GUM & primary care based STI services: Maximising STI control & cost-effectiveness for a population.

Lead Research Organisation: University College London
Department Name: Unlisted

Abstract

We aim to build a web-based tool to help public health decision-makers plan the most effective services for sexually transmitted infections (STIs) according to the characteristics of their local population.
 
Patients with STIs attend a variety of services, including specialist genitourinary medicine (GUM) clinics and primary care (including GP surgeries). In 2001, the government published the ‘National Strategy for Sexual Health and HIV‘. It proposed that, in future, more services for STIs should be provided in primary care. Since then, many areas have started to increase testing for, and treatment, of STIs by GPs and practice nurses. These services, usually called ‘Locally Enhanced Services’, vary considerably, and decision-makers and service commissioners have found it difficult to make appropriate local plans.
 
The aim of all STI services is to reduce the transmission of STIs as cost-effectively as possible. A number of factors influence how well this is achieved in local health economies e.g. the capacity of the services, the extent that the partners of people diagnosed with STIs are also treated, whether services are seeing people at greater or lower risk of STIs. These can be hard to measure.
 
We will develop instruments to measure public health outcomes of existing services and use modelling techniques to identify the key elements of service provision that could impact on the effectiveness (i.e. the number of STIs prevented) and the cost effectiveness of different combinations of primary care and GUM provision. The resulting web tool will facilitate local evidence-based planning of services for STIs across the UK.

Technical Summary

Background: Patients with sexually transmitted infections (STIs) have always presented in a variety of healthcare settings, and it has been increasingly realised that settings outside the traditional genitourinary medicine (GUM) clinic need to be equipped to manage such patients and their partners. Over the past few years, STI Foundation Courses aimed at educating primary care practitioners in STI care, and a competency framework for providers of the various levels of STI services have been jointly developed by GUM and primary care professional groups.

However, the novel development of dedicated STI services in the primary care setting now provides a wider challenge for commissioners and public health specialists beyond the improvement of ad hoc care for patients who present to primary care. A wide range of national and local initiatives for the provision of services in primary care for STIs have developed since publication of the National Strategy for Sexual Health and HIV in 2001. Yet there is little consensus or evidence on the extent to which various models of ?locally enhanced? (LES) and ?nationally enhanced? (NES) primary care services, or indeed GUM services, and in what combination, can provide a cost-effective approach to the control of STIs for differing populations. Commissioners and public health specialists are therefore having to plan services without a clear evidence base.


Aim: To build a Decision Analytic Model (DAM) as a tool for the evidence based planning of cost-effective STI services for differing populations in the UK.


Method: We will construct a DAM, a mathematical tool for decision makers that identifies the major drivers of incremental costs and of cost-effectiveness for a population. We will undertake:
(a) Synthesis and collection of data relating to STI epidemiology (including behavioural studies and modeling data), public health outcomes, economic costs and key elements of the quality of clinical services (including a simple, reproducible ?Rapid Assessment Module capable of supplying local data)
(b) Development of a DAM using the above data, and
(c) Development of a web-based software tool for use by commissioners and public health specialists in estimating the consequences of different options in service configuration.
(d) Implementation of the DAM in 3 contrasting settings with specification of a cost-effective service configuration.
We will measure cost effectiveness in terms of (i) incremental cost per transmission of chlamydia or gonorrhoea averted, and (ii) the incidence and prevalence of chlamydia, gonorrhoea and pelvic inflammatory disease at a range of time horizons.

Publications

10 25 50

 
Description NIHR Health Protection Research Unit
Amount £3,700,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 04/2014 
End 03/2019
 
Description NIHR Health Services & Delivery Research Programme (REACH)
Amount £431,000 (GBP)
Funding ID 11/2004/50 
Organisation National Institute for Health Research 
Department Health Services and Delivery Research (HS&DR) Programme
Sector Charity/Non Profit
Country United Kingdom
Start 02/2013 
End 01/2016
 
Description NIHR Health Technology Assessment Programme (sexual risk reduction)
Amount £500,000 (GBP)
Funding ID HTA/12/191/05 
Organisation National Institute for Health Research 
Department Health Technology Assessment Programme (HTA)
Sector Public
Country United Kingdom
Start 09/2014 
End 08/2016
 
