Timely access to services is essential to reducing the duration of sexually transmissible infections (STIs) and controlling further transmission.1 Access to health services, both preventive and therapeutic, is an important predictor of outcomes for many diseases and plays a particularly central role in the control of STIs.2 Lack of access can arise for a range of reasons including social disadvantage of people at risk, underresourcing of health care services, geographical isolation, and gaps in health service delivery.2
Contributing to the very low rates of bacterial STIs among women engaged in sex work in Australia3,4 is the ease of access to preventive and therapeutic health services. Conversely, the continuing high rates of bacterial STIs in some remote Aboriginal communities5 are now seen as largely attributable to decades of poor access to such services.6 Another example in the United Kingdom is modeling that showed that reduced access to genitourinary medicine services would result in onward transmission of infections, and this increase in numbers of infections would only decline with improved access.7
In New South Wales, Australia, publicly funded sexual health services are directed to provide services only to predefined priority populations laid out in the national and state strategies. Although general practice clinics are involved in sexual health, many people are sensitive about consulting their general practitioner about STIs and prefer the more confidential systems and the greater expertise available in publicly funded sexual health services.8 In Australia, sexual health services can be found in a range of settings, located within hospitals, free-standing, or integrated into other primary care services.
To increase access for at-risk populations, a number of sexual health services in Australia and internationally have introduced fast-track services to allocate patients based on presentation to various screening options.9–12 These services generally involve dedicated staff and space separate from the main service area; staffing by senior, more experienced personnel with the ability to think quickly and independently; a set of triage criteria for service referral; and set operating times.9,13–22
In response to long wait times and an inability to meet patient demand, in December 2010, a large urban public sexual health clinic in Sydney Australia (Sydney Sexual Health Clinic) implemented a new model of fast-track services. The service involved a computer-assisted self-interview (CASI) for risk assessment, self-collected samples for testing of STIs, and staffing by an enrolled nurse (second-level nurse who provides nursing care under the direction and supervision of the registered nurse). We evaluated the impact of this new model of service delivery on the patient population seen, patient journey, staff costs, and clinical capacity.
Routine Triage System
Routinely, all patients attending Sydney Sexual Health Centre without an appointment or telephoning for an appointment are triaged by an experienced sexual health registered nurse using a standardized triage tool.23 Patients are allocated a 30-minute consultation slot with a registered nurse in the routine nurses clinic if they meet the following criteria: asymptomatic for STIs and from a priority population (men who have sex with men, Aboriginal people, sex workers, intravenous drug users (IDUs), HIV-positive people, and youth younger than 25 years). The consultation consists of a pen-and-paper sexual history and risk assessment, using a pro forma, and genital examination and clinician-collected specimens if clinically indicated (Table 1). Asymptomatic patients from nonpriority populations are triaged to primary care. Symptomatic patients are triaged to a doctor or registered nurse according to defined protocols based on signs and symptoms and reason for presentation.
Figure 1 shows the clinic pathway in the Xpress period; during the triage, patients were offered either the routine nurses clinic or the Xpress clinic. Only asymptomatic patients were eligible for the Xpress clinic because the model aims to offer a faster screening service. Patients were recommended to attend the routine clinic if they were symptomatic, were contacts of an STI, and had postexposure prophylaxis in the last 6 months or if they were higher-risk people who had not received formal pretest counseling for HIV at the clinic previously (men who have sex with men, current IDUs, and people who have had sex in a country with high HIV prevalence). Asymptomatic patients who were eligible for both the routine clinic and the Xpress clinic chose which they would prefer to attend.
The Xpress clinic used an interactive CASI similar to that described by Vodstrcil and colleagues.,24 to obtain a risk and sexual history and allocates a 15-minute consultation slot with an enrolled nurse. The patient completes the CASI first, which takes an average of 4 minutes. Computer-assisted self-interview collects the same information as the paper pro forma, and questions are formatted to look like the paper pro forma. Patients must answer each question to progress. The results are then viewed on the enrolled nurse’s computer. Education and streamlined pretest information based on each patient’s reported risk factors is built into the CASI (Table 1). During the Xpress clinical consultation, patients’ self-collect genital specimens and the nurse performs venepuncture and collects throat swabs if required.
The Centre has a networked electronic operating system that houses the medical record database, patient data, appointments, and patient management system, which is used to move the patient through the service electronically. We extracted routine consultation data from the operating system and calculated a range of attributes related to the patient journey, staff costs, and clinic capacity and patient population seen.
We calculated the median wait time to see a clinician in minutes (seen time − arrival time), and the median length of stay in minutes (consult finish time − arrival time). Time periods of more than 100 minutes and less than 3 minutes were excluded from the analysis because these data are likely to be errors associated with clinicians not recording start and finish times correctly.
