1. The Impact of Introducing “Express Visits” for Asymptomatic Persons Seeking STD Services in a Busy Urban STD Clinic System, New York City,
Borrelli J1, Paneth-Pollak R1, Wright S1,
Blank S1,2, Schillinger J1,2 , Harvey K1
1. New York City Department of Health and Mental Hygiene (NYC DOHMH), USA
2. Centers for Disease Control and Prevention (CDC), USA
Good morning.
Disclaimer: The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

2. Background I: Bureau of STD Control
10 Clinics
Offer free and confidential STD testing & treatment on a walk-in basis to persons ≥ 12 years of age
Services include:
Gonorrhea (GC), Chlamydia (Ct), Syphilis and Herpes diagnosis & treatment
HIV & Hepatitis C testing
Hepatitis A & B vaccinations
Pap smears & emergency contraception
MDs provide all clinical care
~ 115,000 Patient visits in 2007
The Bureau of STD Control has 10 public STD clinic sites across NYC’s 5 boroughs.
At each of our clinics, free and confidential STD testing and treatment is offered on a walk-in basis,
to anyone 12 years of age or older.
The services we provide include: Gonorrhea, Chlamydia, Syphilis, Herpes, diagnosis and treatment,
HIV testing, and targeted Hepatitis C testing,
as well as Hepatitis A & B Vaccinations, Pap smears & emergency contraception
Until recently, MDs were the only providers on our staff who could offer clinical care for our patients. This meant that all patients coming to our clinics, seeking care would have to wait to see a physician.
In 2007 there were about 115,000 patient visits to our clinics.

3. Background II: Express Visit (EV) Time Line
2004, rapid HIV testing introduced
Overall patient volume increased
Proportion of clinical visits where STD diagnoses were made decreased
Number of available physician visits was exceeded
2005, “screening” visit type w/out MD offered
Actively demanded by patient population
Express visit option conceived
2006, “express visit” introduced
A number of changes to STD clinic practices before and during 2005 led us to routinely offer Express Visits.
In 2004, we introduced rapid HIV testing. As a result we saw that:
Our overall patient volume increased,
Simultaneously, the proportion clinical visits where STD diagnoses were made decreased,
Additionally, the number of available physician visits was exceeded.
In order to accommodate the additional patients seeking care, late in 2005, we informally began to offer
a new visit type for asymptomatic patients who did not want to wait to see a physician;
were offered:
gc/ct testing by urine NAATs (what else) without seeing an MD.
Through word of mouth this screening visit option became popular and a sought after visit type with patients at our clinics.
All of these events led to our decision to formally create and introduce an express visit option.
At the beginning of 2006 we began to actively offer this to our patients.

4. Background III: Express Visit Definition & Eligibility
Definition: STD screening visit without an MD
Criteria for eligibility:
Asymptomatic
No known contact to an STD case
Do not need to or decline to see an MD
STD screening tests offered during an EV:
GC and Ct (urine Nucleic Acid Amplified Test)
Syphilis RPR (blood draw)
HIV testing (rapid oral swab)
An express visit is a screening visit without having to see a physician.
We determined that Eligibility requirements for an Express Visit would be assessed by triage;
if a patient fulfills the following criteria they are offered an express visit.
Patients must be asymptomatic, have no known contact to an STD case,
and otherwise do not wish or need to see a physician. (for example for Emergency contraception or vaccination)
I want to note that patients are always offered the option to see a physician
and it is at their discretion to accept either an MD visit or an Express Visit.
Once a patient is determined to be eligible, without having to wait to see a physician, they are offered the following testing options:
(any of which they can refuse):
Gonorrhea and Chlamydia urine Nucleic Acid Amplified Testing (or NAATs), Syphilis by serum RPR
and HIV oral rapid testing.

