ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Management of Chiamydia trachomatis genital infections: reported practices Of primary care p ysicians Laura McDougall,* MD, MHSc; Richard G. Mathias,* MD, FRCPC; Brian A. O'Connor, MD, MHSc; William R. Bowie,t MD, FRCPC Objective: To determine the knowledge of primary care physicians about Chlamydia trachomatis genital infection and its management. Design: Self-administered questionnaire comprising direct questions and hypothetical cases. Participants: All 108 general and family practitioners on the north shore of Vancouver were sent the questionnaire; 79 (73%) responded. Results: There was a reasonable level of knowledge in many areas, particularly among the physicians who had graduated more recently than the others. Virtually all stated that they have access to chlamydial diagnostic testing, and most indicated that they test for chlamydial infection at least occasionally. However, many of the respondents failed to consider that youths in their practice may be sexually active, and only 28% knew that women 15 to 19 years of age have the highest reported rates of chlamydial infection. Many of the physicians were confused about syndromes that are or are not associated with C. trachomatis infection; this indicated the possibility of inappropriate testing and treatment decisions. If they had to test for C. trachomatis in a prepubescent girl 34% reported that they would obtain a specimen from the endocervix, a technique that is inappropriately invasive. When presented with a positive test result many of the respondents failed to consider the possibility of a false-positive result. Fortunately all of the physicians were well informed about correct treatment regimens for C. trachomatis infection, although many did not realize how effective they really are. In the case of a young man with suspected or proven gonorrhea or a young female outpatient with pelvic inflammatory disease, only 19% and 20% respectively stated that they would prescribe a regimen appropriate for both penicillinase-producing Neisseria gonorrhoeae and C. trachomatis. Many of the respondents had not heard of management guidelines, and fewer still reported that they consult themn. Conclusions: Despite the availability of several sets of guidelines there appear to be important gaps in the knowledge and practice of many primary care physicians with respect to genital infections. Since the preparation of guidelines is time-consuming and expensive, further work should be done to evaluate their impact and to address their limitations.
Objectif: Preciser les connaissances des medecins en soins primaires au sujet des infections genitales a Chlamydia trachomatis et de son traitement. Conception: Questionnaire autoadministre compose de questions directes et de cas hypothetiques. From the divisions of *Health Care and Epidemiology and of tInfectious Diseases, Faculty ofMedicine, University ofBritish Columbia, Vancouver, BC, and *the North Shore Health Unit, Vancouver, BC
Reprint requests to: Dr. William R. Bowie, Division ofInfectious Diseases, G.F. Strong Research Laboratories, Rm. 452, Dfloor, 2733 Heather St., Vancouver, BC VSZ 3J5 -
For prescribing information see page 773
CAN MED ASSOC J
1992; 146 (5)
715
Participants: La totalite des 108 medecins en medecine generale et medecine familiale de la c6te nord de Vancouver ont recu le questionnaire; 79 (73 %) d'entre eux ont
repondu. Resultats: Les auteurs ont constate un niveau raisonnable de connaissance dans de nombreux secteurs, particulierement chez les medecins qui ont termine plus recemment leurs etudes. Presque tous les medecins ont mentionne avoir acces a des tests de diagnostic de la Chlamydia et la plupart ont indique faire au moins occasionnellement des tests de depistage des infections a Chlamydia. Cependant, nombre des repondants ont oublie de tenir compte du fait que les jeunes de leur clientele pouvaient etre sexuellement actifs et 28 % seulement savaient que les femmes de 15 a 19 ans ont les taux documentes les plus eleves d'infections a Chlamydia. Nombre des medecins interroges ne parvenaient pas a demeler les syndromes associes ou non a une infection a C. trachomatis; cela laisse voir la possibilite de decisions erronees en matiere de test et de traitement. S'ils avaient a faire un depistage de C. trachomatis chez une jeune fille prepubaire, 34 % ont mentionnd qu'ils obtiendraient un specimen endocervical, technique par trop invasive. Devant un resultat de test positif, nombre des repondants ont neglige d'envisager la possibilite d'un resultat faux positif. Fort heureusement, la totalite des medecins connaissaient bien les regimes de traitement adequats des infections a C. trachomatis, bien que nombre d'entre eux n'en connaissaient pas l'efficacite reelle. Dans le cas d'un jeune homme atteint ou soupconne d'etre atteint de gonorrhee ou d'une jeune femme en consultation externe souffrant de salpingo-oophorite, seulement 19 % et 20 % respectivement ont mentionne qu'ils prescriraient un regime approprie a la fois aux infections a Neisseria gonorrhoeae productrice de penicillinase et a C. trachomatis. Nombre des repondants n'etaient pas au courant des lignes directrices de traitement et encore moins mentionnaient les consulter. Conclusions: Malgre l'existence de plusieurs ensembles de lignes directrices, il semble exister des lacunes importantes au niveau des connaissances et de la pratique chez nombre de medecins en soins primaires, en ce qui a trait aux infections genitales. Puisque la preparation de lignes directrices est une tache fastidieuse et couiteuse, il faudrait consacrer plus d'efforts a evaluer leur incidence et a pallier leurs limites.
