Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial - 24/04/24
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HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) Trial Investigators
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Abstract |
Study objective |
Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial.
Methods |
This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed.
Results |
The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests.
Conclusion |
Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.
Le texte complet de cet article est disponible en PDF.Plan
Supervising editor: Nicholas M. Mohr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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Author contributions: JH, EH, JDC, MSL, RER, DAEW are responsible for study concept and design. JH, EH, MSL, RER, DAEW were involved in acquisition of data. JH, EH, JDC, MSL, RER, Y-HH, DAEW, ST, AAA-T, EMG, SER were involved in analysis and interpretation of data. JH, EH drafted the manuscript. All authors critically revised the manuscript for important intellectual content. JH, EH, JDC were involved in statistical analyses. JH obtained funding. JH, EH, MSL, RER, DAEW provided administrative, technical, or material support. JH, MSL, RER, DAEW were responsible for study supervision. JH had full access to all of the data in the study and takes responsibility for the integrity of the data, the accuracy of the data analysis, and the study as a whole. |
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Data sharing statement: All deidentified data, the data dictionary, and analytic code supporting this publication are available from the time of publication upon request to Dr. Haukoos at jason.haukoos@dhha.org. |
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All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). JH was supported, in part, by the National Institute of Allergy and Infectious Diseases (NIAID) (R01AI106057), the National Institute on Drug Abuse (R01DA042982), and the Agency for Healthcare Research and Quality (AHRQ) (K02HS017526 and R01HS021749). MSL was supported, in part, by NIAID (R01AI106057), NIDA (R01DA049282), AHRQ (R01HS021749), the Cincinnati Health Network, Hamilton County Public Health, and Gilead Sciences, Inc. RER was supported, in part, by NIAID (R01AI106057), NIDA (R01DA049282), AHRQ (R01HS021749), the Maryland Department of Health and Mental Hygiene, and Gilead Sciences, Inc. DAEW was supported by NIAID (R01AI106057), NIDA (R01DA049282), and Gilead Sciences, Inc. This study was funded by an investigator-initiated grant from NIAID (R01AI106057). NIAID, NIDA, AHRQ, and Gilead Sciences, Inc. had no role in the design, conduct, or reporting of the study. NIAID reviewed the study design but had no role in the design or conduct of the study, or collection, management, analyses, or interpretation of data. |
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