STD Express Visits at a New Level

Thirteen years ago we initiated a mandatory co-pay for patients visiting our STD clinic in Denver. The results were dramatic: a precipitous decline in patient visits and an almost 40% reduction in diagnosed gonorrhea cases. Alarmed, we introduced an “express visit”, a no-cost alternative to a full-exam visit for asymptomatic patients, offering basic STI and HIV testing without a clinical examination. Currently, many STD clinics in the U.S. and abroad offer some type of express visit or fast-track option to reduce costs and enhance efficiencies in their clinics. However, with advancing computer and diagnostic technologies, the express visit model is evolving rapidly.

Just how far the express visit envelope can be pushed is shown at the Dean Street Express clinic in London’s SoHo district. I recently had a chance to visit Dean Street Express on a tour organized by the National Coalition of STD Directors.

This store-front clinic was conceived when a large HIV clinic down the street had grown beyond its capacity. Thus patients who were formerly seen in this clinic for routine STI and HIV testing are now referred to the new clinic across the street that was designed to operate on a do-it-yourself basis.

Here’s a quick tour:

Coming though the door, you first think you’re in the wrong place. Bright colors and a hi-tec interior make you think you have entered a hair salon rather than an STD clinic.  A person behind the front desk directs you to 1 of 5 touch screen computer stations where you register as a patient, entering personal information and answering a handful of sexual behavioral questions. A mobile phone number is mandatory (you can buy one for 10 pounds down the street). Next, you receive a registration card with a bar code that will expedite your next visit.  Based on the behavioral information you have entered (gender of sex partner, sexual activities, anatomical sites exposed), the receptionist will hand you a number of swabs and collection devices and a container. You then go to one of 4 bathrooms and collect your own specimens., aided by a mirror that cleverly contains a small window in which a video plays continuously that visually explains how to collect your samples. You then put the swabs in the container and send them from the bathroom through a pressured air tube system to the testing area. This is a small room, separated by a glass wall from the reception area, behind which you see how your tests move through an impressive robotic device - a GeneXpert Infinity machine that runs 80 tests simultaneously and gives results in 90 minutes.

If you desire additional HIV and syphilis testing you then proceed to the lower floor of the clinic where a number of counselors take additional history information and collect a blood sample. Rapid HIV testing is available for high-risk patients; all other blood tests are picked up every hour by a courier and sent to a nearby lab that returns the results to the clinic within 6 hours.

Regardless of testing received, there is no need to wait for any of the results (except the rapid HIV test which is conducted while you watch). All results (gonorrhea and chlamydia from the onsite test machine and the blood tests from the nearby lab) are transmitted to the clinic’s electronic medical record. From there an automatic text message is generated that transmits the test results to your cell phone. If any of the tests are positive, you are instructed to come in for treatment (and partner services) at the original Dean Street clinic across the street at #56.

Presto!

Over its first few years of existence, the Dean Street Express clinic has proven very successful. Currently the clinic averages a stunning 250-300 clients per day, translating into over 100,000 chlamydia/gonorrhea tests a year.  Given the high-risk profile of the clinic’s clientele (about 50% gay men, 30% women, many of them sex workers or working in the adult film industry, 20% heterosexual men), the clinic identifies a large proportion of all STI and HIV cases in London.  Because of the low labor-intensity of the clinic, per patient costs are low and are adequately covered by the reimbursement received – mostly from the National Health Service. In fact, the clinic currently turns a small profit.

What can we learn from the Dean Street experience? Given the way most of our STD clinics operate in the U.S. and our (very) different funding structures, the model may not be easily copied within the U.S. public health infrastructure. However, there are two important features of the Dean Street Express clinic that I think we can take to heart immediately. First, Dean Street Express is incredibly user-friendly - from the way it looks and feels to the fully self-driven data and specimen collection process. Second, technological advances enable a seamless interface between self-collected data and specimens, (point-of-care) testing, and providing results, leading to a short turn-around time and a reduction in time to treat – all that with very little staff time. Some of these advances can be adapted to our environment. All that’s needed is an innovative mind-set and a willingness to change.

Disclaimer: These observations were made during a recent visit to Dean Street Express on the invitation by Cepheid, the company who manufactures GeneXpert. My expenses for this trip were paid by the company and Cepheid has also provided in kind support for a study I am involved in Zimbabwe. However, I am not paid by, nor do I have financial interests in the company.