What is the role of express STI testing?
Declining resources in the face of increasing demand are causing sexually transmitted infection (STI) clinics to review new strategies to maximize efficiency without compromising quality of care. Just-published research suggests express STI testing, which bypasses lengthy interviews and physical examinations, might be a viable option.1
Just-published research centers on a cohort of men attending two Baltimore STI clinics. The paper was published by Susan Tuddenham, MD, MPH, a fellow in the Division of Infectious Diseases at the Johns Hopkins University (JHU) School of Medicine in Baltimore, and Khalil Ghanem, MD, PhD, assistant professor of medicine in the Division of Infectious Diseases at the JHU School of Medicine and assistant professor in JHU's Bloomberg School of Public Health. Researchers designed the retrospective study to define the contribution of the physical examination in detecting clinically meaningful diagnoses that might not be identified by current laboratory methods and to identify characteristics that can stratify men into the appropriate risk category.
For determining men's risk of missed diagnosis based on initial screening, patients were retrospectively stratified into three groups based on the self-reported reason for their visit. The first group included men who were asymptomatic presenting for general checkups, while the second group included all men who came in complaining of symptoms such as discharge, dysuria, genital lesion, genital itching, rash, and irritation/odor. The third group included asymptomatic men who presented as known contacts of STI-infected partners.
Only men coming in for their first clinic visit were included in this analysis.
After stratifying men on the basis of reason for visit, the researchers compared proportions for diagnoses that would have been missed without physical examination. Logistic regression was used to assess which factors were most predictive of missed diagnoses.
Of 140,052 patient visit records, 58,073 met the entry criterion; the other 81,979 records were excluded because they represented multiple visits. A total of 29,172 men were asymptomatic, 23,971 were symptomatic, and 4,929 were asymptomatic contacts of an infected partner. Analysis suggests 2.7% of asymptomatic patients, 10.4% of symptomatic patients, and 4.5% of contact patients would have had missed diagnoses if no physical examination had been performed. For symptomatic patients, if those reporting rash, lesion, or genital itch were examined, the percent with missed diagnoses would drop to 3.7%.
In a podcast on www.stdpreventiononline.org, a website run by the Centers for Disease Control and Prevention-sponsored Internet & STD Center of Excellence, Ghanem states there are ways to enhance clinic efficiency without compromising patient care, as long as the right subgroup of patients is targeted and as long as clinic leaders know their limitations of their facilities. (Download the podcast at http://bit.ly/1idRiGB.)
"I think an expedited approach to a subset of patients can enhance efficiency, as long as clinics have the resources to track those patients who were not treated at the time of their expedited visit and bring them back in a timely manner for treatment," Ghanem says in the podcast.
How does testing work?
Pima County, AZ, is home to more than one million people. Its county health department, based in Tucson, has used express STI testing since 2008, says Francisco García, MD, MPH, health department director. The "Express Testing" process began as an alternative effort to offer expedited STI testing for clients who wanted only testing services and were asymptomatic and/or short on time.
How is it determined which patients are best served by express testing?
Patients who present for testing as a part of routine screening, those who are between relationships, or those who are simply concerned they might have had an exposure are ideal for express testing services, says Garcia. Some patients will want only express testing and would rather wait until they receive test results before taking any unnecessary antibiotics, he notes.
Express testing allows patients the ability to complete the screening process in 30 minutes or less, depending on the number of clients present at any given time, says Garcia. Another benefit of express testing is that asymptomatic STIs such as chlamydia are more rapidly detected and treated, thus helping to decrease the amount of untreated infections within the community as well as serving as a disease control measure to preventing new infections, he notes. Gonorrhea, syphilis, and HIV likewise have been successfully detected and appropriate treatment has been offered within a shorter timeframe, he states.
"Increase in routine STI testing, treatment and medical interventions aid in supporting improved health of the community at large," advocates Garcia. (For more information on express testing, see the Contraceptive Technology Update article, "Express STI testing — Can it work in your clinic?" August 2009, p. 90.) It looks at the experience of Denver Metro Health Clinic, the largest STI clinic and HIV testing facility in the Rocky Mountain region, which 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.2
- Tuddenham S, Ghanem KG. Toward enhancing sexually transmitted infection clinic efficiency in an era of molecular diagnostics: the role of physical examination and risk stratification in men. Sex Transm Dis 2013; 40(11):886-893.
- 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(4):336-340.