Initiation of antiretroviral therapy in patients with a CD4 count of less than 350 cells: a retrospective audit against key indicators from the CQUIN payment framework.

A proportion of funding for the South Yorkshire HIV Network is dependant on meeting the targets of the Commissioning for Quality and Innovation (CQUIN) payment framework. This states that 85% of patients with a CD4 count below 350 should be on antiretroviral therapy (ART). We also audited how many patients we started on treatment within six weeks. We found 88% of the 243 patients were on ART at the end of the audit, but significantly less had been started on treatment within six weeks of their CD4 count falling below 350. Although the target was achieved, there were patients who should be excluded as shown by other clinical guidelines, for example patients on treatment for tuberculosis. If these patients were excluded and the threshold level increased, it would help emphasize the at-risk patient group and lead to a fairer allocation of funding.

How good are newly qualified doctors at digital rectal examination?

AIM: Digital rectal examination (DRE) is an essential skill which all newly qualified doctors should have. There is evidence in the literature that junior doctors lack this important examination technique. The aim of our study was to determine, with the help of a questionnaire, the abilities of foundation year 1 (FY1) doctors to perform DRE. METHOD: A questionnaire was developed and sent to newly qualified FY1 doctors qualified in two universities (Nottingham and Sheffield) within the first 4 weeks of starting as a FY1 doctor. RESULTS: Ninety (75%) out of 120 questionnaires were completed. Most FY1 doctors had very little experience in performing DRE on a patient, and 68 (76%) had performed less than 10 procedures prior to qualification. Very few of these doctors had their clinical findings on DRE checked by a senior doctor (n = 7, 8%). Comparing DRE with other forms of examination, newly qualified doctors were most confident at groin hernia examination followed by testicular examination. They were least confident with vaginal examination and DRE (ANOVA P = 0.0082). CONCLUSION: Digital rectal examination is frequently performed by the most inexperienced doctor and may not be verified by a more senior colleague. More training and supervision of junior doctors are required both prior to qualification and during the early stages of their medical career.