Costing & Time & Motion Study of - PowerPoint Presentation

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Costing & Time & Motion Study ofSTD Partner Services in Washington StateEpidemic Characteristics Drive Costs

Rachel A. Silverman, PhD, ScM, David A. Katz, PhD, MPH, Carol Levin, PhD, MSc, Teal R. Bell, MPH, Dawn Spellman, MA, Lisa St. John, MBA, Med, Evelyn Manley Rodriguez, Matthew R. Golden, MD, Ruanne V. Barnabas, DPHil, MBChB, MSc

BackgroundSignificanceCDC recommends STD partner services (PS) to prevent disease & transmissionGiven increased HIV risk associated with STDs, STD PS can be used to promote HIV prevention & treatmentResource needs are not well understood

Aims Evaluate the resource needs (financial costs and time), activities, and areas to improve efficiency of STD PS in Washington State.

Disease intervention specialists (DIS)Conduct telephone-based interviews of STD cases & partner notification (field work last resort)All syphilis, MSM with gonorrhea (GC) & chlamydia (CT), & some heterosexual casesOften focus on specific disease and/or risk groupEnhanced STD PS Activities

Offer expedited partner therapy (EPT) to heterosexuals with GC/CTPromote HIV testingIdentify/refer eligible clients for pre-exposure prophylaxis (PrEP)Promote linkage/re-linkage to HIV-care for HIV infected clientsKing

Pierce

Spokane

STD PS Programs in Washington State

Study Sites: 3 High disease burden jurisdictions representing geographic & epidemic diversity

Public Health – Seattle & King County

Tacoma-Pierce County Health Dept

Spokane Regional Health District

Full-Time Staff (40

hrs

/

wk

)

DIS

Administrative

King

5.4

1

Pierce

3.1

0.4

Spokane

2.7

0.3

Data CollectionQualitative Time & Motion Study: Captures detailed information on process & duration of tasks for service delivery.

Interviews & independent observations: Estimate personnel time on activities.Individual case time-tracking: Staff record activities and time spent per case. Financial expenditures (salaries, overhead, etc.) on STD PS program.Surveillance & STD PS Data: number of people impacted by PS.What was not collected: Resources not specific to STD PS (e.g. STD clinic work).Resources for HIV-only cases.

Total Population Size

King

2,149,970

Pierce

861,312

Spokane

499,072

STD Epidemic Diversity Across WA

State

MSM: Men who have sex w/ men

In King & Pierce, most syphilis cases are MSM vs. heterosexual in Spokane (many methamphetamine users).

Most GC are MSM in King.

Most CT cases are heterosexual in all jurisdictions.

Percent of Reported STD Cases Receiving PS

Cases assigned and interviewed by DISAlmost all syphilis cases assignedSpokane highest % interviewedMost GC cases assigned in King & PiercePierce highest % interviewedMost CT cases are not assigned

Syphilis

6%

41%

11%

22%

19%

8%

Time Study Results – Percent of Total Time Spent on PS Activities

Variation in time for activities across locations and STD

31%

34%

10%

6%

17%

22%

Estimated Total Time Allocated per Case

 KingPierce

Spokane

% MSM

% MSM

% MSM

Syphilis:

88%

82%

38%

GC/CT:

27%

6%

5%

Epidemic Characteristics

Spokane spends over 4x the time on Syphilis

and twice the time on GC/CT than King & Pierce.

(recall higher % of HET case, many methamphetamine users in Spokane, very hard to reach)

Individual Case Tracking Large Variability Across cases, locations, and STD

In Spokane, heterosexual syphilis cases required 3x amount of time vs. MSM (271 vs 71min).

Methamphetamine users required 5x that of MSM (388 vs. 71 min).

Staff & STD

Average Across Jurisdictions

Range Overall

Case

Partner

Case

Partner

Administrative GC/CT

9-18 min

-

2-70 min

-

DIS GC/CT

33-37 min

15-33min

10-195 min

7-58 min

DIS Syphilis

65-166 min

16-52 min

23-960 min

6-127 min

Complicated, high priority cases take lots of time!

Time spent on Enhanced STD PS ActivitiesSpent relatively small amount of time on these activities vs. overall work

EPT for heterosexuals GC/CT:

<5 minutes per case

HIV test discussion & verification:

<2 minutes per case

HIV linkage to care discussion & verification:

<2min per case

PrEP discussion: <2min per case

Depends on other existing programs in the community

Providers test for HIV, refer & prescribe

PrEP

at time of STD test/diagnosis

Health departments with

PrEP

coordinator for referrals (King & Spokane) require minimal DIS work time

Pierce reported DIS spent 69-155 minutes per referral for 3-6 clients per week for

PrEP

referrals and initiation/linkage (no department coordinator), compared to a few minutes in other locations to refer clients to coordinator (self report)

Observed

during interview

Total Financial Expenditures of STD PS Programs (2016)Salaries & Benefits ~80% of Costs

King County twice the expenditures vs. Pierce & SpokaneLifetime cost of HIV treatment >$400,000KingPierce

Spokane

$798,141

$416,098

$400,758

Total Costs Per Case InterviewVaries by location & STD. Syphilis cases costs most per service.

Results similar to a costing analysis of PS in New York State in 2014:Cost per interview:Syphilis: $1,072 Gonorrhea: $608 Chlamydia: $635Johnson, et al. (2017)Total Cost per interview

Syphilis: $526-$2,210Gonorrhea: $219-$484

Chlamydia: $164-$547

What to Consider for STD PS program development, implementation, & improved efficiency

Disease burden & population characteristics (are clients hard to reach?).Methods to locate contact clients (phone/text, fieldwork, Facebook, dating apps).Case reporting efficiency quality from providers (paper vs. electronic reporting).Access to electronic medical records.Access to restricted database (e.g. Accurint ®).Data sharing between DOH and other local jurisdictions (e.g. syphilis serology data, jurisdiction level data for neighboring counties).Database (simple and efficient?).Greater efficiency➔ more time spent tracking/contacting clients ➔ more disease prevention

ConclusionsLarge variability in resource needs within & across STD infection type & jurisdictions.

Casework for syphilis costs more than GC/CTIntegrating HIV related interventions often required relatively little additional effort Costs per outcomes are comparable to other programs with similar objectives.Results inform resource needs & areas to improve efficiency Results can inform math models balancing program costs & benefits to estimate cost-effectiveness over timeGiven lifetime cost of an HIV case is ~$400,000 (1-2x annual cost of local STD PS in WA), efforts to treat & prevent STDs associated with HIV & integrating HIV-related interventions within STD PS can be cost-effective. Can justify diversifying funding streams by utilizing HIV funds for STD treatment & prevention.

Acknowledgements DIS & Admin Staff at Public Health – Seattle King County, Tacoma-Pierce County Health Department, Spokane Regional Health District for their participationSTD PS Supervisors: Dawn Spellman, Evelyn Manley Rodriguez, Lisa St. John

Ruanne BarnabasDavid KatzMatt GoldenCarol LevinTeal BellTom GiftHealth Economics Impact Study Team (HEIST)

Center for AIDS Research (CFAR)

Work is supported by the U.S. Centers for Disease Control & Prevention (Grant: 3H25PS004364-02W1)