Missed Testing Opportunities Among HIV-Positive Adults in a Community Emergency Department

Abstract

Northern Nevada's most utilized emergency department (ED) could represent a locale of missed opportunity for human immunodeficiency virus (HIV) detection, as the ED serves as a source of primary care for many patients at risk for HIV infection. The authors conducted a retrospective chart review, through the electronic health record, evaluating new diagnoses of HIV between 2012 and 2017 within a single hospital system. An opportunity for prior detection of HIV in the hospital's adult ED, within the past 5 years, was recorded as a missed testing opportunity (MTO). Out of 46 new HIV diagnoses at this hospital for a 5-year period, 19 patients with at least one MTO were identified. Eight of these patients with an MTO were diagnosed with acquired immunodeficiency syndrome (AIDS) concomitant with detection of their HIV status. Encouraging earlier HIV detection in the ED could reduce transmission, mortality, and health care expenditures.

Introduction

Approximately 15% of individuals infected with human immunodeficiency virus (HIV) are unaware of their seropositivity¹—these same individuals are 3.5 times more likely to transmit HIV than those who are aware of their HIV status.² The Centers for Disease Control and Prevention (CDC) recommends a nontargeted, opt-out screening of patients between 13 and 64 years of age, in all health care settings where undiagnosed HIV prevalence is ≥0.1%.³ The U.S. Preventative Task Force recommendations generally concur with those of the CDC, endorsing HIV screening of all patients aged 15–64 years.⁴

Washoe County in Nevada reports an HIV positivity rate of 0.53% among tests administered by the health department for the past 10 years.⁵ The estimated prevalence of HIV in Washoe County was reported as 263 per 100,000 in 2017.⁵ The most utilized emergency department (ED) in this region serves a high volume of patients who are at high-risk for HIV infection, similar to other EDs across the United States. Niska et al. ⁶ describe high utilization of the ED among the homeless population and those without health insurance (2010). In addition, one multistate study in 2003 revealed that 32% of the participants infected with HIV had reported visiting an ED within the past 6 months.⁷ EDs similar to the one researched in this study are often the only contact that certain patients have with health care professionals and, therefore, represent a significant opportunity for HIV screening in high-risk individuals.⁸ Evidence that EDs are an underutilized locale for identification of HIV is demonstrated in a chart review of patients with recently diagnosed HIV infection, which found that 31% of them had at least one missed testing opportunity (MTO).⁹ This same review found that the ED was the most common location where an MTO would occur.⁹ The Northern Nevada ED in this study does not currently offer opt-out HIV testing.

Direct medical expenditures of HIV infection are significantly higher for patients whose infection is diagnosed later in the course of disease.^10,11 It is shown that patients with acquired immunodeficiency syndrome (AIDS), presenting with a late initial diagnosis, may ultimately cost $27,275 to $61,615 more than HIV positive patients presenting early.¹⁰ The cost-effectiveness ratio of widespread HIV testing among populations with prevalence of 1% or greater shows 2009 U.S. $49,500 to $49,600 per quality-adjusted life-year, demonstrating that screening drastically improves quality of life and lifespan for a relatively low cost.¹²

Early diagnosis of HIV has not only been correlated with reduced medical expenditures, but also with decreased transmission as well as reduced morbidity and mortality among patients infected with HIV.^4,13 Unfortunately, 19% of the individuals diagnosed with HIV infection in Washoe County during 2017 had already progressed to AIDS, defined as CD4 count <200 cells/mm³, at the time of diagnosis.⁵ This study aims to quantify the number of patients who experienced an MTO for HIV infection at the most utilized ED within Northern Nevada, with the goal of potentially identifying a point of intervention for managing HIV infection in this region. An opt-out testing model in this facility could prevent thousands of infections as well as save tens of thousands of dollars. It also adds to the growing body of evidence that EDs are a pivotal point of contact with individuals who are high risk for HIV, which could affect national standards regarding testing.

Materials and Methods

Retrospective chart review of patients who had utilized the largest hospital network in Northern Nevada was conducted using reports from Epic Electronic Medical Record (EMR). Information needed for this study was provided by the hospital's research and information technology staff; the researchers did not directly view patient charts. The study population included all patients >12 years of age, who received a diagnosis of HIV infection within this hospital system between January 1, 2012 and December 31, 2017. HIV infection was classified as the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes B20 (HIV disease) and Z21 (asymptomatic HIV infection status). With these ICD-10 codes, the hospital staff generated a series of reports containing the following variables: age, gender, race, date of HIV diagnosis, CD4 count at diagnosis, viral load at diagnosis, and date(s) of ED visit(s).

