Testing times: testing patient acceptance and ability to self-screen for a No-Talk Testing service

INTRODUCTION

In the UK, genitourinary medicine (GUM) clinics are struggling to accommodate the increasing numbers of patients attempting to access services.^1–3 The Edinburgh GUM Department is no exception, with 27,315 patient attendances in 9 April 2009 to 10 March 2010, ⁴ compared with 18,910 attendances 3 April 2004 to 4 March 2005. ⁵ GU medicine services have therefore needed to become more resource efficient to deal with these increasing patient numbers, including triaging of patients and more efficient use of clinical staffing and skill-mix.^6–8

At the Edinburgh GUM Department we therefore looked to re-design our services, diverting low-risk, low-care need patients into more resource-efficient, lower-tier clinical care pathways.^6–8 For this, we conceived a separate fast-throughput clinic, for selected asymptomatic patients, self-screening low-risk for significant sexually transmitted infections (STIs). This clinic would be delivered by junior clinical staff (e.g. junior nurses or clinical support workers), and not provide any other clinical care, advice or examination apart from routine STI screening – i.e. ‘No-Talk Testing’. Patients would self-obtain genital samples, while venepuncture would be undertaken by the practitioner.

We undertook a feasibility questionnaire study, to confirm that patients (a) would be interested in utilizing such a future service and (b) be able to self-screen for accessing it.

METHODS

All patients attending general clinics at the Edinburgh GUM Department during the period 5 August 2010 to 17 August 2010 were offered written information regarding the proposed future ‘No-Talk Testing’ (NTT) clinic and how it would function: i.e. only available for individuals identifying as low-risk on a self-completed risk assessment, not requiring other clinical care or advice apart from routine STI screening and not requiring examination.

An attached voluntary questionnaire (Appendix A) enquired about patient opinion on the proposed NTT service (award of a mark out of 10), specific feedback and whether (if deemed eligible) the respondent would utilize a future NTT service.

The questionnaire also requested an estimated self-assessment mark out of 10 on individual risk of having an STI at that clinic attendance and included pilot self-screen risk assessment questions (yes/no tick-box answers only). Respondents were asked whether they had any concerns at that clinic visit, beyond routine STI screening. Respondents were explicitly asked for consent for comparison of their self-screening with their clinician's assessment at that clinic review. Patients who declined consent were excluded from the second part of the study. Patients’ questionnaire data and, for patients who agreed to this, comparison data from clinical notes were analysed using SPSS 17. (SPSS Statistics 17.0, Chicago, IL, USA).

RESULTS

Comparison of respondent and clinician risk-assessments

The majority of respondents (194, 73%) were ineligible for NTT, based on their self-screening, due to either non-completion or scoring positive on one or more of the risk assessment questions.

Ten of the 267 respondents failed to self-award a mark out of 10 for their estimated risk of a STI at that clinic visit. The remaining 257 individuals self-scored an average mark of 4.56: interestingly, the 71 individuals eligible for NTT self-awarded an average mark of 3.25, compared with 5.06 by the 186 respondents who were ineligible for NTT.

Of the overall 267 respondents, 227 were included in the comparison part of the study: 35 individuals were omitted as they declined or failed to reply regarding comparison of their self-screening with their clinician's risk assessment. A further five were excluded due to not being seen in clinic on the day. There was no statistical difference in terms of demographics or decision on using a future NTT service, between patients who were included and omitted from the comparison part of the study.

Of the 227 included in the comparison, 183 (81%) had blood tests including HIV performed at that clinic visit, while 210 (93%) had chlamydia and gonorrhoea screening. All HIV tests were negative. Fifty-five (24%) individuals had another STI identified: 17 patients had chlamydial or non-specific urethritis (NSU), 23 had genital warts and five had gonorrhoea. A further seven patients were diagnosed with syphilis, herpes simplex virus, scabies or molluscum. The remainder had combined infections (chlamydia with either syphilis or warts).

Comparing self and clinician risk assessments, there was at least one discrepancy identified for 85 of the 227 individuals (37%); for a majority (70) this was a single discrepancy, though 12 had two discrepancies and a further three individuals had three discrepancies each (Table 1).

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Table 1

Discrepancies between respondent self-assessments and their clinical notes

Risk factor (RF) related to discrepancy	Risk factor only noted in self-screening	Risk factor only noted in clinical notes	Total discrepancies
Sexual contact/partner outside the UK	29 (94%)	2 (6%)	31
Presence of symptoms	6 (27%)	16 (73%)	22
Any other concern (apart from routine STI screening) at this clinic visit	14 (70%)	6 (30%)	20
Sexual contact/partner diagnosed with STI	8 (80%)	2 (20%)	10
Payment or receipt of money for sexual intercourse	9 (90%)	1 (10%)	10
All other risk factor discrepancies	6 (60%)	4 (40%)	10
Total risk factor discrepancies	72 (70%)	31 (30%)	103

STI=sexually transmitted infections

It was noteworthy that of the 65 individuals who appeared eligible for NTT on the basis of their self-screening, and consented to review of their clinical notes, 14 (22%) actually required an examination, extra tests or treatment at that visit (e.g. warts, symptomatic bacterial vaginosis).

DISCUSSION

The principle aim of this study was to decide on the feasibility of a NTT service in our department, both in terms of patient acceptance and ability to self-screen for access. Our results confirmed significant patient approval for the proposed service, with an average of 7.8/10 awarded for opinion, and 73% agreeing that they would consider utilizing such a future service. The majority of patients were also able to satisfactorily self-screen for access, though in 37% of cases there were some discrepancies between self and clinician risk assessments.

A significant limitation of our study is that we were unable to calculate a response rate for those who completed questionnaires from all who attended general clinics over the study period. It is possible that more of those individuals who disliked a NTT service chose not to complete the questionnaires compared with those who desired the option of such a future service.

It is reassuring that our study results of high levels of patient acceptability and satisfaction with self-sampling for STIs are borne out by other research on this topic.^9–12 Equally, the finding of higher numbers of risks being disclosed in patient self-completed assessments, in comparison to on direct questioning by an interviewer or clinician, is confirmed by previous studies.^13–15

In our study, the most common risk factor noted in the self-screen versus in clinician notes was ‘partners from outside the UK’ (33% of all discrepancies were related to this). This was likely due to this very strict wording in the self-screen questionnaire – in comparison, clinicians would only document as a risk factor any partners from a country of high prevalence for blood-borne viruses (rather than from outside the UK, per se). Following this pilot, therefore, the wording in the self-assessment was changed to specify only partners from high prevalence areas.

Interestingly, the only risk factor more commonly discussed in clinician notes, in comparison with self-screening, was presence of symptoms. It is difficult to speculate the reasons for this finding, but a majority of the symptoms noted in clinician notes alone were non-specific and not requiring treatment at that clinic visit (e.g. skin tags).

In summary, this feasibility study was generally supportive of the development of a NTT clinic pathway in our service, both in terms of patient acceptance and ability to self-screen for eligibility. Based on these results, a NTT clinic has been introduced in our service, and is proving to be both efficient and popular for the screening of asymptomatic low-risk individuals. We suggest that other GU medicine departments may wish to consider a similar approach to such patients.