Opt-out HIV screening choice increases testing rates
Adoption of an opt-out HIV testing policy in hospital EDs could increase the proportion of tested patients, especially among those who report low-risk behaviors, according to recent data.
“The effect of opt-in vs. opt-out defaults has been identified in other settings, but it has not been as carefully identified for HIV testing; the CDC’s endorsement for opt-out testing was based on thin evidence of its efficacy in increasing patients’ acceptance of HIV screening,” Juan Carlos C. Montoy, MD, resident in the emergency medicine department at the University of California, San Francisco, and colleagues wrote. “The wide range in reported test acceptance percentages suggests that the details of the testing regimen — including how the test is offered, by whom, to whom and in what setting — can be crucial to how likely patients are to agree to be tested.”
In their nonmasked, randomized trial, Montoy and colleagues examined the impact of test offers on patients aged 13 to 64 years receiving treatment in an ED between June 18, 2011 and June 30, 2013. During standard care, patients were approached by hospital staff with a questionnaire and, later, an offer of rapid HIV testing. After informing the patient that the hospital was offering routine testing, the researchers instructed the staff to phrase the offer as an opt-in program, an opt-out program or by directly asking the patient whether they wanted testing (active choice). The researcher’s primary outcome was the percentage of patients in each group who accepted HIV testing, with a separate analysis examining acceptance by subgroups representing various levels of HIV risk.
Of the 4,800 patients who consented to the study, 1,607 patients were randomly assigned to the opt-in group, 1,565 to the opt-out group and 1,628 to the active choice group. Test acceptance percentages were 38% for opt-in patients, 65.9% among the opt-out group and 51.3% among active choice patients. The overall acceptance rate was 51.6%. Despite greater test acceptance rates among patients considered to be at high risk, the effect of the opt-out strategy was strongest in low-risk patients. There was no difference in test acceptance rates in regard to a patient’s chief complaint.
Although these data suggest that a minor change in phrasing could improve overall testing rates, the researchers wrote that the language’s effect could obscure a patient’s preferences.
“A central tenet of patient-centered care is the idea that patients’ preferences should be factored into health care decisions,” Montoy and colleagues wrote. “However, if small changes in the way we ask patients about their preferences significantly affect their answers, accurately identifying patients’ true preferences may not be as simple as one might expect.”
In a related editorial, Jason S. Haukoos, MD, professor of emergency medicine and epidemiology at Denver Health Medical Center, and Sarah E. Rowan, MD, assistant professor of medicine at the University of Colorado School of Medicine, wrote that while the data support 2006 recommendations from the CDC for opt-out testing, it is not yet known if this effect will retain its strength in less controlled health care settings.
“What remains unknown is the extent to which the efficacy results translate into effectiveness in clinical practice where there are no research assistants with scripts,” they wrote.
“Test acceptance rates vary widely in practice, particularly in busy settings, and are usually lower than the rates achieved in this trial, perhaps because of inconsistent wording leading to approaches that are not truly opt-out,” Haukoos and Rowan wrote. “However, with growing reliance on electronic health care systems, electronic implementation of HIV screening, and in particular how it is offered, may substantially improve acceptance of tests and, ultimately, identification of infected patients.” – by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures.