Electronic Directly Observed Therapy for TB

State: WA Type: Model Practice Year: 2014

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Clark County Public Health (CCPH) is an LHD in southwest Washington State that serves a population of approximately 425,000 residents and follows an average of 12 active tuberculosis patients a year. Directly observed therapy (DOT) is the standard of care to monitor tuberculosis treatment in the US but due to the extended length of treatment, cost, practical difficulties, and lack of patient acceptability there are significant barriers to successful treatment. CCPH has piloted the use of computer software to electronically observe therapy with the goal of making DOT less burdensome for patients and maintaining the high level of treatment adherence required for successful treatment while saving the tuberculosis program money.Since 2009 CCPH has allowed non-multiple drug-resistant tuberculosis patients without adherence concerns in the initiation phase of treatment to electronically monitor doses using computer software during the continuation phase of treatment. Patients have the option of using either real-time or electronically recorded DOT. In an electronic real-time DOT, the patient takes the medication in the virtual presence of tuberculosis program staff. In an electronically recorded DOT, the patient states the date, displays the medication, and then records themselves ingesting doses. The patient then uploads the recording to CCPH via secure file transfer. The recording is date and time stamped for verification. Those patients performing electronic DOT are managed in the same manner as those using in-person DOT. Patients discontinue electronic DOT if there are concerns about adherence, the medication is not tolerated, or by patient choice.

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Clark County Public Health
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Electronic Directly Observed Therapy for TB
Clark County Public Health (CCPH) is an LHD in southwest Washington State that serves a population of approximately 425,000 residents and follows an average of 12 active tuberculosis patients a year. Directly observed therapy (DOT) is the standard of care to monitor tuberculosis treatment in the US but due to the extended length of treatment, cost, practical difficulties, and lack of patient acceptability there are significant barriers to successful treatment. CCPH has piloted the use of computer software to electronically observe therapy with the goal of making DOT less burdensome for patients and maintaining the high level of treatment adherence required for successful treatment while saving the tuberculosis program money.Since 2009 CCPH has allowed non-multiple drug-resistant tuberculosis patients without adherence concerns in the initiation phase of treatment to electronically monitor doses using computer software during the continuation phase of treatment. Patients have the option of using either real-time or electronically recorded DOT. In an electronic real-time DOT, the patient takes the medication in the virtual presence of tuberculosis program staff. In an electronically recorded DOT, the patient states the date, displays the medication, and then records themselves ingesting doses. The patient then uploads the recording to CCPH via secure file transfer. The recording is date and time stamped for verification. Those patients performing electronic DOT are managed in the same manner as those using in-person DOT. Patients discontinue electronic DOT if there are concerns about adherence, the medication is not tolerated, or by patient choice. Since 2009, 12 of the 52 active tuberculosis cases seen by CCPH have used electronic DOT at least once. Those using electronic DOT were more likely to be male and younger than those doing in-person DOT. All of those using electronic DOT completed treatment and had a similar rate of hospitalization, treatment interruption, and treatment restarts as those using in-person DOT. Overall, 1016 doses were observed using electronic DOT, while 39 doses (3.8%) were missed and added to the end of treatment compared to 67 missed doses out of 2696 counted doses (2.4%) for in-person DOT. In binomial mixed effects regression analysis adjusting for age, electronic DOT doses were no more likely to be missed than in-person DOT (OR: 1.74, 95%CI: 0.76-4.01). When real-time and recorded DOT are considered separately, real-time electronic DOT doses were more likely to be missed than in-person DOT doses (OR: 11.12, 95%CI: 2.94-42.11). Recorded electronic DOT doses were similarly more likely to be missed than in-person doses (OR: 0.79, 95%CI: 0.47-1.35). Cost savings were found through reductions in time observing doses, travel time, and travel mileage. An in-person dose was estimated to take 10 minutes