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Original Investigation |

Modest Public Health Impact of Nontargeted Human Immunodeficiency Virus Screening in 29 Emergency Departments FREE

Kayigan Wilson d’Almeida, MD; Gérald Kierzek, MD; Pierre de Truchis, MD; Stéphane Le Vu, PhD; Dominique Pateron, MD; Bertrand Renaud, MD, PhD; Caroline Semaille, MD, PhD; Vanina Bousquet, DVM; François Simon, MD, PhD; Didier Guillemot, MD, PhD; France Lert, MSPH; Anne-Claude Crémieux, MD, PhD; for the Emergency Department HIV-Screening Group
[+] Author Affiliations

Author Affiliations: Institut National de la Santé et de la Recherche Médicale (INSERM) U1018, Centre de Recherche en Épidémiologie et Santé des Populations, Villejuif, France (Dr d’Almeida and Ms Lert); Université Versailles Saint-Quentin, Faculté de Médecine, Paris Île-de-France Ouest, Saint-Quentin-en-Yvelines, France (Drs d’Almeida, Guillemot, and Crémieux and Ms Lert); Services d’Accueil et de Traitement des Urgences, Hôtel-Dieu Cochin, Paris, France (Dr Kierzek), Hôpital Saint-Antoine, Paris (Dr Pateron), and Hôpital Henri-Mondor, Créteil, France (Dr Renaud), Assistance Publique–Hôpitaux de Paris (AP-HP); Département de Médecine Aigüe Spécialisée et Unité Fonctionnelle de Santé Publique, Hôpital Raymond-Poincaré, AP-HP, Garches, France (Drs de Truchis, Guillemot, and Crémieux); Institut de Veille Sanitaire, St Maurice, France (Drs Le Vu, Semaille, and Bousquet); and Service de Bactériologie–Virologie, Hôpital Saint-Louis, AP-HP, Paris, France (Dr Simon).


Arch Intern Med. 2012;172(1):12-20. doi:10.1001/archinternmed.2011.535.
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Published online

Background To lower the number of undiagnosed infections and to improve early detection, international health agencies have promoted nontargeted human immunodeficiency virus (HIV) screening in health care settings, including emergency departments (EDs). This strategy remains controversial and has yet to be tested on a large scale. We assessed the public health impact of nontargeted HIV–rapid test (RT) screening among ED patients in the metropolitan area of Paris (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually.

Methods During a randomly assigned 6-week period for each of the 29 participating EDs, 18- to 64-year-old patients who were able to provide consent for HIV testing were offered a fingerstick whole-blood HIV RT. Main outcome measures were the number of patients tested for HIV and their characteristics vs those of the general metropolitan Paris population and the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics vs those from the national HIV case surveillance.

Results Among 138 691 visits, there were 78 411 eligible patients, 20 962 of whom (27.0%) were offered HIV RT; 13 229 (63.1%) accepted testing and 12 754 (16.3%) were tested. The ED patients' characteristics reflected the general population distribution. Eighteen patients received new HIV diagnoses (0.14%; 95% confidence interval, 0.08%-0.22%). Like national HIV case surveillance patients, they belonged to a high-risk group (n = 17), were previously tested (n = 12), and were either symptomatic or had a CD4 lymphocyte count lower than 350/μL, suggesting late-stage infections (n = 8); 12 patients were linked to care.

Conclusions Nontargeted HIV testing in EDs was feasible but identified only a few new HIV diagnoses, often at late stages, and, unexpectedly, most patients belonged to a high-risk group. Our findings do not support the implementation of nontargeted screening of the general population in EDs.

Figures in this Article

During the last 15 years, human immunodeficiency virus (HIV) screening combined with early treatment has effectively reduced HIV-related mortality, and some authors have postulated that this strategy plays a key role in controlling the epidemic.1 France has an estimated 140 000 persons living with HIV, and 7000 individuals are newly infected annually.2,3 Despite easy access to free HIV testing services and numerous HIV tests (5 million in 2009, for 65 million inhabitants), late diagnosis remains common, with one-third of HIV infections diagnosed in conjunction with AIDS or CD4 lymphocyte counts of less than 200/μL.4

To lower the number of undiagnosed infections and to improve early detection, nontargeted HIV rapid test (RT) screening in health care settings has been promoted by national health agencies in the United States, the United Kingdom, and, more recently, France.57 Studies showing that many persons who were unaware of their infection or who were diagnosed at late stages did not belong to traditional high-risk groups810 supported this strategy, as did models indicating its cost-effectiveness,11,12 but its efficacy remains controversial. Recently, a Denver, Colorado, emergency department (ED) study compared nontargeted opt-out HIV-RT screening with physician-directed diagnostic HIV-RT screening and showed the former to have modest benefit.13 However, to our knowledge, no large-scale study has yet assessed the relevance of this strategy to improve early HIV infection diagnosis in general populations, and its public health prevention benefit remains unknown.

Urban EDs represent an important health care source for the population, including low-income, uninsured, and other subgroups that might not be reached in other health care settings,14 while being at higher risk of undiagnosed HIV infection.1517 In France, because an estimated 25% of inhabitants (14 million) visit an ED annually,18 EDs appear to be an ideal setting19 to assess nontargeted HIV-RT screening of the general population. In 2009, before the French guidelines were published, we evaluated the public health impact of nontargeted HIV-RT screening among ED patients in the metropolitan Paris region (11.7 million inhabitants), where the highest number of HIV infections (263/million inhabitants) are newly diagnosed annually, ie, half of France's new HIV diagnoses.

The study was approved by Île-de-France XI Committee for Patient Protection (No. 08053, October 9, 2008) and by the Commission Nationale de l’Informatique et des Libertés (French Data-Protection Authority).

