Sexually transmitted infections (STIs) are a major public health concern, with an estimated 20 million new infections in the United States every year.1 The Centers for Disease Control and Prevention estimates that the direct medical cost of STIs totals nearly $16 billion per year. Incidence rates for STIs have increased in recent years, and chlamydia and gonorrhea are now the most commonly reported infectious diseases in the United States.1,2 Growing rates of STIs among men have contributed to the increases in these diseases, and men who have sex with men are at particularly high risk for STIs.1,3
Patients with STIs are often non-white and uninsured, a population often served by urgent care centers.4–6 Urgent care centers are becoming increasingly common sites for medical care,7,8 but relatively little is known about the scope of their practice. Urgent care centers are frequently used by patients without a regular source of medical care due to their quick service and convenient hours and locations.6 Due to access to this high-risk population, urgent care centers may present an opportunity to increase rates of STI testing. However, these centers may not be accustomed to screening and providing care for STIs. Therefore, the objectives of this study were to describe STI testing practices at an urban urgent care center over a 4-year period and to examine provider assessment of sexual history and the relationship with STI testing.
Study Site, Patient Demographic Characteristics, and STI Testing
This study was conducted at the urgent care center affiliated with New York Presbyterian Hospital, a large academic urban hospital. This urgent care is a standalone clinic serving self-referred patients, and is staffed by emergency-trained clinicians. The urgent care is open on weekdays from 8:00 AM to 7:30 PM and on Saturdays from 8:30 AM to 6:00 PM. Men ages 20 to 55 years who used the urgent care center from June 7, 2011, to April 30, 2015 were eligible for the study. Patients were excluded if a provider note was not documented in the medical record. Demographic data collected included age, race/ethnicity, primary language, and insurance. Spanish as a primary language was used as a surrogate marker for Hispanic ethnicity. All chief complaints were evaluated by a single reviewer and categorized as STI risk if they contained concern for genitourinary or sexual issues (e.g., request for STI testing). The senior author reviewed the chart for final categorization when there were discrepancies or uncertainty. Genitourinary issues were defined as dysuria, penile discharge, foul smelling or dark urine, penile pain, hematuria, polyuria or difficulty voiding, flank or suprapubic pain, penile rash, testicular pain, or swelling. Sexual issues were defined as request for STI test, erectile dysfunction, or complaint related to sexual activity. STI testing was broadly assessed because of known risk for coinfection and included rapid plasma reagin (RPR) tests for syphilis; Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) nucleic acid amplification tests (Aptima C2; GenProbe); and human immunodeficiency virus (HIV) antibody, Western blot, and viral load tests (COBAS AmpliPrep/COBAS TaqMan HIV-1 Test kit, version 2.0). Human immunodeficiency virus infection status was based on laboratory-confirmed HIV testing results before the visit. This study was performed as part of a larger quality improvement project aimed at improving the diagnosis of syphilis among men attending the urgent care. This study was approved by the Columbia University Medical Center Institutional Review Board.
Substudy of Provider Documentation of Sexual Health Risk Factors for STIs (January 1, 2015 to April 30, 2015)
We hypothesized that sexual history taking would be associated with increased STI testing, even when presenting complaints might already suggest the need for STI testing. To evaluate this hypothesis, a manual chart review of the urgent care provider note was conducted for visits from January 1, 2015 to April 30, 2015 by a single reviewer using a standardized review tool. The senior author reviewed the chart when questions arose during the chart review process, and electronic medical record data was documented in a standardized worksheet. Provider sexual history assessment was defined by documentation of any component of a sexual history, including gender or number of sexual partners, contraceptive use, STI history, and/or types of sexual activity.
Descriptive statistics were used to describe demographic characteristics, STI testing, chief complaint, and sexual health risk factors. Demographic data were stratified by number of urgent care visits, sexual history documentation, and STI testing; t tests, χ2 analyses, and Fisher exact tests were used as indicated to assess differences. Odds ratios (OR) and χ2 analyses were used to assess for association between chief complaint, sexual history documentation, and STI testing. Demographics were analyzed by unique patients based on initial visit data; all other data were analyzed by visit. Statistical analysis was conducted using Stata Statistical Software: Release 14.1 (StataCorps, College Station, TX).