Reports generated from the Epic EMR consisted of information regarding 949 separate visits to the health care system containing the aforementioned ICD-10 codes. Review of these reports revealed, in several instances, that multiple visits from a single patient were recorded as separate data points. To avoid duplicate data skewing the analysis, records were also obtained from the Nevada Department of Health and Human Services concerning new HIV diagnoses from 2012 to 2017, within the aforementioned hospital network. The researchers verified HIV diagnoses with the new data set using the following criteria: first, diagnosis dates matched within 1 week; and second, patient age matched within a year, to account for birthdates within the week of diagnoses. County-wide data regarding new HIV diagnoses per year were obtained from publicly available Washoe County Health District Annual Communicable Disease Summary reports.^5,14

–18

An MTO was defined as a visit to the hospital's ED within 5 years before a new diagnosis of HIV infection for a single patient. This latency period of 5 years was chosen with the assumption that a patient could have latent viral replication occurring for 5 years before presumed symptom onset or detection.^19,20 This was verified by comparing the number of MTOs using cutoff dates within 7, 3, and 1 years.

Descriptive statistics were obtained for the data in addition to the Wilcoxon rank sum test, or Mann–Whitney U test, which was used to compare the average number of MTOs between groups differentiated by race, gender, CD4 count, and viral load. Statistical significance was set at alpha of 0.05. Two-sided probabilities were calculated. A multivariable analysis using the outcome of MTO and variables of gender, race, and age was conducted for the individuals who had received an HIV diagnosis at the hospital system and had all demographic data recorded in the hospital record. All statistical analyses were conducted through SAS (version 9.4; SAS Institute, Cary, North Carolina). The research project was approved by the Institutional Review Board at the University of Nevada, Reno.

Results

Records directly from the state department revealed that 46 new cases of HIV were diagnosed within the hospital network between 2012 and 2017, of which 39 were successfully matched to the Epic EMR reports. Out of these 39 patients, 19 were found to have experienced at least one MTO in the 5 years before their diagnosis, accounting for 49% of the matched study cohort. In addition, eight of these MTO patients presented with a CD4 count <200 cells/mm³ at diagnosis, consistent with a diagnosis of AIDS. Four of the 20 patients who were diagnosed with AIDS but did not have an MTO also had a diagnosis consistent with AIDS.

Among the 19 patients with at least one MTO, there were 4 females and 15 males, as well as 13 self-reported Caucasian and 6 self-reported non-Caucasian patients. The mean age at diagnosis was 43.7 years, ranging from 23 to 65 years. The mean CD4 count and viral load recorded, if available, were 57 cells/mm³ and 985,078 copies/mL, respectively. Demographic characteristics of all 39 patients are further outlined in Table 1. Controlling for the demographic factors of race, age, and gender, multivariate analysis showed no statistical significance for any specific trait (Table 2). Between MTO and non-MTO patients, similar demographics and disease metrics were observed. The differences between age, CD4 count, viral load, gender, and race were statistically insignificant through Wilcoxon rank sum analysis. The average length of time between definitive HIV diagnosis and most recent MTO in the MTO patients was 262 days.

Table 1.

Summary of Demographic Characteristics for 39 Patients Who were Diagnosed with Human Immunodeficiency Virus Within the Hospital Network

	N	Mean	Median	SD	Range	p
Age at diagnosis (years)
MTO	19	44	46	13.7	23–65	.67
Non-MTO	20	41	39	12	24–61	.67
CD4 count at diagnosis (cells/mm³)
MTO	9	57	16	88	4–277	.35
Non-MTO	6	203	106	257	2–654	.35
Viral load at diagnosis (copies/mL)
MTO	9	985,078	460,000	1,794,250	5,700–5,700,000	.64
Non-MTO	6	1,902,333	435,000	4,265,218	44,000–10,000,000	.64
MTOs per person
—	19	5.2	2.0	6.1	1–24	—
Most recent MTO before diagnosis (days)
—	19	262	64	364	3–1,082	—
Gender
MTO	19	4 F/15 M	—	—	—	.48
Non-MTO	20	7 F/13 M	—	—	—	.48
Race (self-reported)
MTO	19	6 Non-Caucasian 13 Caucasian	—	—	—	.88
Non-MTO	20	5 Non-Caucasian 12 Caucasian 3 Unreported	—	—	—	.88

Missing data for CD4 count and viral load occurred in 10 of the 19 patient files.

