Abstract
The aim of this study is to identify the demographic and diagnostic characteristics of patients attending a genitourinary medicine clinic with booked appointments and compare them with those of walk-in attendees. During a period of three months, 749 patients were seen with new episodes; 61% of them had booked appointments; 50.6% of walk-in attendees had symptoms compared with 40.6% in the appointment category; 58.6% of walk-in attendees gave specific reasons for attendance other than asymptomatic requests for sexual health assessment and tests, compared with 48.1% in the appointment category. It is more likely that students and individuals in employment to attend with appointments. The majority of individuals made the right decision for themselves whether to book appointments or just walk-in. The rates of non-D3 codes and sexually transmitted infections in the two groups were not statistically different.
INTRODUCTION
The UK Department of Health (DoH) recommended every patient attending genitourinary (GU) medicine services should be offered an appointment to be seen within 48 hours of contacting a service. 1 The rising prevalence of sexually transmitted infections (STIs) and the long waiting times are the main reasons for the DoH guidance. It may be perceived that target-driven attendances may promote inappropriate visits, some of which may be at times paying no attention to the incubation period of the common STIs. Patients often chose to attend clinics at times that suited them and when it was convenient for them to do so. 2 One has to acknowledge that long waiting time may increase the risk of complications and onward infection transmission, given the fact that many STIs are asymptomatic.
It is generally accepted that following a defined infection risk, STI testing should be deferred for about a week to enhance test reliability. Although there is no good scientific basis, this time interval is based on microbiological advice and clinical practice. More recent guidance from the Bacterial Special Interest Group of BASHH (British Association of Sexual Health and HIV) is in favour of repeating nucleic acid amplification test for chlamydia two weeks after the last exposure. 3
AIMS
We aim to identify characteristics and diagnosis patterns of walk-in GU medicine attendees and compare them with those of individuals who booked their appointments beforehand.
Clinical setting
The data analysed in this article relate to our previous clinic located near the centre of North Shields. The clinic is a community-based integrated model offering comprehensive sexual health services including GU medicine and contraception and is comprised of five consultation rooms with a common waiting area for all service users. Further expansion of the service was limited by the available space. Attendances to the GU medicine service were primarily by appointment, but one walk-in session was introduced at a very early stage to meet the increasing demands and to reduce the waiting time. The number of walk-in sessions was then increased when more resources became available and especially so, with the move to the new premises.
METHODS
Each attendee was given a registration form to complete while waiting to be seen. The data provided were entered into the computer database by the reception and clerical staff. Previously given and saved information may be updated if necessary. The software appointment diary enables recognition of date and time of attendance as well as type of attendance, whether an appointment or a walk-in. Once a final diagnosis was made, a KC60 code was added to each new patient episode. A database search was made to identify all patients who attended with new episodes during the first three months of 2007. Clinical records of all identified patients were retrieved. Each new and rebook patient episode was reviewed by the article author and a decision made as to the appropriateness of the patient's choice of type of attendance (appointment or drop-in). The decision is based on the reason/s for attendance, time of attendance in relation to sexual activity and the incubation period of common STIs, presence and nature of symptoms, history of contact with an STI, and having a known positive laboratory test result from another service (usually family planning clinic, general practice, antenatal care or termination of pregnancy services). Data analysed include attendance type, age, gender, employment status, reason for attendance, presence and nature of symptoms, appropriateness of attendance to the session in question, KC60 code and any additional problem or action performed.
Data are analysed using the chi-square test.
RESULTS
Seven hundred and fifty-three patients with new episodes attended the GU medicine service between 1 January 2007 and 31 March 2007. Two males and two females were excluded from further analysis as they walked out before being seen by the clinical staff. Therefore, we were able to analyse data from the remaining 749 (375 males and 374 females).
Demographics
The age range of all patients is 14–71 years, with a mean of 26.0 years. The age range of females is 14–60 years, with a mean of 24.7 years, whereas for males the range is 15–71 years with a mean of 27.3 years.
Female attendants were significantly younger than males, chi-squared test (P = 0.0197).
The younger age of females was maintained through all age categories (≤16 vs. >16, ≤20 vs. >20, ≤25 vs. >25).
Type of attendance
Four hundred and fifty-seven (61.0%) individuals attended with appointments and 292 walked-in (Table 1). In total, 64.5% (242/375) of men and 57.5% (215/374) of women attended with an appointment (chi-squared test, P = 0.048).
Attendance type by reason for attendance
STI, sexually transmitted infection
Reason for attendance
If we exclude individuals attending as contacts and those coming to receive treatment for known positive STI test results, the remaining 644 can be further analysed by the presence of symptoms. A total of 50.6% (124/245) of the walk-in attendees declared symptoms, compared with 40.6% (162/399) of the appointment category (chi-squared test, P = 0.013).