while an electronic dose took an estimated 5 minutes. Using 2012 records, CCPH estimated the average travel time to patients’ homes was 10 minutes. We calculated the travel distance saved using Google Maps as 27,915 miles. Using these numbers, the average cost of a community health worker or medical assistant ($30.21 per hour), and the federal reimbursement rate of $0.565 per mile we calculate CCPH saved $12,789 in staff time and $15,771 in mileage. The total savings of $28,561 represents a savings of $28.11 a dose. In addition to being equally effective and cost-saving, electronic DOT had additional benefits. Patients were broadly appreciative and receptive to electronic DOT as they could fit DOT around their lives. As tuberculosis medications can cause fatigue and other minor side effects, some patients chose to take their doses in the evening, outside of business hours. From the LHD perspective, recorded e-DOT was useful in increasing staff flexibility. Staff were not required to schedule DOT for video-recorded doses as they could watch the recording at their convenience. Further, staff could easily manage out-of-jurisdiction travel or treatment during inclement weather, as treatment could continue uninterrupted no matter where or how inaccessible the patient was. Unlike other studies using videophones, technological problems were rare and screen resolution was improved. Although our eligibility criteria likely selected those with higher socio-economic status, the cost savings are significant enough that many local health jurisdictions could provide low-income patients netbooks, tablet computers, smart phones or other means to record electronic DOT, while still saving money compared to in-person DOT.The decreasing cost of high quality technology, our tuberculosis patients advocating electronic DOT, and the support of LHD leadership were essential factors that led to the success of this practice. Electronic recording of DOT has the potential to reduce the significant burden placed on patients and on LHDs by DOT while also reducing costs.
Clark County Public Health (CCPH) is an LHD in southwest Washington that serves a population of approximately 425,000 residents. When compared with the state and nation, Clark County’s population is less diverse in terms of race and ethnicity, although it has significant immigrant populations from Asia, Eastern Europe, and Central America, areas of the world with a high burden of tuberculosis. CCPH sees an average of 12 active tuberculosis cases, slightly lower than the Washington rate, but above the Healthy People 2020 goal of 1.0 new cases per 100,000 population.Despite the widespread availability of affordable and effective treatment, tuberculosis remains a major cause of serious illness and death. One barrier to tuberculosis control is that treatment of tuberculosis requires patients to take multiple medications with potentially significant side effects for a minimum of four months. The recommended treatment for antibiotic-susceptible tuberculosis can be as long as a year. Of cases in the United States in 2010 eligible to complete treatment in less than one year in 2010, only 88.1% of cases did so. Non-adherence or failure to complete treatment is a major public health challenge as it increases the chances of recurrence and the emergence drug-resistant TB, which requires longer, more expensive, and less effective treatment. To ensure adherence to treatment, directly observed therapy (DOT) is recommended by the Centers for Disease Control and Prevention and the World Health Organization. DOT represents a large commitment of time and resources for both patients and healthcare systems. Generally, DOT services that are convenient for LHDs, such as clinic-based DOT, have been impractical for patients, while patient-centered outreach services, such as home-based DOT, are time-consuming and expensive for LHDs. Electronic monitoring of patients taking their medication (eDOT) has the potential to make treatment more acceptable to patients as well as reducing costs to healthcare providers. eDOT can be done in multiple ways, commonly in real time or by electronically recording DOT. Videophones or web-based applications that allow tuberculosis patients to take their medications in the virtual presence of a health worker exemplify real-time eDOT. Several health authorities have piloted the use of videophone technology for real-time eDOT to increase compliance and decrease costs. Real-time DOT requires patients to schedule eDOT so health workers can observe therapy and, although less disruptive than clinic-based or outreach-based in-person DOT, real-time eDOT does not address the common criticism of in-person DOT that DOT does not fit readily into the tempo of people’s lives and is a burdensome interruption, especially for those of low socio-economic