 Jason S. Haukoos, MD, MSc, Director of Research and Clinical Research Fellowship for the Department of Emergency Medicine at Denver Health Medical Center
Screening Patients in the Emergency Department for HIV and Tobacco Use: A Conversation With Two Emergency Physicians
By the Innovations Exchange Team
“Integrating routine, nontargeted HIV screening into ED operations
results in thousands of HIV tests and only a modest number of newly
diagnosed cases.” —Jason Haukoos, MD, MSc
“We have learned that the tobacco screening method is less important
than the person who interacts with patients.” —Steven Bernstein, MD
Introduction:
Hospital emergency departments (EDs), which have more than 120 million
visits annually in the United States, offer a unique setting for
screening patients who are at risk for specific conditions. Profiles
featured recently on the Innovations Exchange focus on identifying
individuals in the ED who are at increased risk of eating disorders, youth violence, and suicide.
Researchers are also exploring other types of screening in this
setting, including screening for sexually transmitted diseases and
substance abuse. Dr. Jason Haukoos and his research team at the Denver
Health Medical Center have developed an HIV screening instrument that is
used in the ED. Dr. Steven Bernstein at the Yale School of Medicine has
developed a screening and treatment intervention for tobacco users in
the ED, as well as programs to train providers in tobacco cessation
approaches.
Innovations Exchange: What led to your interest in screening patients in the ED?
Dr. Jason Haukoos: When I attended UCLA medical school
in the mid-1990s, my mentor’s clinical research focused on the
evaluation and diagnosis of patients with HIV infection who came to the
ED. After highly active antiretroviral therapy became available in 1995,
HIV evolved from a disease linked to nearly certain death to a chronic
disease. When I trained as a resident in emergency medicine from 1998 to
2001, a public policy goal was to identify patients with undiagnosed
HIV infection and prevent transmission of the virus. High-risk patients
routinely seek care in EDs, so HIV screening has become a core component
of efforts to control the HIV epidemic in the United States.
Dr. Steven Bernstein: I trained in internal medicine and
studied hematology–oncology nearly 30 years ago. I left that discipline
to retrain in the ED. Working in the ED, I saw the same types of
diseases that I saw when I was an internist and a hematology–oncology
fellow. These included tobacco-related diseases such as lung cancer,
chronic obstructive pulmonary disease, and emphysema. I noticed that we
treated only acute problems in the ED, rather than looking at the
underlying causes of those conditions. Although many people were working
on the diagnosis of unrecognized HIV infections in the late 1980s and
early 1990s, fewer people were working on identifying people at risk for
tobacco-related diseases in the ED. I decided that I could contribute
my efforts to reducing the number of people with tobacco-related
diseases.
Do you see many at-risk patients in the ED?
Haukoos: Absolutely. Although the rate of AIDS has
decreased since combination treatment became available in 1995,
approximately 50,000 new infections occur annually.1 In addition, 250,000 individuals in the United States remain infected with undiagnosed HIV infections.2
These estimates have remained relatively unchanged over the past
decade. The highest-risk individuals are still men who have sex with
other men, but HIV is increasing most among racial and ethnic
minorities. These are the same groups who tend to be uninsured, have
limited access to primary care, and use the ED as their primary source
of care. These factors and previous missed opportunities to diagnose HIV
in the ED led the Centers for Disease Control and Prevention (CDC) and
other public health organizations to focus attention on HIV screening in
the ED.
Bernstein: For years, tobacco has been the leading
cause of preventable death and illness in the United States. Although
19.8 percent of Americans continue to smoke,3 ED patients generally smoke more, with prevalence rates ranging from 21 percent in an affluent suburban community ED4 to 48 percent in urban areas.5,6
Can you describe screening strategies for at-risk patients in EDs?
Haukoos: A major shift in HIV screening occurred in
2006, when the CDC changed its recommendation from offering HIV testing
only to high-risk patients to offering HIV testing routinely to all
patients ages 13 to 64.7 Recently the U.S. Preventive Services Task Force followed suit.8
Unfortunately, only a very small percentage of EDs in the United
States have adopted such a broad screening practice. Prior to 2006, the
CDC endorsed targeted screening based on risk factors such as an
intravenous drug use, men who have sex with men, and high-risk
heterosexual behaviors. The newer nontargeted approach recommended by
the CDC is difficult for EDs to implement. In reality, few EDs can
routinely offer screening to every patient who comes through the door.
