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Bennett CL, Marks SJ, Liu T, Clark MA, Carey MP, Merchant RC. Factors Associated with Lack of HIV Testing among Latino Immigrant and Black Patients at 4 Geographically and Demographically Diverse Emergency Departments. J Int Assoc Provid AIDS Care 2021; 19:2325958220970827. [PMID: 33143525 PMCID: PMC7675889 DOI: 10.1177/2325958220970827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The need for HIV testing in US emergency departments (EDs) has not been assessed,
particularly among Latino immigrants and Blacks. We surveyed Latino immigrant
and Black 18 to 64-year-old patients at 4 EDs about demographic characteristics,
HIV testing history, and health literacy. A subset of patients was further
surveyed on HIV risk-taking behaviors. Of the 2,265 participants, 24% had never
been tested for HIV. Latino immigrants were more likely than Blacks never to
have been tested for HIV (28% vs. 16%). In multivariable logistic regression,
for Latino immigrants, male gender and lower health literacy were associated
with no previous HIV testing. Among the 1,141-participant subset providing HIV
risk-taking behavior data, 23% reported at least one risk factor and of those
with at least one risk factor, 23% had never been tested for HIV. There remains
a need for HIV testing among adult Latino immigrant and Black patients in US
EDs.
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Affiliation(s)
- Christopher L Bennett
- Department of Emergency Medicine, Brigham and Women's Hospital, 1811Harvard Medical School, Boston, MA, USA
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, 1811Harvard Medical School, Boston, MA, USA
| | - Tao Liu
- Department of Biostatistics, Center for Statistical Sciences, 118721Brown University School of Public Health, Providence, RI, USA
| | - Melissa A Clark
- Department of Health Services, Policy and Practice, 118721Brown University School of Public Health, Providence, RI, USA
| | - Michael P Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, USA.,Department of Psychiatry and Human Behavior, Alpert Medical School, 6752Brown University, Providence, RI, USA
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, 1811Harvard Medical School, Boston, MA, USA
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Escudero DJ, Bahamon M, Panakos P, Hercz D, Seage GR, Merchant RC. How to best conduct universal HIV screening in emergency departments is far from settled. J Am Coll Emerg Physicians Open 2021; 2:e12352. [PMID: 33491000 PMCID: PMC7812459 DOI: 10.1002/emp2.12352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 11/11/2022] Open
Abstract
HIV screening in the emergency department (ED), including universal screening irrespective of risk assessments, has shown strong promise in past studies, identifying many new cases of HIV infection among those who lack access to traditional HIV testing services. Yet, over the years a consistent set of challenges and limitations have presented themselves in settings throughout the United States. We review considerations for evaluating and improving the success of ED-based HIV screening programs in the United States.
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Affiliation(s)
- Daniel J. Escudero
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Monica Bahamon
- Department of Emergency MedicineJackson Memorial HospitalMiamiFloridaUSA
| | - Patricia Panakos
- Department of Emergency MedicineJackson Memorial HospitalMiamiFloridaUSA
| | - Daniel Hercz
- Department of Emergency MedicineJackson Memorial HospitalMiamiFloridaUSA
| | - George R. Seage
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Roland C. Merchant
- Department of Emergency MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
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3
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Klein PW, Martin IBK, Quinlivan EB, Gay CL, Leone PA. Missed opportunities for concurrent HIV-STD testing in an academic emergency department. Public Health Rep 2014; 129 Suppl 1:12-20. [PMID: 24385644 DOI: 10.1177/00333549141291s103] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We evaluated emergency department (ED) provider adherence to guidelines for concurrent HIV-sexually transmitted disease (STD) testing within an expanded HIV testing program and assessed demographic and clinical factors associated with concurrent HIV-STD testing. METHODS We examined concurrent HIV-STD testing in a suburban academic ED with a targeted, expanded HIV testing program. Patients aged 18-64 years who were tested for syphilis, gonorrhea, or chlamydia in 2009 were evaluated for concurrent HIV testing. We analyzed demographic and clinical factors associated with concurrent HIV-STD testing using multivariate logistic regression with a robust variance estimator or, where applicable, exact logistic regression. RESULTS Only 28.3% of patients tested for syphilis, 3.8% tested for gonorrhea, and 3.8% tested for chlamydia were concurrently tested for HIV during an ED visit. Concurrent HIV-syphilis testing was more likely among younger patients aged 25-34 years (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] 0.78, 2.10) and patients with STD-related chief complaints at triage (AOR=11.47, 95% CI 5.49, 25.06). Concurrent HIV-gonorrhea/chlamydia testing was more likely among men (gonorrhea: AOR=3.98, 95% CI 2.25, 7.02; chlamydia: AOR=3.25, 95% CI 1.80, 5.86) and less likely among patients with STD-related chief complaints at triage (gonorrhea: AOR=0.31, 95% CI 0.13, 0.82; chlamydia: AOR=0.21, 95% CI 0.09, 0.50). CONCLUSIONS Concurrent HIV-STD testing in an academic ED remains low. Systematic interventions that remove the decision-making burden of ordering an HIV test from providers may increase HIV testing in this high-risk population of suspected STD patients.
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Affiliation(s)
- Pamela W Klein
- The University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC ; Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Milwaukee, WI
| | - Ian B K Martin
- The University of North Carolina at Chapel Hill, School of Medicine, Departments of Emergency Medicine and Internal Medicine, Chapel Hill, NC
| | - Evelyn B Quinlivan
- The University of North Carolina at Chapel Hill, School of Medicine, Center for Infectious Diseases, Chapel Hill, NC
| | - Cynthia L Gay
- The University of North Carolina at Chapel Hill, School of Medicine, Departments of Emergency Medicine and Internal Medicine, Chapel Hill, NC
| | - Peter A Leone
- The University of North Carolina at Chapel Hill, School of Medicine, Departments of Emergency Medicine and Internal Medicine, Chapel Hill, NC
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Egan DJ, Cowan E, Fitzpatrick L, Savitsky L, Kushner J, Calderon Y, Agins BD. Legislated human immunodeficiency virus testing in New York State Emergency Departments: reported experience from Emergency Department providers. AIDS Patient Care STDS 2014; 28:91-7. [PMID: 24517540 DOI: 10.1089/apc.2013.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In 2010, New York (NY) passed new legislation mandating Emergency Departments (EDs) to offer HIV tests to patients 13-64 presenting for care. We evaluated the requirement's implementation and determined differences based on HIV prevalence or site-specific designated AIDS centers (DACs). We also evaluated policies for linkage to care of new HIV positive patients. An electronic survey on testing practices and linkage to care was administered to all NY EDs, excluding VA hospitals. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). All respondents knew of the legislation and 86% offered testing, but only 65% (159/184) to all patients required by the law. EDs in NYC, high prevalence areas, and DACs were more likely to offer HIV testing. Most facilities (104/159, 65%) used separate written consent despite elimination of this requirement. Most EDs (67%) used rapid testing: oral point-of-care ED testing and rapid laboratory testing. Only 61% of EDs provided results to patients while in the ED. Most (94%) had a linkage-to-care protocol. However, only 29% confirm linkage. We provide the first report of NY ED HIV testing practices since the mandatory testing law. Most EDs offer HIV testing but challenges still exist. Linkage-to-care plans are in place, but few EDs confirm it occurs.
