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Stanford KA, Almirol E, Meyer M, McNulty MC. An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department. Am J Infect Control 2024; 52:770-773. [PMID: 38309531 PMCID: PMC11193631 DOI: 10.1016/j.ajic.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. METHODS This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. RESULTS The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. DISCUSSION An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. CONCLUSIONS Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.
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Affiliation(s)
- Kimberly A Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, IL.
| | - Ellen Almirol
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Makenna Meyer
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
| | - Moira C McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL
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Jackson KJ, Chitle P, McCoy SI, White DAE. A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care. J Community Health 2024; 49:499-513. [PMID: 38127296 PMCID: PMC10981603 DOI: 10.1007/s10900-023-01320-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.
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Affiliation(s)
- Kristopher J Jackson
- Center for AIDS Prevention Studies, University of California, San Francisco, 550 16th Street - 3rd Floor, San Francisco, CA, 94158, USA.
| | - Pooja Chitle
- School of Public Health, University of California, Berkeley, CA, USA
| | - Sandra I McCoy
- School of Public Health, University of California, Berkeley, CA, USA
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Lyons MS, Chawarski MC, Rothman R, Whiteside L, Cowan E, Richardson LD, Hawk K, Tsui JI, Schwartz RP, O’Connor P, D’Onofrio G, Fiellin DA, Edelman EJ. Missed Opportunities for HIV and Hepatitis C Screening Among Emergency Department Patients With Untreated Opioid Use Disorder. J Addict Med 2023; 17:210-214. [PMID: 36170184 PMCID: PMC10023471 DOI: 10.1097/adm.0000000000001074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We assessed the frequency of emergency department (ED) HIV and hepatitis C (HCV) screening in a high-risk cohort of ED patients with untreated opioid use disorder (OUD). METHODS This analysis used data from a prospective, observational study of English-speaking adults with untreated OUD enrolled from April 2017 to December 2018 in 4 urban, academic EDs. Two cohorts were defined for this analysis by self-reported negative/unknown status for HIV (cohort 1) and HCV (cohort 2). Sites featured structured screening programs throughout the entire enrollment period for HIV and during at least part of the enrollment period for HCV. We calculated the proportion tested for HIV and HCV during the study enrollment ED visit. RESULTS Among 394 evaluated ED patients, 328 of 394 (83.2%) were not tested for HIV or HCV and 244 of 393 (62.1%) lacked a usual medical care provider. In cohort 1, 375 reported negative or unknown HIV status; 59/375 (15.7%) overall and 33/218 (15.1%) of those reporting recent injection drug use were tested for HIV. In cohort 2, 231 reported negative of unknown HCV status; 22/231 (9.5%) overall and 9/98 (9.2%) of those reporting recent injection drug use were tested for HCV. The proportion tested by the ED ranged from 3% to 25% for HIV and 4% to 32% for HCV across study sites. CONCLUSIONS Emergency department HIV and HCV screening remains infrequent among patients with untreated OUD, including those who inject drugs, even in EDs committed to screening. Targeted HIV/HCV screening should be considered as an adjunct strategy until the ideal of universal screening is more fully achieved.
