Access to genitourinary medicine clinics in the United Kingdom

Inequalities in access to genitourinary medicine clinics in the UK: results from a mystery shopper survey

STUDY DESIGN

This study investigated whether access to genitourinary medicine (GUM) clinics meets UK-recommended standards.

METHODS

In January 2014 and 2015, postal questionnaires about appointment and service characteristics were sent to lead clinicians of UK GUM clinics. In February 2014 and 2015, researchers posing as symptomatic and asymptomatic 'patients' contacted clinics by telephone, requesting to be seen. Clinic and patient characteristics associated with the offer of an appointment within 48 hours were examined using unadjusted and UK country and patient gender adjusted multivariable logistic regression analyses. In March 2015, a convenience sample (one in four) of clinics was visited by researchers with the same clinical symptoms. Ability to achieve a same-day consultation and waiting time were assessed.

RESULTS

In 2015, 90.8% of clinics offered symptomatic 'patients' an appointment within 48 hours when contacted by telephone, compared with 95.5% in 2014 (aOR=0.46 (0.26 to 0.83); p<0.01). The decline was greatest in women (96.0% to 90.1%; p<0.05), and clinics in England (96.2% to 90.7%; p<0.01). For asymptomatic patients, the proportion offered an appointment within 48 hours increased from 50.7% in 2014 to 74.5% in 2015 (aOR=3.06 (2.23 to 4.22); p<0.001), and in both men (58.2% to 90.8%; p<0.001) and women (49.0% to 59.6%; p<0.01). In adjusted analysis, asymptomatic women were significantly less likely to be offered an appointment than asymptomatic men (aOR=0.33 (0.23 to 0.45); p value<0.001). 95% of clinics were able to see symptomatic patients attending in person.

CONCLUSIONS

Access to GUM services has worsened for those with symptoms suggestive of an acute STI and is significantly poorer for asymptomatic women. This evidence may support the reintroduction of process targets.

The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections

BACKGROUND

Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England.

METHODS

Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway).

RESULTS

Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation.

CONCLUSION

The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

Testing times: testing patient acceptance and ability to self-screen for a No-Talk Testing service

Genitourinary medicine (GUM) departments need to be resource efficient to manage the increasing numbers of patients seeking to access services. At the Edinburgh GUM department, we wished to develop a new No-Talk Testing (NTT) clinic for asymptomatic, low-risk patients attending for routine sexually transmitted infection (STI) screening. We undertook a questionnaire feasibility study to determine patient acceptability and ability to self-screen for this service. A total of 267 respondents completed questionnaires regarding acceptability of a future NTT service; 227 agreed to comparison of their self-screen with clinician risk-assessment. Overall, patient acceptability for a future NTT service was high, with an average of 7.8/10 awarded for opinion. Seventy-three percent of patients agreed they would consider utilizing such a service in the future. Sixty-one percent of respondents suggested at least one benefit to a future NTT service; principally, prospects for increased speed, efficiency, capacity and reduced waiting times. Comparing STI risk self-assessment with clinician assessment, discrepancies were identified for 37% of individuals. However, a majority (70%) of the discrepancies identified were due to a risk being noted in the self-screen alone, and missed from clinician notes. In summary, the study demonstrated NTT as acceptable and feasible. Based on these results, we have now successfully introduced such a service within our department.

The impact of emergency birth control on teen pregnancy and STIs

We use panel data from local authorities in England between 1998 and 2004 to examine the differential impact of increased access for teenagers to emergency birth control (EBC) at pharmacies on teenage pregnancies and sexually transmitted infections (STIs). We estimate both difference-in-difference (DD) and the more robust difference-in-difference-in-differences (DDD) models. The DD estimates provide some evidence that pharmacy EBC schemes are associated with higher teenage conception rates, but this result is not upheld in the DDD models. In contrast both the DD and DDD models provide consistent evidence that pharmacy EBC schemes are associated with higher teenage STI rates.

eTriage--a novel, web-based triage and booking service: enabling timely access to sexual health clinics

In recent years, the sexual health of the nation has risen in profile. We face increasing demands and targets, in particular the 48-hour waiting time directive, and as a result clinic access has become a priority. eTriage is a novel, secure, web-based service designed specifically to increase access to our clinics. It has proved a popular booking method, providing access to 10% of all appointments across the Directorate within six months of introduction. KC60 analyses revealed that the majority of users (58%) underwent asymptomatic screening with the remainder having some degree of pathology. There was a greater percentage prevalence of human papilloma virus, chlamydia, non-specific urethritis, gonorrhoea, herpes and trichomonas in the eTriage population when compared with the general clinic population. A notes review illustrated a high degree of concordance between data entered on eTriage registration and clinical review (97%). A patient survey revealed high levels of patient satisfaction with the service. As an adjunct to our existing booking services, eTriage has served to increase patient choice and has proved itself to be a safe, efficient and effective means of improving patient access.

