Referring clinic turn-aways to GetCheckedOnline to increase capacity for timely STI/HIV testingHaag D, Bondyra M, Hottes TS, Wong S, Doupe G, Buchner C, Holgerson N, Grennan T, Fairley CK, Shoveller J, Ogilvie G, Gilbert M

World STI & HIV CongressSeptember 13-16, 2015

Disclosure

No conflicts of interest to disclose

2

Demand on STI clinic services

• Increasing demands on STI clinical services, coinciding with reductions in capacity and infrastructure1

• Wait times for scheduled or drop-in appointments are a known barrier to testing2

• Need for novel strategies to meet demand:– Streamline clinic flow:

• Computer-assisted self-interviewing3

– Triage asymptomatic or low-risk patients:• Express specimen collection (including self-

collection)4

31Wong et al, 2010; 2Hottes et al, 2012; 3Vodstrcil et al, 2011; 4Rukh et al 2014.

British Columbia is no exception

• Increasing rates of STI• Closures of STI clinics in some

regions• STI clinics operated by the BC

Centre for Disease Control (BCCDC):– Operating at maximum

capacity– Increasing number of drop-in

clients are turned away

• Pressures led to development of an online STI testing service as extension of BCCDC

• Could online testing be an option for drop-ins who are turned-away?

4

Purpose

• Assess the feasibility of referring STI clinic clients who drop-in but can’t be seen to the new online STI testing service

• Pilot program to establish proof-of-concept incorporated into current clinical practice

5

6

Getcheckedonline.com

GetCheckedOnline (GCO)

• Testing for Chlamydia, gonorrhea, syphilis, HIV & hepatitis C

• Integrated with current STI clinical practices at BCCDC

• For clients who are asymptomatic and not contacts

• Six specimen collection sites in Vancouver

• Launched September 2014

7

GetCheckedOnline access points

8

• 2 ways to access testing: – email invitation to STI clinic clients that sign-up

during clinic visit– access code which can be used to create an

account

• Unique access codes created for different types of promotion (e.g., print or online) can track uptake across channels

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep2014 2015

Q4 Q1 Q2 Q3

e-mail invitations access codes to turn-aways

access codes via promotion campaign to MSM

Q4 Q2

Piloted in three clinic settings

9

Provincial STI Clinic

Outreach STI Clinic

Health Initiative for Men Clinic

(HIM)

Annual volume

>10,000 clients >9,000 clients > 5000 clients

Demographics

60% Male 80% Male 99% Male

Type of visits

AppointmentsDrop-in

Drop-in AppointmentsDrop-in

Referral to GCO

BrochureCode over

phone

Brochure Brochure

How made aware

Active (clerical, nursing staff)

Passive (displayed in waiting room)

Active (staff and volunteers)

Referrals documented?

Yes No No

Methods

• Data sources:– Referral logs (Provincial clinic only)– GCO program data, by access code (all pilot clinics)– Common electronic medical record (total tests)

• Analysis:– March 1 to July 31, 2015 (five months)– Creation of accounts and requisitions, testing and

results– Comparison of uptake at Provincial Clinic (clinic vs

phone) and across clinics– Fisher’s exact test or Chi-square test, p<0.05

10

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep2014 2015

0

10

20

30

40

50

60

70

80

90

100

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Accounts created Requisitions created Completed testing Positive results% Completed testing (if Req; 3mos avg)

Number Percent

Trends in uptake

11

Turn-away codes MSM campaign

Referrals to GCO – Provincial STI Clinic

• Schematic illustrating uptake of referrals

12

In Clinic

By Phone

Total turned away 641

Turned away no appt

560

Access code provided

37 108

GCO accounts created

12 80

Completed testing 10 62

Positive results 1 (Chlamydi

a)

1 (Gonorrhe

a)

87%

7%

32%

83%

10%

74% *

78%

2%

* p<0.0001, compared to in clinic

Referrals to GCO – By clinic

• Schematic illustrating uptake of referrals

13

Provincial Clinic

Outreach & HIM Clinics

GCO accounts created

92 37

Completed testing 72 7

Positive results 2 0

Clients tested in clinic

2,413 2,949

Total tested 2,485 2,956

Increased capacity

2.9% 0.2% *

78%

3%

19% *

0%

* p<0.0001, compared to provincial clinic

* p<0.0001, compared to provincial clinic

Summary – Key findings

• Referring to GCO was feasible and led to new STI diagnoses – proof of concept established!

• Clients provided access code over phone were more likely to create accounts than drop-ins turned away

• Lower use of access codes / completion of testing by clients in outreach/HIM clinics:

– Passive versus active referral;

– Prefer to wait or return another time (satisfied with services)

• Small increase in capacity at the provincial clinic14

Limitations & next steps

• Operational proof of concept only: – Add-on to usual operations, relied on existing

procedures– Generic codes, not able to link to specific clinic clients

in EMR

• Do not know whether intervention led to earlier diagnosis:– Time from access code given to completed testing– Comparison to other turn-aways who booked

appointments

• Promising results and more rigorous evaluation needed:– Consistent offer of referral codes– Unique codes linked to client records and testing

history in EMR– Client survey of turn-aways– Compare characteristics of turn-aways to other clients– Controlled study designs

15

Acknowledgments

16

Kim Thomson Kit Fairley Dan Coombs Jean Shoveller Thomas Kerr

Kate Shannon David Wilson Wendy Marina-Davis Titilola Falasinnu

Gina Ogilvie Elaine Jones Warren Michelow Mark Bondyra Travis Salway Hottes

Darlene Taylor Derek Kline Kirsten Smillie Irv Sandstra Irene Llowen-McFetridge

Rich Lester Kris Stephenson Monica Valyi Manav Gil Liz Elliot Melanie Achen

Bobbi Brownrigg Daniel Grace Stanley Wong Janine Farrell Cathy Chabot

Amanda Bonnell Bernhard Konrad Terry Trussler Lisa Elliott Natalie Holgerson

Rick Marchand Olivier Ferlatte Rod Knight Jason Wong Troy Grennan Meaghan Thumath David Moore Nick Foster Shannon Kopp Glenn Doupe Dean Mirau Suki Ludu Wendy Conway-Brown Gina Ogilvie Anna Carson Tony Mitchell James Bayne Kelly Shorter Kacy Sloan

Cheryl Campbell John Andruschak Linda Hoang Anna Paccagnella Ben Wan

Cindy Brice Ciaran Aiken Arden Krystal Mark Tyndall Judy Isaac-Renton Mel Krajden Catherine Simms Leon Bresler Wayne Robert Jody Jollimore Lydia Drasic Norjean Hassam Mike Kwag James Lauder Robin Parry Janet Madsen Elgin Lim Doug McGhee Chris Buchner Yin Chang Susie van der Valk Judith Reyes-Metcalf Jackie Holloway

Jenny Matthews Jesse Brown Hans Bosgoed Sam Larkham Robin Parry

BC Centre for Disease ControlBC Public Health Microbiology and Reference

LaboratoryUniversity of BC Youth Sexual Health Team

Research PartnersProvincial Health Services Authority

BC Regional Health AuthoritiesGetCheckedOnline clients

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