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New HIV Diagnoses Quadruple With Electronic
Testing Prompt in Bronx Hospitals
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IDWeek 2016, October 26-30, 2016, New Orleans
Mark Mascolini
New HIV diagnoses jumped 4.5-fold from 8.2 to 37 per 100,000 people when a Bronx, New York hospital system added an electronic medical record (EMR) prompt to test admitted patients for HIV [1]. Proportions of patients tested rose from under 10% to over 20% after EMR prompting began.
The CDC recommends opt-out HIV testing for 13- to 64-year-olds at all medical encounters--including hospital admissions--at least once as part of regular healthcare [2]. Many hospitals have no systematic way to apply this advice to inpatients. In the Bronx, New York, an area with a 2% HIV prevalence, the Montefiore system instituted an automated EMR prompt signaling health workers to test inpatients with no prior HIV test or to retest those with high-risk diagnoses. The prompt automatically adds HIV testing to the routine testing list.
A Montefiore team assessed the impact of the HIV-testing prompt by comparing testing rates before and after the EMR system became active. Montefiore is the largest health system in the Bronx, with three adult hospitals that admit 80,000 people yearly. This analysis focused on 21- to 64-year-olds admitted before or after EMR prompting began. The study excluded people tested for HIV in the emergency department or during obstetric admissions.
Principal study outcomes were (1) the proportion of hospital admissions with an HIV test performed and (2) the rate of new HIV diagnoses made by screening. The investigators used generalized linear mixed models to explore (1) the association between study phase (before or during EMR prompting) and whether an HIV test was done, and (2) the association between study phase and new HIV diagnoses made by screening.
The analysis involved 55,553 admissions from September 2013 through March 2015, including 36,610 admissions in 377 days before EMR prompting and 18,943 in 199 days during EMR prompting. In both study phases, 55% of admissions involved women, about 90% of admitted patients were black or Hispanic, 70% had public insurance, median age stood at 51 years, and median hospital stay measured 3 days. During both study phases, half of patients had no prior HIV test.
Overall HIV testing rate increased significantly from before EMR prompting (3486 of 36,610 admissions, 9.5%) to the prompting phase 4122 of 18,943 admissions (21.8%) (P < 0.0001). The improvement held true for people with no prior HIV test (from 11% to 32%) and for people with a prior HIV-negative test (from 9% to 13%) (P < 0.0001 for both).
Admission after EMR prompting began independently raised the odds of increased HIV testing for all admissions (adjusted odds ratio [aOR] 2.78, 95% confidence interval [CI] 2.62 to 2.96), for admissions of people without a prior HIV test (aOR 4.03, 95% CI 3.70 to 4.40), and for admissions of patients with a prior negative HIV test (aOR 1.52, 95% CI 1.37 to 1.68) (P < 0.0001 for all).
New HIV diagnoses rose from 8.2 per 100,000 admissions before prompting began to 37.0 per 100,000 admissions during prompting to yield a 4.5 times higher rate with prompting (OR 4.51, 95% CI 1.17 to 17.45, P = 0.03).
The Montefiore researchers concluded that an EMR prompt to test hospitalized patients for HIV resulted in a big increase in HIV testing and an increase in HIV diagnoses made by screening. They cautioned that their findings may not apply to health systems located in areas with lower HIV prevalence, with less robust EMRs, with no access to dedicated counselors, and with different HIV testing policies.
With those caveats in mind, the investigators proposed that "leveraging the EMR to support expanded HIV testing strategies for hospitalized patients can impact key HIV prevention outcomes including decreasing missed opportunities for diagnosis."
References
1. Felsen U, Cunningham CO, Heo M, et al. An expanded HIV testing strategy leveraging the electronic medical record uncovers undiagnosed infection among hospitalized patients. IDWeek 2016, October 26-30, 2016, New Orleans. Abstract 2381.
2. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. September 22, 2006 / 55(RR14);1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
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