5. Study Objective:
To evaluate the impact of routine express visits on the diagnosis and treatment of Neisseria gonorrhoeae (GC) & Chlamydia trachomatis (Ct)
Our study objective was to evaluate the impact of routinely offering the express visit option
on the diagnosis and treatment of Neisseria Gonorrhoeae (GC)
and Chlamydia trachomatis (Ct) at our clinics.

6. Methods I: Study Periods: (September – December) 2005 (before)
(September – December) (after)
Study Population:
Patients with an MD or Express Visit
Data Source:
Clinic electronic medical records
Exclusions:
One clinic site
To evaluate the impact of the Express Visit we created two study periods.
The first, September to December 2005, which was before Express Visits became routine.
And a second, September-December 2006, which was after Express Visits were routine.
The study population included patients who had either an MD or an Express Visit at a bureau clinic within this time period.
Our data source was clinic electronic medical records.
One of our clinics was excluded from this study because it was under construction and closed for a part of the 2006 study period.
(These are stored (housed) in a Microsoft SQL database.
And we used SQL Query Analyzer to run this analysis.)

7. Methods II: Study Definitions
Express Visit:
Did not see a physician
Had a GC/Ct urine NAAT
MD visit:
Saw a physician
Outcomes of interest:
# of EV, # MD visits
Proportion symptomatic for MD visits
# GC/Ct detected and treated
EV: urine NAAT only
MD visit: GC (anal, oral, cervical or urethral culture or NAAT)
GC/Ct: (urine, anal, oral, cervical or urethral NAAT)
In order to analyze the impact of introducing the Express Visit option on clinical care we grouped patient visits into
two groups: those with Express Visits and those with Physician Visits.
Visits where patients did not see a physician and had a Gonorrhea and/or Chlamydia Urine NAAT test ordered
were categorized as an Express Visit
While those visits where patients saw a physician were categorized as a physician visit.
Our outcomes of interest included:
The number of Express Visits and number of MD visits,
The proportion of MD visits that were symptomatic (as determined by documentation within the medical record chief complaint),
And the Number of GC and Ct infections detected as well as treated.
(All positive cases of GC and Ct were lab confirmed).
Testing at an express visit was limited to a Urine NAAT
While an MD visit patient could have had GC testing by culture or NAAT and/or
CT testing by NAAT from any anatomic site including: anal, oral, cervical or urethral, or urine specimen.

8. Methods III: Analytic Approach
Time to Treatment:
Calculated for GC or Ct positive patients with documented treatment
Day of visit (DOV)
Future DOV (≤ 30 days)
Difference, in days, between the DOV at which specimen for GC/Ct was collected and the day of documented treatment
Median Time to Treatment:
Calculated for only patients who received treatment after their DOV
We calculated time to treatment for all positive patients who received treatment at our clinics for either GC or Ct
for those who received treatment on their Day of Visit (DOV),
and for those who received treatment at a future visit which was within 30 days of their original visit.
For the positive patients who received treatment on a future DOV
We calculated the number of days between
the day at which the specimen for GC or Ct was collected and
The day of visit where treatment was documented.
Median Time to Treatment was calculated only for patients who received treatment after their original DOV.
(insert type of treatment included ?)
Another way to write it:
= Day of tx – Day of Visit

9. Results I: MD & Express, Number of Visits by Visit Type & Study Period
23%
Our first results slide shows an overall picture of the number of visits by visit type and study period:
MD visits are shown here in blue and Express visits are shown here in Green.
The time periods are: ‘Before’ express visits became routinely offered: Sept through Dec 2005
and ‘After’ they became routinely offered: Sept through Dec 2006.
The total number of visits in 2005 was 19,925 while in 2006 the total was 24,485.
This represents a 23% increase in the total number of patient’s visits which were either an MD or Express Visit.
If we take a closer look at the green bars we see the number of Express Visits for each year. In 2005, there were 1,476 Express Visits while in 2006 there were 6,064.
This represented an additional 4,588 express visits between the two time periods.
1,476
6,064
2005
2006
Sept - Dec
Sept - Dec

