Gift, Thomas L. PhD*; Lincoln, Thomas MD†‡§; Tuthill, Robert PhD∥; Whelan, Michael RNMS¶; Briggs, L Patricia RN¶; Conklin, Thomas MD†; Irwin, Kathleen L. MD, MPH*
INMATES IN CORRECTIONAL INSTITUTIONS ARE at high risk for many chronic and infectious diseases and they typically do not visit healthcare providers as often as the general population.1,2 In particular, the prevalence of sexually transmitted diseases (STDs) such as chlamydia and gonorrhea is higher among inmates than in the general population.3 However, routine screening or testing of symptomatic patients is not common in correctional settings; a 1997 survey found that less than half of city and county jails had a policy of offering routine testing for any STDs to arrestees.4 Only 20% of responding jails reported providing routine testing for chlamydia to female arrestees (22% for gonorrhea), whereas 12% (16% for gonorrhea) offered it to men.4
Jail-based STD screening programs can promote both the health of inmates and potentially reduce the burden of illness in the surrounding community, because most inmates are quickly released and return to the community.2 Another benefit of jail-based screening is that inmates who are diagnosed with an STD can be interviewed to elicit information about their sex partners in the community, who can then be notified of their potential exposure and treated and tested for other STDs.5
Partner notification can also help identify sexual networks and improve community-wide STD control efforts.6 However, partner notification services for patients infected with chlamydia and gonorrhea tend to be limited, especially for patients identified in correctional facilities. A survey sponsored by the Centers for Disease Control and Prevention and the National Institute of Justice conducted in 1997 found that 59% of city and county jails collaborated with public health departments in notifying sex partners of inmates with STDs.7 Partner notification services are more commonly offered to patients with syphilis than to those with gonorrhea and chlamydia. A survey of jurisdictions with high syphilis, gonorrhea, and chlamydia morbidity conducted in 2000 reported that although 97% offered some form of partner notification services for syphilis, only approximately one third offered any form of partner notification for inmates diagnosed with gonorrhea (35%) or chlamydia (29%).8
Universal screening for chlamydia has been shown to be cost-saving for female inmates in whom the prevalence is 8% or higher, but not for male inmates.9 Cost-effectiveness studies in other settings have had similar conclusions.10 This is because the sequelae of untreated or inadequately treated chlamydial infection in women—primarily pelvic inflammatory disease (PID) and its sequelae of chronic pelvic pain, infertility, and increased risk of ectopic pregnancy—are more common and costly than the most common sequelae of untreated chlamydial infection in men, epididymitis.11 Some evidence suggests that untreated urethritis results in increased HIV shedding in men.12
Screening is important in case detection, because chlamydial infection is commonly asymptomatic; men in correctional settings in particular are often asymptomatic or fail to report symptoms.13–15 Where the overall prevalence is not sufficiently high to make chlamydial screening programs cost-saving or even cost-effective, some form of selective screening algorithm can be used. If the screening criteria are fairly sensitive and specific, fewer people are screened, and the prevalence among those screened is higher. Screening criteria that do not depend on information elicited from the patient such as age are the easiest to apply and the least subject to error.
To evaluate the cost-effectiveness of the existing male chlamydia screening and partner notification program at the Hampden County Correctional Center (HCCC) compared with alternatives of age-based screening and testing based on symptoms of bacterial STDs, we analyzed patient demographic and test data and combined these with cost and time-motion data collected at HCCC while screening inmates and in the surrounding community while notifying infected inmates' sex partners.
Materials and Methods
HCCC is a medium-security correctional facility in western Massachusetts that houses 1,800 inmates, both pretrial and sentenced, for terms of up to 2.5 years, although like with most jails, most inmates return shortly to the community (50% are released within the first month). The average age of the inmates is 30 years. Ninety percent are men. Health-related behaviors and conditions observed in this population have been described elsewhere.1 Dually based healthcare providers follow patients both at the facility and in the community at neighborhood community health centers after release, enabling continuity of care.16
All inmates receive a health screening the day of incarceration that includes a nursing evaluation for chronic health conditions, risk, medications the inmate is currently taking, substance abuse, mental health (particularly suicide risk), laboratory testing (including complete blood count, syphilis serology, serum liver transaminase, and urinalysis), and tuberculosis screening. Inmates are also assessed for signs of bacterial STD infection.