A metapopulation modelling framework for gonorrhoea and other sexually transmitted infections in heterosexual populations

Gonorrhoea continues to be a public health problem in the UK, and is the second most common bacterial sexually transmitted infection (STI) after chlamydia. In the UK, gonorrhoea is disproportionately concentrated in epidemiologically distinct subpopulations, with much higher incidence rates in young people, some ethnic minorities and inner city subpopulations. The original model of STI transmission proposed by Hethcote and Yorke explained some of these features through the concept of the 'core group'. Since then, several authors have modified the original model approach to include multiple sexual activity classes, but found this modelling approach to be inadequate when applied to low-prevalence settings such as the UK. We present a metapopulation framework for modelling gonorrhoea and other STIs. The model proposes that the epidemiology of gonorrhoea is largely driven by subpopulations with higher than average concentrations of individuals with high sexual risk activity. We show how this conceptualization of gonococcal epidemiology overcomes key limitations associated with some of the prior efforts to model gonorrhoea. We also use the model to explain several epidemiological features of gonorrhoea, such as its asymmetric distribution across subpopulations, and the contextual risk experienced by members of at-risk subpopulations. Finally, we extend the model to explain the distribution of other STIs, using chlamydia as an example of a more ubiquitous bacterial STI.

Improving sexual health services in the city: can the NHS learn from clients and the service industry

OBJECTIVE

Genitourinary service providers are struggling to meet patient demand and have introduced changes in access structure to cope. In this study, we explored the perspectives of clients and providers upon the different models of access introduced and whether these maintained service quality using the SERQUAL model.

METHODS

Primary data were collected in May 2005 at two genitourinary medicine clinics, two Accident and Emergency Departments and from members of a university 'gay' society all of which were located in London. Forty-four high-risk clients and 11 health service providers underwent semi-structured face-to-face interviews.

RESULTS

Both the walk-in and appointment-based access systems were appreciated by clients. Clients said that the most important issue was that they were not turned away when they presented. Health-care providers had a variety of opinions about the two systems as they had different impacts on morale, training and service provision.

CONCLUSIONS

Service quality can be maintained by using both walk-in and appointment-based systems. This is because our data, in line with Parasuraman's model of service quality, showed that 'access' is but one determinant of quality. Having different modes of access facilitates patient choice, which is paramount in a modern health-care system. However, to provide a good service it is important to maintain a motivated staff, who can be affected by their working environment.

Use of a primary care database to determine trends in genital chlamydia testing, diagnostic episodes and management in UK general practice, 1990-2004

OBJECTIVE

To determine the extent of testing, diagnostic episodes and management of genital Chlamydia trachomatis (CT) infection in UK primary care using a large primary care database.

METHODS

The incidence of CT tests, diagnostic episodes, treatments and referrals was measured for all adult patients in the General Practice Research Database between 1990 and 2004.

RESULTS

Rates of CT testing in those aged 12-64 years in 2004 increased to 1439/100,000 patient years (py) in women but only 74/100,000 py in men. Testing rates were highest among 20-24-year-old women (5.5% tested in 2004), followed by 25-34-year-old women (3.7% tested in 2004). 0.5% of registered 16-24-year-old women were diagnosed as having CT infection in 2004. Three-quarters of patients with a recorded diagnosis of CT had had an appropriate prescription issued in 2004, a proportion that increased from 1990 along with a decrease in referrals to genitourinary medicine. In 2004, general practitioners treated 25.0% of all recorded diagnoses of CT in women and 5.1% of those in men.

CONCLUSIONS

Testing for and diagnostic episodes of CT in primary care have increased since 1990. Testing continues disproportionately to target women aged >24 years. Extremely low rates of testing in men, together with high positivity, demonstrate a missed opportunity for diagnosis of CT and contact tracing in general practice.

Effectiveness of a Risk-Based Visitor-Prioritizing System at a Sexually Transmitted Infection Outpatient Clinic

OBJECTIVE

The objective of this study was to study the efficacy/effectiveness of a risk-based visitor-prioritizing system at a sexually transmitted infection (STI) clinic aimed to improve screening capacity by providing tailored service.

STUDY DESIGN

In April 2004, a prioritizing system was implemented that classifies visitors as high or low risk depending on reported sexual behavior and previous STI events. The high- and low-risk groups are assigned to standard and short screening protocols, respectively. Both protocols include diagnostic testing for syphilis, urogenital gonorrhea, chlamydia, and optional for HIV. To assess the effectiveness of the system, differences in prevalence of STI diagnoses in the standard and short protocol were analyzed by chi test.

