Is there a place for a molecular diagnostic test for pelvic inflammatory disease in primary care? An exploratory qualitative study.

INTRODUCTION: There is currently no test for pelvic inflammatory disease (PID) that is non-invasive and sufficiently sensitive and specific. Clinicians must therefore diagnose PID clinically, ruling out medical emergencies and conducting pelvic examinations where possible. While guidelines state that clinicians should be prepared to over-diagnose PID, it remains an under-diagnosed condition, with severe reproductive health impacts when left untreated. This research is the first to consider the perspectives of end-users on the development of a diagnostic test for PID. METHODS: Semi-structured live video feed online (Zoom) interviews were conducted with 11 clinicians and nine women (aged 18-30 years) in Australia to understand how a diagnostic test might be used, and what characteristics a test would need for it to be acceptable to clinicians and young women. Participants were recruited via researcher and university student networks. Reflexive thematic analysis was used to identify key themes relating to the acceptability and characteristics of a diagnostic test for PID. RESULTS: Seven general practitioners, four clinicians working in sexual health clinics, and nine young women (aged 21-27 years) were interviewed. Clinicians were aged between 31-58 years and were predominantly female. Clinicians recognised that the development of an accurate test to diagnose PID would be valuable to themselves and other clinicians, particularly those who lack experience diagnosing PID, and those working in certain settings, including emergency departments. They discussed how they might use a test to enhance their clinical assessment but highlighted that it would not replace clinical judgement. Clinicians also considered how a test would impact the patient experience and time to treatment, emphasising that it should be minimally invasive and have a quick turnaround time. Young women said a test would be acceptable if endorsed by a trustworthy clinician. CONCLUSIONS: PID remains a challenging diagnosis. Development of a minimally invasive and sufficiently accurate diagnostic test would be acceptable to young women and benefit some clinicians, although no test would completely replace an experienced clinician's judgement in making a PID diagnosis.

Factors associated with pelvic inflammatory disease: A case series analysis of family planning clinic data.

BACKGROUND: We aimed to better understand factors associated with pelvic inflammatory disease in an outpatient setting. METHODS: We analysed the characteristics of pelvic inflammatory disease cases diagnosed in an outpatient setting during 2018. There were 72 cases included in the final analysis. RESULTS: Of the pelvic inflammatory disease cases analysed, 55% were idiopathic, 22.2% were related to a sexually transmitted infection, and 22.2% had onset of symptoms within 6 weeks of a gynaecological procedure. Of the sexually transmitted infection-positive pelvic inflammatory disease cases, Chlamydia trachomatis was present in 56%, Mycoplasma genitalium was present in 38%, and Neisseria gonorrhoeae was present in 12.5% of cases. Many pelvic inflammatory disease cases had evidence of vaginal dysbiosis or features associated with vaginal flora disruption (recent antibiotic usage and/or vulvovaginal candidiasis). CONCLUSION: This case series highlights the burden of Mycoplasma genitalium pelvic inflammatory disease, and clinicians should be aware to include testing for this when diagnosing pelvic inflammatory disease. Our findings also support the hypothesis that host dysbiotic microbiota may contribute to pelvic inflammatory disease pathogenesis, with further research required to explore this proposition.

Renewal of the National Cervical Screening Program: health professionals' knowledge about screening of specific populations in NSW, Australia.

OBJECTIVES: The National Cervical Screening Program was renewed in Australia from 1 December 2017, with the introduction of 5-yearly human papilloma virus (HPV) screening from age 25, and the release of updated national screening guidelines. This study aimed to determine health professional knowledge of the renewed screening program following implementation. METHODS: We invited health professionals providing cervical screening in New South Wales (NSW), Australia, to complete an online survey in late 2018, to better understand their knowledge of the renewed screening guidelines, in particular regarding screening of specific populations, and to ascertain whether they had undertaken any educational activities relevant to the renewal. RESULTS: A total of 241 responses were included in the data analysis. Health professionals demonstrated good knowledge of some aspects of the renewed program, including 64-85% correctly identifying limited indications for testing people younger than 25 years, 87% correctly identifying the need for completion of the Test of Cure protocol following treatment of high-grade lesions, and 71-80% correctly identifying management of symptomatic women. However several key knowledge gaps were identified including management of immune-deficient women (only 37% of respondents were aware of the need for 3-yearly screening), screening after total hysterectomy (56% were aware of guidance) and approximately 66% of health professionals correctly identifying indications for self-collected screening. One in ten health professionals had not undertaken any education specific to the renewal of the program. We found significant associations between knowledge levels and practitioner characteristics, including practitioners' frequency of access to the guidelines, specific educational activities undertaken and geographic location. CONCLUSION: Health professionals demonstrated strong knowledge of key aspects of the renewed National Cervical Screening program. However, our findings highlight some important gaps that may impact successful delivery of the program in Australia, and some significant associations between practitioner characteristics and knowledge levels, which will be important for education providers to note. Targeted educational interventions informed by these findings could support health professionals to better translate guidelines into practice and ensure successful delivery of this important public health program, particularly in regard to management of immune-deficient women, screening after hysterectomy and indications for self-collected screening.