During the project period (the first quarter of 2001), all male inmates were screened for chlamydia at intake (female inmates were also screened for chlamydia, but the cost-effectiveness analysis here only covers the screening of men). Inmates provided a urine specimen for chlamydia testing using a ligase chain reaction (LCR) assay (LCx; Abbott Laboratories, Chicago, IL). Testing was done off-site at the Massachusetts Department of Public Health (MDPH) laboratory. At the time the urine specimen was collected, it was also tested for the presence of leukocytes using a leukocyte esterase (LET) dipstick (MULTISTIX 10 SG Reagent Strip; Bayer Corp., Tarrytown, NY). A series of questions assessed inmates' STD risk; these included whether, in the last 60 days, they had had a new sex partner, multiple sex partners, or a sex partner with an STD. Inmates were also asked whether they were experiencing any STD symptoms. Men whose answers indicated increased risk for STDs, who had a positive LET, or who exhibited signs of bacterial STD infection were offered gonorrhea testing with a urethral swab specimen using a DNA probe test (PACE 2 GC; GenProbe, Inc., San Diego, CA). At the time of the program evaluation, the MDPH laboratory was not able to test urine specimens for gonorrhea. Men were also offered testing for gonorrhea after intake if their chlamydia test results came back positive. In each case, they were only tested on consent.
Inmates were treated after positive test results and were presumptively treated in some cases if symptoms or signs were noted at the intake health screening. Inmates testing positive or presumptively treated for chlamydia received either doxycycline (100 mg twice daily for 10 days) or azithromycin (1.2 g given as a single dose of 2 600-mg tablets). The choice of regimen was based partly on the inmate's expected time until release (e.g., pretrial inmates were often given azithromycin). Inmates who were released before completing treatment were provided with the remaining antibiotics needed to complete treatment. Inmates testing positive or presumptively treated for gonorrhea were given either ceftriaxone (250 mg given through intramuscular injection as a single dose) or levofloxacin (250 mg given orally as a single dose). Attempts were made to contact inmates who were released before test results were available to notify them that they required treatment.
Inmates who tested positive for chlamydia or gonorrhea were interviewed by an MDPH disease investigation specialist (DIS) to elicit sex partner information. Partners for whom sufficient locating information was provided were notified of their potential exposure and referred for treatment.
While incarcerated, inmates could also request an examination at any time if they experienced symptoms of STD infection or other health problems or if a sex partner informed them of possible STD exposure. In inmate-initiated examinations, patients were managed according to their presenting complaint, receiving testing or treatment as described previously.
We evaluated the cost and cost-effectiveness of the chlamydia and gonorrhea screening program for men using 2 perspectives: that of the correctional institution and that of the healthcare system. For the correctional perspective analysis, we assessed the program costs using prices paid for overhead, labor, testing, treatment, and sequelae in untreated infected men (epididymitis and orchitis) likely to be incurred soon after the acute infection. Aside from the negligible overhead costs associated with making jail space available for DIS interviews, no costs of notifying or treating partners were included. For the healthcare system perspective analysis, we used healthcare system costs for testing and treatment. We also added the costs of the sex partner notification program and costs for treating female partners and sequelae in infected female partners (PID and its sequelae of chronic pelvic pain, ectopic pregnancy, and infertility).