status. Recorded eDOT can potentially solve scheduling and life interruption problems by allowing tuberculosis patients to electronically record themselves taking their medications in a place and time convenient to them. By electronically recording DOT, a patient can take the medications at a time convenient to them. Compared to in-person DOT, using recording software for eDOT eliminates the need for patients to fit their lives around DOT; instead eDOT fits around their lives. Additionally, as tuberculosis medications can cause fatigue and other minor side effects, some patients chose to take their doses in the evening, outside of business hours. Further, recorded eDOT does not require patients to have a consistent internet connection. Patients can record doses without a connection, and then email program staff when they do have an internet connection. From the LHD perspective, recorded eDOT was useful in increasing staff flexibility. Staff were not required to schedule DOT for video-recorded doses as they could watch the recording at their convenience. Further, staff could easily manage out-of-jurisdiction travel or treatment during inclement weather, as treatment could continue uninterrupted no matter where or how inaccessible the patient was. Unlike other studies using videophones, the computer software does not require specialized expensive equipment and technological problems were rare and screen resolution was improved.In 2013 CCPH evaluated its use of eDOT with a focus on whether it was as effective and whether there were costs savings in using eDOT. Since eDOT was initiated in 2009, 12 people have used eDOT for at least one dose and a total of 1016 doses were observed through eDOT. Electronically recorded doses were no more likely to be missed than doses in-person (OR: 0.79, 95%CI: 0.47-1.35). Cost savings were found through reductions in time observing doses, travel time, and travel mileage. An in-person dose was estimated to take 10 minutes while an electronic dose took an estimated 5 minutes. Using 2012 records, CCPH estimated the average travel time to patients’ homes was 10 minutes. We calculated the travel distance saved using Google Maps as 27,915 miles. Using these numbers, the average cost of a community health worker or medical assistant ($30.21 per hour), and the federal reimbursement rate of $0.565 per mile we calculate CCPH saved $12,789 in staff time and $15,771 in mileage. The total savings of $28,561 represents a savings of $28 a dose. The American Thoracic Society, CDC, and Infection Disease Society of America recommendations on the treatment of tuberculosis recognizes that to maximize completion of therapy, patient-centered programs should utilize a broad range of approaches based on the needs and circumstances of individual patients. Alongside other methods, CCPH has used electronic DOT as such an approach to reduce the burden on patients and encourage treatment adherence. Recorded eDOT does not directly address a CDC Winnable Battle but is instead an innovative approach to improving a core function of public health and moving toward achieving the Healthy People 2020 goal of increasing the percent of active tuberculosis cases completing treatment.
The goals of using recorded electronic DOT (eDOT) were to lessen the burden on both tuberculosis patients and LHD’s while maintaining a high level of treatment adherence in the continuation phase of treatment.eDOT was initially suggested to Clark County Public Health (CCPH) in 2009 by a patient who required an extended treatment of one year, did not have pulmonary tuberculosis thus was not contagious, and traveled extensively for work. He maintained contact with family and friends via free computer software that allowed him to record videos of himself and was intimately knowledgeable about the software. CCPH found that since the recordings had a high video resolution and automatic time-stamp, they were an acceptable alternative to in-person DOT. This was in our opinion a logical extension of the American Thoracic Society, CDC, and Infection Disease Society of America’s recognition that to maximize completion of therapy, patient-centered programs should utilize a broad range of approaches based on the needs and circumstances of individual patients. Electronic DOT is such a patient-centered approach. After this initial case, CCPH allowed other active tuberculosis cases to perform continuation phase DOT doses electronically. When initiating the program, we were conscious of privacy concerns related to the transmission of personal health information. While specific interpretations vary, the HIPAA security rule does not apply to real-time videoconferences, however it does apply to electronic recordings. The security rule requires recorded transmissions to be encrypted whenever possible. Some popular free