Measuring outcomes gives direction to health care programs in 2 states

Outcomes based research and data measurements may soon emerge as the driving force behind correctional health care, ultimately determining the size and scope of health related interventions and programs within correctional institutions.

Two states, Florida and Georgia, have already introduced

As more money is poured into correctional health care, there is growing interest in conducting research that analyzes systems and procedures and seeks to measure their results.

State, federal and local governments spend more than $5 billion a year on correctional health care, according to some estimates.

Yet, very little data exist demonstrating the effectiveness or even the appropriateness of health care interventions.

Nevertheless, some correctional systems and institutions have been able to push ahead, putting in place systems of care and creating the necessary infrastructures to support those systems of care.

In Florida, for example, the Department of Corrections implemented directly observed therapy (DOT) for all of its HIV/AIDS patients on combination therapies in 1996, a practice that initially expended more time and money. In 1998, correctional officials initiated a two-year study to measure the effectiveness of DOT for patients on the combination drug regimens. The results surprised even the most ardent supporters of DOT.

Officials studied 84 patients taking one of three commonly used HIV combination regimens from 1998 to 2000, assigning 42 patients to a self-administered medication group and the other 42 patients to a DOT group.

During the two year period, researchers consistently found that the DOT group registered viral load levels twice as low as those in the self administered group, justifying the decision to adopt DOT for HIV medications despite the added time and money involved.

"We expected the DOT patients to do better by a significant margin," says David Thomas, MD, Director of Health Services for the Florida Department of Corrections. "But the magnitude of the difference was surprising."

A follow up study conducted in 2000 confirmed the findings of the first study. Not surprisingly, the follow up study found that simpler regimens led to better adherence, meaning that adherence with HIV medications will become less of an issue as regimens become less complicated and easier to take during the next few years, Thomas said.

The results of both studies, presented this year and last year at the annual Congress of Antiretrovirals and Opportunistic Infections, had a significant impact, convincing many institutions to at least consider the possibility of implementing directly observed therapy for HIV medications, Thomas says.

In Georgia, meanwhile, the state Department of Corrections adopted directly observed therapy for HIV medications in 1997, a move that led to 100 percent adherence among HIV patients and further improved clinical outcomes, says Joe Paris, MD, Ph.D., Medical Director of the Georgia Department of Corrections.

"It is now statistically significant that HIV care has produced outcomes that are better than anything we got in the early 1990s," explains Paris, whose system holds more than 40,000 inmates, about 900 of whom are identified as HIV positive.

"The outcomes are that the patients with HIV are living longer, opportunistic infections are less and less common and the number of deaths in custody due to HIV has dramatically decreased."

The total number of deaths from HIV in the state correctional system dropped from about 33 a year in the early 1990s to about eight a year ofter the introduction of protease inhibitors and combination therapies in 1996.

The federal government is expected to approve fusion inhibitors within the next year, the next class of HIV medications with the potential to add another $4,000 a year to the cost of existing antiretroviral regimens for each patient.

"Unless we continue to emphasize the very favorable outcomes of what we are doing, we are going to be hard pressed to obtain funding to pay for them," Paris says.

(More details on the topic are available in Positive Populations in Prisons, 202-518-7768.)

Inf.: David Thomas, 850-922-6645; Joseph Paris, 404-657-2220.