STUDY DESIGN

This interventional study was conducted in 29 EDs from May 2009 through September 2010. In each ED, the intervention lasted 6 consecutive weeks, randomly allocated. The HIV RTs were performed in EDs on a 24-hour basis, involving existing caregivers and members of the investigation team when needed.

SETTING

The 31 adult EDs selected for this study participate in the French acute syndrome surveillance network OSCOUR (Organisation de la Surveillance Coordonnée des Urgences),20 which accounts for 60% of all patients who are seen at EDs in the region21 and reflects the diversity of French ED settings. The heads of EDs who belong to the OSCOUR network were contacted personally and asked to participate by the principal investigator (A.-C.C.) and the president of the French Association of Emergency Medicine (D.P.), who was also a study investigator. Before implementing the intervention, the principal investigator arranged several meetings with the ED teams to prepare the intervention, to reinforce their motivation, and to reassure them about the possible work overload and the help provided in such cases by the epidemiological research assistant (ERA). In each hospital, a group composed of an ED physician, an ED nurse, an infectious disease physician, and a virologist was responsible for the study. A total of 29 EDs agreed to participate and completed the intervention.

STUDY POPULATION

All 18- to 64-year-old patients who were able to give written informed consent were eligible to undergo HIV RT. Exclusion criteria were self-reported HIV infection; inability to provide consent because of neuropsychiatric disorders, substance abuse, language barrier, or being under arrest; unstable medical illness; and being seen at the ED for prophylaxis after sexual exposure to HIV.

INTERVENTIONS

Before the intervention at each site, every ED team participated in a 60-minute training session, which included an educational lecture, an HIV RT demonstration, hands-on practice, and information about how to disclose test results. On ED arrival, the patients received an information sheet explaining the study. At first contact with triage nurses, eligible patients were asked if they agreed to participate in this research by undergoing HIV RT free of charge (opt-in approach). After written consent was obtained, nurses performed a rapid HIV antibody test (OraQuick Advance Rapid HIV-1/2 Antibody Test; Orasure Technologies Inc, Bethlehem, Pennsylvania). This particular test was selected because of its good performance and ease of use.22,23 Within 20 to 40 minutes, the test results were interpreted as negative, reactive, or invalid. The nurses delivered negative results to the patients before discharge and recommended repeated testing in the case of recent exposure. The HIV RT reactivity was disclosed by an emergency care physician who arranged for a follow-up visit with an on-site infectious disease specialist within the following 72 hours, and nurses drew blood for standard enzyme-linked immunosorbent assay and Western blot confirmation. For invalid test results (interpreted outside the 20- to 40-minute window or uninterpretable), the HIV RT was repeated or blood was drawn for standard enzyme-linked immunosorbent assay and Western blotting.

Patients who agreed to be tested were assigned a code linking HIV RT results to their completed, anonymous, self-administered questionnaire, which included demographics (age, sex, country of birth) and additional information such as health insurance, sexual behavior, HIV testing history, and self-perception of HIV risk (Table 1). The questionnaire was constructed to enable data comparison with the French National population census 2006, metropolitan Paris region (National Institute of Statistics and Economic Studies), and French general population surveys.24,25

Table Graphic Jump LocationTable 1. Characteristics of Patients Who Were Tested for HIV in EDs and Who Completed Questionnaires Compared With a Reference General Population

An ERA was present on site for 8 hours every day to monitor the study and, during that shift, helped the local team by offering and/or performing HIV RTs in EDs when necessary. However, HIV RTs were available and performed on a 24-hour basis by the local team in all EDs. During follow-up visits with the infectious disease specialist, after HIV infection had been confirmed, along with usual counseling, information about HIV testing history, HIV infection–related signs and symptoms, probable mode of transmission, and CD4 lymphocyte counts were recorded for comparison with the French national HIV case surveillance.4

REFUSAL-ASSOCIATED FACTORS

To determine whether HIV RT refusal might bias the study results, a complementary study was conducted to identify covariates of test refusal in 7 EDs reflecting the diversity of the 29 participating EDs (inner Paris, suburbs, and more remote areas; private and public hospitals; and low and high patient flows). An ERA recorded the reasons for refusal among all consecutive eligible patients during randomly selected 40-hour observation periods of ED activity within 5 consecutive days. Age, sex, country of birth, history of HIV testing, and perceived HIV risk were also included for comparisons with the participants' characteristics that were reported in their questionnaire.

STUDY END POINTS

The outcome measures to evaluate the public health impact of nontargeted HIV-RT screening in EDs were the number of patients tested for HIV during the study period and their characteristics vs those of the general metropolitan Paris population as well as the percentage of newly diagnosed HIV patients among those tested and their characteristics vs those from the national HIV case surveillance in the same geographic area.

DATA MANAGEMENT AND STATISTICAL ANALYSES

For each ED, we created a database that included the number of patients who were seen, patients who were eligible, tests offered and performed, and confirmed positive results collected from the ERA's and the nurses' daily records and a test register. The database was used to calculate the eligible patient acceptance, proportion of tested patients, and proportion of new HIV diagnoses. Information on all patients with reactive HIV RT results was examined by an expert panel that was composed of 2 emergency care physicians, 2 epidemiologists, 2 public health specialists, and 2 infectious disease specialists. Each 2-specialist group independently examined those data to identify the patients who were included in the study despite exclusion criteria and to determine HIV infection–associated signs and symptoms at ED consultation.

All analyses were conducted with SAS version 9.2 (SAS Institute Inc, Cary, North Carolina) and Stata version 11.0 (Stata Corp, College Station, Texas). Comparative analyses used a χ2 test or a Fisher exact test, and multivariate analyses applied logistic regressions. The descriptive analyses, conducted exclusively on the database resulting from the merger of the 29 databases obtained through the data capture of each ED's questionnaires, were restricted to the patients with an HIV RT result and a completed questionnaire. Because some variables collected were incomplete, with 0.35% to 11.1% missing values, we applied a multiple imputation method26 with chained equations27 to estimate those values and to improve descriptive accuracy using Stata user's ICE program.28 To optimize power and reproducibility, 50 multiple imputation data sets were analyzed individually and jointly to obtain overall variance estimates and confidence intervals (CIs).

