Comparison of Missed Opportunities for Earlier HIV Diagnosis in 3 Geographically Proximate Emergency Departments

Abstract

Objective Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area. Methods For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing. Results Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%). Conclusion Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department

“…Our results may not be generalizable to centers with different epidemiology; EDs differ in terms of disease prevalence even in the same region, 78,79 and EDs are certain to differ from other healthcare venues. 10,19 Our study was strengthened by controlling overall screening methodology to isolate differences resulting from patient selection strategy.…”

Is Self-Perceived HIV Risk Congruent with Reported HIV Risk Among Traditionally Lower HIV Risk and Prevalence Adult Emergency Department Patients? Implications for HIV Testing

“…Lyons et al 66 demonstrated that there were missed HIV diagnoses in 76 patients who visited an urban academic ED (n = 70), an urban community ED (n = 9), and a suburban ED (n = 4) in the year prior to diagnosis. Another study performed by Czarnogorski et al 62 demonstrated the prevalence of HIV to be 2.74 times higher (95% CI 1.…”

Comparison of HIV Testing Uptake in an Urban Academic Emergency Department Using Different Testing Assays and Support Systems

“…5 Institution of the CDC recommendation in Emergency Departments (ED) has been limited and, in many cases, persons with HIV are diagnosed only after several visits to the ED. [6][7][8] Even in New York State, where voluntary HIV testing is mandated, only 65% of their EDs offer testing to all patients between the ages of 13-64. 9 The ED remains an important venue for HIV testing because 17% of adults only access health care through the ED.…”