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Affiliation(s)
- Daniel J. Egan
- Department of Emergency Medicine, NYU School of Medicine, New York City, New York
| | - Ethan Cowan
- Department of Emergency Medicine, Jacobi Medical Center, Bronx, New York
| | | | - Leah Savitsky
- AIDS Institute, New York State Department of Health, New York City, New York
| | - John Kushner
- AIDS Institute, New York State Department of Health, New York City, New York
| | - Yvette Calderon
- Department of Emergency Medicine, Jacobi Medical Center, Bronx, New York
| | - Bruce D. Agins
- AIDS Institute, New York State Department of Health, New York City, New York
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Gaydos CA, Solis M, Hsieh YH, Jett-Goheen M, Nour S, Rothman RE. Use of tablet-based kiosks in the emergency department to guide patient HIV self-testing with a point-of-care oral fluid test. Int J STD AIDS 2013; 24:716-21. [PMID: 23970610 PMCID: PMC3773057 DOI: 10.1177/0956462413487321] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite successes in efforts to integrate HIV testing into routine care in emergency departments, challenges remain. Kiosk-facilitated, directed HIV self-testing offers one novel approach to address logistical challenges. Emergency department patients, 18-64 years, were recruited to evaluate use of tablet-based-kiosks to guide patients to conduct their own point-of-care HIV tests followed by standard-of-care HIV tests by healthcare workers. Both tests were OraQuick Advance tests. Of 955 patients approached, 473 (49.5%) consented; 467 completed the test, and 100% had concordant results with healthcare workers. Median age was 41 years, 59.6% were female, 74.8% were African-American, and 19.6% were White. In all, 99.8% of patients believed the self-test was "definitely" or "probably" correct; 91.7% of patients "trusted their results very much"; 99.8% reported "overall" self-testing was "easy or somewhat easy" to perform. Further, 96.9% indicated they would "probably" or "definitely" test themselves at home were the HIV test available for purchase; 25.9% preferred self-testing versus 34.4% who preferred healthcare professional testing (p>0.05). Tablet-based kiosk testing proved to be highly feasible, acceptable, and an accurate method of conducting rapid HIV self-testing in this study; however, rates of engagement were moderate. More research will be required to ascertain barriers to increased engagement for self-testing.
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Affiliation(s)
- Charlotte A Gaydos
- Div Infectious Disease, Johns Hopkins University, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melissa Solis
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mary Jett-Goheen
- Div Infectious Disease, Johns Hopkins University, Baltimore, MD, USA
| | - Samah Nour
- Div Infectious Disease, Johns Hopkins University, Baltimore, MD, USA
| | - Richard E Rothman
- Div Infectious Disease, Johns Hopkins University, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
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Kurth AE, Severynen A, Spielberg F. Addressing unmet need for HIV testing in emergency care settings: a role for computer-facilitated rapid HIV testing? AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2013; 25:287-301. [PMID: 23837807 PMCID: PMC4090932 DOI: 10.1521/aeap.2013.25.4.287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
HIV testing in emergency departments (EDs) remains underutilized. The authors evaluated a computer tool to facilitate rapid HIV testing in an urban ED. Randomly assigned nonacute adult ED patients were randomly assigned to a computer tool (CARE) and rapid HIV testing before a standard visit (n = 258) or to a standard visit (n = 259) with chart access. The authors assessed intervention acceptability and compared noted HIV risks. Participants were 56% nonWhite and 58% male; median age was 37 years. In the CARE arm, nearly all (251/258) of the patients completed the session and received HIV results; four declined to consent to the test. HIV risks were reported by 54% of users; one participant was confirmed HIV-positive, and two were confirmed false-positive (seroprevalence 0.4%, 95% CI [0.01, 2.2]). Half (55%) of the patients preferred computerized rather than face-to-face counseling for future HIV testing. In the standard arm, one HIV test and two referrals for testing occurred. Computer-facilitated HIV testing appears acceptable to ED patients. Future research should assess cost-effectiveness compared with staff-delivered approaches.
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Affiliation(s)
- Ann E Kurth
- New York University College of Nursing, New York, NY, USA.
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Schechter-Perkins EM, Rubin-Smith JE, Mitchell PM. Implementation of a rapid HIV testing programme favourably impacts provider opinions on emergency department HIV testing. Emerg Med J 2013; 31:736-40. [DOI: 10.1136/emermed-2013-202806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ganguli I, Collins JE, Reichmann WM, Losina E, Katz JN, Arbelaez C, Donnell-Fink LA, Walensky RP. Missed opportunities: refusal to confirm reactive rapid HIV tests in the emergency department. PLoS One 2013; 8:e53408. [PMID: 23308216 PMCID: PMC3540076 DOI: 10.1371/journal.pone.0053408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 11/30/2012] [Indexed: 11/20/2022] Open
Abstract
Background HIV infection remains a major US public health concern. While HIV-infected individuals now benefit from earlier diagnosis and improved treatment options, progress is tempered by large numbers of newly diagnosed patients who are lost to follow-up prior to disease confirmation and linkage to care. Methodology In the randomized, controlled USHER trial, we offered rapid HIV tests to patients presenting to a Boston, MA emergency department. Separate written informed consent was required for confirmatory testing. In a secondary analysis, we compared participants with reactive results who did and did not complete confirmatory testing to identify factors associated with refusal to complete the confirmation protocol. Principal Findings Thirteen of 62 (21.0%, 95% CI (11.7%, 33.2%)) participants with reactive rapid HIV tests refused confirmation; women, younger participants, African Americans, and those with fewer HIV risks, with lower income, and without primary care doctors were more likely to refuse. We projected that up to four true HIV cases were lost at the confirmation stage. Conclusions These findings underscore the need to better understand the factors associated with refusal to confirm reactive HIV testing and to identify interventions that will facilitate confirmatory testing and linkage to care among these populations. Trial Registration ClinicalTrials.gov NCT00502944; NCT01258582.