SAMPLE SIZE ASSESSMENT

Using national data,29 we estimated the HIV infection prevalence in metropolitan Paris (11 million inhabitants) to 0.88%, with 0.18% undiagnosed HIV infections. As a conservative assumption, persons who were unaware of their HIV infection were considered to have the same ED use as the general population. According to American studies,3035 we expected approximately 15% of eligible patients to be tested. It was estimated that 12 000 HIV RTs were required to achieve 95% power for the estimation of the percentage of newly diagnosed HIV infections with ±0.1% precision. We used the mean number of patients who were seen at each ED per week (OSCOUR database) to calculate the number of weeks necessary to reach the number of participants needed. This calculation led us to propose the study to all 31 adult OSCOUR-network EDs in metropolitan Paris for a randomly selected, 6-week-long, field intervention in each.

Of 138 691 patients who were seen at EDs (Figure), 78 411 (56.5%) were eligible. Of those who were eligible, 20 962 (26.7%) were offered HIV RT and 13 229 (63.1%) accepted. Finally, 12 754 patients (16.3%) were tested, and descriptive analyses were applied to 11 356 who had completed questionnaires. The HIV-RT screening was performed by the ED team alone in 14 of 29 EDs and required ERA support in the other 15, with similar percentages of patients accepting for the 2 groups (62.8% vs 63.5%, respectively). However, because the ED teams working alone offered more HIV RTs (37.5% vs 19.6%, respectively), their percentage of eligible patients tested was higher (27% vs 12.5%, respectively; P < .001).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Patient flow diagram. *Patients who were excluded because they were unable to give informed consent when human immunodeficiency virus (HIV) rapid tests (RTs) were performed (ordered for diagnostic purposes by emergency department [ED] physicians).

The patients who were tested (52.2% male, 76.3% French) had a mean age of 35.8 (interquartile range [IQR], 26-45) years; 98.2% had national health insurance; two-thirds were living as a couple; 22.5% of men and 17.7% of women reported having more than 1 sexual partner during the past 12 months; 4.5% of men reported having sex with men (MSM) at least once in their lifetime; and 57.2% reported having undergone previous HIV testing, with 39.7% having been tested within the past 5 years. Overall, the population tested reflected the general population distribution of the Paris metropolitan region, with a slight overrepresentation of foreign-born persons (particularly sub-Saharan Africans), women with more than 1 sexual partner during the last 12 months, and persons who had undergone more frequent HIV screening (Table 1).

Among the 12 754 HIV RTs performed, the results of 38 were reactive, with HIV infection confirmed in 37 (0.29%; 95% CI, 0.20%-0.40%). Of the patients with confirmed HIV infection, 3 were excluded from the analyses because they had an altered state of consciousness and were tested for diagnostic purposes, irrespective of the study protocol, and 16 were excluded because they subsequently admitted being aware of their HIV positivity.

Therefore, 18 HIV infections were newly diagnosed (0.14%; 95% CI, 0.08%-0.22%) (Table 2). The mean age of the patients with newly diagnosed infections was 32.9 (IQR, 27-40) years. Of them, 12 (66.7%) reported previous HIV testing (median time since the last HIV test, 1 year), 7 (39.0%) were MSM, and 10 (55.0%) were heterosexuals from sub-Saharan Africa. Eight patients (44%) were seen at the ED for HIV-related symptoms: 7 with advanced-stage disease and 1 with HIV primo-infection; 10 infections were asymptomatic. Of those 18 patients, 6 (33.3%) did not return for their first follow-up visit, despite repeated recalls (4 women and 2 men, all born in Africa); 4 (22.2%) were hospitalized for HIV infection–related signs and symptoms; and 8 (44.4%) came to the first follow-up visit. Among the 12 patients (66.7%) linked to care, the CD4 lymphocyte counts were less than 200/μL in 5 (41.6%), 200 to 350/μL in 3 (25%), and higher than 350/μL in 4 (33.3%).

Table Graphic Jump LocationTable 2. Characteristics of the 18 Patients With New HIV Diagnoses in the ED

The proportions of newly identified HIV infections in EDs were the highest in MSM (2.61%; 95% CI, 1.06%-5.31%) and African-born heterosexuals, particularly women (1.57%; 95% CI, 0.63%-3.20%) (Table 3). The demographics of the 18 HIV-infected patients newly diagnosed in EDs and the 3008 cases involving 18- to 64-year-old individuals reported in the metropolitan Paris region by the national HIV case surveillance in 2009 were comparable (Table 4).

Table Graphic Jump LocationTable 3. Proportion of New HIV Diagnoses in EDs According to Risk Group
Table Graphic Jump LocationTable 4. Characteristics of Patients With New HIV Diagnoses in EDs or National HIV Case Surveillance

The complementary study to evaluate the covariates of HIV RT refusal involved 1404 patients who were seen at an ED. Of them, 655 (46.7%) were eligible and were offered HIV RT screening: 404 (61.7%) accepted (vs 63.1% for the whole study). Of the 251 refusers, 102 (40.7%) declined because they had been tested in the last year, 87 (34.7%) did not think that they were at risk for HIV, and 62 (24.6%) declined for other reasons, eg, not the right time or fear of the result. Age, sex, and country of birth were comparable among accepters and refusers. Refusal of HIV RT was associated with low self-perceived risk for HIV infection and having been tested previously (respective odds ratios [95% CI], 12.02 [2.60-55.58] and 2.04 [1.37-3.04]).