10. Results II: MD visits, Proportion Symptomatic, by Study Period
16%
74%
86%
These two pie charts show MD visits in more detail with the proportion symptomatic.
As you can see the total number of MD visits remained relatively unchanged from 2005 to 2006.
However, the proportion of symptomatic patients that physicians saw
rose by 16% from one year to the next; this represented a
a significant increase with a p-value of less than
P-value
<
2005
2006
Symptomatic
Asymptomatic

11. Results III: MD & Express Visits, Number of Visits with GC/Ct Tests Done & Percent Positive, by Study Period
N=19,875
N=16,128
23%
So, how did the increase in patient volume (visits) affect Gonorrhea & Chlamydia detection and positivity?
This bar graph shows the Total Number of GC/Ct tests done by year (all anatomic sites are included) and
the respective percent of tests that resulted in positives (shown in red).
In 2005, there were about 16,000 GC/Ct visits with tests done at either an MD or an Express visit. While in 2006 there were about 20,000 GC/Ct visits with tests done.
Overall, our testing volume increased by approximately 4,000, which is a 23% increase from one year to the next.
The proportion of positive cases (again, represented here in red) remained about the same, about 13% for both years.
Side note:
The number of positive tests: 2005: 2,231 and 2006: 2,617
The total number of positives detected increased by 17%:
13.8%
13.2%
2005
2006
Sept - Dec
Sept - Dec
Visits with Positive GC/CT tests

12. Results IV: GC/Ct Testing & Positivity by Visit Type & Study PeriodMD
Express
2005
2006
No. %
Visits with GC/Ct Tests Done
14,652 -
13,811
1,476
6,064
Visits with Positive GC/Ct Tests
2,043
14%
2,081
15%
188
13%
536 9%
This table shows Gonorrhea and Chlamydia testing, and positivity, by visit type, and study period.
A few things worth noting are that:
- The bulk of all GC and Ct testing is done at MD visits (shown within the first row and MD column),
- There was little change in GC/CT positivity at MD visits (14% in 2005, and 15% in 2006)
- The GC/Ct positivity at Express Visits was lower than that at MD visits, with the lowest observed positivity, 9% in 2006.

13. Results V: Time to Treatment by Visit type & Study Period
2005
2006
No. Treated
% Treated
MD VISITS WITH POSITIVE TEST
(N= 2,043)
(N= 2,081)
Total Treated
1,882
92%
1,996
96%
Treated on DOV1
1,543
76%
1,709
82%
Treated at later visit ≤30 days2
339
17%
287
14%
Median time to treatment
14 days
13 days
EV WITH POSITIVE TEST
(N=188)
(N= 536)
147
78%
437
N/A
10 days
9 days
This table shows time to treatment by visit type and by year.
The type of visit is represented in the left column, with the year across the top right.
In 2005, 92% of positive Ct/GC tests resulting from MD visits were treated, in 2006, 96%. The majority were treated on their DOV,
In 2005, 76% and in %.
This is not surprising since we know that presumptive treatment is common, that the majority of MD visits are for symptomatic patients, and that the proportion symptomatic increased from 2005 to 2006.
Of those not treated on their day of visit, in 2005, 17% were treated at later visit within 30 days while in 2006, 14 % were treated at a later visit.
The median time to treatment for patients treated on a later visit within 30 days was 14 days in 2005 and 13 days in 2006.
With regards to express visits, in 2005, 78% of GC/Ct positive patients were treated while in 2006, 82% of cases were treated.
The median time to treatment in 2005 was 10 days and in 2006, 9 days.
1 Treated on Day of Visit (DOV) or within 30 days 2 Treated after DOV but within 30 days

14. Results VI: Combined Positivity & Time to Treatment, by Study Period
2005
2006 N
(%)
GC/Ct Tests Done
16,128 -
19,875
GC/Ct Positive Tests
2,231
14%
2,617
13%
Number of Patients Treated
2,029
91%
2,433
93%
This slide summarizes the difference between the two study periods.
Compared to 2005, in 2006 :
More gonorrhea and chlamydia tests were done,
More positive tests resulted,
And more cases of disease were treated.

