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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