Abstract
The Department of Health has addressed access to genitourinary medicine services by setting targets that 100% of patients should be offered an appointment within 48 hours of contact and 95% should be seen within 48 hours. Such rapid access appointments are often declined by patients. We wished to ascertain whether patient perception of health risk or the presence of symptoms suggestive of a sexually transmitted infection (STI) might influence how quickly patients accept an appointment. We designed a two-armed study which demonstrated that up to 37% of patients offered an appointment within 48 hours declined it, with work commitments offered by 84% of these patients as the reason for deferring attendance. The presence of symptoms did not influence whether patients accepted an early appointment, however the patient's perception of health risk associated with an untreated STI was statistically significantly associated with earlier attendance (P < 0.0001). Increased public education regarding the consequences of untreated STI may therefore improve the acceptance by patients of appointments within 48 hours.
INTRODUCTION
The timely treatment of patients with sexually transmitted infections (STIs) is vital to prevent individual patient morbidity and to reduce onward transmission of infection. 1 This ideal was emphasized in the Operating Frameworks for the NHS in England, which established 48-hour access to genitourinary medicine clinics as a priority target with 100% of patients to be offered an appointment within 48 hours of contacting a service by March 2008. 2 Furthermore, Strategic Health Authorities were asked to plan for 95% of patients to actually be seen within 48 hours; 3 however, this target has been controversial with some centres reporting that this is not always necessary, or indeed desired, by patients. 4,5
Several previous studies have addressed the potential reasons why patients decline an appointment to attend services within 48 hours. 4,6–8 Common themes that have emerged include lifestyle factors such as work or family commitments 6,7 and therefore the desire to attend clinics at certain times including those at evenings or weekends. 4,6 The overriding conclusion from research conducted to date has been that patient choice is paramount; however, few factors have been identified other than lifestyle reasons that indicate what influences patient choice of appointment and, more importantly, whether that choice is fully informed. Those patients who have a high risk of current STI should be seen as quickly as possible, regardless of lifestyle factors. We therefore designed a study to assess whether patient choice to be seen within 48 hours was related to the presence of potential symptoms of an STI, or to the patient's perception of the risk to their health of a potential untreated STI.
METHOD
This study contained two arms. The initial study arm was retrospective and conducted within the Sexual Health Clinic in the Countess of Chester Hospital for a two-week period in July 2008. During this period, patients attending general sexual health clinic appointments completed a short questionnaire that recorded the following parameters:
Sex; Age; Presence of symptoms; Whether an appointment had been offered within 48 hours and if this appointment was accepted; Reasons for not accepting an appointment within 48 hours. Patients' perception of any risk to their health by delaying their appointment; Overall satisfaction with the appointment made; Suggested additional measures to improve service provision.
(Categorized into work commitments, family commitments, transport issues, specific date wanted and others.)
(Categorized into evening clinic, weekend clinic, walk-in clinic, different clinic location and others.)
The second arm of the study was cross-sectional and conducted in the Countess of Chester Hospital's appointment call centre for a two-week period in July 2008. During this period, patients who declined an appointment offered within 48 hours of calling were interviewed by telephone using a standard proforma that recorded the same parameters as above.
Data from both study arms were recorded categorically on Microsoft Excel worksheets and for statistical analysis contingency tables were constructed. Fisher's and chi-square tests were used to assess statistical significance and results were expressed as two-tailed P values with P < 0.05 deemed to be statistically significant.
RESULTS
Patients attending clinic (retrospective data)
During the study period, a total of 115 questionnaires were distributed to patients attending general sexual health clinic appointments at the Countess of Chester Hospital. Of these, 110 were completed and returned, equating to a return rate of 96%. Regular monitoring of clinic access suggests that all patients were offered an appointment within 48 hours; however, only 73% (80/110) of patients recalled being offered and accepting an appointment within 48 hours; 16% (16/110) recalled refusing the appointment within 48 hours and 13% (14/110) denied that they were initially offered an appointment within 48 hours. Overall, 59% of the attending clinic patients were men and the median age was 27 (range 15–60 years). Work commitments was by far the most common reason cited for delaying attendance at the clinic with 75% (12/16) of patients deferring to attend beyond 48 hours as a result of work. When asked to choose potential alterations to service provision which might encourage them to attend an appointment sooner, patients expressed a preference primarily for evening clinic appointments (50%) followed by walk-in clinics (44%) and weekend clinics (19%).