I nfection with Chlamydia trachomatis is common in Canada and has significant personal and financial consequences.' " Canadian and US guidelines exist to help health care providers in detecting and treating the condition.4-7 However, the influence of these guidelines on health care delivery and the current level of sophistication in the management of chlamydial infections in Canada are unknown. The objective of this study was to question primary care physicians about their knowledge and management of sexually transmitted diseases (STDs) in general and C. trachomatis infection in particular. Such information is lacking and is particularly important since Canadian guidelines are being revised, and some of the premises on which the initial guidelines were based remain unevaluated. As an indication that current practice is not always optimal a cross-Canada study of the antimicrobial susceptibility and treatment of infections due to Neisseria gonorrhoeae showed wide variability in treatment regimens and unacceptable practices for specimen collection in prepubescent girls.8
Vancouver. This north shore community is primarily a residential, middle-to-upper-class suburb of Vancouver served by one hospital. We designed a self-administered questionnaire to assess the practice profile, knowledge and clinical practices of primary care physicians through direct questioning and the use of hypothetical cases. The questionnaire required only 10 minutes to complete. It was tested in a pilot study involving eight firstyear and second-year family practice residents at the
University of British Columbia. (The questionnaire is available from the authors upon request.) We attempted to identify all of the general and family practitioners in the study area using the staff list at the hospital, the registration data of the College of Physicians and Surgeons of British Columbia and the local telephone directory. A cover letter accompanying the questionnaire requested that the physicians refrain from consulting reference material and assured them of their anonymity. They were promised a discussion of both the results and the expected answers at the end of the study if enough interest was expressed. Several strategies were used to ensure the highest return rate possible. Immediately before the start Methods of the study the chief of general practice at the The study was conducted in the districts of hospital announced his support of the project at North and West Vancouver and the city of North grand rounds. After 3 weeks physicians who had 716
CAN MED ASSOC J 1992; 146 (5)
LE 1 er MARS 1992
~ .if-
neither completed the survey nor declared their intention to refuse were sent a personalized reminder. If necessary a telephone call from one of the investigators followed 2 weeks later. The number of years in practice of the nonrespondents was estimated from the graduation dates in the 1990 Medical Directory of the College of Physicians and Surgeons of British Columbia. A 1-year internship was assumed. Sex was confirmed on the telephone at the time of the follow-up calls. We used the Epi Info program (version 5; USD Inc., Stone Mountain, Ga.) to analyse the continuous variables with the Wilcoxon rank-sum test. We used the x2 test to analyse discrete data; for cases in which the expected value was less than five Fisher's exact test was used. The level at which the results were considered to be significant was 0.05. a
difference between the respondents and the nonrespondents in sex; however, the respondents tended to have been in practice for significantly fewer years (p < 0.03) (Table 1). Of those who participated the female practitioners had been out of medical school for fewer years than their male counterparts (p < 0.02). The female respondents had significantly more female patients and patients 15 to 25 years of age than the male physicians (Table 2). The proportion of patients in these categories was not associated with the number of years a physician had been in practice.
no
Understanding of C. trachomatis infection
When asked which group in Canada has the highest rate of C. trachomatis infection 28% of the physicians were correct in identifying women 15 to Results 19 years of age.9 Over half (57%) of the respondents women 20 to 24 years old, who constitute of selected 79 The questionnaire was returned by (73%) highest risk group. Their estimates of the was the second There the 108 physicians to whom it was sent.
I: Ghlc.tsIofphscia9s on the. north
Tal i
No.ofrare..
of phyica
2
5-1*N05g.:..
.3
>15.
