PLHIV diagnosed in females 70.9% [n = 46,313]. Of all the PLHIV and cancer, 25% (n = 16,364 p < 0.001) sought treatment outside their province of residence with 60.7% (n = 10,235) travelling to Gauteng. KZN had 46.6% (n = 4,107) of its PLHIV getting cancer diagnosis in Gauteng. Western Cape had 95% (n = 6,200) of PLHIV getting cancer diagnosis within the province. CONCLUSIONS: Our results showed health systems inequalities across provinces in SA with respect to cancer diagnosis. KZN for example had nearly half of the PLHIV getting cancer diagnosis outside the province while Western Cape is able to offer cancer diagnostic services to most of the PLHIV in the province. Gauteng is getting over burdened with referral for cancer diagnosis from other provinces. More effort is required to ensure equitable access to cancer diagnostic services within the country.

Availability of essential diagnostics in ten low-income and middle-income countries: results from national health facility surveys.

BACKGROUND: Pathology and laboratory medicine diagnostics and diagnostic imaging are crucial to achieving universal health coverage. We analysed Service Provision Assessments (SPAs) from ten low-income and middle-income countries to benchmark diagnostic availability. METHODS: Diagnostic availabilities were determined for Bangladesh, Haiti, Malawi, Namibia, Nepal, Kenya, Rwanda, Senegal, Tanzania, and Uganda, with multiple timepoints for Haiti, Kenya, Senegal, and Tanzania. A smaller set of diagnostics were included in the analysis for primary care facilities compared with those expected at hospitals, with 16 evaluated in total. Surveys spanned 2004-18, including 8512 surveyed facilities. Country-specific facility types were mapped to basic primary care, advanced primary care, or hospital tiers. We calculated percentages of facilities offering each diagnostic, accounting for facility weights, stratifying by tier, and for some analyses, region. The tier-level estimate of diagnostic availability was defined as the median of all diagnostic-specific availabilities at each tier, and country-level estimates were the median of all diagnostic-specific availabilities of each of the tiers. Associations of country-level diagnostic availability with country income as well as (within-country) region-level availability with region-specific population densities were determined by multivariable linear regression, controlling for appropriate covariates including tier. FINDINGS: Median availability of diagnostics was 19·1% in basic primary care facilities, 49·2% in advanced primary care facilities, and 68·4% in hospitals. Availability varied considerably between diagnostics, ranging from 1·2% (ultrasound) to 76·7% (malaria) in primary care (basic and advanced) and from 6·1% (CT scan) to 91·6% (malaria) in hospitals. Availability also varied between countries, from 14·9% (Bangladesh) to 89·6% (Namibia). Availability correlated positively with log(income) at both primary care tiers but not the hospital tier, and positively with region-specific population density at the basic primary care tier only. INTERPRETATION: Major gaps in diagnostic availability exist in many low-income and middle-income countries, particularly in primary care facilities. These results can serve as a benchmark to gauge progress towards implementing guidelines such as the WHO Essential Diagnostics List and Priority Medical Devices initiatives. FUNDING: Bill & Melinda Gates Foundation.

Mentorship on malaria microscopy diagnostic service in Ethiopia: baseline competency of microscopists and performance of health facilities.

BACKGROUND: In Ethiopia, malaria cases are declining as a result of proven interventions, and in 2017 the country launched a malaria elimination strategy in targeted settings. Accurate malaria diagnosis and prompt treatment are the key components of the strategy to prevent morbidity and stop the continuation of transmission. However, the quality of microscopic diagnosis in general is deteriorating as malaria burden declines. This study was carried out to evaluate the competency of microscopists and the performance of health facilities on malaria microscopic diagnosis. METHODS: A cross-sectional study was conducted from 1 August to 30 September, 2019 in 9 regional states and one city administration. A standard checklist was used for on-site evaluation, archived patient slides were re-checked and proficiency of microscopists was tested using a WHO-certified set of slides from the national slide bank at the Ethiopian Public Health Institute (EPHI). The strength of agreement, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: In this study, 102 health facilities (84 health centres and 18 hospitals) were included, from which 202 laboratory professionals participated. In slide re-checking, moderate agreement (agreement (A): 76.0%; Kappa (K): 0.41) was observed between experts and microscopists on malaria detection in all health facilities. The sensitivity and specificity of routine slide reading and the re-checking results were 78.1 and 80.7%, respectively. Likewise, positive predictive value of 65.1% and negative predictive value of 88.8% were scored in the routine diagnosis. By panel testing, a substantial overall agreement (A: 91.8%; K: 0.79) was observed between microscopists and experts in detecting malaria parasites. The sensitivity and specificity in the detection of malaria parasites was 92.7 and 89.1%, respectively. In identifying species, a slight agreement (A: 57%; K: 0.18) was observed between microscopists and experts. CONCLUSION: The study found significant false positive and false negative results in routine microscopy on slide re-checking of Plasmodium parasites. Moreover, reduced grade in parasite species identification was reported on the panel tests. Implementing comprehensive malaria microscopy mentorship, in-service training and supportive supervision are key strategies to improve the overall performance of health facilities in malaria microscopy.