RESULTS

In total, 14,391 visitors (64%) received standard screening and 8,056 visitors (36%) received short screening. The STI prevalence in both groups was 18.1% and 7.6%, respectively (P <0.001); prevalence of HIV was 1.8% and 0.3%, respectively (P <0.001). The sensitivity of the prioritizing system was 74%. Specificity was substantially lower (42%).

CONCLUSIONS

This prioritizing system is effective in differentiating between visitors at high and low risk for STI, contributing to provision of tailored STI service, increasing efficiency, and client access to STI service.

How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs?

OBJECTIVES

To quantify the contribution of patient delay, provider delay, and diversion between services to delayed access to genitourinary medicine (GUM) clinics. To describe the factors associated with delay, and their contribution to STI transmission.

METHODS

Cross-sectional survey of 3184 consecutive new patients attending four GUM clinics purposively selected from across England to represent different types of population. Patients completed a short written questionnaire that collected data on sociodemographics, access, and health-seeking behaviour. Questionnaires were then linked to routinely collected individual-level demographic and diagnostic data.

RESULTS

Patient delay is a median of 7 days, and does not vary by demographic or social characteristics, or by clinic. However, attendance at a walk-in appointment was associated with a marked reduction in patient delay and provider delay. Among symptomatics, 44.8% of men and 58.0% of women continued to have sex while awaiting treatment, with 7.0% reporting sex with >1 partner; 4.2% of symptomatic patients reported sex without using condoms with new partner(s) since their symptoms had begun. Approximately 25% of all patients had already sought or received care in general practice, and these patients experienced greater provider delay.

CONCLUSIONS

Walk-in services are associated with a reduction in patient and provider delay, and should be available to all populations. Patients attending primary care require clear care pathways when referred on to GUM clinics. Health promotion should encourage symptomatic patients to seek care quickly, and to avoid sexual contact before treatment.

Supply and demand: estimating the real need for care while meeting the 48 hour waiting time target in a genitourinary medicine clinic by a closed appointment system

AIM

To attempt to assess demand for access to sexual health services in a community where a "closed" appointment system operates in the local genitourinary medicine (GUM) clinic.

SETTING

A large GUM clinic serving a provincial city in England. Appointments for new episodes are available only 1 or 2 days ahead. Service user complaints about repeated difficulty in getting through to book a visit prompted a review of all methods of access.

METHODS

A prospective review of all calls received in the departmental telephone booking service was performed. Temporary extra staff manned a cascade sequence of telephone lines and recorded all calls and caller characteristics such as age and declaration of symptoms. All attempts to book an appointment in person, by written referral, or by telephone in a period of 5 working days were also logged. This total demand was compared with the actual capacity and maximum theoretical capacity of the clinic during the same time period.

RESULTS

626 appointments would be required in the working week to accommodate all patients within 48 hours of requesting to be seen. 84% of all calls requested a new appointment, and 77% all new appointment requests were by phone. There were 181 new appointments available; 72% of those requesting an appointment could not be seen. The clinic was working at 103% capacity. To accommodate demand at this quiet time of the academic year, the GUM service would need to increase capacity by 3-4-fold.

CONCLUSIONS

Closed appointment systems in GUM services may produce an apparent "improvement" in waiting times to 48 hours, but many callers are not able to book an appointment at all. Demand for GUM services outstrips capacity to an extent that internal efficiency savings cannot hope to address.

Triage up front

OBJECTIVES

To assess the effectiveness of a newly developed triage tool to provide urgent access to genitourinary medicine (GUM) for patients. To appraise its value in compiling statistics for patients attending the department without appointments or those telephoning for advice.

METHOD

Retrospective evaluation of triage forms completed by healthcare professional (HCP). Randomly selected triage forms completed for 250 male and 250 female patients attending a GUM clinic over a 3 month period.

RESULT

Patients attending or telephoning with acute symptoms such as ulceration or abdominal pain, or as a result of sexual assault were offered same day or next day appointments in 100% of cases. However, for untreated chlamydial infection, testicular pain, and male urethritis the success rate fell to between 54-86%.

CONCLUSION

The new form is easy to complete and allows a more structured triage of patients. It provides a standardised template for staff employed in GUM triage and facilitates accurate documentation and data collection of this important activity. All targets are not being met and patient distress is not adequately addressed or recorded to help service planning. However, accountable standardised data can be collected, which is important in defining the extent of the service and provides useful information for commissioners.

Managing genital infection in community family planning clinics: an alternative approach to holistic sexual health service provision

OBJECTIVE

To pilot and evaluate sexually transmitted infection (STI) management in community family planning clinics (FPCs).

METHODS

Number of STI tests taken, positive results, infections treated, contacts traced/treated, referrals to specialist services and time from testing to treatment were documented as well as age and sex of the population tested.