Management of Chiamydia trachomatis genital infections: reported practices Of primary care p ysicians Laura McDougall,* MD, MHSc; Richard G. Mathias,* MD, FRCPC; Brian A. O'Connor, MD, MHSc; William R. Bowie,t MD, FRCPC Objective: To determine the knowledge of primary care physicians about Chlamydia trachomatis genital infection and its management. Design: Self-administered questionnaire comprising direct questions and hypothetical cases. Participants: All 108 general and family practitioners on the north shore of Vancouver were sent the questionnaire; 79 (73%) responded. Results: There was a reasonable level of knowledge in many areas, particularly among the physicians who had graduated more recently than the others. Virtually all stated that they have access to chlamydial diagnostic testing, and most indicated that they test for chlamydial infection at least occasionally. However, many of the respondents failed to consider that youths in their practice may be sexually active, and only 28% knew that women 15 to 19 years of age have the highest reported rates of chlamydial infection. Many of the physicians were confused about syndromes that are or are not associated with C. trachomatis infection; this indicated the possibility of inappropriate testing and treatment decisions. If they had to test for C. trachomatis in a prepubescent girl 34% reported that they would obtain a specimen from the endocervix, a technique that is inappropriately invasive. When presented with a positive test result many of the respondents failed to consider the possibility of a false-positive result. Fortunately all of the physicians were well informed about correct treatment regimens for C. trachomatis infection, although many did not realize how effective they really are. In the case of a young man with suspected or proven gonorrhea or a young female outpatient with pelvic inflammatory disease, only 19% and 20% respectively stated that they would prescribe a regimen appropriate for both penicillinase-producing Neisseria gonorrhoeae and C. trachomatis. Many of the respondents had not heard of management guidelines, and fewer still reported that they consult themn. Conclusions: Despite the availability of several sets of guidelines there appear to be important gaps in the knowledge and practice of many primary care physicians with respect to genital infections. Since the preparation of guidelines is time-consuming and expensive, further work should be done to evaluate their impact and to address their limitations.
Objectif: Preciser les connaissances des medecins en soins primaires au sujet des infections genitales a Chlamydia trachomatis et de son traitement. Conception: Questionnaire autoadministre compose de questions directes et de cas hypothetiques. From the divisions of *Health Care and Epidemiology and of tInfectious Diseases, Faculty ofMedicine, University ofBritish Columbia, Vancouver, BC, and *the North Shore Health Unit, Vancouver, BC
Reprint requests to: Dr. William R. Bowie, Division ofInfectious Diseases, G.F. Strong Research Laboratories, Rm. 452, Dfloor, 2733 Heather St., Vancouver, BC VSZ 3J5 -
For prescribing information see page 773
CAN MED ASSOC J
1992; 146 (5)
715
Participants: La totalite des 108 medecins en medecine generale et medecine familiale de la c6te nord de Vancouver ont recu le questionnaire; 79 (73 %) d'entre eux ont
repondu. Resultats: Les auteurs ont constate un niveau raisonnable de connaissance dans de nombreux secteurs, particulierement chez les medecins qui ont termine plus recemment leurs etudes. Presque tous les medecins ont mentionne avoir acces a des tests de diagnostic de la Chlamydia et la plupart ont indique faire au moins occasionnellement des tests de depistage des infections a Chlamydia. Cependant, nombre des repondants ont oublie de tenir compte du fait que les jeunes de leur clientele pouvaient etre sexuellement actifs et 28 % seulement savaient que les femmes de 15 a 19 ans ont les taux documentes les plus eleves d'infections a Chlamydia. Nombre des medecins interroges ne parvenaient pas a demeler les syndromes associes ou non a une infection a C. trachomatis; cela laisse voir la possibilite de decisions erronees en matiere de test et de traitement. S'ils avaient a faire un depistage de C. trachomatis chez une jeune fille prepubaire, 34 % ont mentionnd qu'ils obtiendraient un specimen endocervical, technique par trop invasive. Devant un resultat de test positif, nombre des repondants ont neglige d'envisager la possibilite d'un resultat faux positif. Fort heureusement, la totalite des medecins connaissaient bien les regimes de traitement adequats des infections a C. trachomatis, bien que nombre d'entre eux n'en connaissaient pas l'efficacite reelle. Dans le cas d'un jeune homme atteint ou soupconne d'etre atteint de gonorrhee ou d'une jeune femme en consultation externe souffrant de salpingo-oophorite, seulement 19 % et 20 % respectivement ont mentionne qu'ils prescriraient un regime approprie a la fois aux infections a Neisseria gonorrhoeae productrice de penicillinase et a C. trachomatis. Nombre des repondants n'etaient pas au courant des lignes directrices de traitement et encore moins mentionnaient les consulter. Conclusions: Malgre l'existence de plusieurs ensembles de lignes directrices, il semble exister des lacunes importantes au niveau des connaissances et de la pratique chez nombre de medecins en soins primaires, en ce qui a trait aux infections genitales. Puisque la preparation de lignes directrices est une tache fastidieuse et couiteuse, il faudrait consacrer plus d'efforts a evaluer leur incidence et a pallier leurs limites.