Although our study intervention reached a large sample (12 754) of individuals consulting at a metropolitan Paris region ED, the benefit of nontargeted screening was only modest. The prevalence of newly diagnosed infections (0.14%) was close to our initial prevalence estimate, ie, that of the general population (0.17%). However, unexpectedly, all but 1 of the 18 newly diagnosed HIV-infected patients belonged to a traditional high-risk group (MSM and persons born in a high HIV-prevalence country, namely, sub-Saharan Africa). Furthermore, most of them had late-stage disease, and one-third could not be linked to care. The major strength of this investigation is that, to our knowledge, it is the first study designed to evaluate the public health impact of nontargeted ED HIV-RT screening on such a large scale, involving an entire region of 11.7 million inhabitants, where half of the country's new HIV diagnoses are made annually.

Of the 138 691 patients who were seen at these EDs during the study, 56.5% were eligible, and 16.3% of the eligible patients were actually tested; the latter percentage is close to the percentages reported in most ED studies3035 and close to our initial hypothesis. A potential study limitation is that HIV RT refusers might be at higher risk of HIV infection than accepters. However, our subanalysis of reasons for refusal showed that most of both groups' demographics were similar, with the only covariates of refusal being low perceived risk and having previously been tested for HIV, as in other studies.36,37

One of the objectives of implementing nontargeted HIV screening in the ED is to reach a large segment of the population, including the economically underprivileged and those with poorer access to health care. Moreover, ED recruitment was expected to reach infected persons who did not belong to the main high-risk groups, ie, heterosexual men and couples, who were not targeted by specific screening programs and who are thought to rarely undergo voluntary testing. Indeed, our results showed that the ED-tested population closely resembled the general population, albeit with slight overrepresentation of sub-Saharan African–born persons. Despite the diversity of the population tested through our intervention, no HIV infection was detected among French-born heterosexuals. Their low infection incidence2 could explain this absence of unknown infections. In contrast, being an MSM and being sub-Saharan African born were associated with new ED-diagnosed HIV positivity, and their respective frequencies of unknown infection were 2.61% (95% CI, 1.06%-5.31%) and 1.12% (95% CI, 0.54%-2.08%), values consistent with data reported by the national HIV case surveillance.

Pertinently, new ED-detected infections were not found at earlier stages, compared with those reported by national HIV case surveillance. Most were already at late stages, as in the US study,13 which can partly be explained by the fact that HIV infection–related symptoms prompted 8 patients' ED visits. However, the unavailability of CD4 lymphocyte counts for 6 patients who were unavailable for follow-up limits the strength of this finding. Finally, one-third of new diagnoses, mainly involving patients from sub-Saharan Africa, could not be linked to further care, despite the on-site availability of follow-up and several ERA's attempts at contact. This issue must be considered when evaluating the benefit of proposing nontargeted HIV screening in health care settings. Our entry-into-care rate is in the lower range of such rates observed in the United States, where the average was 76% (95% CI, 66%-84%) after an HIV-positive test result in an ED, which is slightly above the average of 67% (95% CI, 54%-70%) when testing took place in community locations.38

To our knowledge, our study is the first to measure unknown HIV infection prevalence in a large sample of the French general population. Our 0.14% prevalence is close to the percentages reported by some EDs in low HIV-prevalence countries.13,37 Nontargeted HIV screening was cost-effective in the United States, even when the unknown infection prevalence was as low as 0.1%.11 Applying a French-adapted model12 to our results showed that ED nontargeted HIV-RT screening was at the lower limit of cost-effectiveness. Considering that 8 of 18 persons who were seen for HIV-related symptoms could have been tested for diagnostic purposes or that at least the 4 admitted patients would have been tested during their hospitalizations, this strategy falls below that limit. An ED-based screening strategy limited to men 18-to-45 years old and African-born persons would have identified all new HIV infections for 50% fewer HIV RTs than were actually performed and thus would have enhanced cost-effectiveness. Another way to heighten ED HIV-RT screening effectiveness would be to limit HIV testing to EDs with the highest HIV prevalences and/or located in areas with high-risk populations. Such a frequency-based screening policy, first recommended by the Centers for Disease Control and Prevention in 1993, is difficult to apply because accurate local estimates are not readily available.5

Our study did not compare nontargeted HIV-RT screening with diagnostic testing. In France, HIV testing is rarely performed in EDs, as symptomatic patients are hospitalized or referred for specialized consultations and HIV testing. The modest public health impact of nontargeted HIV screening demonstrated herein applies to EDs and could be different in other health care settings, eg, acute care, primary care center,37 or general practice, where patients present with less severe disease, potentially at earlier stages. However, considering that a substantial segment of the general population visits EDs for a wide range of medical conditions and all grades of disease severity, we think that the main conclusions of our study, concerning the absence of a hidden epidemic in a low-risk population and the low efficiency of nontargeted HIV-RT screening, would have been maintained. Finally, despite some similarity to some data obtained in other low-prevalence countries, eg, the United States and the United Kingdom, our results cannot be extrapolated to other countries. Nonetheless, they clearly highlight the need for additional studies on this new strategy's effectiveness in those countries, where health authorities have recommended nontargeted screening.

In conclusion, ED-based HIV RT screening is feasible and can reach large numbers of patients. However, unexpectedly, nontargeted screening identified only a few new diagnoses, often already at late stages, and most newly diagnosed patients belonged to a high-risk group and had been tested previously. Therefore, our observations do not support the implementation of nontargeted HIV screening of the general population in EDs.

Correspondence: Anne-Claude Crémieux, MD, PhD, Département de Médecine Aiguë et Spécialisée, Hôpital Raymond-Poincaré, 104 Boulevard Raymond-Poincaré, 93380 Garches, France (anne-claude.cremieux@rpc.aphp.fr).

Accepted for Publication: August 28, 2011.