video recording software does have encryption, however the software company may store recordings, and thus are not HIPAA compliant. There are numerous other HIPAA compliant recording and file transfer software available for a modest fee. In order to implement this program we also had to work with our IT department and legal counsel to obtain the necessary permissions and computer programs. As with many government organization’s IT departments, some popular real-time communication software with recording capability are “banned programs” due to human resources concerns. With the support of our leadership we were able to gain access to several of these programs. After the initial patient, CCPH created criteria for those eligible to use eDOT. Tuberculosis patients were eligible for eDOT if they had completed the first 8 weeks of treatment (initiation phase) without incident, did not have treatment adherence concerns, had non-multiple drug resistant tuberculosis, owned an internet connection, and were willing to use eDOT. If the person did not have a web camera, CCPH would purchase one for them. Those who chose to use eDOT were managed in the same manner as those using in-person DOT. Case management included weekly case conferencing with the health officer and a monthly nursing visit where medication tolerance and dosing was assessed. CCPH recognizes that eDOT is not for every patient and for that reason we piloted eDOT only in those who had no adherence concerns, owned an internet connection, and were comfortable with the technology. As a goal of eDOT was to minimize the burden on patients, eDOT has been presented as an option for willing patients rather than as the default option. eDOT is stopped if the patient has adherence concerns, the medication is not tolerated, or if the patient decides they don’t want it. For those tuberculosis patients that are interested in eDOT, CCPH provides a short training and downloads the recording software onto the patient’s device during an in-person DOT visit. The software is available as traditional software and is also available as a smartphone or tablet application. The patient receives education about the basic elements of a successful eDOT. In a typical eDOT, the patient states the date, displays the medications, and ingests the medications. The videos range from about 30 seconds to 2 minutes depending on patient preferences. The patient can then save and securely transfer the recording to the health department.As CCPH holds social justice as a core value, we recognized that we were making tuberculosis treatment easier only for an economically advantaged subset of our tuberculosis patients. As a quality improvement project, CCPH began a technology loaner program in 2013 to tuberculosis patients without an internet connection. CCPH bought a number of tablet computers that have the necessary functionality to perform eDOT. All tablets have the necessary software, applications, and a videocamera with acceptable resolution. Much like eDOT, CCPH will provide a short training during an in-person DOT visit. The county IT department has put controls on what kinds of applications can be loaded onto the tablet and is able to wipe the tablet’s memory remotely. Explicit in the loaner program is that patients will return the technology at the completion of treatment. This practice will begin in 2013 with the goal of expanding access to eDOT in the county to all tuberculosis patients. Start-up costs for eDOT will vary depending on how much technology the LHD decides to provide to patients. There are various HIPAA compliant computer programs available in the $10-$20 per month per patient price range. If LHDs decide to provide technology to patients to ease concerns about social justice, they can expect to pay more. Webcams for patients with an internet connection but without a webcam cost approximately $20. Tablets (and accompanying carrying sleeves, protective cases, data plan, and warranty) cost considerably more, however these can be provided to patients who are willing to use eDOT, but do not have a home internet connection. When CCPH evaluated eDOT in 2013, we found significant cost-savings compared to in-person DOT. This is covered more in-depth in the next evaluation section. In short, CCPH saved on staff time observing doses, staff travel time, and mileage. Since 2009, CCPH saved an estimated $2,558 in staff time observing doses, $10,232 in travel time, and $15,711 in mileage for a total of $28,561 over 1016 doses. That represents a savings of $27 per dose. If a patient has a single dose per month by eDOT instead of in-person DOT, that one dose more than covers the monthly cost of the software and the data plan. On average, CCPH saved $2,380 per patient, which is more than upfront costs for all of the tablets purchased by the tuberculosis program.
