Delta Omega Honorary Public Health Society Poster Session

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A Cost-Effectiveness Evaluation of Syphilis
Screening Among Women at Cook County Jail
Preliminary Results A McIntyre1, H Beidinger
2,3, J Kraut4, K Irwin21 University of Illinois
at Chicago School of Public Health 2 Centers for
Disease Control and Prevention, Atlanta, GA 3
Chicago Department of Public Health 4 Northern
Illinois University, DeKalb, IL

• Delta Omega Honorary Public Health Society Poster
  Session
• 129th Meeting of the American Public Health
  Association
• Atlanta, Georgia
• 23 October 2001
• For more information, contact Anne McIntyre at
  amcint1_at_uic.edu

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Why Should Public Health Go to Jail? ITS WHERE
THE DISEASE IS!
Early Syphilis Detected at CCJ as a of
Chicagos Total
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PURPOSE OF STUDY

• 1996 Stat RPR Project implemented at Cook County
  Jail (CCJ)
• Routine RPR Treatment Rate 44
• Stat RPR Treatment Rate 88
• Syphilis Screening Among Women Arrestees at
  the Cook County JailChicago, 1996 MMWR, June 5,
  1998, 47(21)432-433
• Current Overall number of syphilis cases are
  declining, but the proportion found at the jail
  is increasing
• 152 Early cases in 1996 vs.139 Early cases in
  1999
• Is Stat RPR Screening Project cost effective?

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COOK COUNTY JAIL (CHICAGO, IL)

• One of the largest, oldest one-site facilities in
  the US
• Pre-sentencing detention (lt1 year)
• Average Daily Census 10,000
• 350 New Detainees Each Day
• Average Length of Stay 45 days
• Dependent on Charge, Resources to Bond Out
• 85 Men, 15 Women
• Intake TB, STD, Syphilis Screening for ALL
  Detainees

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RAPID PLASMA REAGIN (RPR)

• Rapid Plasma Reagin is a blood test to detect
  syphilis antibodies
• Qualitative Analysis (Reactive/Not Reactive with
  antigen)
• Quantitative Analysis on Reactives for titer (11
  to 1512)
• All Reactives Jail medical history searched for
  previous diagnosis and/or treatment patient
  interviewed.
• Reactive blood samples sent to state lab for
  confirmation (FTA-ABS)
• Decision to treat is based on multiple factors
• Serofast Reactive RPR, FTA-ABS, but history of
  diagnosis/ treatment
• Biologic False Positive Reactive RPR,
  Non-Reactive FTA-ABS
• Pregnancy Status, Age, HIV Status, Other

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OBJECTIVES

• Evaluate the cost-effectiveness of Stat RPR
  screening project
• Collect demographic information of women with
  reactive RPRs
• Determine screening and treatment outcomes
• Collect data on cost of Stat and Routine RPR
  strategies, including material labor and overhead
• Compare costs of three screening strategies
  using Stat and/or Routine RPR

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METHODS

• Stat RPR Screening
• Voluntary specimen collection, Stat RPR testing,
  treatment administered ALL in Womens Intake Unit
  within hours of arrival
• Routine RPR Screening
• Voluntary specimen collection in Womens Intake
  Unit, RPR testing conducted in laboratory within
  24 hours, treatment administered within 3-4 days
  of arrival
• Data Collection Periods
• March 7, 2000 April 3, 2000 (Stat Routine)
• September 5, 2000 October 3, 2000 (Routine
  only)
• Decision Analysis Model
• Includes estimates of program costs and
  effectiveness based on disease outcomes of
  treated versus untreated reactive RPRs

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SYPHILIS SCREENING STRATEGIES

• Screening Strategy 1
• Stat RPR Screening during 2nd work shift (2 PM11
  PM, MF) 20 shifts/month AND routine screening
  during all other shifts 64 shifts/month
• Time Frame January 1996 August 2000
• Screening Strategy 2
• Routine screening during ALL shifts 84
  shifts/month
• Time Frame 1985 - Current
• Screening Strategy 3
• Stat RPR Screening during ALL shifts 84
  shifts/month
• Time Frame None considered for analysis only

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THE PROCESS ARRIVING AT FINAL COSTS
Define each step of complex syphilis screening
process at CCJ via a flow chart
Assign probabilities to each step in flow chart
from ongoing surveillance, literature
Conduct Time-in-Motion study to gather cost per
staff member for each RPR-related step
Develop Decision Analysis model (decision tree)
based on probabilities and costs per RPR-related
step
Cost per new case detected and treated for
each screening strategy
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(No Transcript)
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DEMOGRAPHICS (N139 REACTIVE RPRs)

• Mean age 34 years
• (Range 17 56 years)
• Race
• 96 Black
• 3 White
• 1 Hispanic
• Marital Status
• 78 Never Married
• 11 Married
• 10 Divorced/Separated
• 1 Widowed

