title: Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, United States of America ; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America ; Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, United States of America.
authors.forename: Jason S
authors.initials: JS
authors.lastname: Haukoos
authors.affiliation: Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States of America.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Campbell
authors.affiliation: Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, Colorado, United States of America ; Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Amy A
authors.initials: AA
authors.lastname: Conroy
authors.affiliation: Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, United States of America.
authors.forename: Emily
authors.initials: E
authors.lastname: Hopkins
authors.affiliation: Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, United States of America.
authors.forename: Meggan M
authors.initials: MM
authors.lastname: Bucossi
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America.
authors.forename: Comilla
authors.initials: C
authors.lastname: Sasson
authors.affiliation: Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, United States of America ; Denver Public Health, Denver, Colorado, United States of America.
authors.forename: Alia A
authors.initials: AA
authors.lastname: Al-Tayyib
authors.affiliation: Denver Public Health, Denver, Colorado, United States of America.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Thrun
mesh_terms: D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000379:methods*; D011446:Prospective Studies; D014481:United States / Q000453:epidemiology