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.
Keywords: Syphilis, STI testing, Automated alert, Gonorrhea, Chlamydia
BACKGROUND
The emergency department (ED) is a strategic setting to screen for HIV and sexually transmitted infections (STIs), as it represents the primary source of care for many populations with limited access to health care.1 ED-based routine HIV screening programs are highly effective and acceptable to both staff and patients.2–4 Furthermore, a large proportion of urogenital STI diagnoses, which are considered a marker of vulnerability to HIV, originate in the ED,5 underscoring the importance of ED interventions to increase HIV testing. With the recent precipitous rise in syphilis rates nationally,6 there is increasing interest in introducing syphilis screening in the ED as well,7 and a few studies have suggested that ED syphilis screening may be an effective intervention to increase syphilis diagnosis among vulnerable populations.8,9
Despite a wealth of data in support of routine HIV screening,10,11 as well as recommendations from the Centers for Disease Control and Prevention,12 many EDs still have no or limited screening programs. This may be due in part to perceived barriers such as increased burden on staff, competing priorities, or concern for disruptions in ED workflow.13 Innovative means of addressing these concerns and increasing screening rates are needed. Prior studies have suggested that the use of a Best Practice Advisory (BPA) in the electronic medical record (EMR) is feasible to implement HIV screening.14,15 These studies largely examine EDs with no pre-existing HIV screening program or policy, however; it is unknown if the use of a BPA would be an improvement over existing screening infrastructure that is not BPA-based. There is also limited data on the effect of a nontargeted BPA on HIV cotesting for patients being evaluated for other STIs. This study evaluates the impact of a nontargeted BPA on HIV and syphilis screening in the ED, both in the general ED population and among those patients receiving urogenital STI testing at a large, urban ED. Despite a longstanding HIV screening program in this ED that included prompts in triage and an STI order set designed with HIV testing preselected, the authors hypothesized that the introduction of a BPA would lead to increased HIV and syphilis screening rates, as well as increased rates of cotesting for HIV among patients tested for other STIs.
METHODS
Study design
This study took place at a large, urban, tertiary care center ED in Chicago. This ED sees more than 75,000 visits per year and has had a program for expanded HIV testing and linkage to care since 2011. All ED HIV testing is performed via fourth-generation enzyme-linked immunosorbent assay, which requires a blood draw. In mid-May 2019, a BPA was introduced that included routine screening for both HIV and syphilis for all patients under age 65 without a known diagnosis of HIV, and who had not had HIV testing in the past 12 months. This is a retrospective study of all ED encounters that included HIV, syphilis, gonorrhea, or chlamydia testing for the 7-month periods prior to (November 1, 2018, to May 30, 2019) and after (June 1, 2019, to December 31, 2019) the introduction of the BPA.
BPA workflow
The BPA was designed to fire a pop-up window for nurses at triage completion and any time a nurse or clinician opened the orders panel, until either an HIV testing order was placed or someone indicated the patient had either declined testing or was unable to opt out (eg, confused, in extremis), after which the BPA would not fire for the remainder of the encounter. While the BPA provided a prepopulated order for HIV and syphilis testing, it required a human to place the orders, in order to provide an opportunity for patients to opt out. The deployment of the BPA was accompanied by a staff education campaign, which included presentations at nursing huddles, resident and faculty meetings, which occurred over a 1-month period, followed by monthly email updates on the screening program sent to all ED staff. Education focused on the logistics of the screening program, as well as the local prevalence of HIV and syphilis. Prior to the introduction of the BPA, nurses were instructed to offer HIV testing at triage, and HIV screening was included as one of several optional triage modules in the EMR, but only visible if the module was actively selected. Nurses received periodic education about the HIV screening program. An STI quick order set designed to be used for gonorrhea, chlamydia, or trichomonas testing in the ED was prechecked to include HIV and syphilis testing. This remained in place after the BPA was introduced.