• Educational Attainment
• 51 Less than a High School Diploma/No GED
• 42 High School Diploma/GED
• 7 More than a High School Diploma/GED
• Number of Children
• 22 No Children
• 50 1-3 Children
• 28 4 or More Children

There were no significant differences between
Stat and Routine groups (?0.05).
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BOOKING DATA

• Mean Length of Stay 20.5 Days
• (Range 1 90 Days)
• Reason for This Arrest
• 54 Drug Related
• 18 Prostitution
• 3 Both Drugs and Prostitution
• 25 Other (theft, forgery, etc)
• Number of Previous Arrests (January 1997 through
  March 2001)
• 26 None
• 53 1 to 4 Arrests
• 21 5 or More Arrests
• Mean 3 Previous Arrests
• (Range 0 to 17 Previous Arrests)

There were no significant differences between
Stat and Routine groups (?0.05).
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COST DATA COLLECTION-I

• Personnel utilized stop watches to accurately
  document time spent on RPR related activities
• Laboratory Technician
• Certified Medical Technician
• Disease Intervention Specialists
• Jail-based STD clinic
• Field follow-up for women with reactive RPR
  released prior to rx
• Stat RPR project (at Womens Intake Unit)

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COST DATA COLLECTION-II

• Customized time log sheets developed for each
  staff member to record activities, function
  within strategies
• Other costs
• Salaries of staff involved in RPR screening
• Stat RPR project start-up costs (centrifuge,
  computer)
• RPR equipment and chemicals (antigen, ASI cards)
• Fixed costs (building, transportation)

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RESULTS
Strategy 1 Stat Routine Stat (2nd Shift) Routine (1st, 3rd Shifts) Strategy 2 Routine Only
Women Booked 1341 616/1341 (46.0) 725/1341 (54.0) 1217
Women Screened 1243/1341 (92.6) 553/616 (89.7) 690/725 (95.1) 1144/1217 (94.0)
Reactive RPR 93/1243 (7.5) 54/553 (9.8) 39/690 (5.7) 46/1144 (4.0)
Serofast 68/93 (73.1) 43/54 (79.6) 25/39 (64.1) 34/46 (73.9)
Biologic False Positive 7/93 (7.5) 4/54 (7.4) 3/39 (7.7) 2/46 (4.3)
New Cases 18/93 (19.4) 7/54 (13.0) 11/39 (28.2) 10/46 (21.8)
New Cases Diagnosed Treated On-Site 8/18 (44.4) 4/7 (57.1) 4/11 (36.4) 6/10 (60.0)
New Cases Discharged Prior to Treatment 10/18 (55.6) 3/7 (42.9) 7/11 (63.6) 4/10 (40.0)
Difference between Stat, Routine Groups plt0.05
Difference between Strategy 1, Strategy 2 plt0.05
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LIMITATIONS

• Small sample size
• All data elements manually collected
• Data not centralized
• CCJ laboratory results not automated
• Potential differences in collection of time data
  5 different staff involved
• Factors that explain the differences between
  strategies are numerous and difficult to quantify

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PRELIMINARY CONCLUSIONS

• High Rate of Turnover and Recidivism (Repeat
  Arrests)
• 1 in 4 women are released within 3 days of
  arrival
• Within 2 weeks of arrival 50 are released
• 21 have 5 or more prior arrests since 1/1/97
• High Screening Rates (gt92 in both Strategies)
• Stat RPR screens nearly the same number of women
  in 5 shifts (46) as Routine screens (54) in 16
  shifts per week
• Treatment and Length of Incarceration
  Relationship
• Stat 50 (2/4) of those treated released in ?
  3 days
• Routine 80 (8/10) of those treated
  incarcerated in ? 7 days
• 64 requiring field work () in Routine group
  released ? 3 days
• Cost-effectiveness evaluation is underway, but
  preliminary results suggest
• Cost per new case detected is similar Stat
  (304), Routine (341)
• If cost for field work very high, Stat Program
  likely cost effectiveprevents greater proportion
  of new cases per unit program cost

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The following people made invaluable
contributions to making this project and
presentation possible. I appreciate the support
and resources they have graciously extended.

• Chicago Department of Public Health (CDC)
• Heidi Beidinger, MPH Dawn Broussard,
  MPH Carol Ciesielski, MD
• Steve Mier Anthony Harden Deborah
  Beete, MPH Jennifer Broad, MPH
• Cook County Jail/Cermak Health Services
• Orlando Valenzuela Connie Gary Frankie
  Hill Judy Klaczak Joan Crawford
• Centers for Disease Control and Prevention
• Kathleen Irwin, MD, MPH John Miles,
  MPA Maureen Sinclair, MPH
• Northern Illinois University
• Julie Kraut, PhD
• University of Illinois at Chicago School of
  Public Health
• Sylvia Furner, PhD, MPH
• University of Illinois at Chicago Department of
  Criminal Justice
• Jess Maghan, PhD
  Michael Maltz, PhD