Abstract
The objective of this study was to identify factors associated with (i) longer patient travel time to genitourinary (GU) medicine clinics and (ii) not attending the nearest clinic. Questionnaires were completed by 4600 new attendees from seven sociodemographically and geographically different GU clinics across England between October 2004 and March 2005. These data were then linked to the routine clinic database. Median travel time was 25 minutes and varied significantly by clinic (P < 0.001) but not by gender (P = 0.96). Of all the respondents, 10% spent at least one hour getting to a GU clinic and this was significantly more likely in patients with less education, those who travelled by public transport and those who did not attend their closest clinic. Longer travel times were not associated with delays in seeking care. Patients reporting a previous sexually transmitted infection (STI) diagnosis were more likely not to go to their nearest GU clinic (P = 0.0006), as were those who used/tried to use other healthcare providers prior to attending the clinic (P = 0.007). To facilitate access to STI care, comprehensive local services need to be provided to avoid long journey times, especially for those who have to rely on public transport to get to clinic.
Introduction
Poor access to genitourinary (GU) medicine clinics continues in the UK despite increasing productivity and work intensity. We use data from a large survey of GU clinic attendees to identify factors where interventions may be expected to reduce delayed access to sexually transmitted infection (STI) care. Specifically, we identify factors associated with long travel time to clinic and not attending the nearest clinic.
Methods
The study methodology has previously been reported. 1 Briefly, seven GU clinics across England with contrasting demographic, geographic and service configuration characteristics were recruited between October 2004 and March 2005. New attendees were given written information about the study and invited to complete an anonymous 22-item self-completion questionnaire exploring health-seeking behaviour and contact with services in relation to patients’ current problems. Clinic identification numbers were used as a link to the routine clinical database. Chi-square was used to determine statistical significance (P < 0.05 for all analyses) and logistic regression was used to obtain crude and adjusted odds ratios. STATA 8.0 survey command was used for analyses to account for clustering by clinic.
Results
Four thousand six hundred questionnaires were completed with matched routine clinical data. Of this, 8% of the questionnaires were excluded owing to missing travel time and the final dataset consisted of 4233 questionnaires of which 48% were from men and 52% from women. Median travel time to clinic was 25 minutes and 10% of patients took one hour or more to get to the clinic with significant interclinic variation (range 4– 14%). This proportion was greatest among patients attending an outer London clinic (14%) and a provincial town clinic serving a large rural population (13.5%) clinic. The maximum reported journey time was two hours 45 minutes by bus (median range 20–30 minutes). Prolonged journey times were associated with less education, travelling by public transport and not attending the nearest clinic (Table 1). Travel times were not significantly associated with the diagnosis of an acute STI, delay in patients seeking care (median seven days) nor with delay at clinics before patients could be seen.
Factors associated with extended travel time to genitourinary clinic
Adjusted for gender, age, ethnicity and education
In patients aged over 21
Overall, 11% of patients did not go to their nearest GU clinic and this was more common in those reporting a previous STI diagnosis (15% vs. 10%, P = 0.0006), and when another healthcare provider had been approached prior to going to the clinic (14% vs. 10%, P = 0.007).
Discussion
Measuring the time patients’ spend travelling to clinic can help to plan the location of clinics for efficient service delivery, and also help to minimize cost and inconvenience to patients.2,3 Longer travel times can be associated with higher clinic appointment default rates 4 and may be of particular relevance for rural communities and in elderly populations. 5 Attendance rates for health screening, as opposed to treatment, may be particularly sensitive to increased journey times. 6 For GU clinic attendees, who are often young and suffer socioeconomic deprivation, patient travel expenses comprise a significant proportion of the overall cost of attending a clinic.7,8
Our data suggest that one in 10 GU clinic attendees travel for more than one hour to get to a clinic, and highlights the need for regular monitoring and improved local provision of sexual health services if high rates of STI screening are to be achieved.
We also found that 11% of GU clinic patients were not attending their closest clinic. This could reflect patients ‘shopping around’ to find an available clinic but the delay at the clinics before patients could be seen was not associated with attendance at the nearest clinic making this less likely. Those with a prior STI diagnosis or who had been to a different healthcare provider before going to the GU clinic were also more likely to attend a distant clinic but we were unable to assess whether this was the result of direct referral, patient choice, concerns about confidentiality, prior experience or due to confounding variables. The choice of which clinic to attend is influenced not only by journey time but also the convenience of transport links and perception of quality of care at different clinics, 9 factors which were not assessed in this study. Inability to speak the local language may also limit the identification and use of local facilities. 10
Patients travel an average of 25 minutes to attend a GU clinic in the England with 10% travelling for over one hour, but prolonged journey times are not associated with delays in seeking care. A significant minority of patients choose not to attend their closest GU clinic and the reasons for this require further exploration.