The goals of using recorded electronic DOT (eDOT) were to lessen the burden on both tuberculosis patients and LHD’s while maintaining a high level of treatment adherence in the continuation phase of treatment.In the summer of 2013, Clark County Public Health evaluated the practice of eDOT looking at three questions. 1) Who used eDOT and in what ways did they use it. 2) Whether those using eDOT had similar clinical outcomes as those using in-person DOT. 3) Whether there were any cost savings compared to in-person DOT. Clinical outcomes were measured as treatment completion, treatment interruptions, treatment restart, missed doses, and hospitalizations in the continuation phase of treatment. Costs were evaluated focusing on technology costs, staff time, travel costs, and mileage. CCPH felt that we needed to formally evaluate whether eDOT was a viable alternative to in-person DOT. The evaluation was based upon a chart review using a common abstraction form of all tuberculosis patients followed by CCPH since 2009 when eDOT was first piloted. The abstraction form included demographic data, risk factors, doses missed, whether doses were in-person DOT or eDOT, treatment completion, and other clinical details. Data was supplemented with information from the Washington notifiable disease registry, Public Health Information Management System (PHIMS). A CSTE/CDC Applied Epidemiology Fellow created the common abstraction form, abstracted the medical records, supplemented data from PHIMS, created the analysis dataset, and analyzed the data. Addressing the first objective of the evaluation, 52 people were followed by CCPH since 2009. Of these, 12 patients used eDOT at least once during the continuation phase of treatment. Those using eDOT were more likely to be male, non-Hispanic, and were on average younger than those who only used in-person eDOT. We did not find a difference in eDOT use by race, tuberculosis risk factors, or by type of tuberculosis (pulmonary vs extrapulmonary) although in some cases this could be due to the small number of subjects. These findings may suggest some selection due socio-economic status and comfort with computer technology as CCPH required those with eDOT to provide their own internet connection at the time of the evaluation. When we looked at how eDOT patients used eDOT during their treatment, we saw that it varied based upon individual circumstances. The first finding of note is that the majority of patients who used eDOT (7 of 12) had treatment regimens longer than six months. As CCPH does not have a tuberculosis clinic, we rely on private physicians who at times prescribe extended treatment regimes beyond the American Thoracic Society, CDC, and Infection Disease Society of America guidelines. How many doses were taken by electronic therapy varied . Three people used it as the only form of DOT in the continuation phase of treatment without exception while the remaining nine patients used a combination of eDOT and in-person DOT. Two people used eDOT only while traveling outside of the county. Of note, one patient chose an interesting strategy to take their dose in-person during their monthly nursing visit while every other dose was eDOT. It is striking that other patients, despite having a CCPH nurse at their home during the visit, regularly decided to electronically record their dose at a time convenient to them rather than during the visit. When looking at clinical outcomes we focused on missed doses because of the low number of treatment incompletions, treatment interruptions, treatment restarts, and hospitalizations in the continuation phase of treatment in both those who used eDOT and those who did not. All 12 of those who used eDOT completed treatment compared to 38 of the 40 using exclusively in-person DOT. Of these two patients not completing treatment, one transferred to another jurisdiction and the other died due to a cause unrelated to tuberculosis and tuberculosis treatment. Those using eDOT had similar and low rates of treatment interruptions, treatment restarts, and hospitalizations as those using exclusively in-person eDOT.A total of 1,016 doses of eDOT were successfully administered via eDOT while 39 (3.8%) doses were missed. In the same time period 2,532 doses of in-person DOT were administered while 67 (2.4%) were missed. Interestingly, of the 57 attempted doses of real-time eDOT, 7 (12.3%) were missed. In order to test whether a dose taken via eDOT was statistically significantly more likely to be missed, we used a binomial mixed-effects model adjusting for age. In our first model we compared whether a dose taken via eDOT (either real-time or in-person) was more likely to be missed than in-person doses. In the second model we considered real-time eDOT doses separately from recorded eDOT doses. Overall, electronic DOT doses were no more likely to be missed than in-person DOT (OR: 1.74, 95%CI: 0.76-4.01). When real-time and recorded DOT