Tuesday, January 26, 2016

Patient Choice in Opt-In, Active Choice & Opt-Out HIV Screening

What is the effect of default test offers-opt-in, opt-out, and active choice-on the likelihood of acceptance of an HIV test among patients receiving care in an emergency department?

This was a randomized clinical trial conducted in the emergency department of an urban teaching hospital and regional trauma center. Patients aged 13-64 years were randomized to opt-in, opt-out, and active choice HIV test offers. The primary outcome was HIV test acceptance percentage. The Denver Risk Score was used to categorize patients as being at low, intermediate, or high risk of HIV infection.

38.0% (611/1607) of patients in the opt-in testing group accepted an HIV test, compared with 51.3% (815/1628) in the active choice arm (difference 13.3%, 95% confidence interval 9.8% to 16.7%) and 65.9% (1031/1565) in the opt-out arm (difference 27.9%, 24.4% to 31.3%). Compared with active choice testing, opt-out testing led to a 14.6 (11.1 to 18.1) percentage point increase in test acceptance. Patients identified as being at intermediate and high risk were more likely to accept testing than were those at low risk in all arms (difference 6.4% (3.4% to 9.3%) for intermediate and 8.3% (3.3% to 13.4%) for high risk). The opt-out effect was significantly smaller among those reporting high risk behaviors, but the active choice effect did not significantly vary by level of reported risk behavior. Patients consented to inclusion in the study after being offered an HIV test, and inclusion varied slightly by treatment assignment. The study took place at a single county hospital in a city that is somewhat unique with respect to HIV testing; although the test acceptance percentages themselves might vary, a different pattern for opt-in versus active choice versus opt-out test schemes would not be expected.

Active choice is a distinct test regimen, with test acceptance patterns that may best approximate patients' true preferences. Opt-out regimens can substantially increase HIV testing, and opt-in schemes may reduce testing, compared with active choice testing.

Below:  HIV test acceptance percentage by risk of infection: unadjusted results. Test acceptance percentage is shown according to treatment assignment (opt-in, active choice, and opt-out), and according to risk of HIV infection. Lines indicate 95% confidence intervals. Numbers of patients from each risk category accepting and offered HIV testing under each treatment group are presented as numerator and denominator

Below:  Test acceptance percentage by study staff member; (a) is composite of study staff who saw fewer than 200 patients each; (b) to (i) are individual staff members who saw more than 200 patients each. Lines indicate 95% confidence intervals

Full article at:   http://goo.gl/aClYwg

By:  Montoy JC1Dow WH2Kaplan BC3.
  • 1Department of Emergency Medicine, University of California, 505 Parnassus Ave, San Francisco, CA 94143, USA juancarlos.montoy@ucsf.edu.
  • 2School of Public Health, University of California, 239 University Hall #7360, University of California, Berkeley, CA 94720-7360, USA.
  • 3Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco CA 94143, USA. 

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