Description NIHR programme grant (Ballseye)
Amount £1,999,478 (GBP)
Funding ID G-0707-10208 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 04/2009 
End 09/2014
 
Description National Co-ordinating Centre for Health Technology Assessment (PN)
Amount £254,529 (GBP)
Funding ID 07/42/02 
Organisation National Institute for Health Research 
Department Health Technology Assessment Programme (HTA)
Sector Public
Country United Kingdom
Start 05/2009 
End 03/2012
 
Description Studentship, as part of a Programme Grant (eSTI2)
Amount £4,000,000 (GBP)
Organisation UK Clinical Research Collaboration 
Sector Charity/Non Profit
Country United Kingdom
Start 02/2011 
End 01/2016
 
Description Technology Strategy Board (POCT)
Amount £436,115 (GBP)
Funding ID 1109_SB1_DIA_AINPT_107158 
Organisation Innovate UK 
Sector Public
Country United Kingdom
Start 09/2012 
End 02/2015
 
Title MSTIC Rapid Assessment Module 
Description This research tool consists of patient questionnaires which can be linked to clinical data extracts, for use in and by sexual health services. It builds upon materials developed for the MRC-funded PATSI study (G0200565). The purpose is (a) to provide audit data useful for planning at the level of an individual service, and (b) to provide data which can feed into the MSTIC tool (which assists the planning of STI services at the population level). 
Type Of Material Data analysis technique 
Year Produced 2010 
Provided To Others? Yes  
Impact Professionals involved in the provision and delivery of sexual health services have stated that they intend to use the tool, and we have already shared our resources with clinical staff in Northern Ireland and delegates attending the British Assoc. of Sexual Health & HIV / British HIV Association conference 2010. 
 
Title MSTIC discrete event simulation model of STI transmission 
Description This is a mathematical model that takes account of the most influential factors on Chlamydia and Gonorrhoea transmission, in order to predict the likely impact of changes in service delivery (for example, the level of succesful partner notification within a service) on the incidence of these infections in three sociodemographically and geographically contrasting populations. 
Type Of Material Data analysis technique 
Year Produced 2010 
Provided To Others? Yes  
Impact Having developed our mathematical model, we are now incorporating the results of this model into a web-tool for sexual health service planners to use to examine the public health impact of changing the capacity and mode of delivery of sexual health provision (e.g. specialist providers vs. primary care) for their locality. 
 
Title PN algorithm 
Description As part of our MRC-funded study (G0601685), we developed an algorithm for service providers and planners to use to estimate the public health impact of *their* partner notification on STI (sexually transmitted infections) transmission. This work was published as a peer-reviewed paper in the American Journal of Public Health (PMID: 21940925) on an open-access basis such that the resulting algorithm (presented as a spreadsheet) is accessible as a web-appendix to the paper. The Health Protection Agency are also planning to host the algorithm on a website they are compiling of resources for sexual health commissioners. 
Type Of Material Data analysis technique 
Year Produced 2011 
Provided To Others? Yes  
Impact A 'second generation' algorithm has now been developed, as part of a collaboration with colleagues at the University of Bern (see section on Collaborations). 
URL http://europepmc.org/abstract/MED/21940925
 
Title MSTIC Rapid Assessment Module 
Description As well as being a research tool (see section 7), the questionnaire and linked clinical data extract ('Rapid Assessment Module') can be used as an audit tool to gather data to inform the planning and delivery of an individual clinical service. 
Type Health and Social Care Services
Current Stage Of Development Small-scale adoption
Year Development Stage Completed 2010
Development Status Under active development/distribution
Impact Professionals involved in the provision and delivery of sexual health services have stated that they intend to use the tool, and we have already shared our resources with clinical staff in Northern Ireland and delegates attending the British Assoc. of Sexual Health & HIV / British HIV Association conference 2010. Through our feedback to participating clinic/practice staff, we are aware that they are already discussing possible changes to the provision of their services, as a result of implementing the Rapid Assessment Module. 
 
