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• W1497409073 abstract "Common sense principles and compelling evidence support the incorporation of human immunodeficiency virus (HIV) screening in emergency settings. First, early identification of individuals with HIV has been proven to delay disease progression, prevent occurrence of HIV-related complications, and save thousands of individuals from ever getting infected, thereby eliminating opportunities for further propagation of disease in the community.1, 2 Second, empirical data demonstrate that individuals with unrecognized late-stage HIV come to emergency departments (EDs) at disproportionately higher rates than any other health care venue,3 and ED patients are highly receptive to agree to HIV screening in this setting.4, 5 Third, the ever-increasing simplicity of the HIV testing process itself, through opt-out consent and availability of multiple point-of-care rapid assays, creates technically feasible opportunities for implementation of screening in EDs. Thus, one wonders why, as reported by Berg et al.6 in this issue of Academic Emergency Medicine, fewer than 20% of EDs report performing routine HIV screening. Two aspects of the study by Berg et al. deserve particular attention with regard to enhancing our understanding of evolving HIV screening efforts in U.S. EDs and highlight one key ongoing challenge. First, despite the far-reaching 2006 Centers for Disease Control and Prevention (CDC) guidelines2 recommending widespread HIV screening across health care settings, the overall rates of HIV screening in EDs reported in the study by Berg et al. remain low (survey conducted in 2009). While methodologic limitations with the survey exist and were appropriately cited by the authors, the rates of screening reported are fairly consistent with those from another large national survey7 conducted over the same time period. In that study, approximately 22% of EDs were reported to offer “systematic” HIV testing, defined as testing or screening organized at the departmental or institutional level, thereby closely approximating the survey query by Berg et al. that assessed availability of “routine HIV screening.” The second focuses on the factors included in the author’s multivariate analysis that concluded that “ED directors concern regarding the added costs of HIV preventative service” was negatively correlated with HIV screening program availability. This issue is particularly relevant, given the evolving vision within the Division of HIV/AIDS Prevention at the CDC to encourage EDs to move toward more self-sustained HIV screening programs [personal communication, National Alliance of State and Territorial AIDS Directors (NASTED) Meeting: HIV Testing in Hospital Emergency Departments: Collaborative Strategies for Implementation, Washington DC, April 9, 2010]. Since 2006, both indirect resource support and directed ear-marked funding have resulted in a dramatic rise in the number of EDs that report conducting any HIV testing, with more than 80% doing so as of 2009.7 Both extramural funding and peer-reviewed publications related to ED-based HIV testing show steady increases annually over the past decade, with annual original research and other publications rising from approximately 50 to over 200 per year (Haukoos, J; as presented at the Annual SAEM meeting in Chicago, June 2012). Still, as described by Berg et al.6 and others,7, 8 the majority of U.S. EDs do not operate HIV screening programs, and 90% of those sites are financially supported by external research or program support, principally derived from federal, state, or local government sources.7 Compounding the challenge of dependency on external support is the lack of experience in seeking or attaining third-party reimbursement for HIV screening costs. Currently, costs of the HIV test kits used across U.S. EDs are principally provided “free of charge” by local or state health departments or federal agencies. Without these public health funds to support HIV testing programs, sustainability remains in doubt. Thus, concerns of the ED directors, as catalogued by Berg et al., seem appropriate. Burke et al.9 addressed obstacles to HIV testing and report that reimbursement for HIV testing performed in both fee-for-service and managed care insurance programs is critical to support sustainability of HIV testing program in EDs. Suggested interventions for the challenges of reimbursement included, “increasing provider reimbursement for HIV testing in fee-for-service programs, and reimbursing HIV testing above the capitated rate for managed care programs.” Although the Center for Medicare and Medicaid Services issued an advisory to all state Medicaid directors indicating that HIV screening is reimbursable, Medicaid reimbursement remains a state-by-state decision.10 Thus, it remains unclear in most locales whether either public or private insurers will pay for routine HIV screening in EDs. Promising news has recently come out of several states. These include California, where state legislation requires all insurers to pay for HIV screening, and New York, where Medicaid provides coverage for HIV screening in EDs.11, 12 