April Articles

Another GREAT Journal Club last night at Brit's house, with terrific food and lively conversation. Two articles on HIV testing in the ED were explored.

I) Haukoos, JS, et. al. Patient acceptance of rapid HIV testing practices in an urban emergency department: Assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 51(3) March, 2008.

This article sought to ask the question "Will patients in the ED accept the CDC recommendation for routine HIV screening in the emergency department?"

Design:
Cross-sectional survey of a convenience sample of patients at an urban ED in Denver. Patients were given a 6-item questionnaire, which attempted to assess their willingness to accept HIV screening in the ED. No actual HIV testing was performed. Specific questions:
1) Opt-out (test UNLESS patient declines) vs Opt-in (test ONLY if patient agrees)
2) Does physician recommendation influence decision?
3) Do patients want pre- and post-test counseling?
4) Do patients want a separate consent?

Results: 529 (8% of eligible patients) enrolled.
1) 81% would accept testing with either the opt-out or opt-in strategy, but 11% of patients needed an explanation of the meaning of "opt-out."
2) 93% would accept testing if recommended by their physician.
3) Roughly 35% felt pre-test counseling was necessary, and a similar number would want counseling after a NEGATIVE test. They did not ask patients whether they would want post-test counseling for a POSITIVE test result.
4) 50% felt that consent for HIV testing should be separate from general medical consent.

Discussion points:
Some major flaws were identified in this paper.

1) First, the patient enrollment process seems problematic. While the authors report that 8% of eligible patients were enrolled, they DO NOT tell us how many potential patients were approached and refused enrollment. If a large number of patients refused enrollment, this might skew the data by only including patients willing to participate. Would the patients who refused to enroll actually agree to testing? Who knows...

The authors also do not explain how patients were chosen. In fact, the demographics of their selected patients was substantially different from their ED population, with far fewer Hispanics. This raised concerns over whether investigators might have preferentially selected patients where there would be no perceived language barrier, and whether there might have been other biases in the selected patients.

2) No HIV testing was performed; study participants were simply asked whether they would agree to be tested without the actual potential consequences of being tested. It is possible that fewer patients would agree if they were actually going to be tested.

3) The questionnaire was unclear in its wording. Specifically, the question concerning the "opt-out" design did not actually present a true opt-out option, as it stated that testing would be "offered" unless patients declined. A true opt-out structure means that testing WILL be performed, unless the patient declines. While seemingly a small semantic difference, it was pointed out that surveys are all about semantics, and that any small inaccuracy could dramatically change results.

The upshot: The group agreed that while the study was deeply flawed, a majority of patients will probably be willing to accept HIV testing in the ED. Concerns were raised about funding and the cost-benefit of screening asymptomatic patients, as well as the ability to obtain follow-up for patients for either counseling or confirmatory testing. We all agreed that these were important issues, and it will be interesting to see how they play out.

Finally, we had a discussion on how to interpret statistical sensitivity and specificity, as well as positive and negative predictive values.

II) Lyss, SB, et. al. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. Journal of Acquired Immune Deficiency Syndrome. 44(4) April 1, 2007.

This article sought to ask not only whether patients would agree to testing in the ED, but whether HIV infection rates would differ in patients who were enrolled by investigators versus those referred by a clinician.

Design:
Cross-sectional study of a convenience sample of patients at an urban emergency department in Chicago. Patients could be enrolled directly by research associates or by ED clinicians who felt they should be tested.

Results: 2824 (58%) eligible screened patients agreed to be tested. 414 (95%) provider-referred patients agreed to be tested.
35 (1.2%) screened patients and 48 (11.6%) provider-referred patients were HIV positive.
Of these, 18 (51%) screened patients and 24 (50%) referred patients reported no traditional risk factors.
27 (77%) screened patients and 38 (79%) referred patients entered HIV care.
Of those with CD4 cell counts available, 14 (45%) of 31 screened patients and 37 (82%) of 45 provider-referred patients had counts <200.

Discussion points:
A few concerns were raised about this study which were similar to those of the previous article. We discussed the advantages and disadvantages of a convenience sample, and it was pointed out that for an epidemiological study, convenience samples are poor ways of obtaining a representative sample. Concerns were raised as to whether patient seen at different times might have different responses to being tested. Specific variables mentioned included patient financial and insurance status, wit time prior to being seen by a physician, and acuity level, all of which might differ depending on when the patient presented to the ED. We were not able to answer whether this might skew the data, but the possibility was raised.

While the follow-up rates seem quite high, the article does not specify what percentage of patients who followed-up were admitted to the hospital versus discharged from the ED. It was speculated by the group that a large percentage of those who followed-up may have been admitted, especially considering how similar the number of admitted patients was to the number who made their follow-up appointments.

The upshot:
The group agreed that having rapid HIV testing as an option would be beneficial, and might alter management on a number of patients we see in the ED. Again, significant questions still exist as to the funding for and cost-benefit of routine screening, as well as to the ability for patients to get appropriate follow-up care.

Great job to all who attended! Who knows what next month will bring.....