From the Department Community and Behavioral Health, Colorado School of Public Health, University of Colorado Denver, and Denver STD/HIV Prevention Training Center, Denver Public Health Department.
Correspondence: Cornelis A. Rietmeijer, MD, PhD, MSPH, 533 Marion St, Denver, CO 80218. E-mail: email@example.com.
Received for publication October 26, 2012, and accepted November 14, 2012.
Sexually transmitted disease (STD) programs are under duress. Health departments are laying off disease intervention specialists, the very core of their STD prevention efforts, and STD clinics are closing.1 Meanwhile, surviving clinics are looking to cut costs, raise revenue, and streamline operations. In this context, it is reasonable to question whether all patients presenting to an STD clinic should undergo a full physical evaluation or whether clinic efficiencies could be achieved by offering different levels of service dependent on the risks or symptoms of the patient. Such an approach has been made possible by the availability of nucleic acid amplification testing (NAAT) that allowed for noninvasive testing for Neisseria gonorrhoeae and Chlamydia trachomatis and thus removed the need for a full physical examination.
Variably termed “express visits,” “fast-tracking,” or “short-protocol,” numerous STD clinics, both domestically and abroad, have experimented with triage-based STD testing without a full clinical examination and have demonstrated that these approaches can result in significant increases in clinic efficiency and reduction of patient waiting time.2–5
In this first edition of The Real World of STD Prevention, we have selected 3 articles that add to the growing literature on this topic and will undoubtedly stimulate further discussion and influence adoption of this practice.
The article by Knight et al.6 reports on the implementation of an express testing service at the Sydney Sexual Health Centre involving a computer-assisted self-interview and self-collection of test samples without a full clinical examination. This service was offered to qualifying patients as an alternative to the traditional, full-examination visit and resulted in an 11% increase in patient volume at no additional cost to the clinic. In an accompanying editorial, Dombrowski and Golden7 place the study’s findings in the context of a set of key operational research questions they propose to set a research agenda related to STD clinic efficiency.
The article by Martin et al.8 (a companion study to the report by Knight et al.) examines the patient perspective on express visits, showing a high level of satisfaction with the service and intent to retest using this model of care. Interestingly, offering the express visit option seemed to be particularly attractive to young heterosexual men in this study because they indicated that they would be more likely to return to the clinic if this option was available.
The article by Xu et al.9 offers a different perspective. This study, involving more than 2500 patients in 3 US STD clinics, suggests that there is a potentially important tradeoff between enhanced efficiency and perhaps increased clinic use when the express visit option is offered versus the cost of missed diagnoses when not all patients undergo a routine STD clinical examination. Among these missed opportunities, Xu et al. specifically identify asymptomatic urethritis in men and asymptomatic trichomoniasis in women. Missing urethritis in men postpones the treatment for men who are later shown to test positive for chlamydia or gonorrhea and negates the opportunity of treating for urethritis-associated pathogens such as Mycoplasma genitalium for which testing is not widely available. In the study of Xu et al., close to 16% of asymptomatic men without chlamydia or gonorrhea were shown to have urethritis. This proportion would likely be even greater if the diagnostic criteria for urethritis be changed to lower cutoff rates on the urethral smear Gram stain.10 Similarly, among asymptomatic women, Xu et al. found that 6% had Trichomonas vaginalis detected on a routinely obtained wet mount of the vaginal fluid. Unlike men with asymptomatic urethritis, who are still tested for chlamydia and gonorrhea, backup testing for trichomoniasis using NAAT is not yet widely available, and these cases would thus go untreated in the express visit scenario.
Although the possibility of missed diagnoses has been acknowledged as a downside of the express visit option in previously published articles, the methods of those studies did not allow the level of quantification offered by the study of Xu et al.
However, these findings should be nuanced by the following. First, the clinical practice at the study sites is very extensive and rigorous and not necessarily the standard of care at other STD clinics. For example, many clinics may not as aggressively pursue Gram-stained smears on asymptomatic men with minimal urethral discharge, and not all clinics routinely perform wet mounts of vaginal samples of asymptomatic women.11 Second, both the wet mount and Gram-stained smears are insensitive tools, and most asymptomatic T. vaginalis and M. genitalium infections would still remain untreated in the full-examination scenario. Wider availability of NAAT for these organisms would undoubtedly yield many more (asymptomatic) infections, but sampling for these tests would be similar to the current NAATs for gonorrhea and chlamydia and could be incorporated as part of an express visit.
To be fair, additional arguments can be made that question the benefits of further implementation of the express visit option. As clinics are exploring ways to enhance their revenue by billing for services, especially in the context of the Affordable Care Act, services that require the involvement of a physician may be billed at higher rates than those that do not, thus changing the cost-benefit ratio. Furthermore, one could argue that the physician expertise available in STD clinics should benefit all attendees and not only those who report symptoms and that STD programs should rather support the testing-only option in settings where such clinical expertise is not available.
In conclusion, clinics that are considering implementation of express visits should follow the advice of Xu et al. and perform an analysis using local clinical standards and resources and make an assessment of whether the gains in clinic efficiency resulting from the express visit option outweigh the potential costs of missed diagnosis and postponement of treatment. In the resource-constrained setting, this balance will be greatly influenced by the additional number of patients who can be evaluated when implementing an express visit system versus the number of patients who are turned away when comprehensive evaluation is the only option.
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10. Rietmeijer CA, Mettenbrink CJ. Recalibrating the Gram stain diagnosis of male urethritis in the era of nucleic acid amplification testing. Sex Transm Dis 2012; 39: 18–20.
11. Rietmeijer C, Bissette J, Golden M, et al.. Variation in Practice Among STD Clinics Participating in the U.S. STD Surveillance Network (SSuN). 17th Biennial Meeting of the International Society for Sexually Transmitted Diseases Research, Seattle, 2007.