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Affiliation(s)
- Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marek C. Chawarski
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine Seattle WA USA
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, NY, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Judith I. Tsui
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Patrick O’Connor
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - David A. Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - E. Jennifer Edelman
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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4
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Pettit N, Ceppa D, Monahan P. Low Rates of Lung and Colorectal Cancer Screening Uptake Among a Safety-net Emergency Department Population. West J Emerg Med 2022; 23:739-745. [PMID: 36205665 PMCID: PMC9541977 DOI: 10.5811/westjem.2022.5.55351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/22/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction A suspected diagnosis of cancer through an emergency department (ED) visit is associated with poor clinical outcomes. The purpose of this study was to explore the rate at which ED patients attend cancer screenings for lung, colorectal (CRC), and breast cancers based on national guidelines set forth by the United States Preventive Services Task Force (USPSTF). Methods This was a prospective cohort study. Patients were randomly approached in the Eskenazi Hospital ED between August 2019–February 2020 and were surveyed to determine whether they would be eligible and had attended lung, CRC, and breast cancer screenings, as well as their awareness of lung cancer screening with low-dose computed tomography (LDCT). Patients who were English-speaking and ≥18 years old, and who were not critically ill or intoxicated or being seen for acute decompensated psychiatric illness were offered enrollment. Enrolled subjects were surveyed to determine eligibility for lung, colorectal, and breast cancer screenings based on guidelines set by the USPSTF. No cancer screenings were actually done during the ED visit. Results A total of 500 patients were enrolled in this study. More participants were female (54.4%), and a majority were Black (53.0%). Most participants had both insurance (80.2%) and access to primary care (62.8%). Among the entire cohort, 63.0% identified as smokers, and 62.2% (140/225) of the 50- to 80-year-old participants qualified for lung cancer screening. No patients were screened for lung cancer in this cohort (0/225). Only 0.6% (3/500) were aware that LDCT was the preferred method for screening. Based on pack years, 35.5% (32/90) of the patients who were 40–49 years old and 6.7% (6/90) of those 30–39 years old would eventually qualify for screening. Regarding CRC screening, 43.6% (218/500) of the entire cohort was eligible. However, of those patients only 54% (118/218) had been screened. Comparatively, 77.7% (87/112) of the eligible females had been screened for breast cancer, but only 54.5% (61/112) had been screened in the prior two years. Conclusion Many ED patients are not screened for lung/colorectal/breast cancers even though many are eligible and have reported access to primary care. This study demonstrates an opportunity and a need to address cancer screening in the ED.
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Affiliation(s)
- Nicholas Pettit
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
| | - DuyKhanh Ceppa
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
| | - Patrick Monahan
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, Indiana
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Haukoos JS, Rowan SE, Galbraith JW, Rothman RE, Hsieh YH, Hopkins E, Houk RA, Toerper MF, Kamis KF, Morgan JR, Linas BP, Al-Tayyib AA, Gardner EM, Lyons MS, Sabel AL, White DAE, Wyles DL. The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial: rationale and design of a multi-center pragmatic randomized clinical trial of hepatitis C screening in emergency departments. Trials 2022; 23:354. [PMID: 35468807 PMCID: PMC9036509 DOI: 10.1186/s13063-022-06265-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/31/2022] [Indexed: 12/24/2022] Open
Abstract
Background Early identification of HCV is a critical health priority, especially now that treatment options are available to limit further transmission and provide cure before long-term sequelae develop. Emergency departments (EDs) are important clinical settings for HCV screening given that EDs serve many at-risk patients who do not access other forms of healthcare. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial. Methods The DETECT Hep C Screening Trial is a multi-center prospective pragmatic randomized two-arm parallel-group superiority trial to test the comparative effectiveness of nontargeted and targeted HCV screening in the ED with a primary hypothesis that nontargeted screening is superior to targeted screening when identifying newly diagnosed HCV. This trial will be performed in the EDs at Denver Health Medical Center (Denver, CO), Johns Hopkins Hospital (Baltimore, MD), and the University of Mississippi Medical Center (Jackson, MS), sites representing approximately 225,000 annual adult visits, and designed using the PRECIS-2 framework for pragmatic trials. When complete, we will have enrolled a minimum of 125,000 randomized patient visits and have performed 13,965 HCV tests. In Denver, the Screening Trial will serve as a conduit for a distinct randomized comparative effectiveness trial to evaluate linkage-to-HCV care strategies. All sites will further contribute to embedded observational studies to assess cost effectiveness, disparities, and social determinants of health in screening, linkage-to-care, and treatment for HCV. Discussion When complete, The DETECT Hep C Screening Trial will represent the largest ED-based pragmatic clinical trial to date and all studies, in aggregate, will significantly inform how to best perform ED-based HCV screening. Trial registration ClinicalTrials.gov ID: NCT04003454. Registered on 1 July 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06265-1.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO, 80204, USA. .,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