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Affiliation(s)
- Ishani Ganguli
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jamie E. Collins
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - William M. Reichmann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
| | - Jeffrey N. Katz
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Christian Arbelaez
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Laurel A. Donnell-Fink
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Divisions of Infectious Disease and General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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Rapid human immunodeficiency virus testing in the pediatric emergency department: a national survey of attitudes among pediatric emergency practitioners. Pediatr Emerg Care 2012. [PMID: 23187980 DOI: 10.1097/pec.0b013e3182767add] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Human immunodeficiency virus (HIV) continues to be a significant public health concern for adolescents and young adults. Since 2006, the Centers for Disease Control and Prevention has recommended more aggressive routine screening for HIV for patients presenting to the emergency department (ED). Our objectives were to design and validate a survey of physician barriers toward the use of rapid HIV testing in the pediatric ED and then to use this validated tool to conduct a national survey of pediatric emergency practitioners' attitudes toward rapid HIV testing in the ED. METHODS Survey design and initial validation steps were conducted with a panel of health care practitioners familiar to HIV testing. Several variables were identified as possible barriers toward rapid HIV testing. The survey was sent via electronic software to a national sample of pediatric emergency practitioners over 2 listservs. The previously identified variables were evaluated by factor analysis for internal consistency and homogeneity, and confirmatory factor analysis was conducted via promax and varimax rotation. All factor analyses were conducted using Stata software. Once the validation was complete, the surveys were sent to groups of pediatric emergency practitioners who had previously identified as having rapid HIV testing available in their EDs. Standard descriptive statistics were used, and group differences were evaluated with t test and χ(2) test. RESULTS Four factors were identified during the validation process as being the most important barriers for rapid HIV testing in the pediatric ED: self efficacy, familiarity, external barriers, and a previously unidentified factor, which we interpreted as related to barriers to the specific environment of one's own ED. A total of 80 participants returned the final, validated survey. The participants came from 9 different pediatric emergency medicine groups (5 in areas of low rates of HIV infection, 4 in areas of high rates of HIV infection). Self-reported rates of testing were not different based on HIV infection rate in the community or the respondent's level of training. High testing was more common when a guideline was reported (39%) than when it was not (13.3%; difference, 25.7%; 95% confidence interval, 2.9%-48.5%). Of the 4 factors identified, we found statistically significant differences in scores on all 4 factors between high versus low testers, with high testers disagreeing more strongly with the various barrier questions proposed. We found no difference in the factor scores between areas of high versus low HIV infection rates. CONCLUSIONS Our results suggest that several factors related to perceived provider barriers are associated with rates of HIV testing in the ED and that personal factors (eg, level of training) and community HIV prevalence were not associated with rates of testing. Our results confirm what has been speculated by numerous authors and provide data to inform efforts to improve compliance with national recommendations for increased testing.
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Patients Can Accurately Perform Their Own Rapid HIV Point-of-Care Test in the Emergency Department. POINT OF CARE 2012; 11:176-179. [PMID: 24031999 DOI: 10.1097/poc.0b013e3182666eb7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility, acceptability, and accuracy of having emergency department (ED) patients perform a rapid, point-of-care (POC) self-test for HIV before routine HIV testing. METHODS Patients aged 18 to 65 years were recruited to perform a rapid POC HIV oral fluid at The Johns Hopkins ED in conjunction with the standard-of-care HIV POC test. Acceptability and ease of use were assessed by a questionnaire. RESULTS A total of 259 patients were approached for testing, and 249 (96.1%) consented to perform a self POC HIV test. Of patients performing a self-test, 100% had concordant results with those obtained by the health care worker. Four females (1.6%) were newly identified as HIV positive. Median participant age was 41 years, and 58% of patients were female; 83% were African American, and 16% were white. Overall, greater than 90% of patients reported trust of the test results, ease of testing, and willingness to test again. Approximately 35% of patients indicated they would pay up to a maximum price of $30 for testing. Overall, 46.9% of patients preferred self-testing, and 39.5% preferred health care professional testing. Regarding preferred location for testing, 51.0% preferred home self-testing, 39.5% preferred clinic/ED self-testing (P > 0.05), and 9.5% had no preference. CONCLUSIONS A significant proportion of patients offered POC testing in the ED agreed to perform a self-HIV test. Patients' results were concordant with those obtained by the health care worker; 1.6% were HIV positive. The majority of participants believed the veracity of their results. A greater number of patients preferred self-testing.
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Jain S, Lowman ES, Kessler A, Harper J, Rumoro DP, Smith KY, Purim-Shem-Tov Y, Kessler HA. Seroprevalence Study Using Oral Rapid HIV Testing in a Large Urban Emergency Department. J Emerg Med 2012; 43:e269-75. [DOI: 10.1016/j.jemermed.2012.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 10/03/2011] [Accepted: 02/13/2012] [Indexed: 11/25/2022]
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Berg LJ, Delgado MK, Ginde AA, Montoy JC, Bendavid E, Camargo CA. Characteristics of U.S. emergency departments that offer routine human immunodeficiency virus screening. Acad Emerg Med 2012; 19:894-900. [PMID: 22849642 DOI: 10.1111/j.1553-2712.2012.01401.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The association between emergency department (ED) characteristics, ED director's perceptions of preventive services, and the availability of human immunodeficiency virus (HIV) screening are unknown. The authors hypothesized that, after adjusting for ED operational and demographic characteristics, teaching hospital status would be associated with increased availability, and ED crowding and ED director agreement with barriers to screening would be associated with decreased availability. METHODS This was a secondary, cross-sectional analysis on previously collected data from 2008 to 2009 regarding availability of ED preventive services. Data were obtained from a random sample of 277 EDs in which ED directors provided information on ED characteristics and availability of HIV screening and rated five barriers to providing preventive services. The association between the availability of HIV screening and teaching hospital and crowding status, ED volume, urban-rural location, ownership, geographic region, patient demographics, state HIV testing consent laws, and ED director opinions on barriers to providing preventive services were determined in univariate analyses and a multivariate logistic regression model. RESULTS Nineteen percent of the sampled EDs offer HIV screening. Teaching hospitals offer HIV screening more frequently than nonteaching hospitals (38% vs. 18%; p = 0.03), but after adjusting for other characteristics in a multivariate model, this association was not significant (relative risk ratio [RR] = 2.07, 95% confidence interval [CI] = 0.91 to 3.59). ED crowding also was not significantly associated with screening availability (RR = 0.66, 95% CI = 0.34 to 1.21). However, public ownership (RR = 2.13, 95% CI = 1.28 to 3.14), 24-hour social work (RR = 1.87, 95% CI = 1.02 to 2.99), uninsured population ≥35% (RR = 2.48, 95% CI = 1.39 to 3.69), increased local nonwhite minority population percentage (RR = 1.14 per 10%, 95% CI = 1.02 to 1.26), and state laws allowing opt-out consent for testing (RR = 1.76, 95% CI = 1.01 to 2.74) were associated with increased availability of screening in multivariable analysis. EDs whose directors were concerned about added costs were associated with decreased availability of screening (RR = 0.45, 95% CI = 0.23 to 0.85). CONCLUSIONS After adjusting for other ED operational and demographic characteristics, ED crowding and teaching hospital affiliation were not independently associated with the availability of HIV screening. EDs whose directors were concerned about the cost of preventive services were less likely to provide routine HIV screening. Addressing ED director's concerns about the added costs of ED preventive services, increasing social work availability, and implementing testing laws consistent with Centers for Disease Control and Prevention (CDC) recommendations may facilitate increased adoption of ED HIV screening.
