O5-S1.06 STD clinic triage based on computer-assisted self interview: the king county experience
Authors: Dombrowski J , Golden M 
Published: July 2011

Background

Triaging patients to different service levels based on responses to computer-assisted self interview (CASI) could increase the cost-efficiency of providing care in STD clinics.

Methods

In October 2010 we began having all patients at the King County STD Clinic provide their medical and sexual histories using CASI. Patients are triaged to express or routine care with a computer algorithm based on CASI data. The express care protocol is to collect specimens for HIV/STD testing without physical examination or counselling. Prior to implementation, we conducted 2 months of parallel data collection in which patients who completed CASI were interviewed by clinicians blinded to CASI results. We used κ statistics to compare CASI and clinician-obtained data. We tracked visit times for walk-in visits in two 10-day periods pre- and post-implementation, and attempted to survey all patients who used CASI on 10 days about interview and visit type preferences.

Results

875 patients completed both CASI and clinician interviews on 33 days (see Abstract O5-S1.06 table 1). Four months post-implementation, 2731 patients had completed CASI, 420 (15%) of whom were triaged to express care. Common reasons for triage to routine care were (mutually exclusive): symptoms (72% of routine care), contact to HIV/STD or a symptomatic partner (12%), and needing a vaccine (12%). Patients triaged to express care had lower rates of gonorrhoea (0.7% vs 5.7%, p<0.001), chlamydial infection (3.0% vs 7.5%, p<0.001) and syphilis (0% vs1.3%, p=0.02) than those triaged to routine care. Chart review and informal qualitative data indicated that clinician adherence to the express care protocol varied. Mean visit times were 32 (SD 3) min pre-implementation and 31 (SD 3) min post-implementation. 133 (39%) of 337 patients completed surveys. 106 (80%) either preferred CASI to clinician interview or had no preference; 27 (59%) of 46 asymptomatic patients preferred express care.

Abstract O5-S1.06 Table 1

Agreement between computer-assisted self-interview (CASI) and clinician documentation (Clin) for key clinical and behavioural variables (N=875)

Variableκ (95% CI)CASI+, Clin+ (%)CASI+, Clin− (%)CASI−, Clin+ (%)CASI−, Clin− (%)Reasons for exclusion from express care* Symptoms of STD0.67 (0.63 to 0.72)436 (50)118 (13)23 (3)298 (34) Known contact to HIV/STD0.60 (0.52 to 0.67)91 (10)72 (8)23 (3)689 (79) Symptomatic sex partner0.15 (0.05 to 0.26)8 (1)62 (7)10 (1)795 (91) Positive STD test, needs treatment0.12 (−0.03 to 0.27)2 (0)28 (3)0 (0)845 (97) Syphilis in past year0.40 (0.23 to 0.72)6 (1)13 (1)0 (0)856 (98) Vaccine indication†0.25 (0.20 to 0.31)71 (8)249 (28)5 (1)550 (63) Interested in Plan B‡0.13 (−0.04 to 0.30)3 (1)4 (2)25 (11)202 (86) Interested in contraception‡0.32 (0.16 to 0.48)15 (6)20 (9)20 (9)166 (71)Sensitive behaviours Male sex partner (lifetime), among men0.93 (0.90 to 0.96)285 (45)13 (2)10 (2)332 (52) Injection drug use0.82 (0.80 to 0.94)43 (5)7 (0)5 (0)820 (94) Methamphetamine use0.71 (0.63 to 0.79)68 (8)38 (4)10 (1)759 (87) Unprotected anal intercourse with partners of discordant or unknown HIV status, among MSM§0.58 (0.48 to 0.68)63 (22)35 (12)17 (6)170 (59) Transactional sex‡0.67 (0.50 to 0.84)15 (6)5 (2)8 (3)206 (88)

* Some reasons for exclusion not included here due to lack of comparative data in clinician documentation.

† Clin+=documented administration or patient declination of HAV, HBV or HPV vaccine.

‡ Limited to female patients; Clin+= dispensation of Plan B (for Plan B variable) or discussion of contraception plan (for contraception variable).

§ Limited to CASI+, Clin+ MSM.

Conclusions

Our CASI system collected accurate data on key aspects of the history, effectively triaged patients at lower risk for bacterial STD diagnosis and was acceptable to most patients surveyed. Lack of acceptability among some clinicians and poor patient recall of vaccine history were barriers to full implementation of the triage system. To date, CASI triage has not improved clinic efficiency as measured by visit time. Our experience suggests that non-clinician staff may be required to implement express care in STD Clinics.