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TB Notes 4, 2004

No. 4, 2004


San Diego County Implements Video DOT Program

The San Diego County TB Control Program has implemented a program that uses videophones to provide directly observed therapy (DOT) for selected patients currently receiving TB treatment. This program is being tested to determine its effectiveness as a safe and reliable method to supplement the existing in-person DOT program.  

San Diego County reported 316 cases of active TB during 2003. Fifteen public health nurse (PHN) case managers working out of six regional offices provide case management for all patients with active TB.  DOT is the initial adherence strategy for virtually all patients. The PHN case managers, in association with eight outreach workers, are responsible for providing all DOT visits. Traffic delays, travel distances, patient availability, and language barriers are only some of the challenges faced by staff members who provide DOT in San Diego County, which covers more than 4,200 square miles with a population of over 2.9 million.

The first videophone was installed in a patientís home in San Diego County on March 23, 2004. The program served a total of 12 patients during the first 3 months of operation.

Each patient begins treatment with standard in-person DOT provided by a PHN or outreach worker. Patients are selected for participation in the video DOT program based upon the PHN case managerís assessment using the following criteria:

  • Patient has successfully completed at least 2 weeks of in-person DOT with 100% adherence;
  • Patient has a stable residence with an appropriate place for videophone equipment;
  • Patient is motivated and has family or other social support;
  • Patient understands the need for TB treatment;
  • Patient has the ability to accurately identify each medication and pour his or her own medications;
  • Patient speaks a language that can be accommodated by video DOT personnel; and
  • Either travel distance or time of patientís availability makes video DOT a good option.

The patient signs a consent form prior to participating in the program. The consent clarifies that participation is voluntary and the patient may opt to return to in-person DOT at any time during treatment. The patient agrees to return the equipment to the health department upon completion of treatment or discontinuation of video DOT.

The videophones purchased by the program have a 4-inch screen and connect directly to a standard telephone line. The PHN sets up the videophone in the patientís home and instructs the patient in the use of the videophone and in video DOT procedures. The PHN observes the first video DOT session in the patientís home. After video DOT is established, the PHN visits the patient at least monthly for routine visits and as needed to address any problems that arise.

Video DOT is observed and documented centrally at the TB control program office. A staff person who has also been introduced to the patient calls the patient at a mutually agreed-upon time. While one staff person is primarily responsible for observing the video DOT, other staff members who speak a variety of languages are available to provide assistance with interpretation as needed. There have been few technical problems in observing video DOT. On rare occasions there may be some difficulty in establishing the video connection. Redialing to establish a better connection has solved this problem.

During the first 3 months of the program, 282 video DOT observations were completed for 12 patients. Travel savings calculated for this implementation phase are summarized in the table below. The average distance of 19.1 miles per visit results in a saving of nearly $7.00 per visit in mileage expenses. Salary savings listed in the table are for typical outreach worker staff and account for an average of $10.40 per visit. These salary savings are even greater when visits are observed by a PHN. These calculations cover only travel time and personnel expenses during travel, and do not include the actual amount of time spent during the visit. Typical video DOT visits last 2 to 3 minutes, while in-person DOT visits may last 10 to 15 minutes.

Travel time and mileage saved in the 3-month implementation phase of the video DOT program:

Total # Video DOT observed

Average miles/ visit @ $.365 per mile

Average travel time/ visit @ $20/hr (salary + benefits)

Total miles @ $.365 per mile

Total travel time @ $20/hr (salary + benefits)


19.1 miles @ $.365 = $6.97

31 minutes @ $20/hr = $10.40

5378 miles @ $.365 = $1963

146 hours @ $20/hr = $2,920

The cost benefits of the program are evident after only 3 months of experience using video DOT. The minimum estimate of nearly $5,000 in savings on travel expenses and staff time is impressive and is anticipated to increase as more patients participate in the program. Patients are enthusiastic about the convenience and flexibility that video DOT provides. There were no DOT failures during the 3-month implementation phase, and all patients chose to continue with the program once it was established.

The program purchased 40 videophones at a cost of less than $200 per unit ($8,000 total). Savings realized in operating the program will soon cover this initial expense. If the videophones prove to be reliable, they will be used multiple times with no need to incur additional equipment costs. With the possibility of as many as 35 participants in the video DOT program at any one time, this program has the potential for significant cost savings while providing safe, convenient, and reliable DOT services for patients. In addition, staff can be shifted to other priority activities, such as contact investigation, while still providing excellent patient adherence services for the community.

óSubmitted by Linda Bethel, PHN IV
San Diego County TB Control Program


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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