Effectiveness of Rapid HIV Screening Methods in Urban Emergency Departments

城市急诊科艾滋病毒快速筛查方法的有效性

• 批准号: 8546977
• 负责人: JASON HAUKOOS
• 金额: $ 63.97万
• 依托单位: DENVER HEALTH AND HOSPITAL AUTHORITY
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-09-18 至 2017-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8546977
• 关键词: Accident and Emergency department; Advisory Committees; Area; Behavioral; Caring; Centers for Disease Control and Prevention (U.S.); Characteristics; Clinical; Clinical Trials; Clinical effectiveness; Cohort Studies; Crowding; Data; Diagnosis; Diagnostic; Diagnostic tests; Early identification; Effectiveness; Evaluation; HIV; HIV Infections; HIV diagnosis; HIV risk; Health; Human immunodeficiency virus test; Individual; Infection; Interdisciplinary Study; Intervention; Investigation; Left; Length of Stay; Measures; Medical; Methods; Metric; Motion; Patients; Prevalence; Preventive; Process; Public Health; Public Health Practice; Publishing; Quasi-experiment; Recommendation; Research; Research Infrastructure; Resources; Risk; Risk Estimate; Sampling; Services; Site; Symptoms; Testing; Time; Underserved Population; United States; Visit; Work; base; compare effectiveness; cost; cost effective; design; disorder prevention; high risk; improved; innovation; instrument; novel; patient population; programs; prospective; public health priorities; screening; time use; tool

DESCRIPTION (provided by applicant): Early identification of undiagnosed HIV infection is a critical public health priority. In the United States, despite several substantial HIV-related publc health initiatives, approximately 250,000 HIV-infected individuals remain undiagnosed and 50,000 new infections occur annually. Although HIV testing is an important intervention, controversy still exists as to how it should be implemented. In 2006, the Centers for Disease Control and Prevention (CDC) recommended nontargeted opt-out HIV screening in clinical settings where the undiagnosed prevalence was ¿0.1%. Emergency departments (EDs) have been a major focus of these recommendations, prompted by the fact that over 120 million ED visits occur annually in the United States, they serve large proportions of underserved patients, and are the most common site of missed diagnostic opportunities for HIV infection. In contrast, in 2007 the United States Preventive Services Task Force recommended targeted HIV screening (i.e., testing high-risk subpopulations) as the principal approach to HIV testing because insufficient evidence existed to support the CDC recommendations. Led by Jason Haukoos, MD, MSc, our research team has pioneered investigations in this area since 2004, recently publishing the largest clinical trial to date, concluding that nontargeted opt-out rapid HV screening in the ED was associated with a small increase in number of newly-identified HIV-infected patients when compared to diagnostic testing (i.e., testing based on clinical signs or symptoms) by clinicians. Our team also recently developed the Denver HIV Risk Score (DHRS), the first multivariable tool to estimate risk of HIV infection. The DHRS combines 3 demographic and 5 behavioral characteristics, and classifies patients into distinct strata with increasing HIV prevalence. To build on this work, we propose the following specific aims: (1) to evaluate and compare the effectiveness of 3 modern rapid HIV screening strategies when fully-integrated into routine ED care; (2) to measure and compare program costs of each HIV screening strategy; and (3) to measure and compare ED operational processes of each strategy. In doing so, we will perform a multi-center prospective clinical trial using a quasi-experimental equivalent time-samples design to test the following hypotheses: (1) targeted rapid HIV screening using the DHRS to identify high-risk patients is significantly associated with new HIV diagnoses when compared to traditional targeted rapid HIV screening and nontargeted rapid HIV screening; (2) targeted rapid HIV screening is more cost effective per newly-identified patient than nontargeted rapid HIV screening; and (3) targeted rapid HIV screening does not significantly impact ED processes of care when compared to nontargeted rapid HIV screening. We will leverage an outstanding interdisciplinary research team to conduct the largest and most comprehensive evaluation of HIV screening in EDs. The results will substantially improve our understanding of how to provide effective and efficient rapid HIV screening in EDs and to predominantly underserved populations, and will inform similar practices in other high-risk care settings.

描述(由申请人提供)：及早识别未诊断的艾滋病毒感染是关键的公共卫生优先事项。在美国，尽管有几项与艾滋病毒有关的重大公共卫生倡议，但仍有大约250,000名艾滋病毒感染者未得到诊断，每年发生50,000例新感染病例。虽然艾滋病毒检测是一项重要的干预措施，但对于如何实施仍存在争议。2006年，疾病控制和预防中心(CDC)建议在未确诊流行率为0.1%的临床环境中进行非定向选择退出艾滋病毒筛查。急诊科一直是这些建议的主要焦点，这是因为美国每年有超过1.2亿急诊科就诊，它们为很大一部分服务不足的患者提供服务，并且是错过艾滋病毒感染诊断机会的最常见场所。相比之下，2007年，美国预防服务工作队建议将有针对性的艾滋病毒筛查(即检测高危人群)作为艾滋病毒检测的主要方法，因为没有足够的证据支持疾控中心的建议。在Jason Haukoos博士、医学博士和理学硕士的带领下，我们的研究团队自2004年以来一直在这一领域进行先驱研究，最近发表了迄今为止规模最大的临床试验，得出结论：与临床医生的诊断测试(即根据临床症状或症状进行测试)相比，急诊室的非定向选择退出快速HV筛查与新发现的艾滋病毒感染患者的数量略有增加。我们的团队最近还开发了丹佛艾滋病毒风险评分(DHRS)，这是第一个估计艾滋病毒感染风险的多变量工具。DHRS结合了3个人口统计特征和5个行为特征，并将患者划分为不同的阶层，艾滋病毒流行率不断上升。在这项工作的基础上，我们提出了以下具体目标：(1)评估和比较3种现代快速艾滋病毒筛查策略在完全整合到常规急诊护理中的有效性；(2)衡量和比较每种艾滋病毒筛查策略的计划成本；以及(3)衡量和比较每种策略的ED操作流程。为此，我们将使用半实验性等量时间样本设计进行一项多中心前瞻性临床试验，以检验以下假设：(1)与传统的定向快速艾滋病毒筛查和非定向快速艾滋病毒筛查相比，使用DHRS进行定向快速艾滋病毒筛查识别高危患者与新诊断艾滋病毒显著相关；(2)对于新确诊的患者，定向快速艾滋病毒筛查比非定向快速艾滋病毒筛查更具成本效益；以及(3)与非定向快速艾滋病毒筛查相比，定向艾滋病毒快速筛查不会显著影响急诊护理程序。我们将利用一支杰出的跨学科研究团队，对急诊室的艾滋病毒筛查进行最大规模和最全面的评估。这些结果将极大地提高我们对如何在急诊室和主要缺乏服务的人群中提供有效和高效的艾滋病毒快速筛查的理解，并将为其他高风险护理环境中的类似做法提供借鉴。