Rates of STIs are high in New Zealand. Chlamydia is the most commonly reported bacterial STI, however, there is evidence
that rates of Mycoplasma genitalium infection are nearly as high as chlamydia in some groups. There has also been a marked
increase in the number of infectious syphilis cases in recent years. The rate of genital warts diagnoses has dramatically
decreased following inclusion of the human papillomavirus (HPV) vaccination (Gardisil 9) in the National Immunisation
Schedule in 2008, however, genital warts remain a common STI in New Zealand.
The highest rates of STIs are typically reported in younger adults and adolescents, due to an increased prevalence of
higher risk sexual behaviours, e.g. frequently changing sexual partners, having sex under the influence of alcohol or
illicit drugs. As these infections can be asymptomatic, increased testing is essential to prevent complications developing
and transmission of infections to others by enabling prompt treatment. Annual STI testing is recommended for all sexually
active people aged < 30 years; more frequent testing may be indicated for certain groups, e.g. people who have multiple
sexual partners, men who have sex with men (MSM).
STI testing rates are significantly lower for males than females. Younger males in particular may rarely attend general
practice, therefore, any consultation should be considered as a potential opportunity to initiate a discussion about sexual
health and offer STI testing as appropriate. This is also an opportunity to check HPV vaccination status and discuss vaccination
with those who are eligible* but have not been immunised, e.g. those who missed out on the school-based programme.
* Males aged nine to 26 years have been eligible to receive the HPV vaccine fully subsidised
since January, 2017; vaccination may be beneficial to certain groups aged 27 years and older, e.g. MSM, those with HIV
infection or those with little previous exposure to HPV, however it is not subsidised.
For further information on how to perform a sexual health check, see:
www.bpac.org.nz/BPJ/2013/April/how-to-guide-sexual-health.aspx
For updates on managing chlamydia, gonorrhoea, Mycoplasma genitalium and syphilis infections in primary
care, see: www.bpac.org.nz/2019/chlamydia-gonorrhoea.aspx
For further information on HPV vaccination, including the vaccination schedule and groups eligible for fully
subsidised vaccination, see: www.bpac.org.nz/2019/hpv.aspx
Summary
This audit identifies male patients aged 16–30 years who have presented in the past 12 months to assess whether they
have been offered a sexual health check or had STI testing and have a record of HPV vaccination or an offer of immunisation
to those who are eligible.
Recommended audit standards
Ideally, all male patients aged 16–30 years should have documented evidence in their patient record of having been offered
a sexual health check or had STI testing in the previous 12 months. Any patients who do not have the recommended information
in their clinical notes should be flagged for review. They should also have a record of HPV vaccination or an offer of
vaccination at any time. Any patients who do not have the recommended information in their clinical notes and are eligible
for vaccination, i.e. aged 26 years and under, should be flagged for review, e.g. a discussion about vaccination at their
next appointment or a recall letter.
Identifying eligible patients
All male patients within the practice who are aged 16–30 years and have attended for any reason in the past 12 months
are eligible for this audit.
You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to
identify patients by running a ‘query’ through their PMS, e.g. by age and sex. Once eligible patients have been identified,
review the patient’s clinical notes to identify whether they have been offered a sexual health check or had STI testing
in the past 12 months and whether there is a record of HPV vaccination or vaccination has been offered at any time.
Sample size
The number of eligible patients will vary according to your practice demographic. A sample size of 20–30 patients is
sufficient for this audit.
N.B. the timeframe of the audit can be extended beyond 12 months if an insufficient number of patients are identified.
Criteria for a positive result
For a positive result for the audit, the patient’s clinical notes should contain both of the following:
- A record of a discussion offering a sexual health check or a record of STI testing in the past 12 months
- A record of HPV vaccination or a discussion offering vaccination to those who are eligible, i.e. aged 26 years or
under, at any time
Data analysis
Use the data sheet provided to record your data. A positive result is any patient who has documented evidence in their
notes of an offer of a sexual health check or a record of STI testing in the past 12 months and a record of HPV vaccination
or a discussion offering vaccination to those who are eligible, at any time. The percentage achievement can be calculated
by dividing the number of patients with a positive result by the total number of patients audited.
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
Taking action
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
Effective interventions
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behaviour
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
Audit
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit of Medical
Practice summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.
