Victims of Our Own Popularity: Screening Visits At New York City Sexually Transmitted Disease (NYC STD) Clinics

Background: In 2006, NYC Department of Health and Mental Hygiene Bureau of Sexually Transmitted Disease (STD) Control began screening visits for asymptomatic patients not needing exam, consisting of urine-based chlamydia/gonorrhea NAAT, RPR and rapid HIV antibody test. 

Objectives: To respond to budget shortfalls, we evaluated relative cost and yield of lab testing for STD and HIV screening.

Project Description: Using financial and electronic medical record (EMR) data we compared screening visit and provider visit yield and costs.

Findings: From 2006 to 2010, visits to NYC STD clinics increased from 111,473 to 123,430 ; screening visits as a proportion of all visits increased from 12% to 36%. From 7/1/09 – 6/30/10, 90% (36,408/40,926) of screening visits yielded NO STD diagnosis, versus 13% (7,338/56,283) of provider visits (Ct, GC and syphilis only). Screening visit Ct/GC positivity was 7.6% (3,126/40,916) and 1.2% (472/40,919) respectively, versus 13.3% (5,877/44,356) and 5.2% (2,332/44,644) among provider visits.  Screening visit costs per Ct/GC case was $118 versus $56 for provider visits.

Conclusions: Screening visits increased STD clinic volumes, without commensurate yield in morbidity. It cost twice as much to find one case of Ct/GC among screening visits as among provider visits. In weighing what to cut, we calculated that screening visits including a rapid HIV test cost BSTDC approximately $800,000 annually; and those without a rapid HIV test cost $413,000 annually. To cut costs and maintain priority services, as of March 2011, persons with no STD exposure or symptoms are offered HIV testing and a referral for screening/primary care services.  Since 3/2011 the number of visits without STD pathology has declined, allowing BSTDC to focus on persons most likely to have and spread disease.

Implications for Programs, Policy, and Research: Referring asymptomatic patients to primary care enables STD clinics to focus on mandated specialty services and appropriately encourages primary care to take on the burden of routine screening.