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HIV Rapid Testing in a VA Emergency Department Setting: Cost Analysis at 5 Years

  • Herschel Knapp
    Correspondence
    Address correspondence to: Herschel Knapp, VA Greater Los Angeles Healthcare System,11301 Wilshire Boulevard, Building 210, Room 210, Los Angeles, CA 90073.
    Affiliations
    Veterans Affairs (VA) Quality Enhancement Research Initiative for HIV and Hepatitis (QUERI-HIV/HEP) and Center for the Study of Healthcare Provider Behavior, Los Angeles, CA, USA

    Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence, Los Angeles, VA, USA

    VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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  • Kee Chan
    Affiliations
    University of Illinois, Chicago, School of Public Health, 1603 W. Taylor St, Chicago, IL 60612

    Edith Nourse Rogers Memorial Veterans Hospital Home, 200 Springs Rd, Bedford, MA 01730, Center for Healthcare Organization and Implementation Research (CHOIR), 715 Albany St., Boston, MA 02118
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Open ArchivePublished:May 19, 2015DOI:https://doi.org/10.1016/j.jval.2015.02.019

      Abstract

      Objectives

      To conduct a comprehensive cost-minimization analysis to comprehend the financial attributes of the first 5 years of an implementation wherein emergency department (ED) registered nurses administered HIV oral rapid tests to patients.

      Methods

      A health science research implementation team coordinated with ED stakeholders and staff to provide training, implementation guidelines, and support to launch ED registered nurse–administered HIV oral rapid testing. Deidentified quantitative data were gathered from the electronic medical records detailing quarterly HIV rapid test rates in the ED setting spanning the first 5 years. Comprehensive cost analyses were conducted to evaluate the financial impact of this implementation.

      Results

      At 5 years, a total of 2,620 tests were conducted with a quarterly mean of 131 ± 81. Despite quarterly variability in testing rates, regression analysis revealed an average increase of 3.58 tests per quarter. Over the course of this implementation, Veterans Health Administration policy transitioned from written to verbal consent for HIV testing, serving to reduce the time and cost(s) associated with the testing process.

      Conclusions

      Our data indicated salient health outcome benefits for patients with respect to the potential for earlier detection, and associated long-run cost savings.

      Keywords

      Background

      An estimated 20% of persons with HIV infection in the United States are unaware of their HIV serostatus and, hence, do not receive the necessary treatment, ultimately increasing the risk of unknowingly transmitting the disease to others [
      Centers for Disease Control and Prevention
      HIV surveillance—United States, 1981–2008.
      ]. The Centers for Disease Control and Prevention and the American College of Physicians have recommended a shift from risk-based HIV testing to once per lifetime routine testing of all patients aged 13 years and older [
      Centers for Disease Control and Prevention
      Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
      ,
      • Qaseem A.
      • Snow V.
      • Shekelle P.
      • et al.
      Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association.
      ]. The US Department of Veterans Health Affairs (VHA), the largest single provider of HIV services in the United States, has adopted these practice recommendations [

      National Human Immunodeficiency Virus (HIV) Program, VHA Directive 1304, Department of Veterans Affairs, Washington, DC 20420, November 24,2014. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3056 [Accessed May 8, 2015]

      ]. Despite this change, HIV testing in the VHA remains relatively low [
      • Halloran J.
      • Czarnogorski M.
      • Dursa E.
      • et al.
      HIV testing in the US Department of Veterans Affairs, 2009–2010.
      ,

      Veterans Affairs Office of Clinical Public Health. HIV Testing Rates in VHA 2009–2011. http://www.hiv.va.gov/provider/policy/testing-rates-2011-slides.asp [Accessed May 8, 2015].

      ].
      A strategy that has shown promise for increasing HIV testing in VHA settings is the use of oral rapid testing administered by nurses, known as nurse-initiated HIV rapid testing (NRT). We have implemented NRT in traditional VHA settings, including primary care clinics [
      • Anaya H.D.
      • Bokhour B.
      • Feld J.E.
      • et al.
      Implementing routine rapid HIV testing within the US Department of Veterans Affairs Healthcare System.
      ,
      • Anaya H.D.
      • Butler J.N.
      • Solomon J.L.
      • et al.
      Implementation of a nurse-initiated rapid HIV testing intervention at two high prevalence primary care sites within the US Department of Veterans Affairs Healthcare System. J.
      ].
      To broaden the scope of our testing efforts within the VHA, we have also explored the potential for expanding HIV testing into nontraditional VHA settings such as substance use disorder clinics [
      • Conners E.E.
      • Hagedorn H.
      • Butler J.
      • et al.
      Implementation of HIV rapid testing in VA substance use disorder clinics.
      ]. In this same vein, we also successfully implemented NRT in a VHA emergency department (ED) setting [
      • Chen J.C.
      • Goetz M.B.
      • Feld J.E.
      • et al.
      A provider participatory implementation model for HIV testing in an ED.
      ].

