STUDY QUESTION:
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?
METHODS:
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.
STUDY ANSWER AND LIMITATIONS:
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.
WHAT THIS PAPER ADDS:
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
- 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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