| | - Sarah E Rowan
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA.,Public Health Institute at Denver Health, Denver, CO, USA
| | - James W Galbraith
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO, 80204, USA
| | - Rachel A Houk
- Department of Informational Technology, Denver Health, Denver, CO, USA
| | - Matthew F Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin F Kamis
- Public Health Institute at Denver Health, Denver, CO, USA
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.,Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Boston, MA, USA
| | - Benjamin P Linas
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Boston, MA, USA.,Division of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - Alia A Al-Tayyib
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.,Public Health Institute at Denver Health, Denver, CO, USA
| | - Edward M Gardner
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA.,Public Health Institute at Denver Health, Denver, CO, USA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA.,Center for Addiction Research, University of Cincinnati, Cincinnati, OH, USA
| | - Allison L Sabel
- Department of Patient Safety and Quality, Denver Health, Denver, CO, USA.,Department of Biostatistics, Colorado School of Public Health, Aurora, CO, USA
| | - Douglas A E White
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - David L Wyles
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
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Waxman MJ, Ray M, Schechter-Perkins EM, Faryar K, Flynn KC, Breen M, Wojcik SM, Berry F, Zheng A, Ata A, Lerner EB, Lyons MS, McGinnis S. Patients' Perspectives on Emergency Department COVID-19 Vaccination and Vaccination Messaging Through Randomized Vignettes. Public Health Rep 2022; 137:774-781. [PMID: 35465764 PMCID: PMC9066270 DOI: 10.1177/00333549221085580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: Emergency departments (EDs) could play an important role in the COVID-19 pandemic response by reaching patients who would otherwise not seek vaccination in the community. Prior to expanding COVID-19 vaccination to the acute care setting, we assessed ED patients’ COVID-19 vaccine status, perspectives, and hypothetical receptivity to ED-based vaccination. Methods: From January 11 through March 31, 2021, we conducted a multisite (Albany Medical Center, Boston Medical Center, Buffalo General Hospital, University of Cincinnati Medical Center, and Upstate Medical Center), cross-sectional survey of ED patients, with embedded randomization for participants to receive 1 of 4 vignette vaccination messages (simple opt-in message, recommendation by the hospital, community-oriented message, and acknowledgment of vaccine hesitancy). Main outcomes included COVID-19 vaccination status, prior intention to be vaccinated, and receptivity to randomized hypothetical vignette messages. Results: Of 610 participants, 122 (20.0%) were vaccinated, 234 (38.4%) had prior intent to be vaccinated, 111 (18.2%) were unsure as to prior intent, and 143 (23.4%) had no prior intent to be vaccinated. Vaccine hesitancy (participants who were vaccine unsure or did not intend to receive the vaccine) was associated with the following: age <45 years, female, non-Hispanic Black, no primary health care, and no prior influenza vaccination. Overall, 364 of 565 (64.4%; 95% CI, 60.3%-68.4%) were willing to accept a hypothetical vaccination in the ED. Among participants with prior vaccine hesitancy, a simple opt-in message resulted in the highest acceptance rates to hypothetical vaccination (39.7%; 95% CI, 27.6%-52.8%). Conclusions: EDs have appropriate patient populations to initiate COVID-19 vaccination programs as a supplement to community efforts. A simple opt-in approach may offer the best messaging to reach vaccine-hesitant ED patients.
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Affiliation(s)
- Michael J Waxman
- Department of Emergency Medicine, Albany Medical College, Albany, NY, USA
| | - Maile Ray
- Center for Human Services Research, State University of New York at Albany, Albany, NY, USA
| | | | - Kiran Faryar
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Karen Coen Flynn
- Center for Human Services Research, State University of New York at Albany, Albany, NY, USA
| | - Mandi Breen
- Center for Human Services Research, State University of New York at Albany, Albany, NY, USA
| | - Susan M Wojcik
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA
| | | | - Amy Zheng
- Department of Emergency Medicine, Albany Medical College, Albany, NY, USA
| | - Ashar Ata
- Department of Emergency Medicine, Albany Medical College, Albany, NY, USA
| | - E Brooke Lerner
- Department of Emergency Medicine, Jacobs School of Medicine & Biomedical Sciences, Buffalo, NY, USA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Sandra McGinnis
- Center for Human Services Research, State University of New York at Albany, Albany, NY, USA