Published Online: October 24, 2011. doi:10.1001/archinternmed.2011.535

Author Contributions: Dr d’Almeida had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design: Kierzek, de Truchis, Le Vu, Pateron, Renaud, Semaille, Simon, Guillemot, Lert, and Crémieux. Acquisition of data: d’Almeida, Lert, and Crémieux. Analysis and interpretation of data: d’Almeida, de Truchis, Le Vu, Semaille, Bousquet, Guillemot, Lert, and Crémieux. Drafting of the manuscript: d’Almeida, Le Vu, Lert, and Crémieux. Critical revision of the manuscript for important intellectual content: d’Almeida, Kierzek, de Truchis, Le Vu, Pateron, Renaud, Semaille, Bousquet, Simon, Guillemot, Lert, and Crémieux. Statistical analysis: d’Almeida, Le Vu, Semaille, Bousquet, Guillemot, and Lert. Obtained funding: Lert and Crémieux. Administrative, technical or material support: Lert, and Crémieux. Study supervision: d’Almeida, Lert, and Crémieux.

Members of the Emergency Department HIV-Screening Group (in alphabetical order by hospital name [all in France]): D. Elkharrat (Hôpital Ambroise-Paré, Boulogne); C. Jordy (Hôpital André-Mignot, Le Chesnay); M. Andronikof (Hôpital Antoine-Béclère, Clamart); D. Brun Ney (AP-HP, Paris); F. Adnet, B. Bernot (Hôpital Avicenne, Bobigny); S. Beaune, L. Bucchini, P. Juvin (Hôpital Beaujon, Clichy); J. Depret-Vassal (Hôpital de Bicêtre, Le Kremlin–Bicêtre); E. Casalino (Hôpital Bichat–Claude-Bernard, Paris); Y. E. Claessens, A. Dabreteau, C. Ginsburg (Hôpital Cochin, Paris); J. P. Bal Dit Solier, S. Lehbil (Centre Hospitalier Intercommunal de Créteil, Créteil); F. Compagnon (Hôpital de Coulommiers, Coulommiers); V. Jumel (Hôpital de la Croix–Saint-Simon, Paris); M. Prevel (Hôpital Delafontaine, Saint-Denis); L. Debastard (Clinique des Franciscaines, Versailles); J. L. Sebbah (Centre Hospitalier de Gonesse, Gonesse); B. Renaud, A. Santin (Hôpital Henri-Mondor, Créteil); G. Kierzek, J. L. Pourriat (Hôtel-Dieu, Paris); C. Chassaignon (Hôpital Jean-Verdier, Bondy); B. Galichon, P. Plaisance (Hôpital Lariboisière, Paris); P. Brun, C. Leroy (Hôpital Louis-Mourier, Colombes); S. Bendaoud, K. E. Hamdi (Hôpital Marc-Jacquet, Melun); B. Coudert, C. Michel (Centre Hospitalier Intercommunal de Meulan–Les Mureaux, Meulan–Les Mureaux); F. Thievet (Hôpital Privé de l’Ouest Parisien, Trappes); A. Afdjei (Centre Médico-Chirurgical de Parly 2, Le Chesnay); J. Chahuneau, N. Simon (Centre Hospitalier Intercommunal de Poissy Saint-Germain-en-Laye, Poissy–Saint Germain-en-Laye); C. Quilliec (Hôpital Privé d’Antony, Antony); D. Pateron, C. Lejeune (Hôpital Saint-Antoine, Paris); S. Dautheville, C. Vincent-Cassy, E. Hinglais (Hôpital Tenon, Paris); and C. Le Gall (Hôpital Victor-Dupouy, Argenteuil).

Financial Disclosure: Dr de Truchis reported receiving financial support from Abbott, BMS, Gilead, MSD, Tibotec Janssen, and ViiV Healthcare for workshops and for travel to meetings and accommodations.

Funding/Support: This study was funded by grants from ANRS (Agence Nationale de Recherche sur le Sida et les Hépatites Virales) and Sidaction, Paris, France. Rapid tests were provided free of charge from Orasure Technologies Inc, Bethlehem, Pennsylvania.

Role of the Sponsor: The funding organizations had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Previous Presentations: The results of this study were presented at the Sixth IAS Conference on HIV Pathogenesis, Treatment, and Prevention; July 17-20, 2011; Rome, Italy. The poster MOPE299 was presented July 18, 2011.

Additional Contributions: We thank the monitoring team: Fanny Abate, Sonia Dogbe, Judith Leblanc, Sylvie Mas, Sophie Padolus, and Olivia Zanatta; the OSCOUR coordinators (affiliation [all in France]): Nadège Caillère, Loïc Josseran (Institut de Veille Sanitaire, St Maurice); and the infectious disease and virology specialists: E. Rouveix, E. Gault (Hôpital Ambroise-Paré, Boulogne); A. Greder-Bellan, J. Marque-Juillet (Hôpital André-Mignot, Le Chesnay); F. Boue, V. Martinez, M. Guillet, C. Vauloup (Hôpital Antoine-Béclère, Clamart); O. Bouchaud, C. Alloui (Hôpital Avicenne, Bobigny); A. Uludag (Hôpital Beaujon, Clichy); J. F. Delfraissy, J. Ghosn, C. Goujard, A. Mazet, C. Pallier (Hôpital de Bicêtre, Le Kremlin–Bicêtre); C. Rioux, F. Damond (Hôpital Bichat–Claude-Bernard, Paris); D. Salmon, A. Krivine (Cochin, Paris); V. Garrait, E. Estrangin (Centre Hospitalier Intercommunal de Créteil, Créteil); M. Gatfossé (Hôpital de Coulommiers, Coulommiers); V. Zeller (Hôpital de la Croix–Saint Simon, Paris); M. A. Khuong, C. Chaplain (Hôpital Delafontaine, Saint Denis); D. Le Du (Clinique des Franciscaines, Versailles); D. Troisvallets, E. Vandemeulebroucke (Hôpital de Gonesse, Gonesse); A. S. Lascaux, Y. Levy, M. Bouvier, D. Challine (Hôpital Henri-Mondor, Créteil); E. Aslangul, J. Loubinoux (Hôtel-Dieu, Paris); V. Jeantils, I. Poilane (Hôpital Jean-Verdier, Bondy); V. Delcey, P. Sellier, M. C. Mazeron (Hôpital Lariboisière, Paris); E. Mortier, H. Ichou (Hôpital Louis-Mourier, Colombes); A. I. Brière, A. Kara (Hôpital Marc-Jacquet, Melun); T. Akpan, J. Clarissou, M. Laforge (Hôpital de Meulan–les Mureaux, Meulan–les Mureaux); G. Courdesse, J. Guittet (Hôpital Privé de l’Ouest Parisien, Trappes); A. Dinh (Centre Medico-Chirurgical de Parly 2, Le Chesnay); H. Masson, Y. Welker, E. Vallée (Hôpital de Poissy Saint-Germain-en-Laye, Poissy–Saint-Germain-en-Laye); P. Bossi, Y. Marsault (Hôpital Privé d’Antony, Antony); P. M. Girard, N. Valin, N. Harchi, L. Morand-Joubert (Hôpital Saint-Antoine, Paris); P. Bonnard, G. Pialoux, C. Amiel, H. Assami, C. Le Pendeven (Hôpital Tenon, Paris); and P. Genet, L. Courdavault (Hôpital Victor-Dupouy, Argenteuil).

 Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach, 2010 revision. World Health Organization Web site. http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf. Accessed March 24, 2011
Le Vu S, Le Strat Y, Barin F,  et al.  Population-based HIV-1 incidence in France, 2003-08: a modelling analysis.  Lancet Infect Dis. 2010;10(10):682-687
PubMed   |  Link to Article
 Epidemiological fact sheet on HIV and AIDS: core data on epidemiology and response. http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_FR.pdf. World Health Organization Web site. Accessed January 12, 2011
Cazein F, Lot F, Pillonel J,  et al.  Surveillance de l’infection à VIH-Sida en France, 2009.  Bull Epidemiol Hebd. 2010;(45-46):467-472
Branson BM, Handsfield HH, Lampe MA,  et al; Centers for Disease Control and Prevention (CDC).  Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.  MMWR Recomm Rep. 2006;55(RR-14):1-17, CE1-CE4
PubMed
 Time to test for HIV: expanded healthcare and community HIV testing in England. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1287145497243. Health Protection Agency Web site. Accessed January 12, 2011
 Plan national de lutte contre le VIH-sida et les IST 2010-2014, November 4, 2010. Ministère du travail, de l'emploi et de la santé Web site. http://www.sante.gouv.fr/IMG/pdf/plan_national_lutte_contre_le_VIH-SIDA_et_les_IST_2010-2014.pdf. Accessed September 12, 2011
Delpierre C, Dray-Spira R, Cuzin L,  et al; VESPA Study Group.  Correlates of late HIV diagnosis: implications for testing policy.  Int J STD AIDS. 2007;18(5):312-317
PubMed   |  Link to Article
Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis in France.  BMJ. 2007;334(7608):1354-1356
PubMed   |  Link to Article
Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006.  J Acquir Immune Defic Syndr. 2010;53(5):619-624
PubMed
Paltiel AD, Weinstein MC, Kimmel AD,  et al.  Expanded screening for HIV in the United States--an analysis of cost-effectiveness.  N Engl J Med. 2005;352(6):586-595
PubMed   |  Link to Article
Yazdanpanah Y, Sloan CE, Charlois-Ou C,  et al.  Routine HIV screening in France: clinical impact and cost-effectiveness.  PLoS One. 2010;5(10):e13132
PubMed   |  Link to Article
Haukoos JS, Hopkins E, Conroy AA,  et al; Denver Emergency Department HIV Opt-Out Study Group.  Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients.  JAMA. 2010;304(3):284-292
PubMed   |  Link to Article
Ullman R, Block JA, Stratmann WC. An emergency room's patients: their characteristics and utilization of hospital services.  Med Care. 1975;13(12):1011-1020
PubMed   |  Link to Article
Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department–based screening programs for HIV infection.  Clin Infect Dis. 1995;21(4):867-875
PubMed   |  Link to Article
Goggin MA, Davidson AJ, Cantril SV, O’Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program.  J Emerg Med. 2000;19(1):13-19
PubMed   |  Link to Article
Trotter AB, Bhayani N, Florsheim R, Novak RM. Implementing universal oral HIV screening in an urban emergency department-do demographic characteristics impact acceptance of testing?  Clin Infect Dis. 2010;50(2):283
PubMed   |  Link to Article
Carrasco V. L’activité des services d’urgences en 2004,une stabilisation du nombre de passages: études et résultats: 2006. Ministère du travail, de l'emploi et de la santé Web site. http://www.sante.gouv.fr/IMG/pdf/er524.pdf. Accessed September 12, 2011
Torres M. Rapid HIV screening in the emergency department.  Emerg Med Clin North Am. 2010;28(2):369-380
PubMed   |  Link to Article
Josseran L, Nicolau J, Caillère N, Astagneau P, Brücker G. Syndromic surveillance based on emergency department activity and crude mortality: two examples.  Euro Surveill. 2006;11(12):225-229
PubMed
 Site de diffusion des données de la statistique annuelle des établissements de santé. Statistiques Annuelles des Établissements de Santé Web site. http://www.sae-diffusion.sante.gouv.fr/Collecte_2009/dwd_dwsgen3.aspx. Accessed February 7, 2011
Wesolowski LG, MacKellar DA, Facente SN,  et al; Post-marketing Surveillance Team.  Post-marketing surveillance of OraQuick whole blood and oral fluid rapid HIV testing.  AIDS. 2006;20(12):1661-1666
PubMed   |  Link to Article
Donovan BJ, Rublein JC, Leone PA, Pilcher CD. HIV infection: point-of-care testing.  Ann Pharmacother. 2004;38(4):670-676
PubMed   |  Link to Article
Observatoire Régional de Santé d’Île-de-France.  Les connaissances, attitudes, croyances et comportements face au VIH-sida en France 1992-2004. http://www.ors-idf.org. 2005
Beltzer N, Wu-Zhou X, Vongmany N, Gremy I. Les connaissances, attitudes, croyances et comportements face au VIH-sida en France 1992-2004: November 2005. Observatoire Régionale de Santé d'Ile-de-France Web site. http://www.ors-idf.org/dmdocuments/Rapport_KABP_IDF_2004.pdf. Accessed September 12, 2011
Rubin DB. Multiple imputation after 18+ years.  J Am Stat Assoc J. 1996;91(434):473-489
van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification.  Stat Methods Med Res. 2007;16(3):219-242
PubMed   |  Link to Article
Royston P. Multiple imputation of missing values: further update of ICE, with an emphasis on categorical variables.  Stata J. 2009;9(3):466-477
 Lutte contre le VIH-sida et les infections sexuellement transmissibles en France 10 ans de surveillance 1996-2005: 2007. Institut de Veille Sanitaire Web site. http://www.invs.sante.fr/publications/2007/10ans_VIH/rapport_vih_sida_10ans.pdf. Accessed September 12, 2011
White DA, Scribner AN, Schulden JD, Branson BM, Heffelfinger JD. Results of a rapid HIV screening and diagnostic testing program in an urban emergency department.  Ann Emerg Med. 2009;54(1):56-64
PubMed   |  Link to Article
Brown J, Shesser R, Simon G,  et al.  Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention Guidelines: results from a high-prevalence area.  J Acquir Immune Defic Syndr. 2007;46(4):395-401
PubMed   |  Link to Article
Christopoulos KA, Schackman BR, Lee G, Green RA, Morrison EA. Results from a New York City emergency department rapid HIV testing program.  J Acquir Immune Defic Syndr. 2010;53(3):420-422
PubMed   |  Link to Article
Calderon Y, Leider J, Hailpern S,  et al.  High-volume rapid HIV testing in an urban emergency department.  AIDS Patient Care STDS. 2009;23(9):749-755
PubMed   |  Link to Article
Ehrenkranz PD, Ahn CJ, Metlay JP, Camargo CA Jr, Holmes WC, Rothman R. Availability of rapid human immunodeficiency virus testing in academic emergency departments.  Acad Emerg Med. 2008;15(2):144-150
PubMed   |  Link to Article
Kelen GD, Rothman RE. Emergency department-based HIV testing: too little, but not too late.  Ann Emerg Med. 2009;54(1):65-71
PubMed   |  Link to Article
Pisculli ML, Reichmann WM, Losina E,  et al.  Factors associated with refusal of rapid HIV testing in an emergency department.  AIDS Behav. 2011;15(4):734-742
PubMed   |  Link to Article
Rayment M, Thornton A, Mandalia S,  et al.  HIV testing in non-traditional settings: the HINTS study. Poster session presented at the 18th International AIDS Conference; July 18-23, 2010; Vienna, Austria
Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis.  AIDS. 2010;24(17):2665-2678
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Patient flow diagram. *Patients who were excluded because they were unable to give informed consent when human immunodeficiency virus (HIV) rapid tests (RTs) were performed (ordered for diagnostic purposes by emergency department [ED] physicians).

