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Evolution in testing technology enables some urban EDs to implement HIV screening at relatively low cost
Hospital reports significant progress in identifying patients with HIV, linking them with care
Five years after the Centers for Disease Control (CDC) in Atlanta issued recommendations calling for all health care settings to routinely screen patients for HIV in areas where HIV prevalence is at 0.1% or higher, the practice has failed to take hold in most EDs, even though many obstacles to testing, such as burdensome informed consent requirements, for example, have been cleared away.1 However, with financial support from the CDC and other sources, as well new testing platforms that have helped to lower the cost of HIV screening, substantial progress has been made, according to Bernard Branson, MD, a medical epidemiologist in CDC's Division of HIV/AIDS Prevention, an author of the CDC recommendations regarding HIV screening, and a co-editor of a just-published special supplement to the Annals of Emergency Medicine that deals with HIV testing in the ED.2
"Screening has basically gone up from about 13% in hospital EDs [in 2004] to a range now of 22% to 25%, especially in academic EDs," says Branson. "And the significant thing is that a lot of this screening is happening in urban centers that have high-risk populations with a high prevalence of HIV, so this has very much gone in the direction that we had hoped."
Further, despite valid concerns that EDs are already overburdened with responsibilities, there are strong arguments in favor of expanded HIV screening in the ED.
"There are studies that suggest that most people who are diagnosed late have missed opportunities for earlier diagnosis in the ED, and late diagnosis is very damaging for individual health and public health," explains Michael Lyons, MD, MPH, an assistant professor of emergency medicine at the University of Cincinnati in Cincinnati, OH, and also a co-editor of the special supplement to the Annals of Emergency Medicine, dealing with HIV screening in the ED. "That suggests that EDs have a role, and very likely a unique role, in terms of screening the population. And the idea that screening the population is beneficial is certain. There is no dispute about that."
Consider "path of least resistance"
One approach that has proven particularly successful at testing large numbers of patients who present to the ED for care was first implemented at Ben Taub General Hospital in Houston, TX, in August of 2008, but has since been expanded to include many other hospitals in Texas, and it is in the process of being implemented in other urban areas as well, according to Ken Malone, the HIV testing project coordinator for the Harris County Hospital District, an entity that includes two other hospitals in addition to Ben Taub and 13 community health centers.
"We had been doing walk-up HIV testing for a number of years," says Malone, noting that the hospital advertised that people could basically walk into the ED and ask for one of the oral swab rapid tests. However, it quickly became clear that this type of personnel-dependent approach would not work with the kind of volume testing that the CDC was looking for, says Malone. (Also, see "Lack of resources a key barrier to HIV screening in the ED," below.)
"We decided it would be easier to concentrate on people who were getting a blood draw because they would likely include the sickest patients and this would require no change in our operating procedure to just add an HIV test [to the list of tests being ordered]," says Malone. "It was like the path of least resistance."
New testing platforms that enable many different types of tests to be conducted at the same time on the same machine are critical to the approach adopted at Ben Taub and other hospitals that have adopted similar HIV testing policies, says Branson. "What they allow is much higher-volume testing that is much less personnel-dependent," he says. "That has enabled [Ben Taub] to bring their costs for doing the HIV test down from $77 per test to about $12 per test."
While this type of high-volume testing does not produce results as quickly as the point-of-service rapid tests that are favored in many EDs, most patients can still receive their results before their ED visit is over, says Malone. "It has worked out fine because it takes 122 minutes turnaround time for the test itself, and the wait time [for results] is now about 8 hours, as opposed to 13 or 14 hours when we started using this process," he says.
Branson adds that the approach is a "very attractive alternative" because when done in accordance with opt-out testing, in which the default action is to go ahead and conduct an HIV test unless the patient requests that the test not be done, fewer than 2% of patients are declining the test. "With a lot of the point-of-care tests, the proportion of people who decline the test can be as high as 30%," he says. "This tends to be a more affordable model, and it very actively involves the laboratory."
Hospitals in the Harris County Hospital District have actually gone a step further than most in their approach to opt-out testing, says Malone. "We have put signage out telling patients that they are going to be tested for HIV, and if they don't want to be tested, they should tell their physician," he says. "It has worked pretty well."
Make plans for care linkage
Of course, a seamless front-end strategy for getting a large number of patients tested is only half the battle. Hospitals also need to develop resources and a process for connecting patients who test HIV positive with care. Administrators at Ben Taub addressed this issue early on.
"We leveraged some other funding that we have for what we call a service linkage worker," says Malone, explaining that this person is charged with explaining the diagnosis to the patient, reviewing what resources are available through the Harris County Hospital District, and then setting up appointments for the patient to see an appropriate care provider. "Then we monitor whether they come to their appointments or not," says Malone. "If they miss appointments, we call them and try to find out what happened. We don't consider them linked to care until they have made a doctor visit. We have had an 80% success rate thus far."
The service linkage worker is also responsible for tracking down patients who test HIV positive but are no longer in the ED when results from their blood work are available from the lab. "We call them and tell them that we have some lab results that we want to go over with them, and that they need to return to the ED so we can talk to them," says Malone.
Reaching patients after they have left the ED can be problematic, as their contact information is not always reliable. "We have missed a few people who we couldn't find after they left, but it is a very small percentage," says Malone. "Normally they are still here and we can contact them right there."