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White DAE, Anderson ES, Basham K, Ng VL, Russell C, Lyons MS, Powers-Fletcher MV, Giordano TP, Muldrew KL, Siatecka H, Hsieh YH, Dashler G, Carroll KC, Mostafa HH, Rothman RE. Clinical Utility of the Signal-to-Cutoff Ratio of Reactive HIV Antigen/Antibody Screening Tests in Guiding Emergency Physician Management. J Acquir Immune Defic Syndr 2022; 89:332-339. [PMID: 35147582 DOI: 10.1097/qai.0000000000002873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The signal-to-cutoff (S/CO) ratio of the HIV antigen/antibody test may help immediately to differentiate true-positive results from false-positive results, which may be particularly useful in time-sensitive circumstances, such as when providing emergency department (ED) care. SETTING Seven US EDs with HIV screening programs using HIV antigen/antibody assays. METHODS This cross-sectional study of existing data correlated S/CO ratios with confirmed HIV status. Test characteristics at predetermined S/CO ratios and the S/CO ratio with the best performance by receiver operator characteristic (ROC) curve were calculated. RESULTS Of 1035 patients with a reactive HIV antigen/antibody test, 232 (22.4%) were confirmed HIV-negative and 803 (77.6%) were confirmed HIV-positive. Of the 803 patients, 713 (88.8%) experienced chronic infections and 90 (11.2%) experienced acute infections. S/CO ratios were greater for HIV-positive (median 539.2) than for HIV-negative patients (median 1.93) (P < 0.001) and lower for acute infection (median 22.8) than for chronic infection (median 605.7) (P < 0.001). All patients with an S/CO ratio < 1.58 (n = 93) were HIV-negative (NPV 100%), and nearly all with an S/CO ≥ 20.7 (n = 760) (optimal level by ROC analysis) were HIV-positive (PPV 98.6%). Of patients with S/CO values between 1.58 and 20.7 (n = 182), 29.7% were HIV-positive. CONCLUSIONS The S/CO ratio may be used in real time to classify most ED patients as almost certain to be either HIV-positive or HIV-negative long before nucleic acid confirmatory testing is available. When combined with clinical judgment, this could guide preliminary result disclosure and management.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
| | - Erik S Anderson
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
| | - Kellie Basham
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
| | - Valerie L Ng
- Department of Laboratory Medicine and Pathology, Alameda Health System, Oakland, CA
| | - Carly Russell
- Department of Emergency Medicine, Alameda Health System, Oakland, CA
- Currently, Abbott Laboratories, Pleasanton, CA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
| | - Margaret V Powers-Fletcher
- Division of Infectious Diseases and Pathology and Laboratory Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Thomas P Giordano
- Division of Infectious Diseases, Department of Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX
| | - Kenneth L Muldrew
- Departments of Pathology and Immunology and Medicine, Baylor College of Medicine, Houston, TX
| | - Hanna Siatecka
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins, Baltimore, MD
| | - Gaby Dashler
- Department of Emergency Medicine, Johns Hopkins, Baltimore, MD
| | - Karen C Carroll
- Division of Infectious Diseases, Departments Pathology and Medicine, Johns Hopkins, Baltimore, MD; and
| | | | - Richard E Rothman
- Division of Infectious Diseases, Departments of Emergency Medicine and Medicine, Johns Hopkins, Baltimore, MD
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Variation in Participation in Nurse-Driven Emergency Department Hepatitis C Screening. Adv Emerg Nurs J 2021; 43:138-144. [PMID: 33915565 DOI: 10.1097/tme.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Emergency departments (EDs) are an important potential site for public health screening programs, although implementation of such programs can be challenging. Potential barriers include system-level issues (e.g., funding and time pressures) and individual provider-level issues (e.g., awareness and acceptance). This cross-sectional evaluation of a nurse-driven, triage-based hepatitis C virus (HCV) screening program in an urban, academic ED assessed variation in nurse participation from April to November 2017. For this program, electronic health record (EHR) prompts for HCV screening were integrated into nurses' triage workflow. Process measures evaluating HCV screening participation were abstracted from the EHR for all ED encounters with patient year of birth between 1945 and 1965. Registered nurses who routinely worked in triage and were full-time employees throughout the study period were included for analysis. The primary outcome was the proportion of eligible ED encounters with completed HCV screening, by nurse. Of 14,375 ED encounters, 3,375 (23.5%, 95% confidence interval [CI]: 22.8, 24.2) had completed HCV screening and 1,408 (9.8%, 95% CI: 3.9, 10.3) had HCV screening EHR sections opened by the triage nurse but closed without action; the remainder of encounters had no activity in HCV screening EHR sections. Among the 93 eligible nurses, 22 nurses (24%, 95% CI: 16, 34) completed HCV screening for more than 70% of encounters, whereas 10 nurses (11%, 95% CI: 6, 19) never completed HCV screening. The proportion of eligible encounters with completed HCV screening was 11.0% higher (95% CI: 9.8, 12.6) for encounters seen between 7 a.m. and 7 p.m. than between 7 p.m. and 7 a.m. (27.5% and 16.3%, respectively). In conclusion, wide variation in individual nurse participation in HCV screening suggests individual-level barriers are a more significant barrier to ED screening than previously recognized. Implementation research should expand beyond questions of resource availability and procedural streamlining to evaluate and address staff knowledge, beliefs, attitudes, and motivation.
