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STDClinicTriage:EvaluationoftheKingCountyApproach

Julie Dombrowski, MD, MPHUniversity of WashingtonPublic Health – Seattle & King County HIV/STD ProgramUW Public Health Capacity Building Center

• MismatchbetweenSTDClinicresourcesandneedservices

• Express care models- Testing only visits with no clinician evaluation- Potential benefits

• Improved clinic efficiency • Increased patient satisfaction

- Potential drawbacks• Lower quality of care (miss the opportunity to treat an STD on the same day as the visit)

• Decreased patient satisfaction

The Problem

• Approximately10,000patientvisitsperyear

The Local Context: Public Health – Seattle & King County STD Clinic

Age(years)19-2425-29≥30

18%23%59%

RaceWhiteBlackOther

60%20%20%

Hispanicethnicity† 9%Gender/sexualorientation

MSMMSW onlyWomen

42%34%24%

STDClinicVisitDemographics,2010-2015

STI Trend

Syphilis ↑74%

UrethralGC ↑146%

UrethralCT ↑61%

HIV ↓36%

CountywidetrendsinratesamongMSM,2007-2015

Diseasedetectionfocused

Triage in the PHSKC STD Clinic

AutomatedTriageAlgorithm• Symptoms• ContacttoSTD/HIV• Symptomaticpartner• HIV+,outofcare• HCV,wantstreatment• HSV,wantssuppressivemeds• Wantscontraception• Wantsemergencycontraception• Female,≥21yo,>1yr sincePap• Transortranssexpartner(previous)

yes no

Standardclinicianvisit

Expressvisit

HealthServicesfocused

Diseasedetectionfocused

Triage in the PHSKC STD Clinic

AutomatedTriageAlgorithm• Symptoms• ContacttoSTD/HIV• Symptomaticpartner• HIV+,outofcare• HCV,wantstreatment• HSV,wantssuppressivemeds• Wantscontraception• Wantsemergencycontraception• Female,≥21yo,>1yr sincePap• Transortranssexpartner(previous)

yes no

Standardclinicianvisit

Expressvisit

HealthServicesfocused

Thisdidnotworkoutatall.

• Opportunitytoevaluatethecounterfactualautomatedtriagestatustothegoldstandardclinicalevaluation

• Crosssectionalstudy

• AllpatientswhocompletedaCASI,Oct2010-June2015

• Outcome:automatedtriagestatusvs.“truth”

• “Neededastandardvisit”=infectionorsyndromethatshouldbedetectedandtreatedthesameday(e.g.1○ or 2○ syphilis,urethralGCdxongramstain)

• “Eligibleforexpresscare”=otherwise

Evaluation of PHSKC triage algorithm

Chambers L, et al. Evaluation of an express care triage model to identify clinically relevant cases in an STD Clinic. Sexually Transmitted Diseases, in press.

Results

Chambers L, et al STD 2017

WomenN=7,639

MenN=24,474

Appropriatelytriaged,N(%) 6,259(82) 21,337(87)

“Underserved”,N(%)(inappropriatetriagetoexpresscare)

120 (2) 893(4)

“Overserved” ,N(%)(inappropriatetriage tostandardvisit)

1,260(16) 2,244(9)

Sensitivity,% 97.9 94.6

Specificity(fordisease-focusedoutcome),% 33.0 71.9

Area underthecurve(95%confidenceinterval) 0.65(0.64-0.67) 0.83(0.83-0.84)

Eligibleforexpressvisits,N (%) 1881(24) 7976(33)

Triaged byCASItoexpressvisit 741(10) 6,625(27)

• Primary reasons for inappropriate triage to standard visit- Women

• No Pap in past year (50.6%)

• Reported contact to STD but did not receive treatment (14.8%)

• Wants contraception (14.8%)

- Men• Reported contact to STD but did not receive treatment (43.5%)

• Reported sore throat (17.6%)

Results

• Primary reasons for inappropriate triage to express care- Women

• Diagnosed with a key infection (45.8%) • (vaginitis without symptoms reported to clinician or kiosk)

• Reported key symptoms to the clinician but not the CASI (31.7%)

- Men• Reported key symptoms to the clinician but not the CASI (51.5%)

• Empiric treatment for contact to STD or otherwise (41.7%)

Results

• The algorithm had very high sensitivity & AUC for identifying patients needing standard visits

• The algorithm triaged many women to standard care who did not need it from a disease-focused perspective

• Inclusion of health service needs in algorithm- E.g.: Pap tests, contraception, HCV & HSV care- Depends on local context

• At ~5% of visits, patient reported symptoms to the clinician but not the CASI- Can be addressed by combining CASI with a brief screening

interview to confirm presence or absence of symptoms

• Could additional optimization improve the specificity of the algorithm?

Summary & Conclusions

Methods

- Primary or secondary syphilis

- Urethral or cervical gonorrhea diagnosed via Gram stain

- Non-gonococcal urethritis

- Epididymitis

- Proctitis

- Mucopurulent cervicitis

- Pelvic inflammatory disease

- Bacterial vaginosis

- Vaginal candidiasis

- Trichomoniasis

- Urinary tract infection

- Genital ulcer of unknown etiology

- Soft tissue infection

- Herpes simplex virus

Infection/syndrome that should be diagnosed and treated that day