Study measures
To assess the separate impacts of the BPA on screening for HIV and syphilis and on HIV and urogenital STI cotesting, encounters were categorized in three ways: any encounter with an HIV test, any encounter with a syphilis test, and any encounter with gonorrhea and/or chlamydia testing. The first two categories may overlap because a single ED encounter may include both HIV and syphilis testing. Given that there was an existing expanded HIV screening program but no syphilis screening program prior to May 2019, these categories were reported separately to reflect the different implementation circumstances of these two programs. Because the order for syphilis was tied to the order for HIV in the post-implementation period, syphilis was not considered independently in the analysis of STI and HIV cotesting. Age, race, ethnicity, and legal sex were extracted from the EMR. These demographic descriptors were included because major disparities in access to HIV prevention and care exist along racial and gender lines. As a very small percentage of study participants had unknown race/ethnicity or fell outside of the three main reported categories, these were grouped together. During the study period, the EMR did not have any means to collect gender identity.
Data analysis
Descriptive statistics of the distribution of patient characteristics among testing categories before and after BPA implementation are reported. Logistic regression was performed to examine the relationship of ED patient demographics to the odds of receiving HIV testing with urogenital STI testing before and after the BPA. Data analysis was performed using R Studio. This study was approved by the University of Chicago Institutional Review Board.
RESULTS
Over the 14-month study period, there were 14,767 unique encounters that had at minimum one HIV, syphilis, gonorrhea, or chlamydia test performed in the ED, with 3,982 encounters in the pre-implementation period and 10,785 in the post-implementation period. Total ED visit volume was similar in both periods: 44,282 encounters pre-implementation and 46,312 post-implementation. Overall, there was a 242% increase in the number of HIV tests in the post-implementation period, with the absolute number of tests rising from 2,851 to 9,757 (Table 1). Syphilis screening, for which there was no pre-existing program, increased 326%, from 2,191 tests pre-implementation to 9,330. Demographics of each group were relatively similar between time periods, with the exception of small changes in the distributions of age and race/ethnicity. In the post-implementation period, there was a shift toward increased HIV and syphilis testing of patients ages 35 and above, with ages 35 to 44 representing 17.8% of those tested for HIV post-implementation compared to 13.5% pre-implementation, and ages 45 to 54 increasing to 16.4% from 11.3%. There was also a slight increase in the proportion of patients tested who identified as White (5.8% vs 3.8%) and Hispanic (4.1% vs 2.9%), with a corresponding small decrease in the proportion of non-Hispanic Black patients (88.3% vs 91.9%). The racial and ethnic distribution of screened patients overall reflected the demographic characteristics of the local ED population.
Table 1.
Demographics of patients tested for HIV or syphilis for the 7-month periods before and after best practice advisory (BPA) implementation
| Pre-implementation (N = 3,058) |
Post-implementation (N = 10,064) |
|||
|---|---|---|---|---|
| HIV (n = 2,851) | Syphilis (n = 2,191) | HIV (n = 9,757) | Syphilis (n = 9,330) | |
|
|
||||
| n (%) | n (%) | n (%) | n (%) | |
| Age | ||||
| 18-24 | 783 (27.5%) | 699 (31.9%) | 1871 (19.2%) | 1,837 (19.7%) |
| 25-34 | 835 (29.3%) | 708 (32.3%) | 2,504 (25.7%) | 2,430 (26.1%) |
| 35-44 | 385 (13.5%) | 290 (13.2%) | 1,733 (17.8%) | 1,678 (18.0%) |
| 45-54 | 322 (11.3%) | 212 (9.7%) | 1,603 (16.4%) | 1,543 (16.5%) |
| 55+ | 526 (18.5%) | 282 (12.9%) | 2,046 (21.0%) | 1,842 (19.7%) |
| Sex at Birth | ||||
| Female | 1,676 (58.8%) | 1,387 (63.3%) | 5,915 (60.6%) | 5,733 (61.5%) |
| Male | 1,175 (41.2%) | 804 (36.7%) | 3,842 (39.4%) | 3,597 (38.6%) |
| Race/Ethnicity | ||||