are considered separately, real-time electronic DOT doses were more likely to be missed than in-person DOT doses (OR: 11.12, 95%CI: 2.94-42.11). Recorded electronic DOT doses were similarly more likely to be missed than in-person doses (OR: 0.79, 95%CI: 0.47-1.35). Addressing cost, we focused on costs to the LHD, specifically investigating time spent observing DOT, travel time, and mileage. Using 2012 patient data we determined that the average drive time to patients’ homes was 10 minutes. Interviews with staff estimated that the average in-person DOT took 10 minutes observing the patient while electronic DOT took 5 minutes. Distance traveled was calculated by an online program. Using the average cost of a community health worker or medical assistant including benefits at CCPH of $30.21 per hour, each eDOT dose saved CCPH $12.59 in staff time and benefits. Over 1016 doses, eDOT saved $12,789 in staff time and benefits. 27,915 miles of roundtrip travel were avoided by using e-DOT since 2009. At the federal reimbursement rate of $0.565 per mile, this represents a savings of $15,771. In total CCPH saved $28,561 by using the program, a savings of $27 per dose. This evaluation assumed free software and computer equipment as, during the time period being evaluated, CCPH did not provide internet connections or electronic hardware with the exception of webcams to a minority of patients. Even if CCPH did provide internet connection and hardware for every patient on eDOT, it would not change the fundamental finding that eDOT can conserve considerable LHD resources. If a patient has a single dose per month by eDOT instead of in-person DOT, that one dose more than covers the monthly cost of HIPAA-compliant software and a tablet data plan. On average, CCPH saved $2,380 per patient, which is far more than upfront costs for a tablet computer. Additionally, eDOT was useful in reducing costs but also in increasing staff flexibility. Staff were not required to schedule DOT for video-recorded doses as they could watch the recording at their convenience. Further, staff could easily manage out-of-jurisdiction travel or treatment during inclement weather, as treatment could continue uninterrupted no matter where or how inaccessible the patient was. Anecdotally, eDOT allowed CCPH to continue to monitor doses while the patient was half the world away, or on top of an icy mountain in a winter storm. Unlike other studies using videophones, technological problems were rare and screen resolution was far better.Although not measured empirically, CCPH believes that eDOT reduces the burden of tuberculosis treatment for patients. Compared to in-person DOT, using recording software for eDOT eliminates the need for patients to fit their lives around DOT; instead eDOT fits around their lives. Recorded eDOT allowed patients to take medications at times that were convenient to them. As tuberculosis medications can cause fatigue and other minor side effects, some patients chose to take their doses in the evening, outside of normal business hours. This evaluation measured whether eDOT was achieving its goals of lessening the burden on LHD’s while maintaining a high level of treatment adherence in the continuation phase of treatment. On both of these measures, eDOT has been a success. Doses taken by eDOT, especially recorded eDOT, were no more likely to be missed than DOT dose administered in-person. eDOT has saved the county an average of $2,380 per patient and has also allowed more flexibility within the tuberculosis program. Anecdotally, we believe that eDOT lessens the burden on tuberculosis patients as well. Evaluation provides an opportunity for system improvement, even if that is not explicit in the objectives of the evaluation. Following this evaluation, CCPH looked more closely at the software commercially currently available and at the social justice considerations of providing eDOT only to those tuberculosis patients who already had the technology. As CCPH holds social justice as a core value, we recognized that we were making tuberculosis treatment easier only for an economically advantaged subset of our tuberculosis patients. As a quality improvement project, CCPH began a technology loaner program in 2013 to tuberculosis patients without an internet connection. CCPH bought a number of tablet computers that have the core functionality to perform eDOT. All tablets have the necessary software, applications, and a videocamera with acceptable resolution. Much like eDOT, CCPH will provide a short training during an in-person DOT visit. The county IT department has put controls on what kinds of applications can be loaded onto the tablet and is able to wipe the tablet’s memory remotely. Explicit in the loaner program is that patients will return the technology at the completion of treatment. This practice will begin in 2014 with the goal of expanding access to eDOT in the county to all tuberculosis patients.