Tables

Table Graphic Jump LocationTable 1. Characteristics of Patients Who Were Tested for HIV in EDs and Who Completed Questionnaires Compared With a Reference General Population
Table Graphic Jump LocationTable 2. Characteristics of the 18 Patients With New HIV Diagnoses in the ED
Table Graphic Jump LocationTable 3. Proportion of New HIV Diagnoses in EDs According to Risk Group
Table Graphic Jump LocationTable 4. Characteristics of Patients With New HIV Diagnoses in EDs or National HIV Case Surveillance

References

 Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach, 2010 revision. World Health Organization Web site. http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf. Accessed March 24, 2011
Le Vu S, Le Strat Y, Barin F,  et al.  Population-based HIV-1 incidence in France, 2003-08: a modelling analysis.  Lancet Infect Dis. 2010;10(10):682-687
PubMed   |  Link to Article
 Epidemiological fact sheet on HIV and AIDS: core data on epidemiology and response. http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_FR.pdf. World Health Organization Web site. Accessed January 12, 2011
Cazein F, Lot F, Pillonel J,  et al.  Surveillance de l’infection à VIH-Sida en France, 2009.  Bull Epidemiol Hebd. 2010;(45-46):467-472
Branson BM, Handsfield HH, Lampe MA,  et al; Centers for Disease Control and Prevention (CDC).  Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.  MMWR Recomm Rep. 2006;55(RR-14):1-17, CE1-CE4
PubMed
 Time to test for HIV: expanded healthcare and community HIV testing in England. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1287145497243. Health Protection Agency Web site. Accessed January 12, 2011
 Plan national de lutte contre le VIH-sida et les IST 2010-2014, November 4, 2010. Ministère du travail, de l'emploi et de la santé Web site. http://www.sante.gouv.fr/IMG/pdf/plan_national_lutte_contre_le_VIH-SIDA_et_les_IST_2010-2014.pdf. Accessed September 12, 2011
Delpierre C, Dray-Spira R, Cuzin L,  et al; VESPA Study Group.  Correlates of late HIV diagnosis: implications for testing policy.  Int J STD AIDS. 2007;18(5):312-317
PubMed   |  Link to Article
Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis in France.  BMJ. 2007;334(7608):1354-1356
PubMed   |  Link to Article
Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006.  J Acquir Immune Defic Syndr. 2010;53(5):619-624
PubMed
Paltiel AD, Weinstein MC, Kimmel AD,  et al.  Expanded screening for HIV in the United States--an analysis of cost-effectiveness.  N Engl J Med. 2005;352(6):586-595
PubMed   |  Link to Article
Yazdanpanah Y, Sloan CE, Charlois-Ou C,  et al.  Routine HIV screening in France: clinical impact and cost-effectiveness.  PLoS One. 2010;5(10):e13132
PubMed   |  Link to Article
Haukoos JS, Hopkins E, Conroy AA,  et al; Denver Emergency Department HIV Opt-Out Study Group.  Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients.  JAMA. 2010;304(3):284-292
PubMed   |  Link to Article
Ullman R, Block JA, Stratmann WC. An emergency room's patients: their characteristics and utilization of hospital services.  Med Care. 1975;13(12):1011-1020
PubMed   |  Link to Article
Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department–based screening programs for HIV infection.  Clin Infect Dis. 1995;21(4):867-875
PubMed   |  Link to Article
Goggin MA, Davidson AJ, Cantril SV, O’Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program.  J Emerg Med. 2000;19(1):13-19
PubMed   |  Link to Article
Trotter AB, Bhayani N, Florsheim R, Novak RM. Implementing universal oral HIV screening in an urban emergency department-do demographic characteristics impact acceptance of testing?  Clin Infect Dis. 2010;50(2):283
PubMed   |  Link to Article
Carrasco V. L’activité des services d’urgences en 2004,une stabilisation du nombre de passages: études et résultats: 2006. Ministère du travail, de l'emploi et de la santé Web site. http://www.sante.gouv.fr/IMG/pdf/er524.pdf. Accessed September 12, 2011