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Affiliation(s)
- Laura J Berg
- Stanford-Kaiser Emergency Medicine Residency, Stanford, CA, USA
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13
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Copeland B, Shah B, Wheatley M, Heilpern K, del Rio C, Houry D. Diagnosing HIV in men who have sex with men: an emergency department's experience. AIDS Patient Care STDS 2012; 26:202-7. [PMID: 22356726 PMCID: PMC3317392 DOI: 10.1089/apc.2011.0303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
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Affiliation(s)
- Brittney Copeland
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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Reichmann WM, Walensky RP, Case A, Novais A, Arbelaez C, Katz JN, Losina E. Estimation of the prevalence of undiagnosed and diagnosed HIV in an urban emergency department. PLoS One 2011; 6:e27701. [PMID: 22110730 PMCID: PMC3218027 DOI: 10.1371/journal.pone.0027701] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/23/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To estimate the prevalence of undiagnosed HIV, the prevalence of diagnosed HIV, and proportion of HIV that is undiagnosed in populations with similar demographics as the Universal Screening for HIV in the Emergency Room (USHER) Trial and the Brigham and Women's Hospital (BWH) Emergency Department (ED) in Boston, MA. We also sought to estimate these quantities within demographic and risk behavior subgroups. METHOD We used data from the USHER Trial, which was a randomized clinical trial of HIV screening conducted in the BWH ED. Since eligible participants were HIV-free at time of enrollment, we were able to calculate the prevalence of undiagnosed HIV. We used data from the Massachusetts Department of Public Health (MA/DPH) to estimate the prevalence of diagnosed HIV since the MA/DPH records the number of persons within MA who are HIV-positive. We calculated the proportion of HIV that is undiagnosed using these estimates of the prevalence of undiagnosed and diagnosed HIV. Estimates were stratified by age, sex, race/ethnicity, history of testing, and risk behaviors. RESULTS The overall expected prevalence of diagnosed HIV in a population similar to those presenting to the BWH ED was 0.71% (95% CI: 0.63%, 0.78%). The prevalence of undiagnosed HIV was estimated at 0.22% (95% CI: 0.10%, 0.42%) and resultant overall prevalence was 0.93%. The proportion of HIV-infection that is undiagnosed in this ED-based setting was estimated to be 23.7% (95% CI: 11.6%, 34.9%) of total HIV-infections. CONCLUSIONS Despite different methodology, our estimate of the proportion of HIV that is undiagnosed in an ED-setting was similar to previous estimates based on national surveillance data. Universal routine testing programs in EDs should use these data to help plan their yield of HIV detection.
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Affiliation(s)
- William M Reichmann
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
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Rothman RE, Hsieh YH, Harvey L, Connell S, Lindsell CJ, Haukoos J, White DAE, Kecojevic A, Lyons MS. 2009 US emergency department HIV testing practices. Ann Emerg Med 2011; 58:S3-9.e1-4. [PMID: 21684405 DOI: 10.1016/j.annemergmed.2011.03.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We characterize HIV testing practices and programs in US emergency departments (EDs) in 2009. METHODS A national Web-based survey of members of the National ED HIV Testing Consortium, participants in the 2007 Centers for Disease Control and Prevention (CDC)-sponsored ED HIV Testing Workshops, all US academic EDs, and a weighted random sample of US community EDs with snowball sampling to recruit additional testing sites was conducted. Data collected included geographic location, estimated seroprevalence, indications for testing, method of consent, weekly number of tests, funding, and costs. RESULTS Of 619 sites surveyed, 338 (54.6%) responded. A total of 277 (82.0%) reported conducting any HIV testing, and 75 (22.2%) reported systematic HIV testing programs, operationally defined as having testing or screening organized at the departmental or institutional level. systematic HIV testing programs were concentrated in the Northeast, at high-volume urban EDs, and in regions with higher HIV/AIDS prevalence. Most systematic HIV testing programs had existed for less than or equal to 3 years, and nearly one third reported using an opt-out approach for consent. Among systematic HIV testing programs, the number of patients tested ranged from less than 1 to 2,100 tests per week. Overall, universal screening was the most commonly reported screening method reported overall, and rates of HIV positivity were consistently above the CDC threshold of 0.1%. CONCLUSION The number of EDs conducting HIV testing has grown substantially since release of the 2006 CDC HIV testing recommendations. Although many EDs have systematic HIV testing programs, the majority do not. Ongoing surveillance will be required to quantify the evolution of ED-based HIV testing and the factors that facilitate or impede expanded translation.
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Affiliation(s)
- Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21209, USA.
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Hsu H, Walensky RP. Cost-effectiveness analysis and HIV screening: the emergency medicine perspective. Ann Emerg Med 2011; 58:S145-50. [PMID: 21684394 DOI: 10.1016/j.annemergmed.2011.03.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cost-effectiveness analysis is a useful tool for decisionmakers charged with prioritizing of the myriad medical interventions in the emergency department (ED). This analytic approach may be especially helpful for ranking programs that are competing for scarce resources while attempting to maximize net health benefits. In this article, we review the health economics literature on HIV screening in EDs and introduce the methods of cost-effectiveness analysis for medical interventions. We specifically describe the incremental cost-effectiveness ratio--its calculation, the derivation of ratio components, and the interpretation of these ratios.
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Hecht CR, Smith MD, Radonich K, Kozlovskaya O, Totten VY. A comparison of patient and staff attitudes about emergency department-based HIV testing in 2 urban hospitals. Ann Emerg Med 2011; 58:S28-32.e1-4. [PMID: 21684404 DOI: 10.1016/j.annemergmed.2011.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study compares and contrasts emergency department (ED) patient and staff attitudes towards ED-based HIV testing in 2 major hospitals in a single city, with an attempt to answer the following: Should routine ED-based HIV testing be offered? If so, who should be responsible for disclosing HIV test results? And what barriers might prevent ED-based HIV testing? METHODS Paper-based surveys were presented to a convenience sample of ED patients and staff at 2 urban, academic, tertiary care hospitals between December 2007 and June 2009. Descriptive statistics were derived with SAS and MicroSoft Excel. Data are reported in percentages, fractions, and graphs. RESULTS A total of 457 patients and 85 staff completed the surveys. The majority of patients favor ED-based HIV testing. Only a minority of ED staff support ED-based HIV testing. In both hospitals, patients prefer to have HIV test results delivered by a physician. This was true for both positive and negative results. However, only about one third of attending physicians feel comfortable disclosing a positive HIV test result. Patients and staff both view privacy and confidentiality as significant barriers to ED-based HIV testing. CONCLUSION Although ED patients are overwhelmingly in favor of ED-based HIV testing, the staff is not. Patients and staff agree that physicians should deliver HIV test results to patients, but a significant number of physicians are not comfortable doing so. Historical barriers continue to hinder ED-based HIV testing programs.