| Non-Hispanic Black | 2,598 (91.9%) | 2014 (92.7%) | 8,596 (88.3%) | 8,114 (88.1%) |
| Non-Hispanic White | 108 (3.8%) | 68 (3.1%) | 565 (5.8%) | 545 (5.9%) |
| Hispanic | 82 (2.9%) | 58 (2.6%) | 395 (4.1%) | 383 (4.2%) |
| Other | 39 (1.4%) | 32 (1.5%) | 175 (1.8%) | 166 (1.8%) |
| Insurance | ||||
| Private | 493 (17.3%) | 381 (17.4%) | 2,052 (21.0%) | 1,998 (21.4%) |
| Medicaid/Medicare | 1,926 (67.6%) | 1,434 (65.5%) | 6,403 (65.6%) | 6,062 (65.0%) |
| Self-Pay | 432 (15.2%) | 376 (17.2%) | 1,300 (13.3%) | 1,268 (13.6%) |
There was a similar number of encounters for gonorrhea and/or chlamydia testing (Table 2) in both periods (2,224 encounters pre-implementation vs 2,281 post-implementation). The proportion of encounters for STI testing without HIV cotesting decreased by 10.3%, from 43.6% of STI testing encounters to 33.3% post-implementation. HIV cotesting occurred at relatively similar rates for all races and ethnicities (56.8%-59.3%) pre-implementation except White patients, who were HIV cotested in only 34.0% of the encounters. This difference decreased post-implementation, with White patients cotested in 57.6% of the encounters, compared to 64.3%-67.0% for the other races and ethnicities. The odds of HIV cotesting with urogenital STI testing increased significantly in the post-implementation period (OR 1.55, 95% CI 1.37, 1.75, P < 0.01). The odds of cotesting among all demographic groups increased post-implementation, but the difference was largest among white patients (OR 2.64, 95% CI 1.21, 5.76, P = 0.02), older patients, particularly those ages 45 to 54 (OR 1.95, 95% CI 1.16, 3.26, P = 0.01), and self-pay patients (OR 1.71, 95% CI 1.28, 2.27, P < 0.01). Because this data set did not include ED patients not tested for HIV or an STI, overall odds of HIV or syphilis testing before and after implementation of the BPA could not be calculated.
Table 2.
HIV testing among patients tested for gonorrhea (GC) or chlamydia (CT) for the 7-month periods before and after implementation of the best practice advisory (BPA)
| Pre-implementation (N = 2,224) |
Post-implementation (N = 2,281) |
Odds Ratio (OR) for HIV Testing Post vs. Pre-implementation | p-value | |||
|---|---|---|---|---|---|---|
| GC and/or CT with HIV testing | GC and/or CT without HIV testing | GC and/or CT with HIV testing | GC and/or CT without HIV testing | |||
|
|
||||||
| n (%) | n (%) | n (%) | n (%) | OR (95% CI) | ||
| Age | ||||||
| 18-24 | 543 (59.2%) | 375 (40.8%) | 620 (67.0%) | 306 (33.0%) | 1.40 (1.16, 1.69) | <0.01 |
| 25-34 | 468 (56.1%) | 366 (43.9%) | 571 (67.8%) | 271 (32.2%) | 1.65 (1.35, 2.01) | <0.01 |
| 35-44 | 149 (52.5%) | 135 (47.5%) | 193 (64.3%) | 107 (35.7%) | 1.63 (1.17, 2.28) | <0.01 |
| 45-54 | 65 (51.6%) | 61 (48.4%) | 83 (67.5%) | 40 (32.5%) | 1.95 (1.16, 3.26) | 0.01 |
| 55+ | 29 (46.8%) | 33 (53.2%) | 54 (60.0%) | 36 (40.0%) | 1.71 (0.89, 3.28) | 0.11 |
| Sex at Birth | ||||||
| Female | 867 (52.8%) | 775 (47.2%) | 1077 (63.3%) | 624 (36.7%) | 1.54 (1.34, 1.77) | <0.01 |
| Male | 387 (66.5%) | 195 (33.5%) | 444 (76.6%) | 136 (23.4%) | 1.65 (1.27, 2.13) | <0.01 |
| Race/Ethnicity | ||||||
| Non-Hispanic Black | 1178 (56.8%) | 896 (43.2%) | 1408 (67.0%) | 695 (33.0%) | 1.54 (1.36, 1.75) | <0.01 |
| Non-Hispanic White | 17 (34.0%) | 33 (66.0%) | 34 (57.6%) | 25 (42.4%) | 2.64 (1.21, 5.76) | 0.02 |
| Hispanic | 37 (58.7%) | 26 (41.3%) | 45 (64.3%) | 25 (35.7%) | 1.27 (0.63, 2.55) | 0.51 |
| Other | 16 (59.3%) | 11 (40.7%) | 22 (66.7%) | 11 (33.3%) | 1.38 (0.48, 3.95) | 0.55 |
| Insurance | ||||||
| Private | 208 (52.8%) | 186 (47.2%) | 246 (64.4%) | 136 (35.6%) | 1.62 (1.21, 2.16) | <0.01 |
| Medicaid/Medicare | 802 (56.4%) | 619 (43.6%) | 962 (65.8%) | 500 (34.2%) | 1.49 (1.28, 1.73) | <0.01 |
| Self-Pay | 244 (59.7%) | 165 (40.3%) | 313 (71.6%) | 124 (28.4%) | 1.71 (1.28, 2.27) | <0.01 |
| Total | 1254 (56.4%) | 970 (43.6%) | 1521 (66.7%) | 760 (33.3%) | 1.55 (1.37, 1.75) | <0.01 |
DISCUSSION
