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Acceptance of Free Routine Opt-out Rapid HIV Screening In the Emergency Department: Assessment of Race/Ethnicity and Payer Status

Jeffrey Sankoff, MD, Emily Hopkins, MSPH, Brooke Bender, MPH, Jason S. Haukoos, MD, MSc, for the Denver ED HIV Opt-Out Study Group, Denver Health Medical Center, Denver, CO; University of Colorado School of Medicine, Aurora, CO; Colorado School of Public Health, Aurora, CO
BACKGROUND
The Centers for Disease Control and Prevention (CDC) have published revised recommendations for HIV testing in healthcare settings. While our understanding of the impact of performing routine HIV screening in EDs has improved, we still have little understanding of specific individual-level characteristics that may influence the performance of this important preventive intervention.
Table 1. Patient demographics and payer status stratified by those who accepted non-targeted opt-out rapid HIV screening. Did Not Opt Out of Opted Out of Total Rapid HIV Testing Rapid HIV Testing N (%) N (%) N (%) 6,409 25,347 31,756 Patient level Age* 35 (25-47) 38 (26-51) 37 (26-50) Gender Male 3,252 (51) 14,114 (56) 17,366 (55) Female 3,157 (49) 11,223 (44) 14,380 (45) Missing 0 (0) 10 (0) 10 (0) Race/ethnicity Asian 58 (1) 384 (2) 445 (1) Black 1,034 (16) 3,427 (14) 4,470 (14) Hispanic 2,658 (41) 9,115 (36) 11,819 (37) White 2,340 (37) 10,435 (41) 12,810 (40) 81 (1) 338 (1) 421 (1) Other Missing 238 (4) 1,648 (7) 1,791 (6) 10,237 34,528 44,765 Patient visit level Payer status Commercial 1,092 (11) 4,538 (13) 5,630 (13) 2,721 (27) 7,442 (22) 10,163 (23) State Medicare/Medicaid 2,748 (27) 10,571 (31) 13,319 (30) Self-pay 3,287 (32) 8,887 (26) 12,174 (27) 219 (2) 1,909 (6) 2,128 (5) Other Missing 170 (2) 1,181 (3) 1,351 (3) * Reported as median with interquartile range in parentheses. Defined as American or Alaskan Native, Native Hawaiian, or Non-Hawaiian Pacific Islander. Defined as the Colorado Indigent Care Program (CICP). Defined as payment provided by the City Attorney (e.g., victims of crime), Department of Safety, workers compensation, or other governmental sources.

RESULTS
During the 12-month study period, 31,756 eligible patients presented to the ED, representing 44,765 unique visits. (Table 1) The median age of the cohort was 37 (IQR: 26-50) years and 55% were male, 40% white, 37% Hispanic, 14% black, 1% Asian, and 6% represented another or unknown race or ethnicity. Of the 44,765 patient visits, 10,237 (23%) did not opt out of rapid HIV testing, and the payer categories included: 50% uninsured, 30% Medicare/Medicaid, 13% commercial insurance, and 8% from another, primarily governmental, source. (Table 2) Patients who were uninsured (OR = 1.49, 95% CI: 1.401.64) or had Medicare/Medicaid (OR = 1.10, 95% CI: 1.01-1.19) were independently more likely than those with commercial insurance to accept testing. (Table 3) Black (OR = 1.26, 95% CI: 1.17-1.34) and Hispanic (OR = 1.14, 95% CI: 1.09-1.20) patients were independently more likely than whites to accept rapid HIV testing. Of the 1,640 black patients who accepted testing, 57% (95% CI: 55%-60%) were uninsured and of the 4,003 Hispanic patients, 64% (95% CI: 63%-66%) were uninsured.

OBJECTIVE
The objectives of this study were to: (1) describe race/ethnicity and payer status in the context of acceptance of routine opt-out rapid HIV screening among ED patients; and (2) estimate associations between race/ethnicity, different payer categories, and acceptance of HIV testing.