We defined the net cost of the partner notification program as the cost of partner notification activities plus the cost examination and treatment of notified partners less the averted sequelae costs realized through treatment of women who were brought to treatment through partner notification and who were assumed (through modeling with literature-based probabilities of concordant infection) to be infected with chlamydia or gonorrhea.17
We did not assign any lost productivity cost to the time inmates spent in examination or treatment or to time and travel costs associated with healthcare visits by their partners. We used treated cases of acute lower genital tract chlamydia and gonorrhea in male inmates and female sex partners as well as cases of PID averted in female sex partners as primary cost-effectiveness outcomes. We included the costs of gonorrhea testing because it was offered to inmates with positive chlamydia tests or with risk factors or signs of bacterial STD infection, and because azithromycin treats gonorrhea, although not with a high enough efficacy to be recommended as a primary therapy.18
Data on testing, treatment, and overhead costs were taken from information provided by HCCC and from the literature.19–27 All costs were adjusted to 2001 dollars using the Medical Care component of the Consumer Price Index for All Urban Consumers.28 The costs of sequelae of chlamydia or gonorrhea in infected female partners were discounted at 3% per year.
HCCC and MDPH staff used time-motion forms to record the amount of staff time associated with intake screenings, DIS interviews of infected inmates, and partner notification activities. Time data on screenings were collected from March to early June, 2001, and time data for DIS interviews and partner notification were collected from September 2001 to January 2002.
Data on chlamydia positivity rates, inmates' ages, and STD risk factors were taken from male inmates screened in the first quarter of 2001. We estimated overall gonorrhea prevalence based on plausible rates of dual infection with chlamydia. Data on the number of partners per male elicited in DIS interviews and the outcome of partner notification activities were taken from logs kept for index patients identified as a result of jail screening during the calendar years 1999 to 2001. Data pertaining to sequelae rates for infected male inmates and their infected female partners were taken from the literature.17,29–32
Data on LCR and DNA probe assay performance and treatment efficacy were taken from the literature.18,32–39 Data on the performance of the LET were generated from HCCC data using LCR test results as a reference standard.40
Data analysis was conducted using Stata 7.0 software (Stata Corp., College Station, TX).
Table 1 lists the variables used in the analysis, their values, and sources, whereas Table 2 lists the costs. One- and 2-way sensitivity analyses were performed on some variables; for these, the range of values used in the sensitivity analyses is shown. For sensitivity analysis of test performance and cost, we considered the hypothetical use of a higher sensitivity transcription-mediated amplification (TMA) assay (AMP-CT; Gen-Probe, Inc.).19,44 When conducting the sensitivity analyses, all variables except those being varied were held at the baseline values shown in Tables 1 and 2.
Using decision analysis software (DATA Pro 1.0; TreeAge Software, Inc., Williamstown, MA), we constructed a decision tree model to estimate the cost of 4 potential testing alternatives and their cost-effectiveness:
1. Universal screening: This is the baseline practice at HCCC described in detail previously (all inmates tested for chlamydia and offered testing for gonorrhea in the presence of risk factors, symptoms, or signs consistent with bacterial STDs or on a positive test result for chlamydia; partner notification follows positive test results).
2. Age-based screening of men <25 years of age: We assumed that inmates <25 years of age would be screened according to existing practice but that inmates ≥25 years of age would only be tested and treated if they presented with symptoms as described in the subsequent paragraph detailing the symptom-based testing strategy.
3. Age-based screening of men <30 years of age: This alternative was the same as the previous age-based alternative, except with an age cutoff of 30 years instead of 25.
4. Symptom-based testing: We assumed inmates would not be screened and that they would only be examined if they reported symptoms. Inmates reporting bacterial STD symptoms would provide a urine specimen for chlamydia testing and be offered gonorrhea testing using a urethral specimen. We assumed all inmates reporting bacterial STD symptoms would be presumptively treated at the time of the examination for both chlamydia and gonorrhea and that a DIS would interview inmates with positive test results.
This project was approved by human subjects protection procedures at the Centers for Disease Control and Prevention and HCCC.