This study demonstrates that a simple automated intervention leveraging the EMR to provide reminders and streamlined ordering can greatly increase participation in an HIV screening program. Despite a pre-existing screening program that included prompts for nursing within the triage module and periodic educational efforts for staff, patients were only screened for HIV slightly more than they were tested for syphilis, which had no formal screening program in place. Testing for both infections increased markedly after the BPA was introduced, 242% for HIV and 326% for syphilis, and increases in testing were seen for all demographic groups. Notably, with the implementation of this enhanced universal screening protocol, older patients were screened more often in the post-implementation period. This may reflect less introduction of personal bias into the ordering of tests when prompted by the EMR, as the BPA fires for all patients under age 65, regardless of other clinical or demographic factors except for history of HIV testing. As HIV and STIs become more common in older populations,5 such an intervention may be essential to ensuring that all the eligible patients are screened. The slight change in the racial and ethnic breakdown of tested patients between the two time periods, as well as the large change in the proportion of cotesting for HIV with STI testing among White patients, may similarly reflect the effect of the BPA in overcoming personal biases about which patients should be tested for HIV.
Notably there was a 10.3% decrease in the number of patients tested for urogenital STIs who failed to receive HIV cotesting. This finding is especially surprising given that HIV and syphilis testing were built into the STI quick order set already during the pre-implementation period; to avoid testing for them, one would have to either intentionally deselect them or circumvent the quick order set by manually searching for orders. Despite this, 43.6% of the patients did not receive cotesting prior to the BPA. HIV cotesting with STI testing is clinically indicated due to the increased vulnerability to HIV indicated by clinical concern for STIs.16 While it is unknown what proportion of HIV testing was ordered by a nurse in triage as opposed to a physician or nonphysician provider at the time of placing STI testing orders, it is possible that the atmosphere of increased routine screening and education around HIV testing led to decreased stigma and less reluctance to offer HIV testing to patients. Alternatively, this finding may simply reflect that more people were tested through the BPA at triage. Lastly, the BPA firing at the time the clinician placed STI testing orders may have served as a timely reminder. Regardless, this simple intervention had a large impact on compliance with clinical care guidelines for HIV cotesting. As interest in improving HIV and syphilis screening in the ED grows, such an intervention may have major implications for reimbursement and quality measurement.
Limitations
The main limitation of this study is that the implementation of the BPA was accompanied by other factors that could have influenced the rate of HIV screening, such as increased staff education. While the effects of other factors cannot easily be isolated, it may not be necessary to tease apart the independent effects of each aspect of the intervention, as they are generally implemented together. Additionally, as a single-site study, more research will be needed to assess the generalizability of this approach. As most institutions now utilize some form of EMR, a similar approach would likely have success at other sites but could potentially face barriers from local laws that may still require written consent for HIV testing or criminalize HIV.17 Other limitations include that data such as race or ethnicity and legal sex are limited to what was reported in the EMR and that as a retrospective review, it is impossible to know why someone might not have been tested (eg, if the patient declined testing), who ordered the test (nurse or clinician), or what other factors may have played into the likelihood of testing before and after the implementation of the BPA. Lastly, because syphilis was included in the BPA and thus linked to HIV testing in the post-implementation period, cotesting for HIV in patients with clinical concern for syphilis could not be evaluated.