I nfection with Chlamydia trachomatis is common in Canada and has significant personal and financial consequences.' " Canadian and US guidelines exist to help health care providers in detecting and treating the condition.4-7 However, the influence of these guidelines on health care delivery and the current level of sophistication in the management of chlamydial infections in Canada are unknown. The objective of this study was to question primary care physicians about their knowledge and management of sexually transmitted diseases (STDs) in general and C. trachomatis infection in particular. Such information is lacking and is particularly important since Canadian guidelines are being revised, and some of the premises on which the initial guidelines were based remain unevaluated. As an indication that current practice is not always optimal a cross-Canada study of the antimicrobial susceptibility and treatment of infections due to Neisseria gonorrhoeae showed wide variability in treatment regimens and unacceptable practices for specimen collection in prepubescent girls.8
Vancouver. This north shore community is primarily a residential, middle-to-upper-class suburb of Vancouver served by one hospital. We designed a self-administered questionnaire to assess the practice profile, knowledge and clinical practices of primary care physicians through direct questioning and the use of hypothetical cases. The questionnaire required only 10 minutes to complete. It was tested in a pilot study involving eight firstyear and second-year family practice residents at the
University of British Columbia. (The questionnaire is available from the authors upon request.) We attempted to identify all of the general and family practitioners in the study area using the staff list at the hospital, the registration data of the College of Physicians and Surgeons of British Columbia and the local telephone directory. A cover letter accompanying the questionnaire requested that the physicians refrain from consulting reference material and assured them of their anonymity. They were promised a discussion of both the results and the expected answers at the end of the study if enough interest was expressed. Several strategies were used to ensure the highest return rate possible. Immediately before the start Methods of the study the chief of general practice at the The study was conducted in the districts of hospital announced his support of the project at North and West Vancouver and the city of North grand rounds. After 3 weeks physicians who had 716
CAN MED ASSOC J 1992; 146 (5)
LE 1 er MARS 1992
~ .if-
neither completed the survey nor declared their intention to refuse were sent a personalized reminder. If necessary a telephone call from one of the investigators followed 2 weeks later. The number of years in practice of the nonrespondents was estimated from the graduation dates in the 1990 Medical Directory of the College of Physicians and Surgeons of British Columbia. A 1-year internship was assumed. Sex was confirmed on the telephone at the time of the follow-up calls. We used the Epi Info program (version 5; USD Inc., Stone Mountain, Ga.) to analyse the continuous variables with the Wilcoxon rank-sum test. We used the x2 test to analyse discrete data; for cases in which the expected value was less than five Fisher's exact test was used. The level at which the results were considered to be significant was 0.05. a
difference between the respondents and the nonrespondents in sex; however, the respondents tended to have been in practice for significantly fewer years (p < 0.03) (Table 1). Of those who participated the female practitioners had been out of medical school for fewer years than their male counterparts (p < 0.02). The female respondents had significantly more female patients and patients 15 to 25 years of age than the male physicians (Table 2). The proportion of patients in these categories was not associated with the number of years a physician had been in practice.
no
Understanding of C. trachomatis infection
When asked which group in Canada has the highest rate of C. trachomatis infection 28% of the physicians were correct in identifying women 15 to Results 19 years of age.9 Over half (57%) of the respondents women 20 to 24 years old, who constitute of selected 79 The questionnaire was returned by (73%) highest risk group. Their estimates of the was the second There the 108 physicians to whom it was sent.
I: Ghlc.tsIofphscia9s on the. north
Tal i
No.ofrare..
of phyica
2
5-1*N05g.:..
.3
>15.
