Anatole Menon-Johansson

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.

Sexually transmitted infections in primary care

Limited exposure to sexual health training, combined with a fear of having difficult conversations, may drive anxiety in dealing with patients’ sexual health concerns. This article focuses on how to assess a patient’s risk of sexually transmitted infections and deliver basic services for managing these infections safely in primary care. Sexual health delivery is changing, but a role for GPs is likely to continue.

Internet-accessed sexually transmitted infection (e-STI) testing and results service: A randomised, single-blind, controlled trial.

Background Internet-accessed sexually transmitted infection testing (e-STI testing) is increasingly available as an alternative to testing in clinics. Typically this testing modality enables users to order a test kit from a virtual service (via a website or app), collect their own samples, return test samples to a laboratory, and be notified of their results by short message service (SMS) or telephone. e-STI testing is assumed to increase access to testing in comparison with face-to-face services, but the evidence is unclear. We conducted a randomised controlled trial to assess the effectiveness of an e-STI testing and results service (chlamydia, gonorrhoea, HIV, and syphilis) on STI testing uptake and STI cases diagnosed. Methods and findings The study took place in the London boroughs of Lambeth and Southwark. Between 24 November 2014 and 31 August 2015, we recruited 2,072 participants, aged 16–30 years, who were resident in these boroughs, had at least 1 sexual partner in the last 12 months, stated willingness to take an STI test, and had access to the internet. Those unable to provide consent and unable to read English were excluded. Participants were randomly allocated to receive 1 text message with the web link of an e-STI testing and results service (intervention group) or to receive 1 text message with the web link of a bespoke website listing the locations, contact details, and websites of 7 local sexual health clinics (control group). Participants were free to use any other services or interventions during the study period. The primary outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and self-reported STI diagnosis at 6 weeks, verified by patient record checks. Secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI. Participants were sent a £10 cash incentive on submission of self-reported data. We completed all follow-up, including patient record checks, by 17 June 2016. Uptake of STI testing was increased in the intervention group at 6 weeks (50.0% versus 26.6%, relative risk [RR] 1.87, 95% CI 1.63 to 2.15, P < 0.001). The proportion of participants diagnosed was 2.8% in the intervention group versus 1.4% in the control group (RR 2.10, 95% CI 0.94 to 4.70, P = 0.079). No evidence of heterogeneity was observed for any of the pre-specified subgroup analyses. The proportion of participants treated was 1.1% in the intervention group versus 0.7% in the control group (RR 1.72, 95% CI 0.71 to 4.16, P = 0.231). Time to test, was shorter in the intervention group compared to the control group (28.8 days versus 36.5 days, P < 0.001, test for difference in restricted mean survival time [RMST]), but no differences were observed for time to treatment (83.2 days versus 83.5 days, P = 0.51, test for difference in RMST). We were unable to recruit the planned 3,000 participants and therefore lacked power for the analyses of STI diagnoses and STI cases treated. Conclusions The e-STI testing service increased uptake of STI testing for all groups including high-risk groups. The intervention required people to attend clinic for treatment and did not reduce time to treatment. Service innovations to improve treatment rates for those diagnosed online are required and could include e-treatment and postal treatment services. e-STI testing services require long-term monitoring and evaluation. Trial registration ISRCTN Registry ISRCTN13354298.

Failure to maintain patient access to GUM clinics

We read with interest the article published by Cassell et al 1 about the maintenance of patient access to genitourinary medicine (GUM) clinics following a switch to an appointment based system. Their data show no significant change in the age, ethnic mix, symptom status, and disease mix following the change to appointments. In addition, such a system of 35% prebooked appointments produced an increase in the number of patients seen over that time. A new appointment based system was introduced at the John Hunter genitourinary medicine clinic at the Chelsea and Westminster Hospital in October 2001. This comprised 80% of appointments which were prebooked …

Interventions to increase access to STI services: a study of England's ‘high-impact changes’ across three central London clinics

Background Increasing access to sexual health services is a key objective for the Department of Health in England and Wales. In 2006 it published 10 high-impact changes (HICs) designed to enhance 48 h access to genitourinary medicine services. However, there is limited evidence on the effectiveness of the proposed interventions. Objective To evaluate the implementation of five HICs in three sexual health clinics over 4 years. These HICs included a text message results service, nurse-delivered asymptomatic service, clinic refurbishment, a centralised booking service and an electronic appointment system. Methods The effect of HICs was evaluated by measuring clinical activity, number of sexual health screens performed, and patients seen within 48 h. These data were obtained from the clinic database, mandatory reports and Health Protection Agency waiting time surveys, respectively. Results The median number of new patients seen per month increased from 3635 to 4263 following the implementation of the five HICs. The follow-up/new patient ratio fell from 0.67 to 0.21 during the study. The biggest fall corresponded to a rise in patients receiving results by text message, from 0% to 40%. Only the centralised booking service was associated with a significant increase in the number of new patients seen. Discussion Providing results by text message was associated with a reduced number of follow-up patients, while implementation of a centralised booking service coincided with a significant increase in patient access. Further research is required to evaluate the relative importance of the other HICs.