This approach also requires substantial resources.9
Integrating routine nontargeted HIV screening into ED operations
results in thousands of HIV tests and only a modest number of newly
diagnosed cases.10
Bernstein: Typical tobacco screening strategies may
consist of the doctor or nurse asking patients if they smoke, and making
a referral to a State quitline or a local cessation program. Health
care professionals may advise the patient to discuss smoking cessation
with his or her primary care doctor.
In our ED at Yale, trained health promotion advocates from the community
ask patients about tobacco use and other substance use. If they find a
smoker who can give consent, they do a brief motivational interview and
refer the patient to an intensive tobacco treatment program, a State
quitline, a clinic, or a private physician. In our studies, research
assistants are funded by grants to conduct screening and arrange
referrals. We also train emergency physicians to conduct tobacco
screening. It has been challenging to educate my ED colleagues that
tobacco screening is within our scope of practice, and that we can’t
just leave that to our primary care colleagues.
Have you developed and tested a specific screening instrument?
Haukoos: A major aim of our Agency for Healthcare
Research and Quality (AHRQ) grant that ended in 2013 was to develop a
clinical prediction instrument that quantifies a patient’s risk for HIV
based on demographics, behavioral characteristics, and the use of HIV
testing. We developed the Denver HIV Risk Score, which we validated
externally and incorporated into our ED and urgent care service in 2011.
The instrument is included in our broader electronic screening program
that nurses use when patients enter the ED.
Bernstein: We have developed a brief “health quiz” that
a nonclinician uses in the ED to screen patients at risk of substance
use behaviors, including alcohol and tobacco use. The assessment tool is
available in print and electronic formats for tablets and kiosks. In
our validation studies, we found the tool to be very effective and
reliable. It is a good case-finding method.
What has your research shown to be the most effective screening strategy?
Haukoos: Our first major study evaluating targeted
screening (using the Denver HIV Risk Score) against nontargeted
screening (as recommended by CDC) resulted in comparable numbers of
newly diagnosed cases of HIV.11
It was notable, however, that only 551 patients in the targeted
screening phase required HIV tests, compared with 3,591 patients in the
nontargeted phase.
The targeted approach enables us to focus our limited HIV testing
resources on the highest-risk patients. On average, we have to conduct
approximately 1,000 HIV tests to find 1 positive test in nontargeted
screening. That doesn’t seem to be an efficient use of resources, when
each rapid HIV test costs between $10 and $15.
Bernstein: My research in tobacco control has involved
two randomized controlled trials looking at ED-initiated interventions
to help tobacco smokers quit. The second trial, which was recently
completed, involved a brief intervention of medication and counseling in
low-income patients. The medication consisted of a 6-week supply of
nicotine replacement therapy (patch and gum), with the first patch
started in the ED. The counseling included motivational interviewing and
an active referral to the Connecticut quitline. A study nurse also
called participants in the intervention arm a few days after enrollment
to check in and encourage them to continue treatment.
The 3-month followup showed that the participants in the brief
intervention arm had quit rates of 12 percent, compared with about 5
percent in the control group. The quit rates were higher in this
randomized controlled trial than in the first trial we conducted in New
York,12
because we added enhancements to the intervention. These enhancements
included administering the first dose of nicotine patch or gum in the ED
and making the quitline referral in real time.
What lessons have you learned about implementing screening in the ED?
Haukoos: To make targeted HIV screening sustainable, it
must be fully integrated into ED processes. Existing clinical staff
should be trained in how to integrate the screening into their clinical
workflows. Furthermore, policymakers who develop HIV screening
recommendations may be unaware of the ED environment and the patients we
serve. It’s impractical to screen everyone for HIV for the following
reasons:
-
The ED provides acute care rather than prevention services.
-
Many people cannot consent to be tested because their mental status is altered due to medical illnesses or substance abuse.
-
As many as 85 percent patients decline HIV testing because they don’t perceive themselves as being at risk for HIV.
Regardless of the type of screening, some people with HIV infection will
not be tested. So the question is this: How best do we use our scarce
resources to identify the most patients with HIV infection? From my
perspective, it’s a targeted approach aimed at high-risk patients, and
my team continues to conduct evaluation and implementation research to
identify the best HIV screening strategies for use in EDs.
Bernstein: We have learned that the tobacco screening
method is less important than the person who interacts with patients. We
put a lot of time and effort into recruiting and training the right
people. In order to talk to people about sensitive topics in a crowded
ED, a person needs to have a personality that is nonjudgmental and
empathic, and to be able to gain a patient’s attention in a difficult
environment.
Will you conduct further research to evaluate screening or treatment interventions?