External validation of the EULAR/ACR idiopathic inflammatory myopathies classification criteria with a Japanese paediatric cohort.

OBJECTIVES: To assess the performance of the EULAR/ACR idiopathic inflammatory myopathies (IIMs) classification criteria to classify juvenile IIMs (JIIMs) in an Asian paediatric population. METHODS: Sixty-eight JIIM patients and 49 non-JIIM patients diagnosed at seven major paediatric rheumatology centres in Japan between 2008 and 2015 were enrolled. Retrospective data were collected, and each patient's data form was submitted. The expert group reviewed the forms and re-examined the diagnoses. The EULAR/ACR criteria were then applied and the probability of having JIIM was determined for each case. The sensitivity and specificity of the EULAR/ACR criteria were compared with those of other existing criteria. RESULTS: The sensitivity/specificity of the EULAR/ACR classification criteria were 92.1/100% with muscle biopsy data (n = 38); 86.7/100% without muscle biopsy data (n = 30) and 89.7/100% in our total cohort (n = 68). The sensitivity of Bohan and Peter's criteria and Tanimoto's criteria were 80.9 and 64.7% in our total cohort, respectively. Among 68 physician-diagnosed JIIM patients, seven cases (three JDM and four overlap myositis) were not classified as JIIM because the probability did not reach the cut-off point (55%). The three JDM patients all presented with only one of the three skin manifestations that are listed in the criteria: Gottron's sign. CONCLUSION: Our validation study with Japanese JIIM cases indicates that the EULAR/ACR classification criteria for IIM generally perform better than existing diagnostic criteria for myositis.

[Survey of the capacity building of the county-level schistosomiasis diagnosis network laboratory in Hunan Province].

OBJECTIVE: To examine the construction and operation of the schistosomiasis diagnostic network platform in Hunan Province, so as to provide insights into the improvements of the schistosomiasis diagnostic network laboratory system in the province. METHODS: According to the criteria and requirements for the construction of the county-level schistosomiasis diagnostic network laboratory in China, the establishment and operation of the laboratory were assessed using self-assessment and field review in national schistosomiasis surveillance sites of Hunan Province. RESULTS: A total of 41 county-level schistosomiasis diagnostic network laboratories were built in national schistosomiasis surveillance sites of Hunan Province, and 36 met the requirements for the construction of the national schistosomiasis diagnostic network laboratory in China, which were approved for inclusion in the province-level schistosomiasis diagnostic network laboratory. During the six inter-laboratory comparisons performed by the national schistosomiasis diagnostic reference center of China, full consistency was achieved by 3 county-level schistosomiasis diagnostic network laboratories in Hunan Province, and the coincidence rates for re-review of serological and pathogenic detection samples were 98.40% and 100%, respectively. CONCLUSIONS: The county-level schistosomiasis diagnostic network laboratory system has been preliminarily built and under effective operation in Hunan Province; however, the building capability remains to be improved.

Effect of pre-consultation testing on clinicians' adherence to malaria test results and waiting time among children under 5 years in the Northern Zone of Volta Region of Ghana.

BACKGROUND: The Ministry of Health, Ghana, in accordance with global policy, recommends that all suspected malaria cases be confirmed parasitologically before treatment. Not all clinicians, however, base their treatment on test results. Patients also spend a lot of time at health facilities waiting to consult a clinician before being asked to go for testing and to see a clinician with test results. The purpose of the study was to determine if testing all children aged 6 to 59 months with fever reporting at an outpatients department (OPD) for malaria before consultation with a clinician (pre-consultation testing) will influence clinicians to adhere to test results and also reduce the time spent by such patients. METHODS: A quasi-experimental study design was used involving two randomly selected government-owned hospitals in the Northern Volta, Ghana. In each hospital, 439 children were recruited between November 2018 and January 2019. The intervention hospital implemented pre-consultation testing. In the comparator arm, standard practices, which involved patients seeing the clinician before he/she decides whether to send the patient for testing or not, were maintained. RESULTS: Out of 878 children screened the overall prevalence of malaria was 31.9% by malaria rapid diagnostic test (RDT) and 26.7% by microscopy. Clinicians in the intervention arm adhered more to the malaria test results than those in the comparator arm (93.2 vs. 84.3%; p < 0.001). The proportion of children who tested negative but were still diagnosed with malaria was significantly lower in the intervention arm compared to the comparator arm (8.4 vs. 21.2%: p < 0.001). Clinicians and mothers/caregivers in both arms preferred pre-consulting testing. Six out of every 10 mothers/caregivers in the comparator arm viewed the waiting time as 'too long'' compared to 4 out of every 10 mothers in the intervention arm. On average, patient waiting time was significantly lower in the intervention arm (2.61 h) than in the comparator arm (3.42 h). CONCLUSION: Pre-consultation testing significantly improves clinicians' adherence to malaria test results, shortens patients' waiting time and leads to overall patient satisfaction. There is a need to establish RDT corners at OPDs of health facilities to implement pre-consultation testing.

Availability of Diagnostic Services and their Impact on Patient Flow in Two Brazilian Referral Centres of Breast Cancer Treatment.

BACKGROUND: System delay (SD) is a leading cause of advanced stage of disease and poor prognosis among Brazilian breast cancer patients. METHODS: Cox regression and Kaplan-Meier analysis were used to identify variables that contributed to SD among 128 breast cancer patients. Time intervals between first medical consultation and treatment initiation were compared among patients of two referral centres: Patients of a referral centre with outsourced (FAP), respectively, integrated (HNL) diagnostic services. RESULTS: Women who used a specialized private clinic at the beginning of patient flow had an 2.32 fold increased chance (95% CI: 1.17 - 4.60; p = 0.016) of hospital admission within 90 days after first medical consultation, compared to women who used a public health care provider (HCP). Of 73 and 34 patients of the FAP hospital and the HNL, respectively, 10 (13.7%) and 11 (32.5%) used one HCP prior to hospital admission (p = 0.000). The median time between first medical consultation and treatment initiation was 150 days. The median time between first medical consultation and hospital admission was 136.0 and 52.0 days for patients of the FAP hospital, respectively the HNL (p < 0.050). The median time between first medical consultation and diagnostic mammography was 36.5 and 23.0 days for patients from the FAP hospital and the HNL (p < 0.050). CONCLUSIONS: Usage of public diagnostic services was associated with increased SD, whereas the usage of private diagnostic services diminished it. The usage of a lower number of HCPs accelerated patient flow.

Factors predicting first-time hepatitis C virus testing uptake among men who have sex with men in China: an observational prospective cohort study.

OBJECTIVES: Men who have sex with men (MSM) are at high risk of hepatitis C virus (HCV). This study investigated predictors of first-time HCV testing uptake during a 6-month period among a sample of MSM in Hong Kong. METHODS: Participants were 351 Chinese-speaking MSM who had never received HCV testing. Participants completed two telephone surveys 6 months apart. At baseline, participants reported on sociodemographics, sexual behaviours, risk perception, depressive symptoms and anxiety symptoms. Illness representations, which refers to how people think about HCV, was measured by the Brief Illness Perception Questionnaire (BIPQ) at baseline. The BIPQ assessed identity (identifying symptoms of HCV), timeline (whether HCV is acute/chronic), consequences (severity of HCV), personal control and treatment control (whether HCV is under volitional control), concern, emotions (anger, guilt or shame) and coherence (overall comprehensibility of HCV). Six months later, participants reported on HCV testing uptake. Logistic regression was used to analyse the associations between baseline predictors and HCV testing uptake. RESULTS: Most participants were aged ≤30 years (55.0%) and had attained college education or above (85.2%). Among 242 participants (68.9%) who completed the month 6 follow-up, 12.4% had tested for HCV during the follow-up period. After adjustment for HIV testing and chemsex in the last year, participants who perceived more severe consequences of HCV reported higher HCV testing uptake (adjusted ORs (AOR): 2.22, 95% CI: 1.65 to 3.00). Belief that treatment can control HCV (AOR: 1.75, 95% CI: 1.35 to 2.26) and having negative emotions related to HCV (AOR: 1.59, 95% CI: 1.25 to 2.03) were also positively associated with HCV testing uptake. CONCLUSIONS: Targeted health promotion efforts are needed to increase HCV testing among MSM in Hong Kong. Healthcare workers engaged in HCV-related programming should consider modifying the illness representations of HCV. Integrating HCV and HIV testing services may also be beneficial.

Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two medical centers.

Background An organization's ability to identify and learn from opportunities for improvement (OFI) is key to increasing diagnostic safety. Many lack effective processes required to capitalize on these learning opportunities. We describe two parallel attempts at creating such a process and identifying generalizable lessons and learn from them. Methods Triggered case review programs were created independently at two organizations, Site 1 (Regions Hospital, HealthPartners, Saint Paul, MN, USA) and site 2 (University of California, San Diego). Both used a five-step process to create the review system and provide feedback: (1) identify trigger criteria; (2) establish a review panel; (3) develop a system to conduct reviews; (4) perform reviews; and (5) provide feedback. Results Site 1 identified 112 OFI in 184 case reviews (61%), with 66 (59%) provider OFI and 46 (41%) system OFI. Site 2 focused mainly on systems OFI identifying 105 OFI in 346 cases (30%). Opportunities at both sites were variable; common themes included test result management and communication across teams in peri-procedural care and with consultants. Of provider-initiated reviews, 67% of cases had an OFI at site 1 and 87% at site 2. Conclusions Lessons learned include the following: (1) peer review of cases provides opportunities to learn and calibrate diagnostic and management decisions at an organizational level; (2) sharing cases in review groups supports a culture of open discussion of OFIs; (3) reviews focused on diagnostic safety identify opportunities that may complement other organization-wide review opportunities.

Relevance of lung ultrasound in the diagnostic algorithm of respiratory diseases in a real-life setting: A multicentre prospective study.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess the role of lung ultrasound (LUS) in a diagnostic algorithm of respiratory diseases, and to establish the accuracy of LUS compared with chest radiography (CXR). METHODS: Over a period of 2 years, 509 consecutive patients admitted for respiratory-related symptoms to both emergency and general medicine wards were enrolled and evaluated using LUS and CXR. LUS was conducted by expert operators who were blinded to the medical history and laboratory data. Computed tomography (CT) of the chest was performed in case of discordance between the CXR and LUS, suspected lung cancer and an inconclusive diagnosis. Diagnosis made by CT was considered the gold standard. RESULTS: The difference in sensitivity and specificity between LUS and CXR as demonstrated by ROC curve analyses (LUS-AUROC: 0.853; specificity: 81.6%; sensitivity: 93.9% vs CXR-AUROC: 0.763; specificity: 57.4%; sensitivity: 96.3%) was significant (P = 0.001). Final diagnosis included 240 cases (47.2%) of pneumonia, 44 patients with cancer (8.6%), 20 patients with chronic obstructive pulmonary disease (COPD, 3.9%), 24 patients with heart failure (4.7%) and others (6.1%). In 108 patients (21.2%) with any lung pathology, a CT scan was performed with a positive diagnosis in 96 cases (88.9%); we found that CXR and LUS detected no abnormality in 24 (25%) and 5 (5.2%) cases, respectively. LUS was concordant with the final diagnosis (P < 0.0001), and in healthy patients, there was a low percentage of false positives (5.9%). CONCLUSION: The results support the routine use of LUS in the clinical context.

Opt-out screening for HIV, hepatitis B and hepatitis C: observational study of screening acceptance, yield and treatment outcomes.