AIDS, acquired immunodeficiency syndrome; F, female; ED, emergency department; HIV, human immunodeficiency virus; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision; M, male; MTO, missed testing opportunity; SD, standard deviation.

Table 2.

Multivariate Analysis of the 36 Patients Diagnosed with Human Immunodeficiency Virus Who Had All Demographic Characteristics Reported

	Odds ratio	Confidence interval	p	Standard error
Gender	2.58	0.49–13.7	.27	0.85
Race: Asian	1.3	0.06–30.3	.87	1.61
Race: black or Hispanic	0.34	0.29–3.99	.39	1.26
Age	0.99	0.94–1.06	.94	0.03

Each patient with at least one MTO experienced an average of 5.2 missed opportunities for HIV testing in the hospital's ED during the 5 years covered by the study. Number of MTOs per patient did not differ when comparing patient race (p = .68), gender (p = .20), CD4 count (p = .80), or viral load (p = .45). Wilcoxon rank sum statistics and category definitions are demonstrated in Table 3. Extending the latency period to 7 years adds three individuals and increases the total number of MTOs to 22 (115%). This number includes every individual diagnosed with HIV who was previously seen by the ED. With this parameter, the only individuals without MTOs are those who did not have a recorded ED visit. Conversely, decreasing the latency period to 3 years still captures 100% of individuals with an MTO at 5 years. With a latency period of 1 year, 14 individuals (73.7%) of the 19 individuals with an MTO in 5 years are captured.

Table 3.

Missed Testing Opportunity's for Human Immunodeficiency Virus Diagnosis in a Hospital's Emergency Department by Race, Gender, CD4 Count, and Viral Load

Characteristic	Mean MTO #	Wilcoxon rank sum	p
Race
Non-Caucasian	10.4	55.0	.68
Caucasian	9.2	—	—
Gender
Female	13.3	53.0	.20
Male	9.1	—	—
CD4 count (cells/mm³)
<200	9.6	76.0	.80
Unknown or >200	10.3	—	—
Viral load (copies/mL)
Recorded	8.9	80.5	.45
Not recorded	11.0	—	—

Significance set at p < .05.

The 46 new HIV diagnoses in this single hospital system represents 21% of the 214 new HIV diagnoses in Washoe county for a 5-year period, including those who had already progressed to AIDS at time of diagnosis. This hospital accounted for the following percentages of new HIV diagnoses, compared with those in Washoe county, as follows: 44% (12/27) in 2017, 9% (4/43) in 2016, 15% (6/40) in 2015, 39% (16/41) in 2014, 8% (3/37) in 2013, and 19% (5/26) in 2012.

Discussion

A significant number of HIV positive individuals will come into contact with a health care system within years of diagnosis and not be screened for HIV, thus representing an MTO.³ The current literature describes an unfortunately high number of MTOs in various health care settings across the world.^{9,19,21

–25} These missed opportunities have been recognized for decades, and tend to affect women more than men.^26,27

Owing to limited power, our study did not find a significant difference in the rate of MTOs between the genders. However, disparity of MTOs between genders is an interesting topic where previous studies have shown conflicting data. Some have shown that HIV testing rates are higher in men than women²⁸ or vice versa.²³ These incongruities could result from multiple influences and biases in both patients and health care workers. Further analysis is warranted to characterize the trend and determine the underlying reasons that biological sex influences HIV testing in EDs.

EDs are one of the most common sites of MTOs, which can be attributed in part to their capacity as a primary health care contact for those who might otherwise not receive care.⁸ This study reports on multiple MTOs for HIV diagnoses at the most utilized ED in Northern Nevada. The results, with hospital data matched to that of the state, suggest that nearly half (49%) of patients infected with HIV who visit this ED will experience an MTO. Even with more conservative estimates, including all 46 new diagnoses provided by the state office (matched and nonmatched to the Epic EMR), the proportion of MTOs to new HIV diagnoses is still 41%. Furthermore, this study may have underestimated the number of MTOs in other EDs and health care settings because it only measured MTOs at one location. These high proportions indicate that intervention in testing practices at this hospital's ED could drastically contribute to earlier detection of HIV infection for its patients.