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Haukoos JS, Lyons MS, Rothman RE, White DAE, Hopkins E, Bucossi M, Ruffner AH, Ancona RM, Hsieh YH, Peterson SC, Signer D, Toerper MF, Saheed M, Pfeil SK, Todorovic T, Al-Tayyib AA, Bradley-Springer L, Campbell JD, Gardner EM, Rowan SE, Sabel AL, Thrun MW. Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2117763. [PMID: 34309668 PMCID: PMC8314142 DOI: 10.1001/jamanetworkopen.2021.17763] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. OBJECTIVE To compare strategies for HIV screening when integrated into usual ED practice. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. INTERVENTIONS Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. MAIN OUTCOMES AND MEASURES New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). RESULTS A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). CONCLUSIONS AND RELEVANCE Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01781949.
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Affiliation(s)
- Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Meggan Bucossi
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Andrew H. Ruffner
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel M. Ancona
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Stephen C. Peterson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Danielle Signer
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Matthew F. Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sarah K. Pfeil
- Department of Emergency Medicine, Highland Hospital, Oakland, California
| | - Tamara Todorovic
- Department of Emergency Medicine, Highland Hospital, Oakland, California
| | - Alia A. Al-Tayyib
- Department of Epidemiology, Colorado School of Public Health, Aurora
- Denver Public Health, Denver, Colorado
| | | | - Jonathan D. Campbell
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Edward M. Gardner
- Denver Public Health, Denver, Colorado
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
| | - Sarah E. Rowan
- Denver Public Health, Denver, Colorado
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
| | - Allison L. Sabel
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado
- Department of Biostatistics, Colorado School of Public Health, Aurora
| | - Mark W. Thrun
- Denver Public Health, Denver, Colorado
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
- Gilead Sciences, Inc, Foster City, California
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10
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Faryar KA, Henderson H, Wilson JW, Hansoti B, May LS, Schechter‐Perkins EM, Waxman MJ, Rothman RE, Haukoos JS, Lyons MS. COVID-19 and beyond: Lessons learned from emergency department HIV screening for population-based screening in healthcare settings. J Am Coll Emerg Physicians Open 2021; 2:e12468. [PMID: 34189516 PMCID: PMC8219288 DOI: 10.1002/emp2.12468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 11/24/2022] Open
Abstract
Emergency departments (EDs) have played a major role in the science and practice of HIV population screening. After decades of experience, EDs have demonstrated the capacity to provide testing and linkage to care to large volumes of patients, particularly those who do not otherwise engage the healthcare system. Efforts to expand ED HIV screening in the United States have been accelerated by a collaborative national network of emergency physicians and other stakeholders called EMTIDE (Emergency Medicine Transmissible Infectious Diseases and Epidemics). As the COVID-19 pandemic evolves, EDs nationwide are being tasked with diagnosing and managing COVID-19 in a myriad of capacities, adopting varied approaches based in part on know-how, local disease trends, and the supply chain. The objective of this article is to broadly summarize the lessons learned from decades of ED HIV screening and provide guidance for many analogous issues and challenges in population screening for COVID-19. Over time, and with the accumulated experience from other epidemics, ED screening should develop into an overarching discipline in which the disease in question may vary, but the efficiency of response is increased by prior knowledge and understanding.
