Express STI testing: Can it work in your clinic?
Express STI testing: Can it work in your clinic?
Look out in the waiting room of your clinic. How many patients are waiting to be seen by a provider to be tested for a sexually transmitted infection (STI)?
The Denver Metro Health Clinic, the largest STI clinic and HIV testing facility in the Rocky Mountain region, has found an effective way to enhance clinic efficiency. It uses a triage system to identify low-risk individuals who qualify for an express, testing-only visit to screen for major communicable diseases without a physical examination. A 2008 evaluation of the service indicates the triage system safely and effectively identifies those appropriate for express visits, reduces waiting times for patients, and increases clinic throughput.1
Clinic officials developed the express visit option in 2003 as a no-cost alternative to a full clinic visit, says Cornelis Rietmeijer, MD, PhD, director of the STD Control Program at the Denver Public Health Department. At the time, the clinic was required to charge a copay for such visits, which led to a significant reduction in clinic volume, as well as the number of cases of diagnosed gonorrhea and chlamydia2, notes Rietmeijer. The express visit system was expanded after the clinic switched to its current electronic medical record system in March 2005, he states.
Where to begin?
The Denver clinic handles about 16,000 visits each year. As a part of Denver Health, which includes a public hospital and 10 community health clinics, and the Denver Public Health Department, the clinic offers free confidential testing, counseling, and treatment for a comprehensive array of STIs for Denver residents.
Before the express visit system, the clinic routinely faced long lines of patients waiting for services at the beginning of the day. Some individuals mistakenly came to the clinic for primary care services and often waited for hours before being seen by clinic staff and told that such services were not available. While clinicians realized that many low-risk patients could be tested without a physical examination, the clinic lacked an effective system for identifying such individuals.
The clinic developed a triage system to identify low-risk individuals who could qualify for an express, testing-only visit that could screen for major communicable diseases but not include a physical examination. It also has modified its entry system from its original walk-in visit protocol. Appointments now are made over the telephone through a computerized scheduling system used by all Denver Health facilities. Separate queues are maintained for those with appointments and walk-ins.
Train staff for triage
Trained medical assistants, called health care partners, triage patients by asking specific questions and gathering information about prior clinic visits, reasons for the visit (such as symptoms, checkup, contact with someone who has an STI), and sexual preferences and behaviors. Walk-ins are triaged on a first-come, first-served basis, while those who make appointments are triaged over the telephone. Those with telephone appointments are told to arrive early for a second brief triage prior to their visit.
To qualify for an express visit, a patient must not have any symptoms of an STI or have engaged in risky behaviors, such as men having sex with men, contact with someone with an STI, injection of drugs, or exchange of sex for money or drugs. Once qualified as an express visit patient, a patient receive stickers that designate what tests should be performed. If needed, patients have blood drawn by the medical assistant for rapid syphilis and/or HIV testing, and then they provide a urine sample and/or vaginal swab to test for chlamydia and gonorrhea. If the initial syphilis or HIV test is positive, staff conduct standard follow-up confirmatory tests.
Comprehensive adds full physical
Comprehensive visits include everything offered in the express visit, along with a full physical examination oriented at identifying other STIs. Additional testing may be performed as needed.
All patients are offered treatment for and appropriate education about any STIs identified immediately through laboratory results or physical examination. For those tests where results are not available immediately (such as confirmatory HIV or syphilis testing), clients are asked to call the clinic results line one week after their visit. Those who test positive and do not call receive a text message. The clinic obtains consent to contact the patient in this manner during the registration process. Patients with a positive diagnosis are offered free treatment and follow-up.
Is express best?
During the first year after introduction of the express-visit option, the clinic handled 8% more visits without increased staffing, including 18% more women and 32% more individuals under age 20.1 The program required no new staff. Incremental costs of the program were minimal, consisting primarily of upfront training for medical assistants.
The process offers time savings for patients as well. A post-implementation time-motion study found that the express visit was much shorter than a comprehensive visit, saving women nearly an hour (46 minutes vs. 105 minutes) and men more than half an hour (52 minutes vs. 85 minutes). These figures do not include time in the waiting room before the triage (which averaged roughly a half-hour for both groups) or triage time, which averaged two minutes.1
The triage system effectively identified those at low risk of common STIs, analysis shows.1 Rates of chlamydia, gonorrhea, syphilis, and HIV were much lower in express visit patients (9.8%) than in those receiving a comprehensive visit (26%). Separate analyses of specific patient subgroups indicated that the potential for underdiagnosis of other STIs (for which diagnosis usually requires a physical examination) appeared to be quite low in express visit patients, researchers found.1
References
- Shamos SJ, Mettenbrink CJ, Subiadur JA, et al. Evaluation of a testing-only "express" visit option to enhance efficiency in a busy STI clinic. Sex Transm Dis 2008; 35:336-340.
- Rietmeijer CA, Alfonsi GA, Douglas JM, et al. Trends in clinic visits and diagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infections after the introduction of a copayment in a sexually transmitted infection clinic. Sex Transm Dis 2005; 32:243-246.
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