Effect of Routine Opt-Out HIV Screening on Emergency Department Operational Metrics: Results From the Pragmatic Randomized HIV TESTED Trial

Austin T Jones; Jason Haukoos; Emily Hopkins; Michael S Lyons; Richard E Rothman; Douglas A E White; Yu-Hsiang Hsieh; Kathleen M Joseph; Evangelia Murray; Sarah E Rowan; HIV TESTED Trial Investigators

doi:10.1016/j.annemergmed.2025.04.011

Effect of Routine Opt-Out HIV Screening on Emergency Department Operational Metrics: Results From the Pragmatic Randomized HIV TESTED Trial

Ann Emerg Med. 2025 May 31:S0196-0644(25)00204-5. doi: 10.1016/j.annemergmed.2025.04.011. Online ahead of print.

Collaborators

HIV TESTED Trial Investigators:
Bryan Austin, Jacob Cohen, Jackie Easley, Somiya Haider, Peter Hill, Mauren Henley, Gabor Kelen, Maggie Leathers, Barbara Maliszewski, Paula Neira, Scott Newton, Stephen Peterson, Mustapha Saheed, Danielle Signer, Lucas Spaeth, Tina Tolson, Matthew Toerper, Valentina Viertel, Maddie Whalen, Rachel Ancona, Catherine Cronin, Frank Fernandez, Carl Fichtenbaum, Cortney Gaffney, Cathy Hamilton, Kim Hart, Dave Hoskins, Sharon Kohrs, Christopher Lindsell, Chris Miller, Brittany Punches, Andrew Ruffner, Geri Rowan, Kim Vance, Teresa Williams, Alia Al-Tayyib, Meggan Bucossi, Steve Cantrill, Angelica Chavez, Ann Comeau, Tracy Daugherty, Alex Delgado, Pamela Doyle, Roberto Esquivel, Maren Fassino, Kelly Finnegan, Greg Fliney, Theresa Freudig, Michael Fuhriman, Edward Gardner, Mary Gillman, Stacey Kahl-Geiger, Korina Keating, Jason Koerner, Karen Laber, Meghan Lang, Carolynn Lyle, Kim Makela, Mary Maltby, David Medina, Tanya Nielsen, Alice Ortiz, Angela Paolucci, Don Pate, Michael Pippins, Steven Roy, Allison Sabel, John Searcey, Jerry Solot, Kelly Stermer, Brian Stuart, Melissa Swanson, Lauren Timkovich, Zenia Toure, Lisa Vogel, Sommer Walker, Diane Weed, Julia Weise, Kerri Wenke, Courtney Wham, Michael Wilson, Jarrod Wright, Melody Zwakenberg, Harrison Alter, Erik Anderson, Brendan Campbell, Grace Chang, Connie Chao, Katie Ellis, Sarah Graffman, Brynn Kron, Rebecca Lucas, Caitlin McCarthy, Valerie Ng, Christine O'Dell, Jim Peck, Mae Petti, Sarah Pfeil, Feuy Saechao, Barry Simon, Tamara Todorovic, Tonya Tyree

Affiliations

¹ Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
² Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO; Colorado Social Emergency Medicine Collaborative, Denver, CO. Electronic address: Jason.Haukoos@dhha.org.
³ Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Colorado Social Emergency Medicine Collaborative, Denver, CO.
⁴ Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH; Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
⁵ Department of Emergency Medicine, , Johns Hopkins University, Baltimore, MD.
⁶ Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA.
⁷ Public Health Institute at Denver Health, Denver, CO; Division of Infectious Diseases, Denver Health Medical Center, Denver, CO; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO.

PMID: 40448979
DOI: 10.1016/j.annemergmed.2025.04.011

Abstract

Study objective: To assess the effect of routine opt-out HIV screening on emergency department (ED) patient throughput.

Methods: We performed a multicenter, prospective, pragmatic 3-arm, parallel-group, randomized clinical trial to evaluate the effectiveness of 3 triage-driven, opt-out HIV screening strategies-nontargeted, enhanced targeted, and traditional targeted screening-when fully integrated into usual ED practices. As the 3 screening approaches were performed concurrently, the trial was nested in an equivalent time samples quasi-experiment to allow for the evaluation of HIV screening on ED operational metrics. Hierarchical multivariable linear and log binomial regression were performed to estimate associations between opt-out HIV screening and patient wait time, length of stay, boarding time, door-to-door time, and left before treatment was complete.

Results: From January 19, 2014, through July 7, 2016, a total of 377,392 patient visits were included, 125,743 (33.3%) of which were included from intervention periods. Among these visits, 65,093 (51.8%) were randomized into the HIV TESTED (HIV Testing Using Enhanced Screening Techniques in Emergency Departments) trial with 39,720 (61.0%) ultimately offered opt-out HIV testing. Of those offered HIV testing, 17,485 (44.0%) did not decline testing and 13,314 (33.5%) tests were completed. HIV screening was associated with an increase, on average, in wait time of 1.4 (95% confidence interval [CI] 0.3 to 2.6) minutes when adjusted for mode of arrival, acuity, overall crowding, time of day, and day of the week. HIV screening was negatively associated with length of stay for admitted patients (-18 [95% CI -30 to -4] minutes) and door-to-door time (-18 [95% CI -24 to -6] minutes), whereas HIV screening was not associated with length of stay for nonadmitted patients (-6 [95% CI -12 to 6] minutes) and boarding time (-6 [95% CI -42 to 24] minutes). Finally, HIV screening was associated with an increased prevalence of left before treatment was complete (prevalence ratio: 1.10, 95% CI 1.06 to 1.15) when adjusted for the same covariates.

Conclusions: When fully integrated into clinical ED care, routine opt-out HIV screening was associated with small but nonclinically meaningful increases in wait time and left before treatment was complete and no significant change in length of stay, boarding time, or door-to-door time.

Keywords: Clinical operations; HIV screening; Nontargeted screening; Targeted screening.