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Affiliation(s)
- Kiran A. Faryar
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Heather Henderson
- Division of Emergency Medicine, Department of Internal MedicineMorsani College of Medicine, University of South Florida, Tampa General HospitalTampaFloridaUSA
| | - Jason W. Wilson
- Division of Emergency Medicine, Department of Internal MedicineMorsani College of Medicine, University of South Florida, Tampa General HospitalTampaFloridaUSA
| | - Bhakti Hansoti
- Department of Emergency MedicineThe Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Larissa S. May
- Department of Emergency MedicineUniversity of California DavisSacramentoCaliforniaUSA
| | - Elissa M. Schechter‐Perkins
- Department of Emergency MedicineBoston University School of Medicine/Boston Medical CenterBostonMassachusettsUSA
| | - Michael J. Waxman
- Department of Emergency MedicineAlbany Medical CollegeAlbanyNew YorkUSA
| | - Richard E. Rothman
- Department of Emergency MedicineThe Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical CenterUniversity of Colorado School of MedicineDenverColoradoUSA
- Department of EpidemiologyColorado School of Public HealthAuroraColoradoUSA
| | - Michael S. Lyons
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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11
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Haukoos JS, White DA, Rowan SE, Lyle C, Gravitz S, Basham K, Godoy A, Kamis K, Hopkins E, Anderson E. HIV Risk and Pre-Exposure Prophylaxis Eligibility Among Emergency Department Patients. AIDS Patient Care STDS 2021; 35:211-219. [PMID: 34097464 DOI: 10.1089/apc.2021.0012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Our objective was to estimate the prevalence of pre-exposure prophylaxis (PrEP) eligibility, characterize self-perceived and quantified human immunodeficiency virus (HIV) risk, and assess PrEP knowledge and receptiveness of initiating PrEP among emergency department (ED) patients. We performed an IRB-approved cross-sectional study from two urban EDs. Patients were eligible if ≥18 years of age and not known to have HIV. Research staff obtained verbal consent and used a structured 29-item instrument to assess HIV risk, PrEP eligibility based on 2017 Centers for Disease Control and Prevention (CDC) guidelines, and general PrEP knowledge among unselected and enriched patient samples, the latter informed by the Denver HIV Risk Score (DHRS). We enrolled 1002 patients with a median age of 39 years; 54.8% were male, 30.9% White/non-Hispanic, 29.5% Black/non-Hispanic, and 22.5% Hispanic. In the full cohort, 119 [11.9%, 95% confidence interval (CI): 9.9-14.0%] were PrEP eligible, and among the unselected cohort, 36 (7.1%, 95% CI: 5.1-9.8%) were PrEP eligible. Using the DHRS, 100 patients were considered "high risk" with 32 (32.0%) reporting zero perceived risk. Correlation between the DHRS and self-perceived HIV risk was low (r = 0.13). Of the full cohort, 203 (20.3%) had heard of PrEP, and of these, 33 (16.3%) were PrEP eligible with 25 (75.8%) willing to start PrEP immediately. Yet, of the 119 patients who were PrEP eligible, only 34 (28.6%) had heard of PrEP. In summary, among a heterogeneous ED population, there was discordance in self-perceived and quantified HIV risk. HIV PrEP eligibility was ∼7% with the highest eligibility among those identified as DHRS "high risk." A significant opportunity exists to identify and initiate PrEP among ED patients.
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Affiliation(s)
- Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Douglas A.E. White
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Sarah E. Rowan
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
- Denver Public Health, Denver Health, Denver, Colorado, USA
| | - Carolynn Lyle
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Stephanie Gravitz
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Kellie Basham
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Ashley Godoy
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
| | - Kevin Kamis
- Denver Public Health, Denver Health, Denver, Colorado, USA
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California, USA
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12
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Faryar KA, Ancona RM, Reau Z, Lyss SB, Braun RS, Rademaker T, Sickles RK, Lyons MS. HIV detection by an emergency department HIV screening program during a regional outbreak among people who inject drugs. PLoS One 2021; 16:e0251756. [PMID: 34003855 PMCID: PMC8130938 DOI: 10.1371/journal.pone.0251756] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/30/2021] [Indexed: 12/20/2022] Open
Abstract
Objective Multiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program’s contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak. Methods This was a retrospective study of electronically queried clinical records from an urban, safety-net ED’s HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED’s contribution to case identification county-wide, overall and for PWID during 2014–2018. Results During 2014–2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID. Conclusions The ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.