By evaluating eDOT Clark County Public Health had the opportunity to quantify whether eDOT was meeting the goals of lessening the burden on both tuberculosis patients and LHD’s while maintaining a high level of treatment adherence in the continuation phase of treatment. By and large, these goals were being met. Doses taken by eDOT, especially recorded eDOT, were no more likely to be missed than DOT dose administered in-person. eDOT has saved the county an average of $2,380 per patient and has also allowed more flexibility within the tuberculosis program. Anecdotally, we believe that eDOT lessens the burden on tuberculosis patients as well.Evaluation also provides an opportunity for system improvement, even if that is not explicit in the objectives of the evaluation. Following this evaluation, CCPH looked more closely at the software commercially currently available and at the social justice considerations of providing eDOT only to those tuberculosis patients who already had the technology. As CCPH holds social justice as a core value, we recognized that we were making tuberculosis treatment easier only for an economically advantaged subset of our tuberculosis patients. As a quality improvement project, CCPH began a technology loaner program in 2013 to tuberculosis patients without an internet connection. CCPH bought a number of tablet computers that have the core functionality to perform eDOT. All tablets have the necessary software, applications, and a videocamera with acceptable resolution. Much like eDOT, CCPH will provide a short training during an in-person DOT visit. The county IT department has put controls on what kinds of applications can be loaded onto the tablet and is able to wipe the tablet’s memory remotely. Explicit in the loaner program is that patients will return the technology at the completion of treatment. This practice will begin in 2013 with the goal of expanding access to eDOT in the county to all tuberculosis patients. Recorded eDOT is better than what has been done before as it is an acceptable alternative from a clinical perspective, but is less burdensome to both patients and LHDs. Generally, DOT services that are convenient for healthcare workers, such as clinic-based DOT, have been impractical for patients, while patient-centered outreach services, such as home-based DOT, are time-consuming and expensive for health services. Other LHDs have seen the potential for technology to fix this problem with the use of videophones or real-time electronic DOT software, but real-time eDOT requires patients to schedule eDOT so health workers can observe therapy. Although less disruptive than clinic-based or outreach-based in-person DOT, real-time eDOT does not address the common criticism of in-person DOT that DOT does not fit readily into the tempo of people’s lives and is a burdensome interruption, especially for those with low SES. Recorded e-DOT can potentially solve both problems by allowing tuberculosis patients to electronically record themselves taking their medications in a time and place convenient to them. In addition to being equally effective and cost-saving, eDOT increased staff flexibility. Staff were not required to schedule DOT for video-recorded doses as they could watch the recording at their convenience. Further, staff could easily manage out-of-jurisdiction travel or treatment during inclement weather, as treatment could continue uninterrupted no matter where or how inaccessible the patient was. Anecdotally, eDOT allowed CCPH to continue to monitor doses while the patient was half the world away, or on top of an icy mountain in a winter storm. Unlike other studies using videophones, technological problems were rare and screen resolution was far better.CCPH conducted an evaluation of which a component was whether CCPH saved money by using eDOT. We focused on costs to the LHD, specifically investigating time spent observing DOT, travel time, and mileage. Using 2012 patient data we determined that the average drive time to patients’ homes was 10 minutes. Interviews with staff estimated that the average in-person DOT took 10 minutes observing the patient. Distance traveled was calculated by an online program. Using the average cost of a community health worker or medical assistant including benefits at CCPH of $30.21 per hour, each eDOT dose saved CCPH $12.59 in staff time and benefits. Over 1016 doses, eDOT saved $12,789 in staff time and benefits. 27,915 miles of roundtrip travel were avoided by using e-DOT since 2009. At the federal reimbursement rate of $0.565 per mile, this represents a savings of $15,771. In total CCPH saved $28,561 by using the program, a savings of $28.11 per dose. This evaluation assumed free software and computer equipment as, during the time period being evaluated, CCPH did not provide internet connections or electronic hardware with the exception of webcams to a minority of patients. Even if CCPH did provide internet connection and hardware for every patient on eDOT, it would not change the fundamental finding that eDOT can conserve considerable LHD resources. If a patient has a single dose per month by eDOT instead of in-person DOT, that one dose more than covers the monthly cost of HIPAA-compliant software and the tablet data plan. On average, CCPH saved $2,380 per patient, which is far more than upfront costs for a tablet computer. Electronic DOT is a sustainable practice as the stakeholders are committed to the practice. CCPH will continue to offer eDOT to those patients that have not had adherence concerns and are willing to do eDOT as it is time and resource-saving. From the patient’s perspective eDOT is an attractive DOT model as it is less burdensome than in-person DOT. CCPH’s political leaders have also shown support for measures that save the department money and impinge less on the residents of Clark County.
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