Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department.

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were$31,355. The average costs per HIV diagnosis were $9,932 and$7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED

Program costs of emergency department nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing from the Denver ED HIV Opt-Out Study.

<p>Abbreviations: N/A = not applicable; ED = emergency department; WB = western blot.</p><p>Includes personnel time for trainers, trainees, and training supplies.</p

Cost effectiveness ratios (CER) and the incremental cost effectiveness ratio (ICER) of nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing for patients newly diagnosed with HIV infection from the Denver ED HIV Opt-Out Study, Denver, Colorado.

<p>Defined as the number of patients newly-diagnosed with HIV infection.</p

Patient flow diagram for the Denver Opt-Out Study.

<p>Eligible patients included those ≥16 years of age who were placed in an emergency department treatment room. (*Screening refers to HIV testing in conjunction with nontargeted opt-out screening, whereas testing refers to HIV testing in conjunction with physician-directed diagnostic testing.)</p