Discussion

There is a paucity of UK data relating to QS HC practice. Clinical practice varies, probably for several reasons such as different attitudes to prescribing outside the product licence; previous lack of clinical guidelines; variable awareness of newly introduced guidelines; and differences in service protocols, patient group directions (PGDs) and availability of support for non-prescribers.

Since the FSRH published its QS guidance we have found a statistically significant increase (16.3%, p=0.011) in the proportion of eligible women being quick started within this Integrated Sexual Health Service in Scotland.

We have also found a 6.2% decrease in those women being asked to return for HC, and a 9.4% decrease in those traditionally started on HC.

Whilst our findings on numbers QS are positive and statistically significant, it is difficult to interpret whether they demonstrate actual clinical improvement in terms of reducing unintended pregnancies.

Our findings are comparable to those of Cameron et al.5 who found that 23% (n=91) of eligible quick starters were initiated on HC following EC (29.9%, n = 49 in 2010 and 34.9%, n = 53 in 2011, excluding continuers). Baird6 has recently published a study of EC prescribing that includes QS data, but it is difficult to make any direct comparisons because of differences in study design and reporting.

However, even though our QS practice increased, around 50% of women eligible to be quick started were still advised to return. Although this is not incorrect practice and some clients may have attended their general practioners for contraception or been using condoms, for others this finding might indicate that there was a delay in accessing potentially more reliable methods. Within the free text clinical notes there was no documented evidence as to why women were asked to return rather than being quick started.

Worryingly, approximately one-third of the women who were advised to return had not done so after at least 6 months. This highlights the fact that plans can fail when relying on re-attendance, and should encourage health practitioners to be proactive in their consultations. Motivational interview techniques may play a role here.

QS guidance encourages bridging women safely onto their subsequent method of contraception, particularity LARC, rather than prescribing HC for traditional starting. As mentioned earlier, women who have further sexual intercourse in the menstrual cycle following EC are at a 2–3-fold greater risk of pregnancy than those who abstain.2 Initiation of LARC is therefore a useful discussion to have with those presenting for EC, as these methods are more effective in reducing unintended pregnancy with typical use. A reluctance to quick start progestogen-only implants was noted in both time frames (7/20 and 9/36 in 2010 and 2011, respectively). This method is longer-acting than oral methods, and it may be that although its use is supported by the FSRH,1 practitioners are more reluctant to initiate a method that is more invasive. This method also requires returning for removal should a pregnancy be identified that the woman wishes to continue. Cost issues may also play a role.

Amongst those women who were prescribed HC at the second visit, the majority were given a QS method in accordance with FSRH guidance.1 Surprisingly, only two women in the entire audit were bridged onto their subsequent method of LARC.

Two women within the audit study were given incorrect advice regarding pregnancy testing: test after 2 weeks or only if no menses 3 weeks post-UPSI. Pregnancy testing should always be done 3 weeks following UPSI, irrespective of bleeding pattern, as unscheduled bleeding is common and can be misleading. Furthermore, two women in 2011 were given incorrect advice regarding additional precautions, with fewer than 7 days advised, when 7 days were required. This could have led to unintended pregnancy and would have defeated the purpose of QS. However, within the study there were no reported pregnancies, although it is possible that women may have presented elsewhere. Therefore it is fundamental that the health practitioner provides correct advice, particularly when prescribing outside the product licence.

Within the service audited, medical staff, nurse prescribers and nurses via PGD may prescribe EC and HC.7–9 PGD limits staff to strict criteria. At the time of the audit the PGD did not allow QS contraception following EC administration. During both phases of the audit a doctor was available as a central support for all staff, particularly at the peripheral nurse-led clinics. Our service allows electronic prescribing; therefore nursing staff bound by a PGD should be empowered to discuss these cases with staff who can quick start. This audit suggests that QS could perhaps be facilitated by inclusion of QS in PGDs and/or better utilisation of the supporting doctor.

Given the nature of the specialised service it is difficult to know if these results are generalisable across other services such as general practice. In addition, local clinical practice may have been influenced by the presence of the guidance authors (the FSRH Clinical Effectiveness Unit) within the same clinical service and may therefore not be representative of other sexual health clinics.

Other limitations to the study include the retrospective nature of the audit, for example, possible missing data, and its reliance on descriptive data, which may not reflect the consultation.

Case notes were reviewed by different primary medical researchers in 2010 and 2011, which may have led to slight interpretational differences. All data were, however, checked for consistency prior to analysis. The information gained from NaSH was from a combination of free text and the pre-set EC proforma, both of which have varying usage. Within the EC proforma there is no mention of ongoing contraception. This may also be a missed opportunity to remind staff to consider QS.