Risk profile of walk-in triage compared with an appointment-based phone-triage evening clinic

Abstract

The aim of this study is to compare risk factors in new clients attending the walk-in triage-based day clinic (WITS) to those attending a telephone-triage appointment-based evening clinic of a sexual health service. The method involves an audit of computerized medical records of new clients attending between July 2002 and December 2007. There were 37,833 new clients of which 37,223 (98.4%) attended WITS and 610 (1.6%) attended the evening clinic. WITS clients were significantly older (31% vs. 30%, P < 0.041), more likely to be male (58% vs. 43%, P < 0.001), sex workers (6% vs. 3%, P < 0.001), not employed (34% vs. 10%, P < 0.001), diagnosed with gonorrhoea (1.7% vs. 0.7%, P < 0.041), herpes (4% vs. 2%, P < 0.000), non-specific urethritis (6% vs. 2%, P < 0.000) and less likely asymptomatic (35.1% vs. 53.4%, P < 0.001). Men attending WITS had significantly more female partners in the 12 months (3.9 vs. 3.0, P < 0.001), but other risks were similar in both clinics. A telephone-triage appointment-based evening clinic is important for asymptomatic high-risk individuals.

Keywords

triage clinic appointment clinic high-risk factors sexually transmitted infections

INTRODUCTION

Effective control of sexually transmitted infections (STIs) requires those at highest risk of STIs to have access to clinical services. The optimal method for providing accessible services is not well characterized, however, data appear to support the provision of same day access with triage to identify individuals at higher STI risk.¹ No studies have compared a walk-in triage system (WITS) operated during normal working hours with a telephone-based triage system that is appointment-based and operates after hours. Our objective was to compare the risk factors of new clients attending a walk-in triage day clinic to a telephone-triage appointment-based evening clinic.

METHODS

An audit of the electronic medical records of clients attending the Melbourne Sexual Health Centre (MSHC) was conducted between July 2002 and December 2007. New clients who attended the centre through the WITS were compared with new attendees of the evening clinic. A triage nurse assessed all new clients attending the WITS, which operated between 09:00 hours and 17:00 hours, five days a week except on Friday mornings. The triage-nurse triaged in clients with symptoms or who were considered high-risk for STIs and triaged out low-risk clients to see a general practitioner. No appointments were available for new clients during business hours. The average waiting time from arrival at the clinic to being seen by a practitioner was 40 minutes on an average. The evening clinic operated every Thursday from 17:00 hours to 19:30 hours, and catered for new clients as well as follow-up clients who could not re-attend during business hours. Clients could make appointments for the evening clinic after seeing the triage nurse if they could not wait to be seen on that day or through the telephone, after calling the MSHC to inquire about care. Clients making a telephone appointment for the evening clinic needed to first speak with a sexual health nurse, who discouraged attendance by low-risk individuals. Appointments could be made up to four weeks in advance. All new clients had their epidemiological data entered by a clinician onto the electronic medical record. Data included demographics, diagnosis and behavioural risk factors. This audit fulfilled the national guidelines for a clinical audit and did not require a formal ethics approval.²

Differences were determined using an independent t-test for numerical variables and the chi-square test for categorical variables in SPPS v.15 (SPSS Inc, Chicago, IL, USA).

RESULTS

During the audit period, 37,833 new clients attended the centre, of whom 37,223 (98.4%) attended through the WITS and 610 (1.6%) attended through the evening clinic.

WITS clients were older (P < 0.041), more often male (P < 0.001), married (P < 0.041), not employed (P < 0.001) and sex workers (P < 0.001) (Table 1). WITS clients were more likely to have had overseas sexual contact (P < 0.001), to have been previously HIV-tested (P < 0.001) and less likely to be asymptomatic (P < 0.001). Heterosexual men attending through the WITS had had more female sexual partners (P < 0.001). WITS clients were more likely to have been diagnosed with gonorrhoeae (P < 0.041), herpes (P < 0.000) and non-specific urethritis (P < 0.001).

Table 1

Characteristics of clients attending a walk-in triage-based day clinic vs. a telephone-triage appointment-based clinic*