Title MSTIC webtool 
Description We developed a web-based tool to assist sexual health commissioners to quantify the public health impact for their locality of different combinations of health services (e.g. GUM, general practice). Underlying the MSTIC web-tool are the results of a mathematical model of STI transmission used to identify the most important factors to take account of in predicting transmission. The Health Protection Agency plan to include the MSTIC web-tool as part of a package of online resources they are making available for sexual health commissioners. 
Type Health and Social Care Services
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2010
Development Status Under active development/distribution
Impact As yet, none known of. 
 
Title PN algorithm 
Description As part of our MRC-funded study (G0601685), we developed an algorithm for service providers and planners to use to estimate the public health impact of *their* partner notification on STI (sexually transmitted infections) transmission. This work was published as a peer-reviewed paper in the American Journal of Public Health (PMID: 21940925) on an open-access basis such that the resulting algorithm (presented as a spreadsheet) is accessible as a web-appendix to the paper. The Health Protection Agency are also planning to host the algorithm on a website they are compiling of resources for sexual health commissioners. 
Type Health and Social Care Services
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2010
Development Status Under active development/distribution
Impact As yet, none known of. 
URL http://europepmc.org/abstract/MED/21940925
 
Description 2011 British Association of Sexual Health & HIV (BASHH) conference 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact We held a stand at the 2011 BASHH conference where we show-cased our MSTIC webtool to healthcare providers and planners attending the conference. We also provided flyers giving an overview as to the rationale for our webtool, thus promoting the need for evidence-based service planning for sexually transmitted infections. Those interested provided us with their email addresses so that we could send them the link to our webtool for them to try with their local data and provide us with feedback.

We are engaging with service planners and commissioners and the MSTIC webtool is proving to be a useful educational (as well as practical) tool for demonstrating the public health need for evidence-based service planning.
Year(s) Of Engagement Activity 2011
 
Description 2011 Health Protection Agency conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach National
Primary Audience Health professionals
Results and Impact We were invited to give an oral presentation that asked the question: "Using routine data to plan STI services: are we nearly there yet?" In this, we presented the MSTIC webtool and the MSTIC rapid assessment module as examples of how resources are available for STI service providers and planners to use to undertake evidence-based decision-making. Following this presentation, we were contacted by several members of the audience who wanted to find out more about the MSTIC study and to experiment with the MSTIC webtool and rapid assessment module.

The Health Protection Agency have since approached us about including the MSTIC webtool and rapid assessment module as online resources available via a website that they are assembling for sexual health commissioners. This adoption by the HPA would ensure the MSTIC outputs can be accesssed by those for whom they were developed.
Year(s) Of Engagement Activity 2011
 
Description 2011 International Society for Sexually Transmitted Disease Research conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Health professionals
Results and Impact We were invited to give an oral presentation of survey data collected as part of the MSTIC study at this prestigious international conference. We demonstrated how concurrent sexual partnerships may be as common as serially monogamous partnerships, and that even when partnerships are serially monogamous, the gap in time between these partnerships is often less than a couple of weeks. Given the duration of infectivity for many, if not most STIs, is weeks if not months, our finding was recognised as being important for clinical practice, e.g. influencing health promotion messages, as well as how epidemiologists conceptualise the timing of partnerships.

We were encouraged to write-up our findings for publication in a high-impact peer-reviewed journal, which is what we are currently doing.
Year(s) Of Engagement Activity 2011
 
Description 2012 MRC Population Health Methods & Challenges conference 
Form Of Engagement Activity Scientific meeting (conference/symposium etc.)
Part Of Official Scheme? Yes
Type Of Presentation Paper Presentation
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact My peer-reviewed abstract, titled: 'The 'Maximising STI Control' (MSTIC) webtool: a new approach to evidence synthesis to facilitate the planning of services for sexually transmitted infections' was selected for oral presentation at the Medical Research Council's 'Population Health Methods and Challenges' conference, 24-26 April 2012 in Birmingham, UK. Approximately 100 people attended the presentation, which was followed by discussion and then one-to-one Q and As. My co-authors for this presentation were: Macdonald N, Shirley MDF, Aicken CRH, Estcourt CS, Keane F, Brook G, White PJ, and Cassell JA.