      Objectives

      The objectives of this article were to quantitatively examine the first 5 years of the ED NRT program and to conduct a comprehensive cost analysis of this implementation [
      • Chen J.C.
      • Goetz M.B.
      • Feld J.E.
      • et al.
      A provider participatory implementation model for HIV testing in an ED.
      ].

      Methods

      A QUality Enhancement Research Initiative for HIV (QUERI-HIV) research and implementation team, whose primary mission is to improve the quality of HIV diagnostics and care for patients in the VHA, was assembled. The team, consisting of one physician, one registered nurse, two PhD social scientists, and a health science research assistant, coordinated with an ED physician and an ED nurse manager to derive a minimally obtrusive plan for introducing HIV rapid test (RT) into the ED [
      • Knapp H.
      • Hagedorn H.
      • Anaya H.D.
      HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation.
      ]. The registered nurse and one of the PhD staff members conducted the HIV RT trainings in the ED for all day-shift (07:00–19:00) registered nurses. The initial goal was to conduct five tests per day during the slow(er) time in the ED: 07:00 to 12:00 at the Greater Los Angeles VHA Medical Center, a full-service health care facility. For the first month of this implementation, nurses approached a random sample of 10% of the patients (those whose Social Security Numbers ended in 0), who had a cogent mindset, and offered the HIV RT. After the initial month of conducting HIV RT in this domain, it was evident that this supplemental activity did not adversely affect patient care or nursing productivity; hence, the 10% limitation was lifted and nurses were encouraged to offer HIV RT to all patients universally (regardless of risk factors) on a regular basis. Nurses administered the informed consent and the test procedure, recorded the results in the patient’s electronic medical record, and (verbally) reported the test results to the patient’s physician, who would then impart the test results to the patient. Initially, written informed consent was required for running an HIV test, which required about 5 minutes. In August 2009, US Department of Veterans Affairs policy shifted to verbal consent for HIV testing, which involves about 1 minute. Before this implementation, ED physicians could order an HIV enzyme-linked immunosorbent assay blood test if, in their judgment, such testing was diagnostically indicated; however, such tests were not offered on a universal basis, as was the practice with this HIV RT program.
      During the first few months, the health science research assistant made twice-weekly visits to the ED to verify that there was an ample supply of test devices on hand, and conferred with the nurses, verifying that tests were being administered per the established protocol. She also answered questions and gathered feedback from the nurses (if offered). Monthly HIV RT reports, consisting of figures and graphics, were delivered to the ED leadership to provide feedback to staff affirming their performance. After 6 months, the research team disbanded, enabling the ED leadership (ED champion physician and ED nurse manager) to take over the day-to-day operations of the implementation, at which time, the time boundaries were eliminated—nurses, now comfortable with the HIV RT process, were instructed that they can carry out HIV RT beyond the noon cutoff, time permitting.

      Results

      We queried our electronic medical record system to gather quarterly ED NRT figures spanning the first 5 years of this implementation (July 2008 to June 2013). Analyses revealed that a total of 2,620 tests were conducted during this time frame, with a quarterly mean of 131 ± 81. The solid line (Fig. 1) represents the number of tests administered in each of the 20 quarters; the positive slope of the (dotted) trend line, computed using bivariate (r) regression analysis, shows an average quarterly increase of 2.73%, amounting to 3.58 additional tests administered per quarter.
      Figure thumbnail gr1
      Fig. 1 Quarterly nurse-administered HIV RTs in VA ED and urgent care: July 2008 to June 2013. ED, emergency department; RT, rapid test; VA, US Department of Veterans Affairs.