BACKGROUND: We initiated an emergency department (ED) opt-out screening programme for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) at our hospital in Dublin, Ireland. The objective of this study was to determine screening acceptance, yield and the impact on follow-up care. METHODS: From July 2015 through June 2018, ED patients who underwent phlebotomy and could consent to testing were tested for HIV, HBV and HCV using an opt-out approach. We examined acceptance of screening, linkage to care, treatment and viral suppression using screening programme data and electronic health records. The duration of follow-up ranged from 1 to 36 months. RESULTS: Over the 36-month study period, there were 140 550 ED patient visits, of whom 88 854 (63.2%, 95% CI 63.0% to 63.5%) underwent phlebotomy and 54 817 (61.7%, 95% CI 61.4% to 62.0%) accepted screening for HIV, HBV and HCV, representing 41 535 individual patients. 2202 of these patients had a positive test result. Of these, 267 (12.1%, 95% CI 10.8% to 13.6%) were newly diagnosed with an infection and 1762 (80.0%, 95% CI 78.3% to 81.7%) had known diagnoses. There were 38 new HIV, 47 new HBV and 182 new HCV diagnoses. 81.5% (95% CI 74.9% to 87.0%) of known patients who were not linked were relinked to care after screening. Of the new diagnoses, 86.2% (95% CI 80.4 to 90.8%) were linked to care. CONCLUSION: Although high proportions of patients had known diagnoses, our programme was able to identify many new infected patients and link them to care, as well as relink patients with known diagnoses who had been lost to follow-up.

The Needs of LGBTI People Regarding Health Care Structures, Prevention Measures and Diagnostic and Treatment Procedures: A Qualitative Study in a German Metropolis.

(1) Background: Studies indicate that lesbian, gay, bisexual, transgender and intersex (LGBTI) people constantly face challenges and disadvantages in the health care system that prevent them from getting the best possible patient-centered care. However, the present study is the first to focus on LGBTI-related health in a major German metropolis. It aimed to investigate health care structures, prevention measures and diagnostic as well as treatment procedures that LGBTI individuals need in order to receive appropriate patient-centered health care and health promotion. (2) Methods: Following a participatory approach, five expert interviews with LGBTI people with multiplier function, i.e., people who have a key role in a certain social milieu which makes them able to acquire and spread information in and about this milieu, and three focus groups with LGBTI people and/or health professionals were conducted. Qualitative data were analyzed according to the principles of content analysis. (3) Results: The specific needs of LGBTI individuals must be recognized as a matter of course in terms of depathologization, sensitization, inclusion, and awareness. Such an attitude requires both basic knowledge about LGBTI-related health issues, and specific expertise about sufficient health care services for each of the minorities in the context of sex, sexual orientation and gender identity. (4) Conclusions: For an appropriate approach to LGBTI-centered health care and health promotion, health professionals will need to adopt a better understanding of specific soft and hard skills.

A cohort study comparing rate of repeat testing for sexually transmitted and blood-borne infections between clients of an internet-based testing programme and of sexually transmitted infection clinics in Vancouver, Canada.

OBJECTIVES: Internet-based sexually transmitted and blood-borne infection (STBBI) testing services reduce testing barriers through bypassing face-to-face clinical encounters, potentially enabling clients at ongoing sexual risk to test more frequently. To our knowledge, this hypothesis has not been previously tested. We compared the frequency of repeat testing between Vancouver-based clients of GetCheckedOnline (GCO)-an internet-based STBBI testing service in British Columbia, Canada-and clients of three sexually transmitted infection (STI) clinics in Vancouver for 29 months after GCO launched. METHODS: An administrative data cohort (n=19 497) was assembled using GCO, clinical and laboratory databases. We included all individuals who tested for HIV, gonorrhoea/chlamydia, syphilis or hepatitis C at three STI clinics or using GCO, between September 2014 and February 2017. The rate of repeat testing (>30 days after first episode) was compared between clients who used GCO at least once and those who tested only in STI clinics. Poisson regression was used to generate relative rate (RR) for repeat testing, with adjustment for age, gender/sexual orientation, risk factors (eg, history of STI diagnosis) and rate of testing before GCO launched. RESULTS: 1093 GCO clients were identified, of whom 434 (40%) had repeat test episodes; 8200/18 404 (45%) of clinic clients tested more than once. During the 29-month analysis period, GCO clients repeat tested 1.87 times per person-year, whereas clinic clients repeat tested 1.53 times per person-year, resulting in a crude RR of 1.22 (95% CI: 1.14 to 1.31). Adjustment for covariates increased the RR to 1.26 (95% CI: 1.15 to 1.37). CONCLUSIONS: In this cohort, individuals using internet-based STBBI testing had a rate of repeat testing 22% greater than clinic-based clients. This effect was increased after adjusting for characteristics associated with higher test frequency. The online interface of GCO may facilitate more frequent testing and may therefore contribute to earlier STBBI diagnosis.

Incomplete Filling of Laboratory Request Forms: A Look at the Practice at a Federal Medical Centre in South Eastern Nigeria.