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Affiliation(s)
- Kiran A. Faryar
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
- * E-mail:
| | - Rachel M. Ancona
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Zachary Reau
- HIV, STI, and Viral Hepatitis Interventions and Treatment Section, Office of Health Improvement and Wellness, Ohio Department of Health, Columbus, OH, United States of America
| | - Sheryl B. Lyss
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States of America
| | - Robert S. Braun
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Todd Rademaker
- HIV Testing, Care, and Prevention, Hamilton County Public Health, Cincinnati, OH, United States of America
| | - Ryane K. Sickles
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
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13
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Abstract
BACKGROUND Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population. METHODS The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population. RESULTS In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis. CONCLUSION Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).
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14
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Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City. J Emerg Med 2020; 60:299-309. [PMID: 33213988 DOI: 10.1016/j.jemermed.2020.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/18/2020] [Accepted: 09/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach. OBJECTIVES We examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED. METHODS Retrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion. RESULTS There were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%. CONCLUSIONS Nontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.
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15
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Yax JA, Niforatos JD, Summers DL, Bigach MH, Schmotzer C, Gripshover BM, Avery A. A Model for Syphilis Screening in the Emergency Department. Public Health Rep 2020; 136:136-142. [PMID: 33166486 DOI: 10.1177/0033354920967302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. Although syphilis is relatively inexpensive to treat and cure and is a predictor for HIV incidence among men and transgender women who have sex with men, rates of co-screening for syphilis are low in the emergency department setting, with a dearth of literature on this topic since the 1990s and early 2000s. In this case study, we describe an operational model for routine syphilis screening implemented in June 2017 at the University Hospitals Cleveland Medical Center in Cleveland, Ohio. We describe the advantages of screening using a reverse testing algorithm rather than the traditional method and the necessity of partnering with the Cleveland Department of Public Health for both diagnostic and follow-up logistics.
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Affiliation(s)
- Justin A Yax
- 24575 Division of Population Health, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western University School of Medicine, Cleveland, OH, USA
| | - Joshua D Niforatos
- 24575 Division of Population Health, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,161821 Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel L Summers
- 24575 Division of Population Health, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Margaret H Bigach
- 24575 Division of Population Health, Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christine Schmotzer
- Case Western University School of Medicine, Cleveland, OH, USA.,24575 Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Barbara M Gripshover
- Case Western University School of Medicine, Cleveland, OH, USA.,365856 John T. Carey Special Immunology Unit, Department of Medicine, Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ann Avery
- Case Western University School of Medicine, Cleveland, OH, USA.,2559 Division of Infectious Diseases, MetroHealth Medical Center, Cleveland Medical Center, Cleveland, OH, USA
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16
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Ancona RM, Habib D, Faryar KA, Ruffner AH, Hart KW, Lyons MS. Clarifying the volume of estimated need for public health and prevention services within an emergency department population. J Am Coll Emerg Physicians Open 2020; 1:845-851. [PMID: 33145530 PMCID: PMC7593451 DOI: 10.1002/emp2.12168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening. METHODS This cross-sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade. RESULTS There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0-97.2) for HIV and 86.1% (95% confidence interval, 85.9-86.3) for HCV. CONCLUSIONS Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.
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Affiliation(s)
- Rachel M. Ancona
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - David Habib
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Kiran A. Faryar
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Andrew H. Ruffner
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Kimberly W. Hart
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Michael S. Lyons
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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17
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Zuckerman M, Kelly T, Heard K, Zosel A, Marlin M, Hoppe J. Physician attitudes on buprenorphine induction in the emergency department: results from a multistate survey. Clin Toxicol (Phila) 2020; 59:279-285. [PMID: 32870039 DOI: 10.1080/15563650.2020.1805461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Emergency Departments (ED) are rapidly becoming an important location for initiation of buprenorphine (EDBUP) for the treatment of opioid use disorder (OUD). Previous investigations of emergency medicine physicians' perceived barriers and attitudes toward EDBUP exclusively sampled from urban, academic-affiliated physicians. We administered a multistate survey to an institutionally and geographically diverse collection of emergency medicine physicians to better understand the professional opinions of EDBUP implementation across a variety of practice settings. METHODS This cross-sectional survey study used an online survey instrument to convenience sample emergency medicine physicians. In order to sample from various practice environments, participants were identified from (1) statewide ACEP chapters and (2) Facebook groups exclusive to emergency medicine physicians. The survey explored physicians' attitudes of EDBUP adoption and the perceived barriers to doing so. RESULTS 162 emergency medicine physicians completed the survey. 76% of respondents agreed that emergency medicine physicians should offer EDBUP in the treatment of OUD. When stratified by practice setting and X-waiver status, 96% of X-waivered physicians, 73% of academic physicians, 49% of non-academic physicians, and 34% of non-X-waivered physicians felt comfortable initiating EDBUP. Lack of access to outpatient MOUD referral was the most frequently cited barrier to EDBUP across all practice settings. CONCLUSIONS An institutionally and geographically diverse group of emergency medicine physicians endorsed substantial support for EDBUP. Emergency medicine physicians practicing in different clinical environments endorsed similar barriers to EDBUP implementation.