Demographics and STI Testing
From June 7, 2011 to April 30, 2015, there were 10,983 visits at the urgent care center for men aged 20 to 55 years. Of these visits, 63% were for unique patients (n = 6,946) and their demographic characteristics are listed in Table 1. The mean age of patients was 35.17 ± 0.12 years, and the majority of patients were Hispanic (60%; n = 4195). Forty-four percent of patients were uninsured (n = 3069). Patients with multiple visits to the urgent care were more likely to be older (P < 0.01) and Hispanic (P < 0.05), and less likely to be commercially insured (P < 0.01) than patients with one visit (Supplemental Table 1, http://links.lww.com/OLQ/A150).
Most patients had an unknown HIV infection status (76%; n = 8354) at the time of visit, with 1% identified as HIV positive (n = 98) and 23% as previously HIV negative (n = 2531). Most patients had no documented STI testing in the previous year, including no testing for syphilis (92%; n = 10,144/10,983), GC/CT (91%; n = 10,010/10,983), or HIV (85%; n = 9,307/10,983). During the study period, STI testing was ordered from 5% of visits (n = 505). This included RPR testing from 2% of urgent care visits (n = 259), GC/CT testing from 2% of visits (n = 222), and HIV testing from 2% of visits (n = 208). Of these tests, 4% were positive for syphilis (n = 11/259), 13% were positive for C. trachomatis (n = 29/222), 6% were positive for N. gonorrhea (n = 13/222; 3 coinfections with C. trachomatis), and 0.5% were positive for HIV (n = 1/208). Syphilis testing was completed in 38% of GC/CT-tested patients (n = 85/222); 7% of these tests were reactive (n = 6/85). Younger age was associated with STI testing (data not shown).
Current STI Testing Practices: The Relationship Between Chief Complaint and STI Testing
Of the 10,983 patient visits, 10% (n = 1118) were for symptoms potentially related to an STI. This included 9% of visits with genitourinary symptoms (n = 979) and 2% with sexual issues or request for STI testing (n = 233). Ninety percent (n = 9865) of visits were for unrelated chief complaints.
Patients with STI-relevant chief complaints had STI testing ordered from 26% of visits (n = 293/1118) (Table 2). This included RPR testing from 15% of visits (n = 169/1118), GC/CT testing from 17% of visits (n = 189/1118), and HIV testing from 8% of visits (n = 95/1118). Of these tests, 6% were positive for syphilis (n = 10/169), 15% were positive for C. trachomatis (n = 28/189), 6% were positive for N. gonorrhea (n = 11/189), and none were positive for HIV. Patients with unrelated chief complaints had STI testing ordered from 2% of visits (n = 212/9865). This included RPR for 0.9% of visits (n = 90/9,865), GC/CT from 0.3% of visits (n = 33/9,865), and HIV tests from 1% of visits (n = 113/9865). Of these tests, 1 was positive for syphilis, 1 for C. trachomatis, 2 for N. gonorrhea, and 1 for HIV. Patients with STI-relevant chief complaints were significantly more likely to have any STI test ordered than patients with an unrelated chief complaint (OR, 16.2; P < 0.01).
Substudy: Provider Documentation of Sexual Health Risk Factors (January 2015 to April 2015)
In the study subperiod from January to April 2015, there were 906 patients seen at the urgent care. During this period, 8% of urgent care visits had any documented component of a sexual history (n = 72). The following components of a sexual history were documented: gender of partners (6%; n = 55), number of partners (5%; n = 47), contraceptive use (4%; n = 37), STI history (4%; n = 34), and types of sexual activity (1%; n = 8). Demographic data were not associated with sexual history documentation (data not shown). Documentation of sexual history was associated with syphilis, GC/CT, and HIV testing at the visit (P <0.01) (Table 3).
Patients with STI-relevant chief complaints had a sexual history documented for 64% of visits (n = 62/97). This included: 63% of visits with genitourinary symptoms (n = 47/75) and 77% of visits with sexual complaints (n = 27/35). Patients with unrelated chief complaints had a sexual history documented for 1% of visits (n = 10). Patients with chief complaint concerning for STI were significantly more likely to have a sexual history documented than patients with an unrelated chief complaint (OR, 141.5; P < 0.01). When only visits with STI-relevant chief complaints were analyzed, sexual history documentation was significantly associated with testing for syphilis, GC/CT, and HIV (P <0.01) (Table 4).
