Transcript A Cost-Effectiveness Evaluation of Two Jail

A Cost-Effectiveness Evaluation of the
Sexually Transmitted Disease (STD)
Prevention Program at the Hampden County
Correctional Center, Massachusetts
Gift T1, Conklin T2, Lincoln T2, Miller A3, Tuthill R3,
Whelan M4, Irwin K1
1Centers
for Disease Control and Prevention, Atlanta, GA; 2Hampden County
Correctional Center, Ludlow, MA; 3University of Massachusetts-Amherst,
Amherst, MA; 4 Massachusetts Department of Public Health
Background
• Inmates in correctional institutions are an important
population for STD prevention
– Inmates’ sex partners also frequently have high STD rates
• STD testing and treatment programs must often
compete with other correctional healthcare programs
• Cost-effectiveness evaluation is a tool that can:
– guide resource allocation decisions
– quantify the impact of correctional STD testing programs on
community health
Background-2
• Hampden County Correctional Center (HCCC)
STD Program:
– Intake screening for chlamydia
• Leukocyte esterase test (LET)
• Nucleic acid amplification test (NAAT; LCx®, Abbott
Laboratories)
– Gonorrhea testing
• Performed if symptoms, risk factors, or LET results warrant
• Nucleic acid probe test (probe; Gen-Probe PACE® 2 GC; GenProbe, Inc.)
Objective
• Determine the cost and cost-effectiveness of
universal vs. targeted screening for chlamydia and
gonorrhea in male inmates at intake
Methods-Data Sources
• Test Data
– Test results provided by Massachusetts Dept. of Public
Health (MDPH)
– Test performance parameters:
• NAAT for chlamydia, probe for gonorrhea: literature estimates
• LET: MDPH
• Costs
– Labor costs: time-motion studies at HCCC
• Partner services costs: literature estimates
– Testing, treatment, overhead, and supply costs: HCCC
– Sequelae costs (epididymitis, PID): literature estimates
Methods-Data Sources (Cont.)
• Partner Data
– Estimates of partner data provided by MDPH and HCCC
• Data collection is proceeding
• Literature estimates used for costs
• Inmate Data
– Demographics, symptoms, risk factors collected by HCCC
and reported by MDPH for first quarter, 2001
Methods-Program Alternatives
• Four program alternatives were modeled:
• 1) Present Practice
– Screen all males for chlamydia with LET and NAAT
– Offer probe test for gonorrhea if:
– Inmate is symptomatic, discloses risk factors, or LET is positive
• 2) Age-based testing (Under 25 years of age)
– Same as present practice for inmates < 25 years of age
– symptom-based testing for inmates over the age cutoff
• 3) Age-based testing (Under 30 years of age)
– Same as (2) except upper age cutoff is 30
• 4) Symptom-based testing only
– Only test inmates (all ages) who present with symptoms for
chlamydia and gonorrhea
Descriptive Statistics
Variable
Mean
St. Dev. Data Source
Chlamydia prevalence
Under 25 only
Under 30 only
25 or older only
30 or older only
Gonorrhea prevalence
Proportion < 25 years
Proportion < 30 years
Proportion w/ symptoms
Proportion w/ risk factors
Sex partners per male
Probability sex partner of
infected male is infected
0.054
0.139
0.118
0.017
0.005
0.015
0.340
0.505
0.008
0.131
1.7
0.67
0.012
0.027
0.022
0.024
0.005
N/A
0.025
0.025
0.005
0.017
N/A
N/A
MDPH
MDPH
MDPH
MDPH
MDPH
Modeling, literature est.
MDPH, HCCC
MDPH, HCCC
MDPH
MDPH
Literature-based estimate
Literature-based estimate
Male Inmates and Male Inmates with
Chlamydia: Age Breakdowns
2%
 30
23%
34%
 30
< 25
25-29
49%
< 25
25-29
75%
17%
Male Inmates
(n = 394)
Male Inmates with
Chlamydia (n = 24)
Results
• Data shown are for 1000 male inmates with
the prevalences shown in the descriptive
statistics table
• All costs in 2001 dollars
Results
CT/GC Program
Alternative
Symptom-based testing
Age-based screening (25)
Age-based screening (30)
Present practice*
*Eliminating
Program
Cost
$1220
9110
12,500
24,880
Cases CT/GC Incremental Cost
Treated
Effectiveness
6.2
33.8
$ 286
40.0
547
43.9
3174
the LET and relying only on the NAAT would reduce
program costs by $2520. The cases of CT/GC treated would be 42.2
Results
Program Alternative
Healthcare Cases of PID
system cost Averted
Symptom-based testing
$22,550
0.29
Age-based screening (25)
30,530
1.69
Age-based screening (30)
34,620
1.98
Present practice
46,640
1.99
*Eliminating
the LET and relying only on the NAAT would reduce healthcare
system cost by $2520. The cases of PID averted would be 1.99
Limitations
• Some data taken from literature:
– Partner services cost and effectiveness
– Cases of PID in partners
– Cases of gonorrhea in male inmates
• Age-based prevalence of chlamydia and gonorrhea may
not be constant across time
• Chlamydia program benefits not included:
– reduction in HIV transmission due to treated chlamydial
infections
– increased HIV counseling and testing opportunities resulting
from STD diagnoses
Conclusions
• Chlamydia and gonorrhea screening:
– can detect and treat a high proportion of both
infections among male inmates
– is more effective than restricting testing to
symptomatic inmates only
– may lead to the detection and treatment of PID
in their female sex partners
• Age-based screening has the potential to
reduce program costs with little loss in
effectiveness.