BACKGROUND: Laboratory request forms serve as a medium for communication between clinicians managing medical cases and the pathologist. Improperly filled forms impairs the ability of pathologists to generate sound and valuable reports. This research focused on finding out the extent to which doctors in Federal Medical Centre, Umuahia properly fill laboratory request forms. METHODOLOGY: A total of 1,509 laboratory request forms directed to the electrolyte bench, already filled out by various doctors in the hospital between May and October, 2018 were retrospectively studied. The completeness of information supplied by requesting physician based on some parameters were analysed. RESULTS: In descending order, the most frequently provided data were as follows; name of patient, 1,509[100.0%]; gender,973[64.5%]; provisional diagnosis,866[57.4%]; age,639[42.4%]; hospital number,428[28.4%]; clinical summary,47[3.1%]. 26[2%] forms were completed in their entirety per the 6 variables assessed. CONCLUSION: Proper and adequate filling of laboratory request forms is very poor in this hospital. Therefore, continuous medical education on the need for adequate completion of request forms is absolutely necessary.

BK virus viral load: analysis of the requests received by the microbiology laboratory and clinical involvement of the issued results.

Automation of viral diagnosis has led to an increase of BK virus (BKV) viral load (VL) requests. The aim of this study was to assess the suitability of serum creatinine (SCr) for controlling the demand and to study the clinical characteristics of BKV infection. This is a retrospective study including patients with BKV VL request during April-July 2017. Clinical records and SCr were analyzed. Five hundred samples from 333 patients were included; 61.4% of samples were from males (55.5 ± 14.8 years), and all belonged to transplant recipients (86.4% renal). BKV VL was detectable in 40 samples (8.0%) from 23 patients (6.9%), who presented high SCr (100% vs. 90.9%, P = 0.038). Most of detectable VLs (62.5%) belonged to patients in their first year post-transplant. Six patients with detectable VL (26.1%) developed clinical manifestations, most of them (83.3%) had a first BKV VL greater than 10,000 copies/mL (P = 0.001). In conclusion, SCr would be useful to identify suitable specimens for BKV VL testing without missing cases.

Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions.

BACKGROUND: Long diagnostic intervals following abnormal breast imaging (DI) cause patient anxiety and possibly poorer prognosis. This study evaluates the effect of a provincial diagnostic pathway for BI-RADS 5 lesions on wait times and the patient-reported experience (PRE). METHODS: With multidisciplinary input, we developed a pathway for BI-RADS 5 lesions featuring expedited biopsy, early surgical referral, and nurse (RN) navigator support. Key diagnostic intervals were captured prospectively and compared with a prepathway control cohort. PRE data were obtained from a voluntary survey. RESULTS: 1205 patients were managed on the BI-RADS 5 pathway with 797 primary care physicians, 57 imaging centers, and 2 regional breast programs participating. Median duration from DI to biopsy was 6 days, from biopsy to pathology report was 5 days, DI to surgical referral was 6 days, and DI to surgical consult was 21 days. Compared with 128 prepathway controls, median intervals from DI to surgical referral and consult were significantly improved (15 vs. 6 days, 26 vs. 21 days, p < 0.001). Amongst 294 women who completed the survey, 92% experienced ≥ 1 anxiety complaint during assessment; prompt surgical consultation and multiple features of RN support reduced anxiety, and wait time satisfaction was high (70%). Patient preferences varied for receiving biopsy results from a surgeon (57%) vs. another provider (43%). CONCLUSIONS: A diagnostic pathway for BI-RADS 5 lesions reduced wait times and improved the patient experience through prompt surgical referral and RN navigator support. Differing preferences for receiving biopsy results emerged, and future iterations should incorporate individualized patient wishes.

Just Google it! Impact of media coverage of an outbreak of high-level azithromycin-resistant Neisseria gonorrhoeae on online searches, and attendances, testing and diagnoses at sexual health clinics in England between 2015 and 2016: an interrupted time series analysis using surveillance data.