Studies have shown that patients seen in urgent care settings have demographic characteristics associated with vulnerable populations, such as minority race/ethnicity and lack of insurance.6 This urgent care site has similar demographics to previously reported studies. We found that older patients, Hispanic patients, and patients without commercial insurance were more likely to use the urgent care center multiple times over the study period.
This urgent care center is located in an area where STIs are a significant health issue: the majority of the STI diagnoses in New York State occur in New York City,9 and Northern Manhattan has rates in the top quintile of the city's neighborhoods.10 Although urgent cares are becoming increasingly common sites for the provision of medical care,7,8 there has been little if any research describing the scope of STI testing at these locations. We found that approximately 5% of visits to this urgent care were associated with STI testing. As patients seeking care in acute walk-in settings rarely receive preventative care,8 the tests ordered at this site were likely for diagnosis of suspected STIs rather than for screening.
There was a high prevalence of chlamydia, gonorrhea, and syphilis infection among men seen at this urgent care center, suggesting that patients seen at this site should be considered a high-risk group. Patients with STI-relevant chief complaints had especially high rates of infection, with 6% testing positive for syphilis, 15% testing positive for chlamydia, and 6% testing positive for gonorrhea. Among urgent care patients tested for an STI, we found that a minority was tested for multiple STIs at the same visit. This confirms findings from emergency department (ED) settings, which have suggested that the majority of patients are not concurrently tested for multiple STIs.11,12 In those patients who were tested for multiple STIs, we found a high rate of positive tests. Among patients tested for GC/CT, 7% were positive for syphilis. This is slightly higher than has been reported in ED settings, which have reported syphilis rates of 1.4% to 6% for patients evaluated for other STIs.11,13,14 This is likely due to the fact that our study population is exclusively men, who have a higher risk of syphilis than the overall population.1
In this study, we found that patients with STI-relevant symptoms were more likely to be tested for an STI than patients with unrelated complaints. This is consistent with prior findings that STI testing in ED settings is largely driven by presenting symptoms.15 Research in ED settings has also found that many patients who present with symptoms suggestive of an STI do not have documented sexual histories.16 Sexual history taking is critical in evaluating likelihood of STIs.3 This is especially true in men, where STI screening guidelines differ based on sexual risk.3,17 Although we found that almost one third of urgent care patients who presented with STI-relevant symptoms did not have a documented sexual history, this may be an overestimation as we used chief complaint rather than final diagnosis for classification of symptoms. In general, however, our results support primary care findings that providers tend to conduct sexual histories infrequently for complaints that are not overtly related to sexual disease.18 We found that patients who had a documented sexual history at their urgent care visit were significantly more likely to have STI testing ordered at that visit. This is consistent with previous findings from ED settings.16 Importantly, we found that these results remained significant even when only the subset of visits with STI-relevant chief complaints were analyzed. This indicates that even when presenting symptoms might already suggest the need for STI testing, sexual history taking is still associated with significantly higher rates of testing. These results suggest that a sexual history assessment is a key first step to assessing whether a patient has elevated sexual risk and should be tested for STIs.
Sexually transmitted infections are often asymptomatic, and national guidelines for STI screening recommend testing patients based largely on sexual risk.3,17 Studies in ED settings have shown that screening identifies many patients who test positive for chlamydia, gonorrhea, and syphilis.11,19,20 Although little research has been conducted in urgent care settings, 1 study found that 1% of patients presenting with viral illness were positive for acute HIV.21 However, the role of acute care settings in providing screening for STIs is controversial. Although EDs and urgent care centers were not designed to provide primary care, a large share of first-contact medical visits now take place in EDs and nonprimary care settings.22 Emergency medicine physicians now handle more than half of first-contact ambulatory visits for uninsured patients, making this an opportunity to prevent the spread of disease. However, there is concern that providing primary care in acute care settings may undermine continuity of care.23 Multiple obstacles to effective STI diagnosis and treatment have been noted in the acute care setting and have limited these sites from providing STI screening. These include insufficient time, lack of training, and challenges with patient follow-up.11,24 It is possible that with quality improvement interventions, use of patient-administered sexual history assessments, and clinical decision support tools, identification of asymptomatic infected patients will improve.