RESULTS

STI tests taken increased from 233 to 308/month and male clients seen increased from 114 to 147/month across all clinics. Chlamydia prevalence rates in one large clinic increased from 6.7% to 11.9%. 82% of those with STIs in this clinic were treated. Of 44 clients treated for chlamydia, 84% had partner notification performed, 0.43 contacts were treated for every client with chlamydia and referrals to specialist services decreased. 70% of STIs were detected in clinic users under the age of 25 and 45.5% of clients tested under the age of 16 had an STI. Before STI treatment was available at FP clinics 52% of clients with STIs attended specialist services after referral and time from testing to treatment was 19 days. Managing STIs in the community increased treatment rates to 82% with a testing to treatment time of 10 days.

CONCLUSIONS

The management of uncomplicated genital infection in community FPCs working in partnership with specialist services is a feasible and effective approach to holistic sexual health service provision.

Variation in clinical practice in genitourinary medicine clinics in the United Kingdom

OBJECTIVES

This study was conducted to examine the variation in clinical practice in genitourinary medicine clinics in the United Kingdom in early 2002.

METHODS

Questionnaires were sent to all 234 consultants in charge of genitourinary medicine clinics in the United Kingdom in March-May 2002. The questions concerned clinical practice in respect of asymptomatic patients presenting for an infection screen, and practice in respect of some specific sexually transmitted and other genitourinary infections.

RESULTS

The test for infection least likely to be offered to heterosexuals is an HIV test (71% and 70% of clinics routinely offer this to male and female heterosexuals respectively). The practice of permitting "low risk" patients to telephone for their HIV results now extends to 24% of clinics. 34% of clinics do not require patients with non-specific urethritis to attend for follow up. 41% of clinics routinely ask patients treated for Chlamydia trachomatis to return for a follow up chlamydia detection test. 25% of clinics routinely offer two tests of cure to all patients with gonorrhoea. 6% of clinics do not routinely offer syphilis serology to heterosexuals. Other significant variations in clinical practice were documented.

CONCLUSIONS

Overall, our findings indicate the need for further evidence to guide clinical practice and a wider knowledge and debate of national guidelines.

Maintaining patient access to GUM clinics: is it compatible with appointments?

OBJECTIVES

To determine whether a planned change from a walk-in service to a system in which 35% of appointments were prebooked and 65% obtained on the day, preserved access to the service for patients with, or at risk of, STIs. To describe patients' attitudes and behaviours in relation to accessing the clinic, and relate these to disease status and other epidemiological factors. To evaluate the effect of the change on clinical outcomes. To develop a tool for evaluating access to services.

METHOD

A natural experiment was studied, in which a cohort of patients attending just before the change in appointments policy (phase 1) was compared with a cohort following the change (phase 2). A questionnaire was administered to all new patients, and linked to disaggregated epidemiological and demographic data and case notes.

RESULTS

The age, ethnic, symptom status, and disease mix of the clinic did not change significantly, and more patients were seen in phase 2. Time from telephoning to being seen did not change. Under 25s and Afro-Caribbeans used prebooked appointments less than others. Partner notification improved and HIV testing rates increased, while staff preferred the new system.

CONCLUSION

This specific appointment system in a GUM clinic preserved access for high risk groups. However, this may not generalise to systems with a higher proportion of prebooked appointments.

An outbreak of early syphilis: cases from North Manchester General Hospital

OBJECTIVES

To describe the features of an outbreak of early syphilis in North Manchester.

METHODS

Retrospective KC60 and case note review.

RESULTS

In a 25 month period, 10 cases of primary, 22 of secondary, and nine cases of early latent syphilis were diagnosed. 39 were homosexual or bisexual men, 20 being co-infected with HIV. Most infections were acquired locally and in 19/41 cases oral sex was the only risk factor. High rates of unprotected anal sex were reported among the homosexual men and co-infection with other STIs was common.

CONCLUSION

This outbreak will facilitate the spread of HIV in the homosexual male population. Unsafe sexual practice is common and the perception that oral sex is "safe" needs revisiting. Delays in accessing GUM clinic appointments must be addressed as part of the control strategy.

Sexually transmitted infections and human immunodeficiency virus infection in Europe: the way ahead?

The incidence of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection is increasing in Europe. The reasons for this are multifactorial but ease of travel is one of them. This is worrying in view of the established role of STIs in facilitating HIV transmission. Care of this group of infections is provided by a variety of doctors, often not following agreed guidelines. It is vital that doctors and their specialist societies engage in setting standards, in ensuring that STIs and HIV infection are moved up the healthcare agendas of all European countries and in making sure that access to care is rapid. Surveillance should be enhanced, interventions evaluated and the media engaged.