Associations of anticipated prescribing of long-acting reversible contraception by general practice registrars: A cross-sectional study.

BACKGROUND AND OBJECTIVES: Long-acting reversible contraception (LARC) is highly effective, but uptake in Australia is low. The aim of this study was to establish general practice registrars' LARC training/insertion experience, as well as frequency of and factors associated with choosing LARC in response to clinical vignettes. METHOD: This was a cross-sectional questionnaire-based study of general practice registrars in NSW or ACT. The questionnaire elicited a contraceptive management response to three clinical vignettes. The outcome factor in each of three multivariate logistic regression analyses was: 'LARC chosen' or 'LARC not chosen'. RESULTS: Of 223 registrars, 18.5% had received intrauterine device (IUD) insertion training, and 9.4% had inserted IUD in general practice. For contraceptive implants, these figures were 64.3% for training and 50.3% for insertion. Significant multivariate associations (all odds ratios >2.5) of choosing LARC in at least one vignette included Australian medical graduate, female gender and confidence in knowledge regarding IUD/implant. DISCUSSION: Modest proportions of general practice registrars have training in, and in-practice experience of, LARC insertion. The most notable association with choice of LARC was confidence in knowledge regarding LARC.

Prescribing of long-acting reversible contraception by general practice registrars across different rural regions of Australia: A cross-sectional analysis of the Registrar Clinical Encounters in Training Study data.

OBJECTIVE: To describe the pattern of prescribing long-acting reversible contraception by Australian general practitioner registrars across different classifications of rurality/urbanicity. METHODS: A study nested within the Registrar Clinical Encounters in Training ongoing cohort study of Australian general practitioner registrars' in-consultation experience. DESIGN: A cross-sectional analysis of Registrar Clinical Encounters in Training data collected 2010-2017. Type of contraception prescribed by general practitioner registrars to women aged 12-55 for contraception-related indications was documented. Chi-square statistical analysis was performed to assess association of specific long-acting reversible contraception methods with rurality/urbanicity. SETTING/PARTICIPANTS: General practitioner registrars enrolled in the Australian General Practice Training program in regional training providers/organisations participating in Registrar Clinical Encounters in Training. MAIN OUTCOME MEASURES: Long-acting reversible contraception was defined as etonogestrel implant, copper intrauterine device, levonorgestrel intrauterine device and medroxyprogesterone injection. RESULTS: In all 1737 registrars recorded 4073 registrar rounds of data from 2010 to 2017 (response rate 96%). Type of long-acting reversible contraception prescribed differed significantly across Australian Statistical Geography Standards classification of rurality (Pearson's χ2  = 17, P = .002). Women living in outer regional/remote/very remote regions are prescribed proportionately more medroxyprogesterone injection and less levonorgestrel intrauterine device compared to major cities/inner regional areas. CONCLUSIONS: Long-acting reversible contraception methods prescribed differ across different classifications of rurality. Women living in more rural/remote regions might have access difficulties for the levonorgestrel intrauterine device.

Barriers to prescribing of long-acting reversible contraception (LARC) by general practitioner registrars: A cross-sectional questionnaire.

