The Impact of Introducing “Express Visits” for Asymptomatic Persons Seeking STD Services

1. The Impact of Introducing “Express Visits” for Asymptomatic Persons Seeking STD Services in a Busy Urban STD Clinic System, 2005-2006 Borrelli J1, Paneth-Pollak R1, Wright S1, Blank S1,2, Schillinger J1,2 , Harvey K1 1. New York City Department of Health and Mental Hygiene (NYC DOHMH), USA 2. Centers for Disease Control and Prevention (CDC), USA BACKGROUND METHODS RESULTS LIMITATIONS • The NYC DOHMH Bureau of STD Control: • Has 10 clinics with ~115,00 visits annually • Provides free and confidential STD testing and treatment on a walk-in basis to persons ≥12 years of age. • Limited physician (MD) resources make it difficult to provide physical exams to all patients seeking care. • In January 2006 we introduced a routine “Express Visit” (EV) option for persons who at triage: • Are determined to be asymptomatic • Deny either contact to known STD case(s) or receptive anal sex within previous 3 months • Do not have the need for: Hepatitis A or B vaccination, Hepatitis C testing, pap smear or emergency contraception • Do not wish to have an examination • Tests offered during an EV include Neisseria gonorrhea (GC) & Chlamydia trachomatis (Ct) urine Nucleic Acid Amplified Test (NAAT), syphilis RPR and HIV oral rapid test. • STUDY PERIOD: • September - December, 2005 (before EV) • September – December, 2006 (after EV) • STUDY POPULATION: Patients with an MD visit or EV at 9 NYC DOHMH STD clinics. • DATA SOURCE: Clinic electronic medical records (EMR) • EXPRESS VISIT DEFINITION: • Patients who did not see a physician and had a GC/Ct urine NAAT • MD VISIT DEFINITION: • Patients who saw a physician • Specimen types counted for an MD visit: • GC culture: anal, oral, cervical or urethral, • GC NAATs: oral, cervical, urethral or urine, • Ct NAATs: oral, cervical, urethral, anal or urine • OUTCOMES OF INTEREST: • # of EV, # MD visits • Proportion patients symptomatic at MD visits • # cases GC/Ct detected and treated • Time to Treatment: • Calculated for GC or Ct positive patients with documented treatment on either their day of visit (DOV) or future DOV (within 30 days of visit). • Difference, in days, between the DOV when specimen was collected & treatment date. • Median Time to Treatment:Was calculated only for patients who received treatment after their DOV up to 30 days. Figure 1. Number of Visits by Visit Type Figure 2. Number of Total Visits With GC/Ct Tests Done & Percent Positive • MD and Express visits may have been mis-categorized if a physician unintentionally omitted their electronic signature. • Our evaluation periods were constrained by the earliest date at which all of our clinics began to utilize our EMR, which was 9/2005. • Simultaneous clinic improvements which occurred during the two study periods were not accounted for in our analysis (i.e. electronic requisitioning of GC/CT NAATs). 23% N= 19,925 N= 24,485 N= 19,875 N= 16,128 2,653 4,865 23% 13,584 15,768 13.8% 13.2% Asymptomatic MD Visits Express Visits Visits with Positive GC/Ct test results Symptomatic MD Visits • Among tests done, the proportion positive remained about the same, ~ 13% before and after introducing EV. • Overall, visits increased by 23%. • The proportion of MD visits that were symptomatic increased by 16%; a significant increase with a p-value < 0.0001. CONCLUSIONS Table 1. Time to Treatment by Visit Type & Study Period • From this analysis we have seen that the introduction of Express Visits has enabled: • GC & Ct screening of a large number of asymptomatic patients • MD resources were better directed towards symptomatic patients • More Gonorrhea and Chlamydia positive patients were treated • Improved time to treatment • Disclaimer: The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy. OBJECTIVE To evaluate the impact of routine express visits on the diagnosis and treatment of GC & Ct. 1 Treated on DOV or within 30 days 2 Treated after DOV but within 30 days • The proportion of infected individuals who were treated within 30 days of screening increased from 2,029 or 91% (2005) to 2,433 or 93% (2006). • The number of positive cases detected increased from 2,231 in 2005 to 2,617 in 2006.