OBJECTIVES: To determine if media coverage of an outbreak of high-level azithromycin-resistant Neisseria gonorrhoeae (HL-AziR) impacted online search interest or was temporally associated with health-seeking behaviours in several English cities. METHODS: A descriptive analysis of outbreak-related online media articles and relative search interest (RSI) using Google and an interrupted time series analysis using routine surveillance data from sexual health clinics (SHCs) in England (GUMCAD STI surveillance system). The main outcomes were adjusted incidence rate ratios (IRRs) of weekly attendances, gonorrhoea tests and diagnoses of gonorrhoea or 'any STI' in selected cities after media coverage of the outbreak in 2015 and 2016. RESULTS: RSI for outbreak-related terms peaked during media coverage in September 2015 with smaller peaks coinciding with subsequent coverage. The greatest increase in RSI was in Leeds, which coincided with a 63% rise (n=1932; IRR 1.26, 95% CI 1.12 to 1.43) in SHC attendances by women. There was only a 7% (n=1358; IRR 1.01, 95% CI 0.91 to 1.11) increase in attendances by men. Modest increases in outcomes occurred in four other cities with a high RSI. There was no evidence of increases in outcomes in cities, other than Leeds, after subsequent media coverage of the outbreak. CONCLUSIONS: National and local media coverage of the HL-AziR outbreak coincided with peak RSI for related terms, and a transient increase in attendances, gonorrhoea tests and diagnoses of gonorrhoea or 'any STI' in some cities with a high RSI. Our analysis demonstrates the potential for media coverage to influence health-seeking behaviours during high-profile STI outbreaks.

Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey.

OBJECTIVES: HIV testing among high-risk groups is a key intervention to diagnose persons living unknowingly with HIV to enable linkage to care and effective antiretroviral treatment. This study aimed to evaluate the uptake of Testpoint, the first large-scale HIV testing programme in Sweden where peer, non-healthcare personnel offered venue-based testing. Testing was performed by staff from the Swedish Foundation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL Sweden) and testing was performed at the RFSL offices, gay clubs and gay cruising areas, as well as at various gay festivals. The test was a rapid test using capillary blood from a finger prick. METHODS: A cross-sectional survey of all persons aged >18 years who came for HIV testing at one of Testpoint's locations in Sweden between 1 February and 31 December 2016. RESULTS: 595 respondents (96% response rate) were included. Five persons were diagnosed with HIV and referred for treatment and care. A fifth of participants had never tested for HIV before. More than half of the participants were foreign born and the median age was 31 years. About one-fifth of participants stated they would not have tested through the healthcare system if Testpoint was not available. CONCLUSIONS: Testpoint reached their target population of young, foreign-born men who have sex with men (MSM) as well as first time testers and persons who stated that they would not have tested within the healthcare system. Such peer HIV testing outside the healthcare setting is a possible way of increasing uptake of testing in high-risk groups.

Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention.

OBJECTIVE: Indicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC. METHODS: A prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18-65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016). RESULTS: During the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30-54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC. CONCLUSIONS: A significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.

Qualitative analysis of the experiences of gay, bisexual and other men who have sex with men who use GetCheckedOnline.com: a comprehensive internet-based diagnostic service for HIV and other STIs.

OBJECTIVES: To describe the factors that influence gay, bisexual and other men who have sex with men's (gbMSM) experiences with GetCheckedOnline.com (GCO) in British Columbia (BC), Canada. GCO clients complete an internet-based risk assessment and print a laboratory test requisition form for HIV and other STIs to take to a private laboratory for diagnostic services. METHODS: Drawing on a purposive stratified sampling framework, we conducted 37 in-depth semistructured interviews with gbMSM who had used GCO at least once between 2015 and 2017. RESULTS: Participants expressed a preference for GCO (instead of clinic-based testing) because of convenience, privacy and control over specimen collection (specifically with doing one's own throat or anal swab). Participants preferred receiving their results online via GCO compared with phone or email follow-up by clinic staff. GCO was viewed positively because it offers gbMSM living outside of urban city centres easy access to diagnostic services, including access to pooled nucleic acid amplification testing. Many participants also continued to positively view the clinic-based services available for gbMSM in their community. These services were frequently described as highly competent, tailored and comprehensive in responding to more complex needs. For example, attending a clinic was viewed as preferential to GCO in instances where there was a desire to access services addressing co-occurring health issues (eg, mental health; substance use disorders). Almost all of the participants anticipated using both GCO and clinic-based services in the future. CONCLUSIONS: gbMSM report positive experiences and perceptions of GCO; however, they do not view GCO as a panacea. The results of this study point to the need to ensure that a wide range of integrated service options (eg, online; clinic-based) are available to address the range of sexual health needs of gbMSM living in BC's diverse settings.