Staff and Patient Costs
We calculated the total clinical staff hours worked and salaries associated with staff hours worked in Australian dollars using a standard rate for both enrolled and registered nurses and doctors. The cost per patient seen was calculated by dividing the total staff costs by the total number of patients seen in the period.
We calculated the total patients seen (not including patients who failed to attend for their appointments), average patients seen per clinical staff hour, utilization (patients that could be seen/patients that actually attended and were seen), and capacity (total patients that could be seen in clinic hours). In the routine clinic, patients are given half-hour appointment slots, meaning that 2 clients can be seen per hour. In Xpress, the appointment slots are 15 minutes, which means that 4 clients can be seen per hour. We used these total numbers in our calculations of capacity.
Change in Patient Population
We assessed the number and proportion of patients who were asymptomatic, male and female, and in specific risk groups (Aboriginal people, heterosexuals, men who have sex with men, current sex workers, current IDU).
Frequency distribution and percentages were used to describe the demographic and other characteristics of attendees by period. Groups were formally tested using the χ2 test. Patients’ ages, waiting time to see a clinician, and length of stay were described using summary statistics and formally tested using analysis of variance methods. The ratio of total patients seen per total clinic hour was calculated and formally tested by odds ratio and P value.
We compared all these attributes in the first 5 months Xpress clinic was operating (10th December 2010 to 30th April 2011) with a similar 5-month period before (10th December 2009 to 30th April 2010) and by clinic type (Xpress/routine nurse/routine doctor).
Ethics approval was granted by the South Eastern Sydney Illawarra Area Health Service (Northern Sector) Human Research Ethics Committee for use of retrospective patient data.
Characteristics of Patients Seen
In the Xpress period, the median age of the 5335 patients seen was 29 years (interquartile range [IQR], 24–36) and younger than 30 years (IQR, 25–37) among 4804 patients seen in the before period (P < 0.01). In the Xpress period, the slightly lower median age was due to a younger population of patients attending the Xpress clinic (median age, 25 years; IQR, 23–31). There was no significant difference in sex of patients between study periods. The proportion of symptomatic patients and men who have sex with men seen in the Xpress period was 46.9% and 48.2%, respectively, compared with 43.7% and 53.2%, respectively, in the before period (P < 0.01; Table 2). The proportion of sex workers in the Xpress period was 11.8% compared with 13.4% in the before Xpress period (Tables 2 and 3).
The median waiting time to see a clinician in the Xpress period was lower at 19 minutes (IQR, 8–36; 10 minutes in the Xpress clinic and 17 minutes in routine clinics) compared with 23 minutes in the before period (P < 0.001). The median length of stay in the Xpress period was also lower at 40 minutes (IQR, 27–58; 21 minutes in the Xpress clinic and 40 minutes in routine clinics) compared with 43 minutes in the before period (P < 0.001) (3).
Staff hours in the Xpress period were 13% greater compared with the before period (3567 vs. 3151). However, in the Xpress period, there was a higher number of nursing staff hours: 437 enrolled nurse and 1524 registered nurse compared with 0 and 1341 in the before period, respectively. The cost per patient seen in the Xpress period was lower compared with the before period ($26.79 compared with $28.48). Overall total staff costs increased 4.5% in the Xpress period compared with the before period ($AUD 142,954.89 vs. $AUD 136,844.44) (3).
In the Xpress period, 5335 patients were seen, of which 705 were seen in the Xpress clinic. This is 11% more than the 4804 seen in the before period. The ratio of total patients seen and clinical staff hour rostered in the Xpress period was 1.49 (1.7 in the Xpress clinic and 1.4 in other clinics) compared with 1.52 in the before period (odds ratio, 1.02; confidence interval, 0.96–1.09; P < 0.44). The total capacity of the clinic in the Xpress period was 8007 patients compared with 6301 in the before period. The utilization rates were lower in the Xpress period at 67% (40% in the Xpress clinic and 74% in other clinics) compared with 76% in the before period (P < 0.01) (3).
To our knowledge, this is the first evaluation of an express STI screening service using CASI and enrolled nurses, which has demonstrated improved sexual health service efficiencies and the patient journey. Our evaluation found that during the period when the express clinic was operating, a greater number of patients were seen, particularly young heterosexuals and symptomatic patients; the average wait times to be seen and length of clinic visits declined; clinic capacity increased substantially; and the cost per visit declined. These findings were in the context of only a 40% utilization rate of the Xpress, suggesting that with future active promotion and a lower threshold for accessing the Xpress clinic, the demonstrated benefits should be even greater.
