Gidwani RA (VA Greater Los Angeles HealthcareSystem, UCLA School of Public Health), Goetz MB
(VA Greater Los Angeles Healthcare System), Needleman J
(UCLA School of Public Health), Kominski G
(UCLA School of Public Health), Mattocks K
(VA New England Healthcare System), Samet JH
(Boston University School of Medicine), Justice A
(VA New England Healthcare System), Gandhi N
(Albert Einstein College of Medicine), Asch SM
(VA Greater Los Angeles Healthcare System)
The CDC recommends routine HIV testing for patients, yet concerns remain about the costs this would entail. We determined the marginal economic impact of implementing an HIV screening program in the emergency department (ED) beyond usual care.
We conducted a budget impact analysis (BIA) to determine the financial impact of HIV screening in the Greater Los Angeles ED. Costs were projected for seven years, over four budgets of interest: inpatient, outpatient, pharmacy, and global. Two programs were compared: Usual Care (UC, diagnostic testing using standard blood tests) and Rapid Test (RT, screening using oral rapid tests). Healthcare utilization was modeled from past utilization patterns of 113 treatment-naïve patients seen in the Greater Los Angeles VA. Cost was allocated to this utilization using 2007 DSS and PBM cost data. Implementation costs were determined through time-and-motion studies. Treatment costs were assumed to be dependent on disease severity at diagnosis. Using MonteCarlo simulation, a hypothetical cohort of patients, separated into four disease severity categories (CD4 < 50, 50 to 199, 200 to 350, 351+) was run through both programs. Data from the Veterans Aging Cohort Study were used to estimate the proportion of patients in each CD4 category, which differed across the UC and RT arms.
Assuming a prevalence of 1%, the RT program will identify 15 patients per year. Preliminary results indicate over a seven-year period, the RT program was less expensive than the UC program: $670,000 vs. $681,000. The RT program had higher outpatient costs than UC ($164,000 vs. $149,000). However, RT had lower pharmacy costs than UC ($388,000 vs. $406,000) and lower inpatient costs than UC ($86,000 vs. 126,000). Costs of implementing the RT program were almost $32,000.
Although the RT program had higher outpatient and implementation costs, the lower inpatient and pharmacy costs associated with identifying patients at earlier stages of disease show RT to be less expensive than UC. The health benefits of early detection and linkage to care further support the implementation of RT.
VA managers can use these data to plan implementation of this cost-effective program while working within the capacity constraints of this environment.