Patients telephoning the call centre for an appointment (cross-sectional data)
During the designated study period, a total of 138 patients telephoned the appointments call centre to request an appointment at the sexual health clinic. Of these, 100% were offered an appointment within 48 hours. Overall, 37% (47/138) call centre patients declined an appointment within the 48-hour timeframe and were interviewed by telephone by the investigators. Of the ‘decliners’ 43% were men and the median age was 24 years (range 17–60 years), neither of these demographic characteristics differing significantly from the patients who completed questionnaires in clinic in the first arm of the study. Approximately, half of the patients (45%) declining a 48-hour appointment offered by the call centre had symptoms and ‘work commitments’ was again the most common reason given for deferring attendance (87%). Evening clinics were again proposed most frequently by patients as a helpful addition to services (55%) followed by walk-in clinics (25%) and weekend clinics (23%).
Differences between patients accepting and those declining an appointment within 48 hours
Overall from the telephone survey and clinical questionnaire, there were 80 patients who accepted a clinic appointment within 48 hours (‘Acceptors’) and 63 patients who declined an appointment within 48 hours (‘Decliners’). There were no significant differences between acceptors and decliners with respect to gender, age or presence of symptoms. However, when patients were asked if they perceived any potential health risks in delaying an appointment for testing for STIs acceptors were statistically significantly more likely to answer ‘yes’ than decliners (41/80 versus 9/63, P < 0.0001).
DISCUSSION AND CONCLUSION
Our real time cross-sectional data suggested that 37% of patients preferred not to accept the offer of an appointment to be seen within 48 hours. This is high, but similar to the rates of 24–38% reported by similar previous studies. 4,6,7 Interestingly, when asked retrospectively only 16% of patients reported declining the offer of an appointment in less than 48 hours, which may be a reflection of either recall bias, or the fact that a sizeable proportion of actual clinical attenders may be ‘walk-in’ emergencies, needing to be seen on the day. Recall bias is almost certainly the explanation for the 13% of patients who denied ever being offered an appointment within 48 hours and highlights one of the potential pitfalls in retrospective questionnaire-based data collection. Gratifyingly, when asked if they were satisfied with the appointment made, more than 98% of our overall study populations responded ‘yes’ with 96.8% of those who declined an appointment within 48 hours also expressing satisfaction with the appointment they chose. Our data therefore support the Department of Health emphasis on patient choice 9,10 and echo the previous findings that patients wish to be able to choose an appointment that suits them and are happy with this, even if it is more than 48 hours from booking. 5,8
There are understandable reasons why patients do not accept appointment at sexual health clinics within 48 hours of contact with the service. Work commitments are the primary reasons stated by patients for declining an earlier appointment, both in ours and other studies. 6 In keeping with this our patients expressed a preference for evening clinic appointments to be provided (84.1% of all ‘Decliners’); however, this was not the most popular suggestion according to other previous studies. 6,7 In contrast to Carlin and Kellock 6 weekend appointments were the option thought to be least helpful by our cohort, including those less than 25 years old. Younger patients in our study did however express a statistically significant preference for walk-in clinics when compared with those older than 25 years (P = 0.0087, data not shown).
It is apparent from our data, however, that service opening hours are not the only consideration for patients. Ours is the first study to demonstrate that patients who perceive a potential health risk in delaying attendance for STI testing and/or treatment are more likely to wish to be seen within 48 hours, and that this risk perception does not correlate with the presence of symptoms. This dichotomy would perhaps be understandable if we believe that our patients are well enough educated to understand that a lack of symptoms does not necessarily indicate the absence of STI. However, fewer patients in our overall cohort perceived themselves to be at any health risk by delaying treatment (n = 50) than actually had symptoms (n = 73); therefore, there is certainly a cohort of patients who have symptoms of an STI but do not see this as a risk to their health if assessment and treatment are delayed. Furthermore, these patients are likely to continue to have unprotected sex with new partners before they are seen and treated. 11 In addition to this, not all patients who describe themselves as symptomless truly are, and a significant proportion will subsequently be diagnosed with an STI. 12
Our data verify the suggestion by Carlin and Kellock 6 that we should be providing information as to why being seen within 48 hours may be important, and our findings represent a clear justification for increased public awareness of the dangers of STI. In this way, the path to increased 48 hour uptake of appointments lies not only with sexual health service reconfiguration, but also with continued education of the general public as to the potential serious consequences of untreated STI. Our study supports fully the vital concept of patient choice in booking appointments for sexual health services; however, we must be aware that it remains our responsibility to educate patients and ensure that their choice is an informed one.