The cost, yield, and cost-effectiveness of the 4 testing alternatives from the correctional institution's perspective are shown in Table 3. The outcome used for this analysis was cases of chlamydia and gonorrhea treated in a hypothetical cohort of 1,000 male inmates. At the baseline prevalences in Table 1, 79 cases of chlamydia or gonorrhea would be expected. The least effective approach, symptom-based testing, would treat only 9.5 cases, or 12% of the total. The most effective approach, universal screening, would treat 49.9 cases, or 63% of the total. Symptom-based testing would be relatively inexpensive for the correctional institution (approximately $1.41 per inmate), whereas universal screening would cost substantially more—nearly $26 per inmate. Age-based screening of men <30 years of age would successfully treat nearly as many cases as universal screening (47.7 vs. 49.9) but cost approximately half as much ($13.65 per inmate). The incremental cost-effectiveness column of Table 3 shows the additional cost per additional case of chlamydia or gonorrhea treated in inmates. Because universal screening was only slightly more effective but twice as expensive as age-based screening of men <30 years of age, the cost of switching from the alternative of screening men <30 years of age to universal screening would be very high—approximately $6,000 per additional case of chlamydia or gonorrhea detected. The cost-effectiveness of the 4 screening alternatives from the healthcare system perspective for a hypothetical cohort of 1,000 male inmates is shown in Table 4. The outcome used for this analysis was the combined total of treated cases of chlamydia or gonorrhea in male inmates and in their female sex partners who would be brought to successful treatment through partner notification services. In addition to the healthcare system costs, shown also are net partner notification costs and an estimate of the number of averted cases of PID in infected women who would be located and treated through DIS partner notification services. Like when considering only the correctional institution's costs and impact on inmates, screening men <30 years of age would cost substantially less (28%) than universal screening and would be nearly as effective in terms of acute cases of chlamydia and gonorrhea treated in inmates and their sex partners and in terms of PID prevention. The incremental cost of switching from screening men <30 years of age to universal screening was high at $4,592 per additional case of chlamydia or gonorrhea treated, which was sharply higher than the incremental cost-effectiveness of either of the age-based screening alternatives.
Sensitivity Analysis Results
Even when PID costs were set at the upper end of the range of cost per case in Table 2, none of the male testing alternatives was cost-saving. The results for the correctional institution and healthcare system costs were qualitatively the same as shown in Tables 3 and 4. This was also true in 2-way sensitivity analysis when PID cost was varied with chlamydia prevalence in male inmates. However, assuming a higher cost per case of PID resulted in partner notification being cost-saving (from −$70 for symptom-based testing to −$430 for age-based screening of men <30 years of age).
Although net partner notification costs were negative at the high end of cost per case of PID, the cost savings realized were not enough to impact the rank order of the male testing alternatives shown in Table 4.
When we varied the performance and cost of the test for chlamydia to match those of the TMA assay, the cost per case of chlamydia or gonorrhea treated in both male inmates and their partners declined when considering both the correctional institution and healthcare system perspectives. However, the results reported in Tables 3 and 4 (in terms of cost per case treated and incremental cost) remained qualitatively the same. For example, the healthcare system perspective cost per case (in inmates and partners) treated when screening men <30 years of age declined from $503 per case to $432 per case, a reduction of 13.7%. Although there was no change in the number of inmates treated for chlamydia or gonorrhea under the symptom-based testing alternative, the number of inmates treated increased from 7.7% to 9% in the 3 alternatives using chlamydia testing. The identification of additional chlamydia-infected inmates similarly increased the number of partners treated by the same magnitude. However, these changes were not dramatic enough to make any of the screening alternatives cost-saving compared with symptom-based testing.
Varying the other variables in Tables 1 and 2 (percent of men interviewed about sex partners, LET sensitivity and specificity, treatment efficacy, and epididymitis and orchitis costs) did not materially impact the results reported in Tables 3 and 4.
The results of our analysis of the HCCC program of screening men on intake for chlamydia indicate that an age-based screening program for men restricted to those <30 years of age is nearly as effective as universal screening and is substantially less costly than universal screening. When considering only the program costs incurred by the correctional institution (those for testing and treatment alone), universal screening is twice as costly as screening only men <30 years of age. When considering all costs borne by the healthcare system, age-based screening of men <30 years of age is 28% less costly than universal screening.
Another important finding is that providing partner notification services to male inmates who test positive for chlamydia imposes a very low net cost or is even cost-saving when considering both the costs of DIS activities and those of averted sequelae in female partners brought to treatment.