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Affiliation(s)
- Matthew Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Timothy Kelly
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Zosel
- Department of Emergency Medicine, Section of Medical Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Marlin
- Department of Emergency Medicine, Medical Toxicology Services, University of Mississippi Medical Center, MI, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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18
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Ruffner AH, Ancona RM, Hamilton C, Fernandez FJ, Faryar KA, Lane BH, Lyons MS. Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services. Am J Emerg Med 2020; 38:1831-1833. [PMID: 32739853 DOI: 10.1016/j.ajem.2020.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Routine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation. METHODS Cross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017-July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care. RESULTS There were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%-8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%-23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services. CONCLUSIONS Patients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.
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Affiliation(s)
- Andrew H Ruffner
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America
| | - Rachel M Ancona
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America.
| | - Catherine Hamilton
- University of Cincinnati Health, 3200 Burnet Ave, Cincinnati, OH 45229, United States of America.
| | - Francisco J Fernandez
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America.
| | - Kiran A Faryar
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America.
| | - Bennett H Lane
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America.
| | - Michael S Lyons
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America.
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Olatosi B, Siddiqi KA, Conserve DF. Towards ending the human immunodeficiency virus epidemic in the US: State of human immunodeficiency virus screening during physician and emergency department visits, 2009 to 2014. Medicine (Baltimore) 2020; 99:e18525. [PMID: 31914025 PMCID: PMC6959905 DOI: 10.1097/md.0000000000018525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 11/01/2022] Open
Abstract
Human immunodeficiency virus (HIV) testing is important for prevention and treatment. Ending the HIV epidemic is unattainable if significant proportions of people living with HIV remain undiagnosed, making HIV testing critical for prevention and treatment. The Centers for Disease Control and Prevention (CDC) recommends routine HIV testing for persons aged 13 to 64 years in all health care settings. This study builds on prior research by estimating the extent to which HIV testing occurs during physician office and emergency department (ED) post 2006 CDC recommendations.We performed an unweighted and weighted cross-sectional analysis using pooled data from 2 nationally representative surveys namely National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 2009 to 2014. We assessed routine HIV testing trends and predictive factors in physician offices and ED using multi-stage statistical survey procedures in SAS 9.4.HIV testing rates in physician offices increased by 105% (5.6-11.5 per 1000) over the study period. A steeper increase was observed in ED with a 191% (2.3-6.7 per 1000) increase. Odds ratio (OR) for HIV testing in physician offices were highest among ages 20 to 29 ([OR] 7.20, 99% confidence interval [CI: 4.37-11.85]), males (OR 1.34, [CI: 0.91-0.93]), African-Americans (OR 2.97, [CI: 2.05-4.31]), Hispanics (OR 1.80, [CI: 1.17-2.78]), and among visits occurring in the South (OR 2.06, [CI: 1.23-3.44]). In the ED, similar trends of higher testing odds persisted for African Americans (OR 3.44, 99% CI 2.50-4.73), Hispanics (OR 2.23, 99% CI 1.65-3.01), and Northeast (OR 2.24, 99% CI 1.10-4.54).While progress has been made in screening, HIV testing rates remains sub-optimal for ED visits. Populations visiting the ED for routine care may suffer missed opportunities for HIV testing, which delays their entry into HIV medical care. To end the epidemic, new approaches for increasing targeted routine HIV testing for populations attending health care settings is recommended.
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Affiliation(s)
| | | | - Donaldson Fadael Conserve
- Department of Health Promotion Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
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