None to date.
Year(s) Of Engagement Activity 2012
 
Description 2012 Presentation to DH's Sexual Health Improvement Directorate 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Invited presentation titled 'Evidence-based tools for sexual health service provision' given to the UK Department of Health's Sexual Health Improvement Directorate, London, UK. 13 December 2011. Presentation was followed by discussion with members of the directorate.

None to date.
Year(s) Of Engagement Activity 2011
 
Description British Assoc. for Sexual Health & HIV/British HIV Association conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact We presented three posters of our research findings to this audience of healthcare professionals and organisations working on sexual health and HIV. One of the posters was awarded a special commendation by the organising committee.

As our findings were presented as posters we had plenty of opportunity for discussion with other conference delegates. In response to feedback about the most applicable findings in terms of both individual patient and public health benefit, we are now designing health promotion posters to communicate these findings to patients.
Year(s) Of Engagement Activity 2010
 
Description English sexual health commissioners' meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We discussed the utility of a web-tool in this area of health service planning, and the assumptions it could reasonably make.
Through this we identified commissioners keen to pilot the web-tool and provide us with further feedback from this.


We incorporated feedback into the development of the web-tool.
Year(s) Of Engagement Activity 2010
 
Description Feedback presentation at Patrick Clements' clinic 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Health professionals
Results and Impact At the weekly clinic education meeting of this participating clinic, we presented data collected from this clinic as part of our study. This was followed by a discussion with clinic staff on the meaning of these data and implications for local practice.
We also prepared a study report for the clinic, to be finalised in light of discussions with staff.

We gained greater insight into how to interpret our data. There was also a discussion about how to increase response rates in this and future studies at the clinic.
Year(s) Of Engagement Activity 2010
 
Description Feedback visit to Cornwall 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Health professionals
Results and Impact At the weekly clinic education meeting, data from our study specific to the clinic's population were presented, followed with a discussion on their meaning and implications for local practice. Two of three GPs who run sexual health Local Enhanced Services in Cornwall were able to attend (all three GPs' practices participated in our study; as their practices are geographically dispersed we were delighted that two could attend and the third has been sent a copy of the slides from the presentation).
We also prepared two study reports (separately for the clinic, and for practices providing a local enhanced service for sexual health), to be finalised in light of discussions with staff.

We gained greater insight into how to interpret our data, and there were several suggestions for future interesting and practically useful research from the audience.
Year(s) Of Engagement Activity 2010
 
Description MRC/DH Sexual Health & HIV Research Strategy Committee dissemination meeting for the British Assoc. for Sexual Health & HIV 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact We were invited to present our study as part of an event showcasing DH/MRC funded sexual health research to BASHH members. Following our presentation we had a helpful audience-led discussion as to the strengths and weaknesses of our proposed web-tool.

We have incorporated the BASHH members' constructive criticism and feedback in the development of our webtool and we plan to exhibit our webtool to BASHH members at their next annual conference (May 2011).
Year(s) Of Engagement Activity 2010
 
Description North Central London Research Consortium (NoCLoR) conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact We presented our research at this local conference which is for those involved is health research. Most of the audience are health professionals who are also involved in research, some are involved with local planning/policy-making (e.g. commissioners) and some are academics.

We received feedback on our research and its outputs.
Year(s) Of Engagement Activity 2009
 
Description Regional HPA meeting (on the use of Sexual Health Intelligence) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact Stakeholder consultation: We presented plans for our research at this meeting of health professionals and commissioners (the end-users of the Decision Analytic Model (DAM) we are developing, which will be presented as a web-tool). We solicited feedback on the methods and assumptions within the DAM.

We incorporated feedback into our research plans.
Year(s) Of Engagement Activity 2009
 
Description Regional Public Health leadership meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact We presented our research plans to this group of Public Health leads in one region of England, and they provided feedback on them.

We incorporated feedback on the methods we are using and the outputs we are developing.
Year(s) Of Engagement Activity 2009