There are several limitations to our findings. The results from this urban academic urgent care center in a largely Hispanic community may not apply to other settings, especially those that have different demographic populations. Our findings are limited by their reliance on EMR documentation, which may not reflect the entire medical history obtained or counseling provided at each visit. Providers may be more likely to document parts of the history deemed pertinent to the presenting symptom or workup, which may lead to documentation bias. In addition, although steps were taken to ensure standardization of the chart review process, a single reviewer was available to categorize chief complaints and perform the substudy chart review. Finally, in this study we use chief complaint data as proxy for presenting symptoms. Chief complaint data are less specific than a final diagnosis, which may have led us to overstate the number of visits for which STIs were on the differential diagnosis.
Our results suggest that there is a high prevalence of chlamydia, gonorrhea, and syphilis infection in men seen at urgent care centers. The prevalence of chlamydia and syphilis is especially high for those men presenting with genitourinary and sexual complaints. Providers in these settings are likely to test for STIs primarily based on symptoms rather than sexual risk. Given the asymptomatic nature of many STIs, urgent care centers may represent a practice location to identify, treat and lower community burden of disease. As STIs continue to become increasingly common among vulnerable populations that may not have primary care providers, urgent care visits will likely represent more opportunities for testing and treating STIs.
2. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2009. Atlanta, GA: U.S. Department of Health and Human Services; 2010.
3. Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64(Rr-03):1–137.
5. Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis 2008; 35(12 Suppl):S13–S18.
6. Scott DR, Batal HA, Majeres S, et al. Access and care issues in urban urgent care clinic patients. BMC Health Serv Res 2009; 9:222.
8. Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff (Millwood) 2010; 29:1630–1636.
9. Bureau of Sexually Transmitted Disease Prevention and Epidemiology, New York State Department of Health. STD Statistical Abstract 2009.
10. New York City Department of Health and Mental Hygiene. Geographic Co-Occurrence of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases and Tuberculosis in New York City. Epi Data Brief 2012; 20, 1–2.
11. White DA, Alter HJ, Irvin NA, et al. Low rate of syphilis screening among high-risk emergency department patients tested for gonorrhea and chlamydia infections. Sex Transm Dis 2012; 39:286–290.
12. Klein PW, Martin IB, Quinlivan EB, et al. Missed opportunities for concurrent HIV-STD testing in an academic emergency department. Public Health Rep 2014; 129(Suppl 1):12–20.
13. Merchant RC, Depalo DM, Stein MD, et al. Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible Chlamydia and/or Gonorrhoea urethritis. Int J STD AIDS 2009; 20:534–539.
14. Ernst AA, Samuels JD, Winsemius DK. Emergency department screening for syphilis in patients with other suspected sexually transmitted diseases. Ann Emerg Med 1991; 20:627–630.
15. Jenkins WD, Zahnd W, Kovach R, et al. Chlamydia and Gonorrhea screening in United States emergency departments. J Emerg Med 2013; 44:558–567.
16. Goyal M, McCutcheon M, Hayes K, et al. Sexual history documentation in adolescent emergency department patients. Pediatrics 2011; 128:86–91.
17. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for syphilis infection in nonpregnant adults and adolescents: US preventive services task force recommendation statement. JAMA 2016; 315:2321–2327.
18. Loeb DF, Lee RS, Binswanger IA, et al. Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting. J Gen Intern Med 2011; 26:887–893.
19. Todd CS, Haase C, Stoner BP. Emergency department screening for asymptomatic sexually transmitted infections. Am J Public Health 2001; 91:461–464.
20. Mehta SD, Rothman RE, Kelen GD, et al. Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention. Sex Transm Dis 2001; 28:33–39.
21. Pincus JM, Crosby SS, Losina E, et al. Acute human immunodeficiency virus infection in patients presenting to an urban urgent care center. Clin Infect Dis 2003; 37:1699–1704.
22. Pitts SR, Carrier ER, Rich EC, et al. Where Americans get acute care: increasingly, it's not at their doctor's office. Health Aff (Millwood) 2010; 29:1620–1629.
23. Villaseñor S, Krouse HJ. Can the use of urgent care clinics improve access to care without undermining continuity in primary care? J Am Assoc Nurse Pract 2016; 28:335–341.
24. Mumma BE, Suffoletto BP. Less encouraging lessons from the front lines: barriers to implementation of an emergency department-based HIV screening program. Ann Emerg Med 2011; 58(1 Suppl 1):S44–S48.