The addition of Xpress clinic resulted in more total patients being seen in the Xpress period, but more enrolled nursing staff hours were rostered to see the additional patients. However, because enrolled nurses are on a lower annual salary, the average cost per patient seen was lower in the Xpress clinic, and overall equated to a lower cost per patient between the Xpress period and before period. Other fast-track STI screening services have also been demonstrated to provide greater access for at-risk populations without using extra resources.9–12
The evaluation also showed that there has been a significant increase in the number of youth younger than 25 years seen in the Xpress clinic reflected by the median age being 25 years in the Xpress clinic compared with close to 30 years in other routine clinics. In particular, more young heterosexuals were seen, which is an important public health outcome because the burden of chlamydia disease is high in this group,25 but only a small proportion get tested in primary care clinics. Chlamydia testing rates range from 3.3% of 15- to 24-year-old females and 1.0% of males in general practice clinics in the southeast of England in 2006/200726 and 12.5% of young sexually active females and 3.7% of males in Australia in 2008.27
Similarly, there were more symptomatic patients seen in the Xpress period compared with the before period (P < 0.01). This is most likely due to asymptomatic patients being streamed to the Xpress clinic and thus freeing up registered nurses and doctors to see symptomatic patients. There were slightly less men who have sex with men seen in the Xpress period, which probably reflects the restrictive eligibility criteria of the Xpress clinic, with new MSM unable to have an HIV test as part of Xpress clinic until they have had a test and pretest discussion in the routine clinic. We aim to enhance access by removing the prerequisite for high-risk patients to have previously had an HIV test at the routine clinic. Less sex workers were also seen in the Xpress period, which may be because the Xpress clinic is only for people who read and understand English and therefore is not an option for the non–English-speaking background sex workers seen at the Centre.
The average length of stay was significantly reduced in the Xpress period. This could be due to a range of factors including using CASI in Xpress clinic for collecting the risk assessment, the use of enrolled nursing staff, or self-collected swabs being used in Xpress and more frequently in the routine nurses clinic for asymptomatic patients. The literature consistently shows that use of CASI in sexual health identifies high-risk behavior more commonly than clinician interview and is more complete and acceptable to both patients and clinicians. On the other hand, a recent evaluation of routine use of CASI at Melbourne Sexual Health found CASI had no significant influence on the duration of consultations; however, their model does not use an enrolled nurse.24
The “drop-in” nature of the new Xpress clinic, reduced waiting times to see a clinician, and reduced length of stay could play a strong role in the ongoing use of services, which we plan to evaluate in 12 months. We previously reported the findings of a patient questionnaire that found that satisfaction with the Xpress clinic was high; respondents felt involved in their care and had as much time with the health care worker as they wanted, and overall, and the majority reported that they would use Xpress again and recommend it to others.28 Assuming the Xpress clinic had a similar utilization rate of 80% to the routine nurse clinics in the before period, the clinic has the potential to increase the total patients seen by 25%. The rate of patients failing to attend for their appointments at Sydney Sexual Health Centre have been shown to be between 12% and 16%.
Utilization in the first 5 months of the Xpress clinic was only 40%. We believe that this was due to 2 main reasons. First, the service was being trialled and had not been marketed outside the Centre, so only patients calling the Centre or attending the Centre could be offered it. Second, the restrictive eligibility criteria of the Xpress clinic with new MSM unable to have a HIV test as part of Xpress clinic until they have had a test and pretest discussion in the routine clinic meant that many of the new clients to the Centre could not be offered Xpress. Marketing of the service and changes to the inclusion criteria have resulted in Xpress use improving to 74% for the first 3 months of 2012 (1192 patients seen in 1618 rostered patient slots).
The strengths of the evaluation are as follows: we assessed a range of different efficiency attributes, we compared 2 periods (during and before) to minimize the influence of confounders, and the before period was the same time of the year to minimize any influence of seasonal variation on clinic attendance. This study was limited by the inability to control for differences between clinicians, which may have influenced the consultation duration. In addition, we did not evaluate every specific component of the Xpress service separately (electronic pretest information in the CASI, acceptability of self-collected swabs), so we cannot determine the differential impact of these factors. Our study reports on actual patient visits rather than on study participants enrolled into a research trial; therefore, we believe that it is generalizable to the general sexual health clinic population.
In conclusion, this evaluation of the first 5 months of operation of the Xpress clinic has demonstrated that it improves the patient journal by successfully reducing the time asymptomatic patients spend at the clinic, and although the Xpress clinic was not fully used, 11% more patients were seen with minimal additional staffing costs. If fully used, the Xpress clinic has the potential to increase the total patient seen at the clinic even further.
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