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Affiliation(s)
- Carrie R Hecht
- Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH 44109-1998, USA
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Mumma BE, Suffoletto BP. Less encouraging lessons from the front lines: barriers to implementation of an emergency department-based HIV screening program. Ann Emerg Med 2011; 58:S44-8. [PMID: 21684407 DOI: 10.1016/j.annemergmed.2011.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We describe barriers to, and discuss recommendations for, implementing a limited emergency department (ED)-based HIV screening program. METHODS A pilot program was designed to study the feasibility of integrating HIV screening into ED care among patients aged 18 to 64 years at an urban academic emergency department with an annual census of 50,000 patients. RESULTS During the first 12 weeks of the pilot program, 395 patients were screened. Of those, 2 (0.5%; 95% confidence interval 0.06% to 1.8%) received a positive test result for HIV. Both were contacted by telephone, and one was seen for result notification, posttest counseling, and further care in the local health department. Of the patients who received a negative test result, 98% were contacted about their results. We encountered numerous barriers to implementation, which we categorized as departmental, public health, legal, institutional, test limitations, and infrastructure. CONCLUSION Understanding potential barriers and making plans for dealing with them are critical to the successful implementation of an HIV screening program in the ED.
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Affiliation(s)
- Bryn E Mumma
- Department of Emergency Medicine, University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, PA 15261, USA
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Hoxhaj S, Davila JA, Modi P, Kachalia N, Malone K, Ruggerio MC, Miertschin N, Brock P, Fisher A, Mitts B, Giordano TP. Using nonrapid HIV technology for routine, opt-out HIV screening in a high-volume urban emergency department. Ann Emerg Med 2011; 58:S79-84. [PMID: 21684414 DOI: 10.1016/j.annemergmed.2011.03.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We implement an opt-out routine screening program in a high-volume, urban emergency department (ED), using conventional (nonrapid) technology as an alternative to rapid HIV tests. METHODS We performed a retrospective cohort study. Since October 2008, all patients who visited Ben Taub General Hospital ED and had blood drawn were considered eligible for routine opt-out HIV screening. The hospital is a large, publicly funded, urban, academic hospital in Houston, TX. The ED treats approximately 8,000 patients monthly. Screening was performed with standard chemiluminescence technology, batched hourly. Patients with positive screening test results were informed of their likely status, counseled by a service linkage worker, and offered follow-up care at an HIV primary care clinic. Confirmatory Western blot assays were automatically performed on all new HIV-positive samples. RESULTS Between October 1, 2008, and April 30, 2009, 14,093 HIV tests were performed and 39 patients (0.3%) opted out. Two hundred sixty-two (1.9%) HIV test results were positive and 80 new diagnoses were made, for an incidence of new diagnoses of 0.6%. There were 22 false-positive chemiluminescence results and 7 indeterminate Western blot results. Nearly half the patients who received a new diagnosis were not successfully linked to HIV care in our system. CONCLUSION Opt-out screening using standard nonrapid technology, rather than rapid testing, is feasible in a busy urban ED. This method of HIV screening has cost benefits and a low false-positivity rate, but aggressive follow-up and referral of patients with new diagnoses for linkage to care is required.
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Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium. Ann Emerg Med 2011; 58:S151-9.e1. [PMID: 21684395 DOI: 10.1016/j.annemergmed.2011.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Understanding perceived benefits and disadvantages of HIV testing in emergency departments (EDs) is imperative to overcoming barriers to implementation. We codify those domains of public health and clinical care most affected by implementing HIV testing in EDs, as determined by expert opinion. METHODS Opinions were systematically collected from attendees of the 2007 National ED HIV Testing Consortium meeting. Structured evaluation of strengths, weaknesses, opportunities, and threats analysis was conducted to assess the impact of ED-based HIV testing on public health. A modified Delphi method was used to assess the impact of ED-based HIV testing on clinical care from both individual patient and individual provider perspectives. RESULTS Opinions were provided by 98 experts representing 42 academic and nonacademic institutions. Factors most frequently perceived to affect public health were (strengths) high volume of ED visits and high prevalence of HIV, (weaknesses) undue burden on EDs, (opportunities) reduction of HIV stigma, and (threats) lack of resources in EDs. Diagnostic testing and screening for HIV were considered to have a favorable impact on ED clinical care from both individual patient and individual provider perspectives; however, negative test results were not perceived to have any benefit from the provider's perspective. The need for HIV counseling in the ED was considered to have a negative impact on clinical care from the provider's perspective. CONCLUSION Experts in ED-based HIV testing perceived expanded ED HIV testing to have beneficial impacts for both the public health and individual clinical care; however, limited resources were frequently cited as a possible impediment. Many issues must be resolved through further study, education, and policy changes if the full potential of HIV testing in EDs is to be realized.
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Abstract
OBJECTIVES In 2006, the Centers for Disease Control and Prevention (CDC) published recommendations for HIV testing in health care settings, calling for nontargeted opt-out rapid HIV screening in most settings, including emergency departments (EDs). Although a number of ED-based testing strategies exist, it is unclear to what extent they are used. The objective of this study is to survey academic and community EDs throughout the United States to determine ED-based HIV testing practices. METHODS This was a cross-sectional survey study of all academic EDs and a weighted random sample of all community-based EDs in the United States. A standardized survey instrument was developed and administered with an Internet-based survey platform, followed by direct contact and mail. The survey included domains related to perceived HIV testing barriers, whether HIV testing was performed and methods used, and familiarity with the CDC recommendations and whether they had been adopted. RESULTS Of the 131 total academic sites and the 435 community sites, 99 (76%) and 150 (35%) completed the survey, respectively. A larger proportion of academic sites believed HIV testing was needed (P=.02) and a larger proportion actually provided HIV testing (65% versus 50%; P=.04). Among the academic and community EDs that provided testing, 74% and 62% performed diagnostic testing, 26% and 22% performed targeted screening, and 16% and 6% performed nontargeted screening, respectively. A larger proportion of academic EDs reported receiving external funding to support testing (23% versus 4%; P=.001), whereas a large proportion of community sites considered costs a significant barrier to testing (P=.03). A larger proportion of academic EDs reported being familiar with the 2006 CDC recommendations (64% versus 40%; P<.001), although only 26% and 37% reported having implemented any part of them, respectively. CONCLUSION Academic EDs only make up approximately 3% of all EDs in the United States. Significant differences exist between academic and community EDs as they relate to performing HIV testing. Increased efforts should be made to improve the ability of community EDs to provide this service.