Torres M. Rapid HIV screening in the emergency department.  Emerg Med Clin North Am. 2010;28(2):369-380
PubMed   |  Link to Article
Josseran L, Nicolau J, Caillère N, Astagneau P, Brücker G. Syndromic surveillance based on emergency department activity and crude mortality: two examples.  Euro Surveill. 2006;11(12):225-229
PubMed
 Site de diffusion des données de la statistique annuelle des établissements de santé. Statistiques Annuelles des Établissements de Santé Web site. http://www.sae-diffusion.sante.gouv.fr/Collecte_2009/dwd_dwsgen3.aspx. Accessed February 7, 2011
Wesolowski LG, MacKellar DA, Facente SN,  et al; Post-marketing Surveillance Team.  Post-marketing surveillance of OraQuick whole blood and oral fluid rapid HIV testing.  AIDS. 2006;20(12):1661-1666
PubMed   |  Link to Article
Donovan BJ, Rublein JC, Leone PA, Pilcher CD. HIV infection: point-of-care testing.  Ann Pharmacother. 2004;38(4):670-676
PubMed   |  Link to Article
Observatoire Régional de Santé d’Île-de-France.  Les connaissances, attitudes, croyances et comportements face au VIH-sida en France 1992-2004. http://www.ors-idf.org. 2005
Beltzer N, Wu-Zhou X, Vongmany N, Gremy I. Les connaissances, attitudes, croyances et comportements face au VIH-sida en France 1992-2004: November 2005. Observatoire Régionale de Santé d'Ile-de-France Web site. http://www.ors-idf.org/dmdocuments/Rapport_KABP_IDF_2004.pdf. Accessed September 12, 2011
Rubin DB. Multiple imputation after 18+ years.  J Am Stat Assoc J. 1996;91(434):473-489
van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification.  Stat Methods Med Res. 2007;16(3):219-242
PubMed   |  Link to Article
Royston P. Multiple imputation of missing values: further update of ICE, with an emphasis on categorical variables.  Stata J. 2009;9(3):466-477
 Lutte contre le VIH-sida et les infections sexuellement transmissibles en France 10 ans de surveillance 1996-2005: 2007. Institut de Veille Sanitaire Web site. http://www.invs.sante.fr/publications/2007/10ans_VIH/rapport_vih_sida_10ans.pdf. Accessed September 12, 2011
White DA, Scribner AN, Schulden JD, Branson BM, Heffelfinger JD. Results of a rapid HIV screening and diagnostic testing program in an urban emergency department.  Ann Emerg Med. 2009;54(1):56-64
PubMed   |  Link to Article
Brown J, Shesser R, Simon G,  et al.  Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention Guidelines: results from a high-prevalence area.  J Acquir Immune Defic Syndr. 2007;46(4):395-401
PubMed   |  Link to Article
Christopoulos KA, Schackman BR, Lee G, Green RA, Morrison EA. Results from a New York City emergency department rapid HIV testing program.  J Acquir Immune Defic Syndr. 2010;53(3):420-422
PubMed   |  Link to Article
Calderon Y, Leider J, Hailpern S,  et al.  High-volume rapid HIV testing in an urban emergency department.  AIDS Patient Care STDS. 2009;23(9):749-755
PubMed   |  Link to Article
Ehrenkranz PD, Ahn CJ, Metlay JP, Camargo CA Jr, Holmes WC, Rothman R. Availability of rapid human immunodeficiency virus testing in academic emergency departments.  Acad Emerg Med. 2008;15(2):144-150
PubMed   |  Link to Article
Kelen GD, Rothman RE. Emergency department-based HIV testing: too little, but not too late.  Ann Emerg Med. 2009;54(1):65-71
PubMed   |  Link to Article
Pisculli ML, Reichmann WM, Losina E,  et al.  Factors associated with refusal of rapid HIV testing in an emergency department.  AIDS Behav. 2011;15(4):734-742
PubMed   |  Link to Article
Rayment M, Thornton A, Mandalia S,  et al.  HIV testing in non-traditional settings: the HINTS study. Poster session presented at the 18th International AIDS Conference; July 18-23, 2010; Vienna, Austria
Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis.  AIDS. 2010;24(17):2665-2678
PubMed   |  Link to Article

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