A specific reason for attendance (such as the presence of symptoms, contact with an STI or to receive treatment for a known positive STI test result) was declared by 58.6% (171) of the walk-in individuals, the remaining 121 (41.4%) gave no reasons other than requests for sexual health assessments and STI tests. Among the appointment group, specific reasons for attendance were given by 48.1% (220 individuals) and the rest (237) just wanted sexual health assessments and STI tests (chi-squared test, P = 0.005).
Gender and reason for attendance
In all 50.5% (189/374) of females attended for a sexual health check compared with 45.6% (171/375) of men. The rest gave specific reasons for their attendance (chi-squared test, P = 0.176).
Attendance type against employment
Six hundred and seventy-one individuals declared their employment status in the self-completed registration form. About 89.2% (370) of individuals in the appointment category were in employment or students, compared with 83.6% (214) in the walk-in category (chi-squared test, P = 0.037; Table 2).
Attendance type by employment status
Attendance type by appropriateness
A total of 97.6% of the appointment attendances were judged appropriate compared with 93.5% of the walk-in category (chi-squared test, P = 0.005; Table 3).
Attendance type and visit assessment
Attendance type and KC60 code
In total 52.2% of walk-in attendees had a non-D3 diagnosis code compared with 52.1% in the appointment category (chi-squared test, P = 0.121; Table 4).
KC60 code by attendance type
One hundred and ninety-four (40.1%) episodes of the appointments visits indicate the presence of an STI and/or another problem requiring treatment or further action taking, compared with 136 (46.7%) similar episodes in the walk-in category X2 test, P = 0.107.
Rates of STIs (data not shown) were comparable in the two attendance types. Fifty-seven (12.4%) individuals in the appointment category were found to have chlamydia compared with 43 (14.7%) in the walk-in category (chi-squared test, P = 0.46).
DISCUSSION
Until recently, due to increased demand, many GU medicine services reduced or abandoned walk-in clinics and introduced appointment systems instead. 4 However, with the escalating STIs and the long waiting time for appointments, it became necessary that new measures have to be implemented. The pressure on services had grown leading to changes in clinic policies, staff's role change and reduction in follow-up visits. 5
GU medicine clinics reviewed and modernised their practices when the UK government introduced a 48-hour access target for sexual health services. 5,6 The GU medicine service for North Tyneside introduced one walk-in session along with appointments long time before the introduction of the 48-hour access target. This was part of the ongoing efforts to provide more flexible options to service users, reduce appointment waiting time and to meet the increasing demand. With the availability of new resources and modernising the service, we were able to meet the target of offering all clinic contacts an appointment to be seen within 48 hours.
The purpose of this research is to identify any differences between individuals booking their appointments before attending the GU medicine clinic and those who walk in and are seen by the clinical staff.
The study period, January to March 2007, assumes that all schools and colleges are operational to reflect the actual demand, which may change with holidays.
As reported elsewhere, attendees to GU clinics are young people and many of them are less than 25 years of age. 7
The reasons for clinic attendance are taken from the information given by the patients to the professional they see at the time of attendance. It is noted that individuals attend the GU medicine clinic for either an asymptomatic request for sexual health assessment and STI tests or for a specific reason/s, such as the presence of symptoms, been a sexual contact with an STI, or coming to receive treatment for an infection diagnosed elsewhere. A higher proportion of walk-in attendees gave specific reasons for their attendances when compared with those who booked their appointments beforehand. Women were not statistically different from men in giving specific reasons for attendance.
Individuals with symptoms were more likely to walk in. This may indicate that the development of symptoms triggered an earlier attendance.
Although patients were not asked whether school or college opening times or work commitment influenced their choice, students and individuals in employment were a higher proportion of the appointment attendances.
The vast majority of individuals made the right decision in choosing their mode of attendance (appointment or walk-in), but those who booked their appointments beforehand made a more appropriate choice (97.6% vs. 93.5%, respectively).
It is noted that individuals in the walk-in attendance category had the same rates of D3 and non-D3 diagnosis codes as those who attended with appointments. Similarly, the rates of STIs in the walk-in individuals were not statistically different from those who attended with appointments. Genital chlamydia rates were not statistically different in the two types of attendance (12.4% and 14.7% in the appointment group and in the walk-in group, respectively).
We conclude that walk-in attendees have the same rates of STIs as those booking their appointments beforehand. Individuals with specific reasons for attendance other than asymptomatic requests for sexual health assessment and tests preferred to walk in. Our data showed that when GU medicine appointment and walk-in opportunities were made available, patients' choice between the two is highly accurate and consistent with the clinicians' judgement.