The CDC's 2006 HIV testing guidelines mention that EDs are an important site for HIV testing.³ However, routine opt-out HIV screening in the ED, although ideal, presents many practical challenges for the institutions, administration, staff members, and physicians. Cited barriers to ED HIV screening include time constraints, confidentiality concerns, and limitations with follow-up.²⁹ Therefore, the authors recommend that EDs incorporate site-specific HIV screening guidelines, which are suitable for their unique circumstances.³⁰ Special considerations for individual EDs include delegating responsibility to existing or new staff as well as efficiently incorporating HIV testing into their workflow.⁸ Cost-effectiveness measurements are an important consideration as well.¹² Overall, the authors posit that an opt-out method of HIV screening would lead to an improved detection rate in the currently studied ED as well as all EDs around the country.

Strengths of the study

This study utilized a moderate sample size of individuals diagnosed with HIV within a single hospital system for a 5-year period. This hospital system is currently the largest in Northern Nevada and contains the most utilized ED in the region. This study's method of measuring MTOs has been previously defined in the literature as a valid technique to measure such missed opportunities in clinical situations.^19,25 The fact that 100% of the 19 individuals still had an MTO at a latency period of 3 years and 73.7% still had an MTO at 1 year shows that using different parameters would yield similar results. Matching of subjects between two data sources provided high assurance that the diagnostic information and subject identification were accurate. None of the analyses resulted in statistical significance of MTO rates between demographic groups, consistent with a similar previous study.⁹ This study was conducted with previously recorded and anonymized EMR data, which maintained patient privacy and confidentiality throughout the process, as well as reduced potential researcher bias.

Weaknesses of the study

Despite the widespread use of MTO as a research statistic, the definition could be considered to be inaccurate due to the assumption of a standard latency period among all patients. Although some prior studies have used a latency period of 1 year, an identical 5-year cutoff period has been previously researched as well.^19,20 A larger sample size would have increased the power to detect a significant difference, if present, of MTO rates between groups. In addition, several patients reported by the state office could not be matched to patients in the Epic EMR reports, and there were incomplete data for some parameters.

Recently, the authors have been collaborating with university and hospital administration to demonstrate a severe need for increasing the availability of HIV testing in this ED. Considering this hospital system captured 21% of new HIV diagnoses in the county for the 5-year period, intervention at this one ED could have a significant impact on the whole Northern Nevada community. In addition to institutional policy, broader public policy, regulations, and laws could also impact this issue at the county and state level. The authors recommend that all health care providers and facilities follow CDC guidelines regarding opt-out HIV testing. In this model, patients are informed through pamphlet or discussion that HIV testing is included in preventive screening tests and can decline testing if it is unwanted.

Future research is needed regarding cost-effectiveness, receptivity by ED providers, barriers to routine HIV testing, and implementation of site-specific guidelines. Other future analyses might assess patient sexual practices, attitudes toward testing, opportunistic infections, mortality rates, access to medications, or health care payer status.

Conclusions

The most utilized ED in Northern Nevada is here presented to serve as a significant source of MTOs, whereby patients sought health care at the ED and were not tested for HIV infection, despite potentially harboring the virus at these times. Encouraging earlier detection of HIV in this ED could provide the hospital with an opportunity to decrease the cost of caring for patients with HIV infection, while also decreasing transmission and reducing mortality.

It is the hope of the authors that physicians in various settings, including the ED, consider the findings of this study to increase awareness of MTOs in their own practices, and eventually implement HIV screening guidelines to best provide for their unique patient populations.

Footnotes

Authors' Contributions

All authors contributed to the project inception, data collection, data analysis, writing, and editing of the article.

Acknowledgments

Previous versions of this study, including a literature review and methodology proposal, were presented at the 2018 American Academy of Family Physicians Conference, 2017 Nevada State Medical Association Conference, and 2017 Nevada Public Health Association Conference by the authors. They also thank the University of Nevada, Reno School of Medicine Office of Medical Research, Nevada Department of Health, and Human Service Office of Analytics, and the hospital IT staff for their assistance in obtainment of data and continued research support.

Author Disclosure Statement

All authors declare that there are no competing interests, personal financial interests, or employment interests regarding publication of this article.

Funding Information

No funding was received for this article.

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