Long-acting reversible contraception (LARC) is highly effective but uptake in Australia is low. We aimed to establish general practitioner (GP) registrars' (vocational trainees') perspectives on barriers to prescribing LARC. We conducted a cross-sectional questionnaire-based study of 191 GP registrars in NSW and ACT. Outcome factors were levels of agreement with eight barriers to prescribing LARC. We found the most-reported barriers to prescribing LARC were limited access to training and limited opportunities to maintain skills. Registrars perceived greater barriers to the use of intrauterine devices, compared to contraceptive implants, regarding indemnity insurance, difficulty accessing training, and insufficient insertion opportunities to maintain skills.

National Cervical Screening Program renewal in Australia: survey of clinician views and attitudes.

From 1 December 2017, the National Cervical Screening Program was renewed in Australia, with updated national cervical screening guidelines released. This study was performed to determine clinicians' familiarity with the updated guidelines and explore their views and attitudes towards the renewed program. Clinicians providing cervical screening in New South Wales, Australia, were invited to complete an online survey in 2018. Of the 241 clinicians who responded, 91.5% supported the change to 5-yearly human papillomavirus screening from the age of 25 years. However, nearly 13% indicated they did not know where to access the renewed guidelines and 37% had never or rarely accessed them. Open-ended responses highlighted clinicians' concerns about missed cancers and missed opportunities for health checks. Those raising these concerns accessed the guidelines less frequently. The findings highlight important areas for additional education and support for clinicians in translating guidelines into practice to ensure successful delivery of the renewed program.

Prevalence and associations of prescribing of long-acting reversible contraception by general practitioner registrars: a secondary analysis of ReCEnT data.

OBJECTIVE: Long-acting reversible contraception (LARC) is the most effective form of contraception but use in Australia is low. Uptake of LARC prescribing by early-career general practitioners (GPs) has important implications for community reproductive health. We aimed to investigate the prevalence and associations of Australian GP registrars' LARC prescribing. METHODS: A cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) cohort study 2010-2017. GP registrars collected data on 60 consecutive consultations on three occasions during their training. The outcome factor was prescription of LARC (compared with non-LARC). A secondary analysis was performed with problems involving prescription of LARC (compared with other problems). Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression. RESULTS: 1737 registrars recorded 5382 problems/diagnoses involving women aged 12-55 years in which contraception was prescribed. 1356 (25%) involved LARC. Significant multivariable associations of prescribing LARC included patient age (OR 2.85, 95% CI 3.17 to 3.74, for age 36-45 years compared with age 12-18 years), practice rurality - inner-regional (OR 1.47, 95% CI 1.22 to 1.79) and outer-regional/remote/very remote (OR 1.47 95% CI 1.15 to 1.87) compared with major cities, practices in areas of lower socioeconomic status (SES) (OR 0.93, 95% CI 0.91 to 0.96 for SES by decile), generating learning goals (OR 1.37, 95% CI 1.04 to 1.79), in-consultation assistance-seeking (OR 1.58, 95% CI 1.24 to 2.01), and the registrar having reproductive health-related postgraduate qualifications (OR 1.33, 95% CI 1.01 to 1.76). CONCLUSIONS: The prevalence of LARC prescribing by Australian GP registrars is higher than has been previously estimated in established GPs. Postgraduate qualifications in reproductive health are associated with prescribing LARC. Prescribing practice differs according to rurality and relative socioeconomic disadvantage.

Factors associated with the initiation of testosterone replacement therapy in men from the 45 and Up Study

BACKGROUND AND OBJECTIVES: There have been large increases in testosterone prescribing since 2000. The aim of this study was to identify factors associated with testosterone replacement therapy (TRT) initiation in men. METHODS: Data were from the 45 and Up Study, an ongoing cohort study involving 266,942 participants from New South Wales aged ≥45 years. Baseline data (2006−09) were linked to administrative data on government-subsidised prescriptions and medical services. RESULTS: The study included 105,429 men. In two years following baseline, 2.9 per 1000 men (95% confidence interval: 2.6, 3.2) had initiated TRT. Men with self-rated poor health, those treated for osteoporosis; anxiety, depression or high blood cholesterol, and those who lived in major cities or were aged 55­74 years had greater odds of TRT initiation. In the six months before TRT initiation, 41% of men had a hormone test record. DISCUSSION: Discussion The high rate of TRT initiation and low rate of recommended investigations suggest TRT may have been prescribed outside recommended indications.