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Torres GW, Heffelfinger JD, Pollack HA, Barrera SG, Rothman RE. HIV Screening Programs in US Emergency Departments: A Cross-Site Comparison of Structure, Process, and Outcomes. Ann Emerg Med 2011; 58:S104-13. [DOI: 10.1016/j.annemergmed.2011.03.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schrantz SJ, Babcock CA, Theodosis C, Brown S, Mercer S, Pillow MT, Watts K, Taylor M, Pitrak DL. A Targeted, Conventional Assay, Emergency Department HIV Testing Program Integrated With Existing Clinical Procedures. Ann Emerg Med 2011; 58:S85-8.e1. [DOI: 10.1016/j.annemergmed.2011.03.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Waxman MJ, Popick RS, Merchant RC, Rothman RE, Shahan JB, Almond G. Ethical, Financial, and Legal Considerations to Implementing Emergency Department HIV Screening: A Report From the 2007 Conference of the National Emergency Department HIV Testing Consortium. Ann Emerg Med 2011; 58:S33-43. [DOI: 10.1016/j.annemergmed.2011.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dowdy DW, Rodriguez RM, Hare CB, Kaplan B. Cost-effectiveness of targeted human immunodeficiency virus screening in an urban emergency department. Acad Emerg Med 2011; 18:745-53. [PMID: 21762236 DOI: 10.1111/j.1553-2712.2011.01110.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Although targeted screening of patients at high risk for human immunodeficiency virus (HIV) infection in the emergency department (ED) improves patient outcomes and may prevent HIV transmission, ED-based screening programs incur additional costs and have thus not been widely scaled up. The objective of this study was to evaluate the cost-effectiveness of ED-based targeted HIV screening as implemented in actual practice. METHODS This was a cost-utility analysis of a rapid HIV screening program in an urban ED. Physicians were encouraged to screen patients undergoing inpatient admission or who had HIV risk factors. The authors measured costs directly and estimated quality-adjusted life expectancy using chart review, literature assumptions, and mathematical modeling. Incremental cost utility was evaluated from a societal perspective using a lifetime time horizon. RESULTS From June 2008 through September 2009, a total of 3,766 HIV tests were ordered (235 tests per month), of which an estimated 2,406 (64%) represented screening in patients without HIV-related signs or symptoms. Nineteen (0.8%) patients were newly diagnosed through screening during the study period, of whom nine (47%) were eligible for antiretroviral therapy (ART) and maintained consistent outpatient follow-up. Estimated screening costs were $82,300 per year, or $45.53 per screening test, of which $28.01 (62%) was for program management. Targeted screening prevented an estimated 2.1 HIV transmission events over 16 months. Per patient screened, targeted screening saved $112 (95% uncertainty range [UR] = $20 to $225) and resulted in 2.71 quality-adjusted life-days gained (95% UR = 1.71 to 4.01). Cost-utility was most sensitive to the prevalence of undiagnosed HIV in the screened population. CONCLUSIONS Targeted HIV screening, as implemented in an urban ED, is cost saving and increases quality-adjusted life expectancy.
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Affiliation(s)
- David W Dowdy
- Department of Medicine, University of California, San Francisco, USA.
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26
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Spielberg F, Kurth AE, Severynen A, Hsieh YH, Moring-Parris D, Mackenzie S, Rothman R. Computer-facilitated rapid HIV testing in emergency care settings: provider and patient usability and acceptability. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2011; 23:206-221. [PMID: 21696240 DOI: 10.1521/aeap.2011.23.3.206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Providers in emergency care settings (ECSs) often face barriers to expanded HIV testing. We undertook formative research to understand the potential utility of a computer tool, "CARE," to facilitate rapid HIV testing in ECSs. Computer tool usability and acceptability were assessed among 35 adult patients, and provider focus groups were held, in two ECSs in Washington State and Maryland. The computer tool was usable by patients of varying computer literacy. Patients appreciated the tool's privacy and lack of judgment and their ability to reflect on HIV risks and create risk reduction plans. Staff voiced concerns regarding ECS-based HIV testing generally, including resources for follow-up of newly diagnosed people. Computer-delivered HIV testing support was acceptable and usable among low-literacy populations in two ECSs. Such tools may help circumvent some practical barriers associated with routine HIV testing in busy settings though linkages to care will still be needed.
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Chen JC, Goetz MB, Feld JE, Taylor A, Anaya H, Burgess J, de Mesa Flores R, Gidwani RA, Knapp H, Ocampo EH, Asch SM. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med 2011; 29:418-26. [DOI: 10.1016/j.ajem.2009.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 10/07/2009] [Accepted: 11/11/2009] [Indexed: 10/19/2022] Open
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Pisculli ML, Reichmann WM, Losina E, Donnell-Fink LA, Arbelaez C, Katz JN, Walensky RP. Factors associated with refusal of rapid HIV testing in an emergency department. AIDS Behav 2011; 15:734-42. [PMID: 20978834 PMCID: PMC3082047 DOI: 10.1007/s10461-010-9837-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
HIV screening studies in the emergency department (ED) have demonstrated rates of HIV test refusal ranging from 40–67%. This study aimed to determine the factors associated with refusal to undergo routine rapid HIV testing in an academic ED in Boston. HIV counselors offered routine testing to 1,959 patients; almost one-third of patients (29%) refused. Data from a self-administered survey were used to determine independent correlates of HIV testing refusal. In multivariate analysis, women and patients with annual household incomes of $50,000 or more were more likely to refuse testing, as were those who reported not engaging in HIV risk behaviors, those previously HIV tested and those who did not perceive a need for testing. Enrollment during morning hours was also associated with an increased risk of refusal. Increased educational efforts to convey the rationale and benefits of universal screening may improve testing uptake among these groups.
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Affiliation(s)
- Mary L. Pisculli
- Division of Infectious Disease, Brigham and Women’s Hospital, Boston, MA USA
| | - William M. Reichmann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | | | - Christian Arbelaez
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jeffrey N. Katz
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA USA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA USA
| | - Rochelle P. Walensky
- Division of Infectious Disease, Brigham and Women’s Hospital, Boston, MA USA
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA USA
- Center for AIDS Research, Harvard Medical School, Boston, MA USA
- Division of Infectious Disease, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114 USA
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Clauss H, Collins JM, Eldakar-Hein S, Palermo B, Gentile N, Adige S, Pace W, Duffalo C, Menajovsky J, Zambrotta J, Zachary D, Axelrod P, Samuel R, Bettiker R. Prevalence and characteristics of patients with undiagnosed HIV infection in an urban emergency department. AIDS Patient Care STDS 2011; 25:207-11. [PMID: 21323565 DOI: 10.1089/apc.2010.0196] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Centers for Disease Control and Prevention (CDC) recommends offering HIV testing to persons admitted to emergency departments (EDs). Whether by opt-in or opt-out, many EDs (including our own) have found a seroprevalence of 0.8-1.5% when rapid testing is offered. The true seropositivity rate is unknown. We performed a retrospective chart analysis upon all patients presenting to our ED over a 2-week period in the fall of 2007 who had serum drawn as a part of their emergency care. Demographics and clinical characteristics were linked via de-identified serum, which was sent for HIV testing. Nine hundred fifty nine patients had sera available for rapid HIV testing. One hundred twenty one (13%) samples were reactive via the OraQuick(®) test (OraSure Technologies, Bethlehem, PA), a point of care rapid antibody test. Due to concerns about the appropriateness of sera as substrate for the OraQuick(®) technology, reactive samples were retested via standard enzyme immunoassay (EIA)/Western blot. One hundred twelve analyzable samples were retested-38 were positive and 27 of these were from patients who reported a history of HIV infection. The rate of undiagnosed HIV infection was 1.2% (11/914 potentially analyzable samples). Of all patients with HIV in our ED, 29% of them were presumably unaware of their diagnosis. In conclusion, HIV seroprevalence in our urban ED is high, and a large fraction of the patients appears to be unaware of the infection.