Haukoos: Our research team is planning a large,
multicenter clinical trial to evaluate thoroughly the following three
HIV screening methods: targeted, using the Denver HIV Risk Score;
targeted, using conventional methods (based on criteria such as
injection drug use, high-risk sexual behaviors, or clinical signs of an
immunocompromised state); and nontargeted, as recommended by the CDC in
2006. This multicenter study, which is known as The HIV Testing using
Enhanced Screening Techniques in EDs (TESTED) Trial, is the first and
largest of its kind. We hope that when the results are available in
2017, one screening method will emerge as more effective and efficient
than the others. These results will inform our recommendations for broad
implementation in ED settings.
Bernstein: Our next study will involve training doctors
in hospital inpatient units at Yale to conduct tobacco interventions.
Inpatient physicians will have access to comprehensive tobacco order
sets that are integrated into the hospital’s electronic health records
system.
About Jason S. Haukoos, MD, MSc:
Dr. Haukoos is the Director of Research and Clinical Research Fellowship
for the Department of Emergency Medicine at Denver Health Medical
Center, Denver, Colorado. He is an Associate Professor in the Department
of Emergency Medicine at the University of Colorado School of Medicine,
and in the Department of Epidemiology at the Colorado School of Public
Health. Dr. Haukoos is a past recipient of an Individual National
Research Service Award and an Independent Scientist Award from AHRQ. His
research focus includes health services research and the epidemiology
of emergency medical care, in particular HIV screening.
About Steven L. Bernstein, MD:
Dr. Bernstein is a Professor of Emergency Medicine and Vice Chair,
Academic Affairs, Department of Emergency Medicine, Yale School of
Medicine, New Haven, CT. Dr. Bernstein's chief interest is in clinical
trials of tobacco dependence treatment. He developed a screening and
treatment intervention for tobacco users in the ED, as well as programs
to train providers in tobacco control.
Disclosure Statements:
Dr. Haukoos reported that his institution received grants from AHRQ, the
National Institute for Allergy and Infectious Diseases, and the Denver
Health and Hospital Authority (his primary employer) that are relevant
to the HIV research described in this perspective.
Dr. Bernstein reported that his institution received grants from the
National Institutes of Health, the National Cancer Institute, the
National Heart, Lung, and Blood Institute, and the National Institute on
Drug Abuse that are relevant to the tobacco research described in this
perspective. In addition, the American College of Emergency Physicians
has supported his work in various ways, including dissemination of
tobacco interventions among ED physicians, and revising and
strengthening the tobacco treatment guideline in its 2010 policy statement on tobacco products .
1 Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006–2009. PLoS One. 2011;6:e17502. [PubMed]
4
Richman PB, Dinowitz S, Nashed A, Eskin B, Cody R. Prevalence of
smokers and nicotine-addicted patients in a suburban emergency
department. Acad Emerg Med. 1999;6(8):807–10. [PubMed]
5
Lowenstein SR, Koziol-McLain J, Thompson M, et al. Behavioral risk
factors in emergency department patients: a multisite study. Acad Emerg
Med. 1998;5(8):781–7. [PubMed]
6
Lowenstein SR, Tomlinson D, Koziol-McLain J, et al. Smoking habits of
emergency department patients: an opportunity for disease prevention.
Acad Emerg Med. 1995;2(3):165–71. [PubMed]
7
Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for
HIV testing of adults, adolescents, and pregnant women in health-care
settings. MMWR Recomm Rep. 2006;55:1-17. [PubMed]
9
Conroy AA, Hopkins E, Byyny RL, et al. Cost-effectiveness of routine
opt- out rapid HIV screening in the emergency department: results from a
prospective controlled clinical trial. Acad Emerg Med. 2009;16:S147-8. [PubMed]
10
Brown J, Shesser R, Simon G, et al. Routine HIV screening in the
emergency department using the new US Centers for Disease Control and
Prevention guidelines: results from a high-prevalence area. J Acquir
Immune Defic Syndr. 2007;46(4):395–401. [PubMed]
11
Haukoos JS, Bender B. Comparison of enhanced targeted rapid HIV
screening using the Denver HIV risk score to nontargeted rapid HIV
screening in the emergency department. Ann Emerg Med. 2013;61(3):353-61.
[PubMed]
12
Bernstein SL, Bijur P, Cooperman N, et al. A randomized trial of a
multicomponent cessation strategy for emergency department smokers. Acad
Emerg Med. 2011; 18(6):575–83. [PubMed]
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Last updated: November 20, 2013.
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Steven L. Bernstein, MD, Professor of Emergency Medicine and Vice Chair, Academic Affairs, Department of Emergency Medicine, Yale School of Medicine (Image courtesy of Yale School of Medicine)
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