METHODS
This was a secondary analysis from a prospective controlled clinical trial aimed at evaluating non-targeted opt-out rapid HIV screening in the ED at Denver Health Medical Center (DHMC) in Denver, Colorado. DHMC is a 500-bed urban teaching hospital with approximately 55,000 ED patient visits per year. Consecutive patients 16 years old were offered free rapid HIV testing using an opt-out approach during registration. Trained registration personnel collected patient demographics, including age, sex, race/ethnicity, and payer status and these data were linked to acceptance of testing. Repeated measures multivariable logistic regression analysis were used to mode the associations between race/ethnicity and payer categories and whether patients accepted rapid HIV testing, while adjusting for age and sex.

Table 2. Patient demographics by payer status. CICP / CICP Medicare / Other Commercial Missing Self-Pay Pending Medicaid N (%) N (%) N (%) N (%) N (%) N (%) Total 5,630 10,163 13,319 12,174 2,128 1,351 Age* 32 (23-46) 42 (32-50) 49 (33-61) 33 (24-44) 37 (28-47) 38 (25-51) Gender Male 3,009 (54) 5,753 (57) 6,128 (46) 7,693 (63) 1,564 (74) 802 (59) Female 2,621 (46) 4,400 (43) 7,187 (54) 4,477 (37) 564 (26) 549 (41) Missing 0 (0) 10 (0) 4 (0) 4 (0) 0 (0) 0 (0) Race/ethnicity Asian 102 (2) 88 (1) 188 (1) 126 (1) 20 (1) 0 (0) Black 472 (8) 1,490 (15) 2,571 (19) 1,611 (13) 347 (16) 4 (0) Hispanic 1,330 (24) 4,326 (43) 5,177 (39) 4,810 (40) 630 (30) 9 (1) White 3,446 (61) 3,772 (37) 4,831 (36) 4,924 (40) 1,021 (48) 9 (1) 69 (1) 203 (2) 222 (2) 268 (2) 16 (1) 0 (0) Other Missing 211 (4) 264 (3) 330 (3) 435 (4) 94 (4) 1,329 (98) Patient visits constitute the unit of analysis for data reported in this table. *Reported as median with interquartile range in parentheses. Defined as American or Alaskan Native, Native Hawaiian, or Non-Hawaiian Pacific Islander. Defined as the Colorado Indigent Care Program (CICP). Defined as payment provided by the City Attorney (e.g., victims of crime), Department of Safety, workers compensation, or other governmental sources.

Table 3. Multivariable logistic regression to estimate the associations between payer status and patient demographics and whether patients agreed to and completed HIV testing as part of nontargeted opt-out rapid HIV screening in the emergency department. Completed Rapid HIV Agreed to Rapid HIV Testing Testing OR (95% CI) OR (95% CI) Payer Status Commercial 1.00 1.00 Medicare/Medicaid 1.10 (1.01 1.19) 1.15 (1.05 1.26) 1.53 (1.40 1.66) 1.61 (1.47 1.76) State* Self-pay 1.51 (1.39 1.64) 1.49 (1.37 1.63) 0.50 (0.42 0.58) 0.48 (0.39 0.57) Other Age Gender Male Female 0.99 (0.99 0.99) 0.99 (0.99 1.00)

CONCLUSIONS
Patients who are uninsured are more likely to accept free routine opt-out rapid HIV screening. Acceptance of routine opt-out HIV testing is high among poor, black and Hispanic patients, a subset of patients considered at high risk for HIV infection.

0.82 1.00

(0.78 0.85) -

0.82 1.00

(0.78 0.86) -

Race/ethnicity Asian 0.64 (0.50 0.82) 0.61 (0.46 0.81) Black 1.27 (1.19 1.36) 1.27 (1.18 1.36) Hispanic 1.14 (1.09 1.20) 1.15 (1.09 1.22) 0.93 (0.77 1.11) 0.91 (0.75 1.12) Other White 1.00 1.00 Abbreviations: OR = odds ratio; CI = confidence interval. Age was modeled as a continuous variable and in addition to the variables listed above, both models included day of the week and time of day as covariates. The Hosmer-Lemeshow goodness-of-fit pvalues for the two models were 0.84 and 0.81, respectively. * Defined as the Colorado Indigent Care Program (CICP). Defined as payment provided by the City Attorney (e.g., victims of crime), Department of Safety, workers compensation, or other governmental sources. Defined as American or Alaskan Native, Native Hawaiian, or Non-Hawaiian Pacific Islander.

Denver Health Medical Center Denver, Colorado

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