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Affiliation(s)
- Heather Clauss
- Section of Infectious Diseases, Temple University, Philadelphia, Philadelphia
| | - Julie M. Collins
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Philadelphia
| | - Shaden Eldakar-Hein
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Philadelphia
| | - Brandon Palermo
- Section of Infectious Diseases, Drexel University, Philadelphia, Philadelphia
| | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Philadelphia
| | | | - William Pace
- Section of Infectious Diseases, Drexel University, Philadelphia, Philadelphia
| | - Chad Duffalo
- Section of Infectious Diseases, Tufts University Boston, Massachusetts
| | - Jose Menajovsky
- Section of Infectious Diseases, University of Maryland, Baltimore, Maryland
| | - Jaime Zambrotta
- Department of Medicine, Nazereth Hospital, Philadelphia, Philadelphia
| | - Dalila Zachary
- Section of Infectious Diseases, Brown University, Providence, Rhode Island
| | - Peter Axelrod
- Section of Infectious Diseases, Temple University, Philadelphia, Philadelphia
| | - Rafik Samuel
- Section of Infectious Diseases, Temple University, Philadelphia, Philadelphia
| | - Robert Bettiker
- Section of Infectious Diseases, Temple University, Philadelphia, Philadelphia
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Silverman RA, Arora H, Kwiatkowski TM, Graff KK, Baneman E, Kohn N, Foss Bowman C, Smith KN, Lesser ML. Increased A1C among adult emergency department patients with type 2 diabetes. Ann Emerg Med 2011; 57:575-81. [PMID: 21227541 DOI: 10.1016/j.annemergmed.2010.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2009] [Revised: 10/31/2010] [Accepted: 11/11/2010] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Long-term glycemic control can prevent or delay complications of diabetes. Although diabetes is a common comorbidity in emergency department (ED) patients, the adequacy of long-term control is not known. Our objectives are to determine the frequency of poorly controlled type 2 diabetes among adults presenting to an ED and to identify characteristics associated with poor control. METHODS An A1C level was obtained for diabetic patients 18 years and older who presented to the ED for acute medical problems and had blood tests performed for usual medical care. Consecutive patients were screened for a total of 58 24-hour periods during a 10-week period. A1C values were stratified, with less than 7% defined as good control and greater than or equal to 7% poor long-term control. Logistic regression analysis was used to identify factors associated with poor control. RESULTS Of the 500 patients with type 2 diabetes, 53.4% had inadequate long-term control. An increased ED glucose level was independently associated with an increased A1C level. If the ED glucose level was 126 to 149 mg/dL, the odds ratio (OR) for an increased A1C level relative to a glucose level less than 100 mg/dL was 2.3 (95% confidence interval [CI] 0.95, 5.68); the OR was 6.4 (95% CI 2.9, 14.1) for glucose levels 150 to 199 mg/dL, and for glucose level of 200 mg/dL or above, the OR for an increased A1C level was 21.2 (9.1, 49.3). Other factors independently associated with increased A1C level were black race, aged 40 to 59 years, and Medicaid insurance. CONCLUSION The high frequency of A1C levels more than 7% points to the ED as a potential source for identifying patients with poorly controlled type 2 diabetes.
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Affiliation(s)
- Robert A Silverman
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
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Abstract
OBJECTIVE A 'test and treat' strategy to reduce HIV transmission hinges on linking and retaining HIV patients in care to achieve the full benefit of antiretroviral therapy. We integrated empirical findings and estimated the percentage of HIV-positive persons in the United States who entered HIV medical care soon after their diagnosis; and were retained in care during specified assessment intervals. METHODS We comprehensively searched databases and bibliographic lists to identify studies that collected data from May 1995 through 2009. Separate meta-analyses were conducted for entry into care and retention in care (having multiple HIV medical visits during specified assessment intervals) stratified by methodological variables. All analyses used random-effects models. RESULTS Overall, 69% [95% confidence interval (CI) 66-71%, N = 53 323, 28 findings] of HIV-diagnosed persons in the United States entered HIV medical care averaged across time intervals in the studies. Seventy-two percent (95% CI 67-77%, N = 6586, 12 findings) entered care within 4 months of diagnosis. Seventy-six percent (95% CI 66-84%, N = 561, 15 findings) entered care after testing HIV-positive in emergency/urgent care departments and 67% (95% CI 64-70%, N = 52 762, 13 findings) entered care when testing was done in community locations. With respect to retention in care, 59% (95% CI 53-65%, N = 75 655, 28 findings) had multiple HIV medical care visits averaged across assessment intervals of 6 months to 3-5 years. Retention was lower during longer assessment intervals. CONCLUSION Entry and retention in HIV medical care in the United States are moderately high. Improvement in both outcomes will increase the success of a test and treat strategy.
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Torres M. Rapid HIV Screening in the Emergency Department. Emerg Med Clin North Am 2010; 28:369-80, Table of Contents. [DOI: 10.1016/j.emc.2010.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hsieh YH, Jung JJ, Shahan JB, Moring-Parris D, Kelen GD, Rothman RE. Emergency medicine resident attitudes and perceptions of HIV testing before and after a focused training program and testing implementation. Acad Emerg Med 2009; 16:1165-73. [PMID: 20053237 DOI: 10.1111/j.1553-2712.2009.00507.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives were to determine attitudes and perceptions (A&P) of emergency medicine (EM) residents toward emergency department (ED) routine provider-driven rapid HIV testing services and the impact of both a focused training program (FTP) and implementation of HIV testing on A&P. METHODS A three-phase, consecutive, anonymous, identity-unlinked survey was conducted pre-FTP, post-FTP, and 6 months postimplementation. The survey was designed to assess residents' A&P using a five-point Likert scale. A preimplementation FTP provided both the rationale for the HIV testing program and the planned operational details of the intervention. The HIV testing program used only indigenous ED staff to deliver HIV testing as part of standard-of-care in an academic ED. The impact of the FTP and implementation on A&P were analyzed by multivariate regression analysis using generalized estimating equations to control for repeated measurements in the same individuals. A "favorable" A&P was operationally defined as a mean score of >3.5, "neutral" as mean score of 2.5 to 3.5, and "unfavorable" as mean score of <2.5. RESULTS Thirty of 36 residents (83.3%) participated in all three phases. Areas of favorable A&P found in phase I and sustained through phases II and III included "ED serving as a testing venue" (score range = 3.7-4.1) and "emergency medicine physicians offering the test" (score range = 3.9-4.1). Areas of unfavorable and neutral A&P identified in phase I were all operational barriers and included required paperwork (score = 3.2), inadequate staff support (score = 2.2), counseling and referral requirements (score range = 2.2-3.1), and time requirements (score = 2.9). Following the FTP, significant increases in favorable A&P were observed with regard to impact of the intervention on modification of patient risk behaviors, decrease in rates of HIV transmission, availability of support staff, and self-confidence in counseling and referral (p < 0.05). At 6 months postimplementation, all A&P except for time requirements and lack of support staff scored favorably or neutral. During the study period, 388 patients were consented for and received HIV testing; six (1.5%) were newly confirmed HIV positive. CONCLUSIONS Emergency medicine residents conceptually supported HIV testing services. Most A&P were favorably influenced by both the FTP and the implementation. All areas of negative A&P involved operational requirements, which may have influenced the low overall uptake of HIV testing during the study period.