Screening men for chlamydia on intake to HCCC is not a cost-saving intervention; this matches modeling estimates published previously for screening men both in a correctional setting specifically and on a population-wide basis.9,46 Although the screening program itself is not cost-saving, the partner notification program provides a link between disease identified in the incarcerated population and disease in the surrounding community and provides a way for the healthcare services provided to inmates to benefit individuals in the nonincarcerated population who may also have limited access to care. In the case of HCCC, an institution that has decided to screen male inmates for chlamydia, partner notification is a cost-effective adjunct. However, if the male screening program is viewed as an intervention that is solely designed to reach infected women, it would not be cost-effective compared with programs that directly screen women. Case detection and treatment in men must be a worthwhile goal in itself for the male screening program to be attractive.
The data from HCCC suggested that the costs of the program could be greatly reduced without a great reduction in effectiveness, but also showed that the effectiveness of selective screening was impacted by the criteria chosen. Age-based screening performed better than symptom-based testing, because a high proportion of infected men at HCCC lacked symptoms, a finding observed in other studies of male inmates.13–15 On implementation of a selective screening program, periodic prevalence monitoring with universal screening can help determine the continued validity of the screening criteria. After preliminary analysis of screening at HCCC and other sites, HCCC began age-based screening of men, screening only men <30 years of age or those ≥30 years of age with a new or 2 or more sex partners, or a sex partner with an STD, within the prior 60 days.47
The LET, although inexpensive, was relatively insensitive and its use contributed little to Chlamydia trachomatis and Neisseria gonorrhoeae case detection. A recently published study found higher sensitivity with the LET than realized at HCCC when used with adolescents in juvenile detention.48 The LET has been found to perform better with adolescent males than with older men, although the sensitivity has generally been found to be higher than that found by HCCC.49 It is possible that some HCCC inmates may have voided shortly before providing the urine specimen that was tested with the LET or may not have provided a first-catch urine specimen, both of which would reduce the sensitivity of the test.
The sensitivity analysis showed that the yield and cost-effectiveness of the screening program (whether age-based or universal) could be improved using an improved assay for chlamydia such as the TMA, which offers improved sensitivity at similar or reduced cost. The improvement, however, would not be enough to make screening men cost-saving.
There are limitations to this analysis. Because HCCC does not screen all men for gonorrhea, the prevalence of gonorrhea in inmates was estimated. The actual prevalence may be different. Data from other correctional institutions show that the prevalence of gonorrhea varies widely.3 We did not attempt to model the impact of using a combination assay that would test for both chlamydia and gonorrhea because previous modeling work suggests that although it would offer improved case detection, it would do so only at greatly increased cost in men.9 Because the rate at which jail inmates return to the community is variable, this analysis did not incorporate the effects of secondary transmission to uninfected sex partners or reinfection of inmates after release. For the same reason, we did not include averted cases of HIV as a benefit of treating chlamydia and gonorrhea in male inmates, although both can promote HIV infection.50
Although the STD screening that men received at intake was brief, it did provide an opportunity for the clinician to encourage safer sexual behavior and conduct a risk assessment. In our age-based screening alternatives, asymptomatic inmates in the age groups not receiving screening would not receive these services unless they were incorporated into another intake screening routine. Because we focused on direct medical costs, we did not attribute any explicit benefit to these services; this is another limitation. If they could be incorporated into our analysis they might impact the results—by making universal screening more attractive compared with age-based screening—but the difference in cost between age-based screening of men <30 years of age and universal screening is large enough that the results would probably not be materially different.
Because men who enter correctional institutions represent an underserved population, the healthcare services they receive while incarcerated may be services they would not receive otherwise. Because inmates often have relatively high STD rates, STD screening can provide a tangible benefit to them, although at some cost. Partner notification services for the sex partners of male inmates can bring infected women in the community to treatment at no net cost to the healthcare system as a whole. The STD services offered to inmates can thus provide benefits to their community if partner notification is provided and can reduce the STD morbidity in the population at large.
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