Service linkage workers are not licensed social workers, but the Harris County Hospital District equips them with training in protocol-based counseling and motivational interviewing, says Malone. "The motivational interviewing is very important because patients typically come to the ED thinking they have something else only to find out that they are HIV positive," he says. "You have to be able to assess where that patient is in an instant and attract his attention because you don't have many chances to get these people into care; you have to turn their heads so that they understand exactly what you are talking about."
Early analyses of the patients who have tested positive through Ben Taub's HIV testing program reveal that most had visited the ED at least four times before they were diagnosed, says Malone. "It is an enormous burden on our system because while you can't say that HIV is what caused them to be here, obviously there is something that made them sick and they couldn't get it figured out because they kept coming back," he says. "We have seen that by identifying people, you can [pin point] the problem and start addressing their care in a more proactive fashion."
Since the HIV testing program commenced in August of 2008, the Harris County Hospital District has identified 780 patients as HIV positive, and these are people who had no idea of their disease status, says Malone. "Now we have helped reduce the transmission of disease by some factor," he says, noting that researchers plan to measure this impact in the near future. "The program has not been without problems; no program is. But it has been tremendously successful."
In fact, the project spawned another effort in the hospital aimed at making sure that all inpatients with a diagnosis of HIV are identified and connected with appropriate resources. This is accomplished through the creation of an ID team, says Malone. "If inpatients have HIV in their diagnosis at all, they get a visit from the ID team, and our service linkage workers are attached to that team as well," he says. "We are making sure that all the people coming through our facilities are taken care of, and that we give them the resources they need so that once they leave any one of our facilities they will be in care and stay in care."
Get a champion, consider a pilot
ED managers who are interested in exploring the HIV screening approach used at Ben Taub should consult the guidelines published by the Chicago, IL-based Health Research and Education Trust (HRET), advises Malone. (See Resource Box for link to HRET resources, below.) "I used the HRET framework and sold the program from the ground up and top down at the same time," he says. Malone stresses that it is also critical to find a champion who is at a sufficiently high level to cut through administrative red tape and really push things through.
Shkelzen Hoxhaj, MD, MBA, director of the ED, championed the approach at Ben Taub, and published data on the results.3 "He was given the assignment and told that the problems weren't fixable," says Malone. "But they're always fixable. You just have to do it right. He is very creative and forward thinking, and that is what you need."
Ben Taub was fortunate in that it had funding from the CDC and some other sources to support the program. This was critical, says Malone, and he advises hospitals to make sure they have adequate financial resources to carry out their plans. "You have to be able to fund this type of program at all levels," he says. "We are, right now, working towards making our program completely sustainable after our funding diminishes or goes away."
Starting the effort as a pilot may work to your advantage, says Malone, noting that this approach helped get the testing program off to a quick start at Ben Taub. "We didn't have to go through all sorts of forms and committees," he says. "If we had done that, three years later we would still be trying to plan the program."
Lack of resources, philosophical issues remain barriers to HIV screening in the ED
While more EDs are implementing HIV screening programs, significant barriers remain, emphasizes Michael Lyons, MD, an assistant professor of emergency medicine at the University of Cincinnati in Cincinnati, OH. For example, Lyons points out that one persistent roadblock is that some emergency physicians don't feel as though public health or prevention should be a primary focus in the ED.
"There is a philosophical issue in the emergency medicine community about this," says Lyons. "It is not that emergency physicians don't understand that HIV testing is important, but it is one thing among many that is important, and in their daily jobs where they are already overburdened taking care of emergent illness and injury, it is an open question how much attention they are going to choose to give to issues that they see as someone else's role."
The biggest barrier, however, is generally lack of resources, says Lyons. "Emergency departments are already overcrowded, they are already overwhelmed, they're already unable to meet their basic mission, so anything new is going to be perceived as an unfunded mandate, particularly if there is not a clear way to pay for it," he says.
While some public and private payers will reimburse for HIV testing, such coverage is not always assured or clearly spelled out. "A lot of EDs have a bundled charge so that for whatever the service is, whether it is a sprained ankle or something else, there is a fixed reimbursement that is negotiated with the insurance company," explains Bernard Branson, MD, a medical epidemiologist at the Division of HIV/AIDS Prevention at the Centers for Disease Control in Atlanta. However, he points out that many hospital systems and payers have only just begun to negotiate the addition of HIV screening into the reimbursement rate for the bundled service.
Further, while Medicare pays for HIV screening for high-risk persons, Medicaid policies on this issue differ from state to state. "In New York, Medicaid actually incentivizes HIV screening in the ED by providing extra reimbursements, but other states don't necessarily pay for HIV screening explicitly, although in many ED situations for high-risk people, it is indicated and covered for diagnostic reasons," says Branson.
The problems with reimbursement are likely to remain a stumbling block for HIV screening in many EDs. However, Lyons believes that health systems have yet to fully acknowledge the degree to which being proactive on this issue could ultimately save money in the long run. "We know that HIV testing is cost-effective in a general sense to society," he says. "We don't have as good an understanding of how much an individual hospital could save itself by implementing HIV testing, but it is clear that at least in many centers there would be some savings there."