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Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Arbelaez C, Block B, Losina E, Wright EA, Reichmann WM, Mikulinsky R, Solomon JD, Dooley MM, Walensky RP. Rapid HIV testing program implementation: lessons from the emergency department. Int J Emerg Med 2009; 2:187-94. [PMID: 20157472 PMCID: PMC2760703 DOI: 10.1007/s12245-009-0123-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 07/12/2009] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The US Centers for Disease Control and Prevention (CDC) guidelines and the World Health Organization (WHO) both recommend HIV testing in health-care settings. However, neither organization provides prescriptive details regarding how these recommendations should be adapted into clinical practice in an emergency department. METHODS We have implemented an HIV-testing program in the ED of a major academic medical center within the scope of the Universal Screening for HIV Infection in the Emergency Room (USHER) Trial-a randomized clinical trial evaluating the feasibility and cost-effectiveness of HIV screening in this setting. RESULTS AND CONCLUSION Drawing on our collective experiences in establishing programs domestically and internationally, we offer a practical framework of lessons learned so that others poised to embark on such HIV testing programs may benefit from our experiences.
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Affiliation(s)
- Christian Arbelaez
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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White DA, Scribner AN, Schulden JD, Branson BM, Heffelfinger JD. Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department. Ann Emerg Med 2009; 54:56-64. [DOI: 10.1016/j.annemergmed.2008.09.027] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 09/17/2008] [Accepted: 09/24/2008] [Indexed: 10/21/2022]
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Kelen GD, Rothman RE. Emergency department-based HIV testing: too little, but not too late. Ann Emerg Med 2009; 54:65-71. [PMID: 19398241 DOI: 10.1016/j.annemergmed.2009.03.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 03/26/2009] [Accepted: 03/30/2009] [Indexed: 11/19/2022]
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Emergency care of urban women with sexually transmitted infections: time to address deficiencies. Sex Transm Dis 2009; 36:51-7. [PMID: 18813030 DOI: 10.1097/olq.0b013e318188389b] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient education upon diagnosis of a sexually transmitted infection (STI) may effect changes in high-risk sexual behavior. OBJECTIVE Describe emergency department (ED) communication with urban female patients treated for STIs. METHODS : This secondary analysis of data collected during a study of ED communication used mixed quantitative and qualitative methods. The medical records of female patients ages 18 to 35 presenting to an urban ED for low abdominal/pelvic pain, gynecological complaints, and urinary symptoms (n = 134) were reviewed for STI testing and treatment proportions. A subsample of 30 audiotaped interactions with women treated for STIs were coded for provider assessment of sexual risks and delivery of STI prevention messages. RESULTS Audiotape analysis found sexual histories were very limited and only 17% of women received prevention messages. Provider STI treatment had an estimated overall sensitivity of 46% (95% CI, 24.4%-69.0%) and specificity of 66% (95% CI, 61.8%-70.7%). CONCLUSIONS Urban female patients treated for an STI in the ED rarely received recommended STI prevention messages. The study raises policy issues regarding the need for quality indicators in acute STI care. Access to STI treatment in other practice settings or by alternative methods need to be strongly considered.
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Rothman RE, Kalish B. Update on emerging infections: news from the Centers for Disease Control and Prevention. False-positive oral fluid rapid HIV tests--New York City, 2005-2008. Ann Emerg Med 2009; 53:151-4; discussion 154-6. [PMID: 19123264 DOI: 10.1016/j.annemergmed.2008.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Richard E Rothman
- Departments of Emergency Medicine and Medicine (Division of Infectious Disease), Johns Hopkins University School of Medicine, Baltimore, MD, USA
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National estimation of rates of HIV serology testing in US emergency departments 1993-2005: baseline prior to the 2006 Centers for Disease Control and Prevention recommendations. AIDS 2008; 22:2127-34. [PMID: 18832876 DOI: 10.1097/qad.0b013e328310e066] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The 2006 Centers for Disease Control and Prevention recommendations place increased emphasis on emergency departments (EDs) as one of the most important medical care settings for implementing routine HIV testing. No longitudinal estimates exist regarding national rates of HIV testing in EDs. We analyzed a nationally representative ED database to assess HIV testing rates and characterize patients who received HIV testing, prior to the release of the 2006 guidelines. DESIGN A cross-sectional analysis of US ED visits (1993-2005) using the National Hospital Ambulatory Medical Care Survey was performed. METHODS Patients aged 13-64 years were included for analysis. Diagnoses were grouped with Healthcare Cost and Utilization Project Clinical Classifications Software. Analyses were performed using procedures for multiple-stage survey data. RESULTS HIV testing was performed in an estimated 2.8 million ED visits (95% confidence interval, 2.4-3.2) or a rate of 3.2 per 1000 ED visits (95% confidence interval, 2.8-3.7). Patients aged 20-39 years, African-American, and Hispanic had the highest testing rates. Among those tested, leading reasons for visit were abdominal pain (9%), puncture wound/needlestick (8%), rape victim (6%), and fever (5%). The leading medication class prescribed was antimicrobials (32%). The leading ED diagnosis was injury/poisoning (30%) followed by infectious diseases (18%). Of note, 6% of those tested were diagnosed with HIV infection during their ED visits. CONCLUSION Prior to the release of the 2006 Centers for Disease Control and Prevention guidelines for routine HIV testing in all healthcare settings, baseline national HIV testing rates in EDs were extremely low and appeared to be driven by clinical presentation.
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Kelen GD. Public health initiatives in the emergency department: not so good for the public health? Acad Emerg Med 2008; 15:194-7. [PMID: 18275451 DOI: 10.1111/j.1553-2712.2008.00068.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G D Kelen
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, MD, USA.
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Bernstein SL, Haukoos JS. Public health, prevention, and emergency medicine: a critical juxtaposition. Acad Emerg Med 2008; 15:190-3. [PMID: 18275450 DOI: 10.1111/j.1553-2712.2008.00055.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Steven L Bernstein
- Department of Emergency Medicine Albert Einstein College of Medicine and Montefiore Medical Center Bronx, NY, USA.
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Gaddis GM, Hauswald M. The provision of public health services in the emergency department: "begin with the end in mind". Acad Emerg Med 2008; 15:198-200. [PMID: 18275453 DOI: 10.1111/j.1553-2712.2008.00056.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Gary M Gaddis
- Department of Emergency Medicine St. Luke's Hospital of Kansas City and The University of Missouri-Kansas City School of Medicine Kansas City, MO, USA.
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