CONCLUSIONS
Identifying innovative means of increasing participation in HIV screening programs without increasing workload or affecting ED workflow will be key to encouraging more hospitals to implement screening programs, a major facilitator to ending the HIV epidemic. As syphilis numbers rise, the same principles will apply to improving syphilis screening. This study shows that a simple intervention consisting of an automated EMR prompt for screening can have a huge impact on HIV and syphilis testing rates, even when a screening program with EMR support already exists. Furthermore, testing the patients most vulnerable to HIV, such as those with concern for other STIs, is critical to early diagnosis and linkage to care. This study also demonstrated that a nontargeted BPA prompting universal HIV testing increased the number of these patients who received HIV testing. Utilization of an automated EMR prompt for routine HIV screening thus increases both overall testing and targeted screening of patients undergoing STI testing. This type of intervention is simple to implement and should become the standard of care in any ED wishing to improve HIV screening rates.
Acknowledgments
Research reported in this manuscript was supported in part by NIAID of the National Institutes of Health under award number K23AI166277. The Expanded HIV Testing and Linkage to Care Program is funded by the Chicago Department of Public Health. Additional support is provided through Gilead’s Frontlines of Communities in the United States (FOCUS) program. FOCUS funding supports HIV, HCV, and HBV screening and linkage to the first medical appointment after diagnosis; FOCUS funding does not support any activities beyond the first medical appointment and is agnostic to how FOCUS partners handle subsequent patient care and treatment.
Footnotes
Conflicts of interest: Dr McNulty has served on an advisory board for Gilead Sciences, Inc. All other authors have no conflicts of interest to declare.
References
- 1.Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010;304:664–670. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Leblanc J, Côté J, Auger P, et al. Acceptability of nurse-driven HIV screening for key populations in emergency departments: a mixed-methods study. Nurs Res. 2021;70:354–365. [DOI] [PubMed] [Google Scholar]
- 3.Haukoos JS, Lyons MS, Rothman RE. The evolving landscape of HIV screening in the emergency department. Ann Emerg Med. 2018;72:54–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rothman RE, Lyons MS, Haukoos JS. Uncovering HIV infection in the emergency department: a broader perspective. Acad Emerg Med. 2007;14:653–657. [DOI] [PubMed] [Google Scholar]
- 5.Stanford KA, Mason JA, Friedman EE. Trends in STI testing and diagnosis rates during the COVID-19 pandemic at a large urban tertiary care center, and the role of the emergency department in STI care. Front Reprod Health. 2023;5:1082429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021. Accessed August 15, 2023. https://www.cdc.gov/std/statistics/2021/overview.htm.
- 7.California Department of Public Health. Screening for Syphilis in Emergency Departments: Resource Guide. Accessed September 6, 2023. https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Screening-for-Syphilis-in-Emergency-Departments-Resource-Guide.pdf.
- 8.Stanford KA, Hazra A, Friedman E, et al. Opt-out, routine emergency department syphilis screening as a novel intervention in at-risk populations. Sex Transm Dis. 2021;48:347–352. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Larios Venegas A, Melbourne HM, Castillo IA, et al. Enhancing the routine screening infrastructure to address a syphilis epidemic in miami-dade county. Sex Transm Dis. 2020;47(5S Suppl 1):S61–S65. [DOI] [PubMed] [Google Scholar]
- 10.Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44:435–442. [DOI] [PubMed] [Google Scholar]
- 11.Lyons MS, Lindsell CJ, Ruffner AH, et al. Randomized comparison of universal and targeted HIV screening in the emergency department. J Acquir Immune Defic Syndr. 2013;64:315–323. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Centers for Disease Control and Prevention (CDC), Branson BM, Handsfield HH, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1–17. [PubMed] [Google Scholar]
- 13.DeMarco RF, Gallagher D, Bradley-Springer L, Jones SG, Visk J. Recommendations and reality: perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions. Nurs Outlook. 2012;60:72–80. [DOI] [PubMed] [Google Scholar]
- 14.Burrell CN, Sharon MJ, Davis S, et al. Using the electronic medical record to increase testing for HIV and hepatitis C virus in an Appalachian emergency department. BMC Health Serv Res. 2021;21:524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ford JS, Rouleau SG, Voong S, et al. Universal HIV screening in the emergency department: an interrupted time series analysis. AIDS. 2022;36:1605–1607. [DOI] [PubMed] [Google Scholar]
- 16.Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Accessed September 11, 2023. https://www.cdc.gov/std/treatment-guidelines/hiv.htm.
- 17.Centers for Disease Control and Prevention. State HIV Testing Laws: Consent and Counseling Requirements.; 2017. Accessed January 24, 2024. https://www.cdc.gov/hiv/policies/law/states/testing.html.