      Cost Analysis

      In any resource-limited health care setting, understanding the cost of implementing a new program such as HIV rapid testing is valuable for health care managers to anticipate the budget impact and potential cost and benefits. We evaluated the cost impact associated with the implementation using an Excel spreadsheet analysis of the gross costing of the key parameters for stakeholders to consider both the initial phase of training in the first few months and the continuous phase including the monthly feedback reports, HIV test kits, and personnel times (Table 1). The fixed cost of the personnel salary may vary on the basis of regional salary, and the relative cost of additional HIV testing kits will be based on the prevalence in the specific population and needs of the facilities. Based on our assessment of the cost of the HIV test kits at $10.09 (per unit) plus the 5-minute pretest counseling, the cost of the HIV program between July 2008 and August 2009 was about $3,930. Since the change from written to verbal consent, in August 2009, the total cost of the program was estimated at $25,322. Although there was an increase in the number of HIV tests performed after August 2009, the removal of written consent reduced the time associated with pretesting counseling from 5 to 1 minute. This time reduction resulted in an average cost of $2.94 per test in the NRT HIV program.
      Table 1Comparative cost-impact analysis of nurse-initiated rapid testing for HIV at urgent care and ED.
      Urgent careEDUrgent care + ED
      ExpenseJul 2008 to Aug 2009Sep 2009
      After August 2009, pre- and posttest counseling was no longer required and pretesting counseling time reduced from 5 to 1 min.
      to Jun 2013
      Jul 2008 to Aug 2009Sep 2009
      After August 2009, pre- and posttest counseling was no longer required and pretesting counseling time reduced from 5 to 1 min.
      to Jun 2013
      Jul 2008 to Aug 2009Sep 2009
      After August 2009, pre- and posttest counseling was no longer required and pretesting counseling time reduced from 5 to 1 min.
      to Jun 2013
      HIV Kits
      Federal pricing for HIV rapid testing kit for Veteran Affairs is $10.09.
      The program in urgent care started in August 2009 and thus, no data were collected here.
      On average, posttesting counseling for a positive case can take about 20 min.
      5652841,7712842,336
      Cost of HIV testing ($)
      Annual salaries and fringe benefits of personnel are based on an average and may vary across different facilities.
      5,7002,86517,8702,86523,570
      Pretest counseling ($)
      On average, pretesting counseling takes about 5 minutes, and the salary of a nurse was $45.05/h. We estimated $3.75 for the 5-min counseling and $0.75 for the 1-min counseling.
      Annual salaries and fringe benefits of personnel are based on an average and may vary across different facilities.
      4241,0651,3281,0651,752
      Cost of program ($)
      Annual salaries and fringe benefits of personnel are based on an average and may vary across different facilities.
      6,1243,93019,1983,93025,322
      Cost per test ($)
      Annual salaries and fringe benefits of personnel are based on an average and may vary across different facilities.
      13.8010.84
      ED, emergency department.
      low asterisk After August 2009, pre- and posttest counseling was no longer required and pretesting counseling time reduced from 5 to 1 min.
      Federal pricing for HIV rapid testing kit for Veteran Affairs is $10.09.
      The program in urgent care started in August 2009 and thus, no data were collected here.
      § On average, posttesting counseling for a positive case can take about 20 min.
      || On average, pretesting counseling takes about 5 minutes, and the salary of a nurse was $45.05/h. We estimated $3.75 for the 5-min counseling and $0.75 for the 1-min counseling.
      Annual salaries and fringe benefits of personnel are based on an average and may vary across different facilities.

      Cost Implication

      Comparative cost analysis is important for health care managers to consider when deciding on new initiations such as NRT in their facilities. These important decisions weigh the increase in health benefits and potential cost and benefits. Here, we conducted a cost analysis that highlighted the effect of the increased number of HIV tests performed in the context of the new HIV counseling policy change. The cost associated with the increasing HIV testing rate is proportional to the increasing time spent on HIV testing counseling by nurses. Our findings suggest that the primary personnel (nurses and physicians) time for patient care and salaries did not change significantly before or after the implementation and the time associated with posttest counseling remained the same before and after the new HIV testing policy in August 2009. We highlighted the impact of the pretesting counseling. With the removal of the written consent required for HIV testing, however, the pretest counseling time significantly reduced from 5 to 1 minute, which resulted in an average cost of $2.96 per test. Overall, implementing a nurse-administered HIV testing program yielded an increased HIV testing rate at a considerably low cost.
      In addition to the cost associated with the program, we briefly detailed other factors in the preprogram phase that may be under consideration such as project manager, training time, and feedback evaluation. We decided to not include this as a part of the program cost because facilities can vary greatly in terms of staffing and operational infrastructure. For example, a facility may already have a program manager or a quality improvement staff member familiar with HIV testing who could administer such a program as a supplemental task.

      Conclusions

      Even with the availability of antiviral therapy medication, the benefits of medical management of HIV patients largely depend on the early identification of HIV status. Late identification of HIV status could increase the likelihood of further HIV transmission because individuals who were not aware of their status tend to engage in more risky behavior. Also, among those identified late, the immune system of these patients could be compromised from infections, which could further increase complications and costs of hospitalizations and additional medications to treat other comorbidity conditions. Most of the total cost of the program was due to the additional cost of the HIV testing kits. The cost of personnel is minimally affected. In some facilities, however, additional personnel may be required; thus, additional cost may be incurred. As such, we believe that because the personnel time for HIV testing and counseling is minimal, it will not significantly affect the total cost of the program. In our study, the cost of our total program is about $25,322. For facilities interested in adopting this program, additional time may need to be reserved for training and counseling. Also, the range of salary of personnel may affect the total cost. The test kit, however, cost is the fixed cost. We included the cost of the nurse time because the time spent on HIV testing is time taken away from other nursing activities.
      Thus, the cost of the early identification is crucial to the downstream cost analysis of a program and future implementation. Although studies have shown the cost-effectiveness of more widespread implementation of HIV testing in hypothetical large settings, this specific study emphasized on evaluating the cost associated with a HIV testing program using NRT in an urgent care and emergency department. Our data indicated not only the salient health outcomes benefits for patients but also included an analysis of the costs and benefits of the NRT program for health care administrators for their consideration.
      Source of financial support: There is no direct or indirect funding associated with this study.

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