Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

中文翻译：

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急诊科 HIV 筛查的成本效益：在急诊科使用增强筛查技术进行实用随机 HIV 检测试验的结果


HIV 的识别仍然是一个关键的卫生重点，急诊科 （ED） 是其中心重点。急诊科中各种 HIV 筛查策略的比较成本效益在很大程度上仍然未知。本研究的目的是使用多中心、实用随机临床试验的结果，比较急诊科非靶向和 2 种形式的靶向选择退出 HIV 筛查的计划成本和成本效益。这项经济评估嵌套在急诊科使用增强筛查技术进行 HIV 检测 （TESTED） 试验中，这是一项针对 2014 年 4 月至 2016 年 1 月进行的不同基于 ED 的 HIV 筛查策略的多中心实用临床试验。年龄在 16 岁或以上、精神状态正常且病情不危重或未知为 HIV 感染者的患者被随机分配到 3 种 HIV 选择退出筛查方法中的一种，包括非靶向、增强靶向或传统靶向，在美国的 4 个城市急诊室。每种筛查方法都完全整合到常规紧急护理中。使用实际试验结果确定直接程序成本，并使用时间运动评估来估计人员活动成本。主要结局是新诊断的 HIV。按筛选方法计算的年化 ED 计划总成本使用调整至 2023 年的美元计算，每位新诊断为 HIV 的患者的成本也是如此。进行单向和多向敏感性分析。该试验随机分配了 76,561 名患者就诊，导致 14,405 人完成了 HIV 检测，并有 24 人 （0.2%） 新诊断。年化新诊断总数为 12.9 例，非靶向、增强靶向和传统靶向筛查的年化总成本分别为 111,861 美元、88,629 美元和 70,599 美元。 在筛查方法中，每个新 HIV 诊断的成本分别为 20,809 美元、23,554 美元和 18,762 美元。与传统的靶向筛查相比，增强型靶向筛查的成本更高，但年化新发病例的检出率相似。与传统的靶向筛查相比，非靶向筛查产生的增量成本效益比为 25,586 美元。结果对 HIV 流行率和 HIV 检测成本最敏感。非靶向 HIV 筛查比靶向筛查更昂贵，这主要是由于进行的 HIV 检测数量增加。每种 HIV 筛查策略对每个新 HIV 诊断的策略内成本相似，传统的靶向筛查对每个新诊断的成本最低。对于预算有限或 HIV 流行率非常低的地区，传统的靶向方法可能是首选;然而，鉴于每次新 HIV 诊断的成本仅略高，希望检测最多新病例的急诊科机构可能更喜欢非靶向筛查。