Washington, DC, also requires insurers to pay for HIV screening in EDs, but “bundling” of ED fees has left it unclear (as of the time of this writing) whether claims for HIV screening in the ED will be universally recouped. Several other states around the U.S. are actively pursuing legislation around reimbursement for HIV screening, which will affect EDs. However, for the majority of states that have not yet pursued legislative action, experiences of others are not translatable. Accordingly, with increasing pressure from both the CDC and the public health departments that allocate funds to EDs, several emergency physician leaders are beginning to investigate the issue of insurer reimbursement for the costs of the HIV testing, via pilot partnerships with local health departments (personal communication, 2012 National ED HIV Testing Consortium at SAEM, Chicago, June 2012). These pioneering experiences may help EDs across the U.S. identify nonlegislative solutions to address the costs associated with achieving sustainable HIV screening in EDs. One newly evolving approach is to focus investments and resources on those patient groups that might benefit most. Although somewhat controversial, since it is seen by some as at odds with the original vision of the 2006 CDC guidelines, a “targeted” HIV testing approach is currently under investigation by researchers at Denver Health Medical Center.13 Notably, in an initial study by Haukoos et al., the investigators derived and then subsequently validated a robust risk score that accurately categorizes patients into groups with significantly different probabilities of HIV infection according to demographics, sexual and injection drug use risk behaviors, and prior HIV testing history.13 A subsequent external validation in a city with high rates of undiagnosed HIV infections, using an abbreviated version of the risk score, found it to be highly accurate, with area under receiver operating characteristics curve of close to 80%.14 Employing tailored HIV risk score tools may offer one means to increase efficiency and lower costs of ED HIV screening, while maintaining both the clinical and public health utility of offering HIV screening to patients in the ED. A multisite study to address such an approach (relative to nontargeted testing) is currently in development. Finally, the integration of technology into HIV screening programs offers a promising opportunity to reduce costs while improving efficiency. Prior to the 2006 CDC recommendations for HIV testing, the medical informatics literature had shown that information technology can achieve the following: 1) reduce duplicate laboratory testing,15 2) increase preventative care utilization,16 3) improve cost-effectiveness of physician prescribing,17 and 4) increase physician adherence to clinical guidelines.18 Recent studies have begun to demonstrate how information technology can be effectively incorporated into HIV testing programs. Examples include several studies using novel free-standing computerized kiosk systems that have demonstrated the feasibility of providing kiosk-based screening at triage19 and ED registration.20 Another example leveraging information technology demonstrated streamlined identification of patients for HIV testing by integrating a computer reminder system with the electronic medical record to determine patient eligibility,21 decreasing redundancy and offering potential cost savings. The focus on information technology in health care has dramatically increased since the data collection period described by Berg et al.6 Future, thoughtfully engineered integration of medical informatics into ED-based HIV testing programs could substantially reduce the marginal costs of ED HIV screening in the long run and improve overall rates of HIV screening for eligible ED patients. In summary, the study by Berg et al. provides another piece of evidence that the majority of our nation’s EDs are still falling short of the goal of providing HIV testing as a routine preventative service. While significant progress has been made over the past 5 years, the challenge of sustainability and costs looms large. Approaches to meet these challenges require a multipronged strategy that includes advancing innovative approaches such as incorporating information technology into HIV screening programs, evaluating the outcomes associated with targeted (vs. nontargeted) screening strategies, and partnering with public health and policy leaders to define and evaluate various reimbursement strategies for HIV testing. To this end, a workshop coordinated by the ED National HIV Testing Consortium, and The Forum for HIV Collaborative Research is being planned, to be held in November 2012 at the National HIV and Viral Hepatitis Summit. Taken together, these approaches may ultimately change “perceptions” and permit the most effective use of ED resources to improve the health of our ED patients and those in the surrounding communities that we serve." @default.
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• W1497409073 title "HIV Testing in U.S. Emergency Departments: At the Crossroads" @default.
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