15. Limitations: MD & Express visits may have been mis-categorized
Study time periods were limited
Analysis does not account for other changes in clinic practice
Electronic requisitioning of GC/Ct NAATs
I’d like to mention a few study limitations.
Although a rare event, a physician may not have always electronically signed his or her chart which may have led to a mis-categorization on our part of an MD visit as an Express Visit.
Also, our study periods were constrained by the earliest date at which all of our clinics began to utilize our electronic medical record system, which was Sept 2005.
Additionally, there were simultaneous clinic improvements which occurred during the two study periods which our analysis does not account for.
For example: Electronic requisitioning and reporting of GC/Ct NAATs became routine at all clinics in 2006
And this reduced the turn around time for test results.
This may partially explain the decrease in time to treatment that we saw from one study period to the next.

16. Conclusions: Express visits enabled
GC/Ct screening of a large number of asymptomatic patients
Better use of MD resources
Treatment of more GC/Ct positive patients
Improved time to treatment
In conclusion.
We’ve seen from this analysis that the introduction of Express visits has enabled:
GC & Ct screening of a large number of asymptomatic patients,
That MD resources were better directed towards symptomatic patients,
That more Gonorrhea & Chlamydia positive patients were treated
And that overall time to treatment for positive patients improved.

17. Acknowledgements Dr. Julia Schillinger Dr. Susan Blank
Rachel Paneth-Pollak
Susan Wright
Dr. Kristen Harvey
All clinic staff
Finally, I would like to thank everyone involved in the routine introduction of Express visits as well as those
Who contributed to this analysis.
Disclaimer: The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

18. Additional Slides:

19. Results IV: Positivity & Time to Treatment at Express Visits by Gender, 2006
Total
Male
Female
Express Visits (N)
6064
64%
36%
No. %
GC Tests Done
3910
2153
GC positive tests 63 1% 39 24
Total treated <31d 52
83% 30
77% 22
92%
Ct Tests Done
Ct positive tests
500 8%
320
180
406
81%
255
80%
151
84%
This is a closer look at Express Visit GC and Ct testing, positivity and time to treatment by gender for the after time period, which was 2006.
Again, the total Number of Express Visits in 2006 was 6,064.
With 64% of those visits made by male patients
While 36% of those visits were made by female patients.
Across Express Visits there were 63 positive patients with Gonorrhea.
39 of the positive patients were male And 24 patients were female.
This represented 1% of the males and 1% of females who had Express Visits.
The total number of GC positive patients treated was 52 or 83% of all tested.
77% of male patients positive for gonorrhea were treated within 30 days while 92% of females were treated.
There were 500 positive patients for Chlamydia.
320 of the positives were male patients and 180 of the positive patients were female.
This represented 8% of both male and female Express Visit patients.
80% of male positive patients were treated within 30 days while 84% of females were treated for Chlamydia.
The variation in treatment seen amongst positive patients by gender is something to consider for patient follow-up.

20. Results VI: Time to Treatment by Visit type & Study Period (<90d)
2005
2006
No. Treated
% Treated
MD VISITS WITH POSITIVE TEST
(N= 2,043)
(N= 2,081)
Total Treated
1,942
95.0%
2,019
97.0%
Treated on DOV1
1,543
75.5%
1,709
82.1%
Treated at later visit ≤ 30d2
339
16.6%
287
13.8%
Treated at later visit >30 ≤ 90d3 60
2.9% 23
1.1%
EV WITH POSITIVE TEST
(N=188)
(N= 536)
158
84.0%
463
86.3%
N/A
147
78.2%
437
81.5% 11
5.9% 26
4.9%
1 Treated on Day of Visit (DOV) or within 30 days 2 Treated after DOV but within 30 days 3 Treated within 90days