Client characteristics	Triage (n = 37223)		Evening clinic (n = 610)		P value	OR	95% CI
Client characteristics	No. or mean	%	No. or mean	%	P value	OR	95% CI
Sex
Male	21,697	58.3	261	42.8	<0.001	1.9	1.6–2.2
Female	15,476	41.6	349	57.2		1.0
Transgender	47	0.1	0	0.0
No. of MSM ^†
No MSM	31,900	85.7	534	87.5		0.9	0.7
MSM	5323	14.3	76	12.5	0.2	1.0
Age (years)	3109		30.44		0.04		0.03–1.2
Marital status
Married	4622	13.4	56	10.4	0.02	1.34	1.0–1.78
Other	29,980	86.6	485	89.6		1.0
Employment status
Employed	22,530	66.5	476	90.2	<0.001	0.2	0.1–0.3
Other	11,352	33.5	52	9.8		1.0
Sex worker
No	32,981	88.6	560	91.8		1.0
Yes	2198	5.9	15	2.5	<0.001	2.5	1.5–4.3
Drug use
Never injected	32,299	94.8	543	95.6	0.4	0.9	0.6–1.2
Previously injected	1756	5.2	25	4.4		1.0
Sex overseas
No	25,586	74.9	468	82.2		1.0
Yes	8597	25.1	101	17.8	<0.001	1.6	1.3–1.9
Previous HIV test
No	11,762	45.9	200	52.1		1.0
Yes	13,850	54.1	184	47.9	0.02	1.3	1.04–1.5
No. male sexual partners (3/12) ^‡
MSM	5.4		5.5		0.9
Female	1.5		1.5		0.7
No. male sexual partners (12/12) ^§
MSM	15.4		20.7		0.2
Female	2.8		2.7		0.9
No. female sexual partners (3/12)**
Male	1.9		1.5		0.01
Female	1.3		1.3		0.9
No. female sexual partners (12/12) ^††
Male	3.9		3.0		0.01
Female	1.9		1.9		1.0
Diagnosed STIs^‡‡
No	26,654	71.6	484	79.3		1.0
Yes	10,569	28.4	126	20.7	<0.001	1.5	1.3–1.9
Chlamydia
No	35,415	95.1	582	95.4		1.0
Yes	1808	4.9	28	4.6	0.8	1.1	0.7–1.6
Bacterial vaginosis
No	36,081	96.9	595	97.5		1.0
Yes	1142	3.1	15	2.5	0.4	1.3	0.7–2.2
Gonorrhoeae
No	36,577	98.3	606	99.3		1.0
Yes	646	1.7	4	0.7	0.06	2.7	1.0–8.3
Herpes
No	35,674	95.8	601	98.5		1.0
Yes	1549	4.2	9	1.5	<0.001	2.9	1.4–5.9
Non-specific urethritis
No	35,128	94.4	600	98.4		1.0
Yes	2095	5.6	10	1.6	<0.001	3.6	1.9–2.5
Syphilis
No	37,125	99.7	610	100.0%		1.0
Yes	98	0.3	0	0.0	0.2	0.0	0.0–3.0
Warts
No	32,988	88.6	541	88.7		1.0
Yes	4235	11.4	69	11.3	1.0	1.0	0.8–1.3
Asymptomatic clients
No	24,149	64.9	284	46.6		1.0
Yes	13,074	35.1	326	53.4	<0.001	0.5	0.4–0.6

*Numbers shown in columns may not add up to the total number of clients because of missing data

^†MSM denotes men who have sex with men. Includes only male clients who have had sex with men in the last 3 or 12 months

^‡Includes only clients who have had sex with men in the last 3 months

^§Includes only clients who have had sex with men in the last 12 months

**Includes only clients who have had sex with women in the last 3 months

^††Includes only clients who have had sex with women in the last 12 months

^‡‡Total number of diagnosed sexually transmitted infections (STIs). Clients can be diagnosed with more than one STI. STI is defined as: chlamydia, bacterial vaginosis, gonorrhoeae, herpes, non-specific urethritis, syphilis and warts

OR = odds ratio; CI = confidence interval

DISCUSSION

In our study we found that clients attending the walk-in triage day clinic were more likely to have an STI and were in some, but not all respects higher-risk than clients attending a telephone-triage appointment-based evening clinic.

Few studies have addressed the risk and disease profile of attendees of after hours sexual health services compared with services during business hours. One Australian sexual health service found that their evening service was primarily utilized by a client group not defined as ‘high-risk’;³ however, the evening clinic in this study was not appointment-based. Another found that the risk characteristics of the clients attending the evening service were either similar or lower than the clients attending the day clinic, but it was not clear whether this evening clinic is appointment-based.⁴

The interpretation of the results of this study is complicated by the fact that several factors are being compared: in-person triage combined with a daytime walk-in clinic to a telephone-triage combined with an appointment evening clinic. This makes it difficult to attribute the differences in risk factors to the differences in triage system or the appointment system or the time of day. Nevertheless, for our purposes the differences we found do not argue strongly for extending evening booked clinics even if a phone triage system operates.

We have concluded that a telephone-triage appointment-based evening clinic with wait times of weeks is not appropriate for acutely symptomatic clients but important and well-suited to asymptomatic high-risk individuals.

Footnotes

ACKNOWLEDGEMENTS

We gratefully acknowledge Elias Track (MSHC) for extraction of the data and the VU University of Amsterdam, The Netherlands, for providing a grant to support the accomplishment of this research project.

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