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TB Notes 4, 2004
No. 4, 2004
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
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
- 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
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
visit @ $.365 per mile
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