21. Results V: MD vs. Express Visit, Positivity & Time to Treatment by Visit Type & Study Period
2005
N (%)
2006
GC/Ct Tests Done
14,652
13,811
1,476
6,064
Positive Tests
2,043 (14)
2,081 (15)
188 (13)
536 (9)
Number Treated1
1,882 (92)
1,996 (96)
147 (78)
437 (82)
Median Time to tx (days)2 14 10 13 9
We are looking at Time to treatment by visit type: MD visits vs. Express Visits, and by year 2005 to 2006.
Here we are able to compare the Number & proportion of GC & Ct tests done,
positive tests detected,
and the number of positive cases treated with the median time to treatment for patients not treated on their DOV.
A few things here to point out are that: - most GC and Ct testing was done at MD visits.
-GC/CT positivity remained relatively the same within MD visits 14% in 2005 & 15% in 2006;
-While the most noticeable difference in positivity was within Express Visits in 2006 which was only 9%.
The next outcome that we considered was the number treated. This includes GC and/or Ct positive patients who
received treatment on either their day of visit or at a future visit within 30 days of the visit with GC/Ct specimen collection.
The proportion of MD visit patients treated within 30 days increased by 4%, to 96%.
This increase would most likely be attributed to the increase in the proportion of symptomatic visits seen by each physician in the after period.
While the proportion of Express Visit patients treated within 30 days increased by 5%.
Which might be attributed to better account of Express Visit patients.
The last point I’d like to make on this slide is the Median time to treatment (expressed here in days).
Again, this does not include patients who were treated on their DOV.
Now although, there is variation amongst this measure from year to year there is really a minimal difference
within each year Between MD visit and Express Visit.
For instance the median time to treat a positive patient who had an MD visit in 2006 was 10 days and
Similarly it only took 9 days to treat a patients with an Express Visit in the same time period.
rationale
1 Treated on Day of Visit (DOV) or within 30 days
2 Not including treatment on DOV

22. (Should I include anything about wait or cycle time?)
Alternate approach: Here is a slide that describes our increase in patient HIV testing by year. (update with pt volume relative to HIV tests)
As you can see -Before rapid testing was introduced, the number of HIV tests pretty much stayed the same.
-However, in 2004, when we introduced the oral rapid method, we saw an increase of the number of HIV tests by 15%
-In 2005 we saw another 15% increase
As you can see, the trend is continuing.
With an increase in patient volume, due to the availability of rapid oral HIV testing, our patient volume reached (surpassed) it’s maximum capacity
Because of our ‘No Turn Away’ Policy Clinic staff began to work beyond their scheduled work hours. (as per Susan Wright)
(At this point we also saw the percentage of STD diagnoses made at clinical visits
Drop from ~70% to ~55% (from Sue – needs confirmation))
In order to accommodate all patients (persons) seeking care, late in 2005, we began to offer
GC/Ct urine NAAT lab testing to asymptomatic patients without having to wait to see a physician.
(Should I include anything about wait or cycle time?)
This shortened screening visit, or Express Visit, later became routinely offered in January 2006.
Rapid Testing
Slide courtesy Alexis Kowalski

23. New York City Department of Health and Mental Hygiene
(NYC DOHMH)
Bureau of STD Control (BSTDC)
The Busy Urban STD clinic system that we analyzed was the NYC Department of Health and Mental Hygiene’s
Bureau of STD Control.
To familiarize you with the distribution of our clinics & some background for context
here is a map of New York City broken down by borough and (UHF?) neighborhood.
Starting from the North we see that the Bronx is represented by the color purple,
Manhattan is blue,
Queens is yellow,
Brooklyn is green
and Staten Island is pink.
The (New York City Department of Health and Mental Hygiene’s) Bureau of STD Control has 10 public STD clinics throughout NYC’s 5 boroughs.
These are represented here by the small red circles/dots.