Proven prevention tools for addressing STI epidemics

The ongoing rise of sexually transmitted infections (STIs) poses a global public health challenge and the risk of acquiring one of these infections depends upon sexual practices, the number of sexual encounters and the location of that individual within the sexual network. Commercial sex workers (CSWs) have potentially a pivotal role in the transmission of STIs; however, a new study presented in this journal describes markers of risk but no increase in infections amongst men who pay for sex (MPS). This commentary highlights some of the growing evidence regarding STI prevention and the value of using these tools to protect CSWs, their clients and by extension the sexual partners of MPS.

Higher specialty training in genitourinary medicine: A curriculum competencies-based approach:

Specialty trainees in genitourinary medicine (GUM) are required to attain competencies described in the GUM higher specialty training curriculum by the end of their training, but learning opportunities available may conflict with service delivery needs. In response to poor feedback on trainee satisfaction surveys, a four-year modular training programme was developed to achieve a curriculum competencies-based approach to training. We evaluated the clinical opportunities of the new programme to determine: (1) Whether opportunity cost of training to service delivery is justifiable; (2) Which competencies are inadequately addressed by direct clinical opportunities alone and (3) Trainee satisfaction. Local faculty and trainees assessed the ‘usefulness’ of the new modular programme to meet each curriculum competence. The annual General Medical Council (GMC) national training survey assessed trainee satisfaction. The clinical opportunities provided by the modular training programme were sufficiently useful for attaining many competencies. Trainee satisfaction as captured by the GMC survey improved from two reds pre- to nine greens post-intervention on a background of rising clinical activity in the department. The curriculum competencies-based approach to training offers an objective way to balance training with service provision and led to an improvement in GMC survey satisfaction.

O011 Hitting the bull’s-eye: Partner notification real-time metrics

Introduction Partner notification (PN) is a key but challenging service to deliver. The gold standard for PN confirmation is health care worker (HCW) verification. A cloud-based anonymous tool was developed to inform partners, support them to find a testing service and record when the HCW uses a unique code to reveal the sexually transmitted infection (STI), timing of PN initiation and closing the PN loop. Objective To test the impact of the new tool on PN delivery. Methods A live pilot commenced on 27th January 2016 and analysis of all index patients using the PN tool over 49 days was performed using spreadsheet pivot tables and formulas. Results A total of 259 index patients across nine providers with nine different STIs were analysed. These index patients declared 421 contactable contacts and 162 (38%) were informed using the tool. A total of 96 (59%) partners contacted opened the link embedded in their text message or email and 30 (31%) were seen and tested by a HCW. A total of 13 STI testing centres received partners and the median (range) distance & time from PN initiation to HCW verification was 2.1 (0.0–12.3) kilometres & 63.8 (1–189.5) hours respectively Discussion The PN tool has demonstrated that it is able to support partners to find a service and get tested expeditiously. The limited number of partners being informed is the rate limiting step and more work is required to develop strategies to enable effective PN initiation.

2nd BASHH Oxford Diagnostics Course, November 2015

The second British Association for Sexual Health and HIV Oxford Diagnostics Course of 2015 focussed on recent challenges and emerging concepts within diagnostics and service design. In response to increasing sexually transmitted infection rates and subsequent demand on UK sexual health services, multiple approaches to improving patient flow and reducing waiting times were presented. The value of novel remote sexually transmitted infection testing was explored, with a description of the patient journey, emerging demographics and rates of testing uptake for the UKs leading National Health Service provider. A cost-benefit evaluation was made for the use of nucleic acid amplification tests versus traditional microscopy and culture for detecting Trichomonas vaginalis, with practical consideration of application to higher risk groups. Two speakers stressed the importance of vigilance against growing antimicrobial resistance. The significance of testing for genotypic markers for antimicrobial resistance, and the emergence of point-of-care tests for resistance were also presented. The meeting closed with a first-hand account of tendering, and practical advice on rebuilding professional relationships and services after a competitive process.

O18 Use of a novel queue management software program to improve patient satisfaction at a large urban gum clinic

Background/introduction Since opening a new clinic there has been high patient flow particularly at weekends. Even with adequate staffing and patients performing self-triage, waiting times sometimes exceed three hours. This frequently resulted in patient aggression towards reception staff, poor patient feedback about waiting times and staff complaints with incident reporting forms (IR1). In October 2014 – new software was introduced to improve patient satisfaction. Methods Upon entry to the clinic all symptomatic patients were registered on the program which automatically sent a text message informing them of their place in the queue. They were then invited by reception staff to leave the clinic until they were sent another text when they were due to be seen. Patients in possession of a Smartphone could refresh a link to check their place in the queue at any time. IR1s and patient feedback were assessed before and after implementation Results Average no of symptomatic patients seen over a weekend was 70 with an average wait time of 89 min. In the 4 month period prior to the software implementation there were 6 IR1 forms received from staff about patient aggression. In the 4 month period after its introduction there were none. Two months post its introduction the average number of patient complaints about waiting times received was 1 from an average of 4 prior to its use. Conclusion The introduction of the queuing software has been an inexpensive and effective method of reducing complaints about patient waiting times and improving patient satisfaction with the service.