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Module 9: Patient Adherence to Tuberculosis Treatment
Reading Material

Using DOT to Improve Adherence

Directly Observed Therapy (DOT)

A component of case management that helps to ensure that patients adhere to treatment is directly observed therapy (DOT). DOT is the most effective strategy for making sure patients take their medicines. DOT means that a health care worker or other designated individual watches the patient swallow every dose of the prescribed drugs. DOT should be considered for all patients because it is difficult to reliably predict which patients will be adherent. Even patients who intend to take their medicine might have trouble remembering to take their pills every time. All DOT visits should be documented. In many health departments, DOT is the standard of care. Figure 9.2 is an example of a form used to monitor and document a patient's DOT.

Many TB programs use their area treatment completion rates to decide how to implement DOT. If the percentage of patients who finish therapy within 12 months is less than 90%, or is unknown, programs will often increase the use of DOT. Many programs have substantially improved completion rates after deciding to make DOT the standard of care for TB treatment.

Figure 9.2   This is an example of a Directly Observed Therapy log form.

All patients should be considered for DOT. However, there are certain groups of patients for whom DOT is often the best option, regardless of local treatment completion rates. These groups include

  • Patients with drug-resistant TB
  • Patients receiving intermittent therapy
  • Persons at high risk for nonadherence, such as
    • Homeless or unstably housed persons
    • Persons who abuse alcohol or illicit drugs
    • Persons who are unable to take pills on their own due to mental, emotional, or physical disabilities
    • Children and adolescents
    • Persons with a history of nonadherence

DOT for Latent TB Infection (LTBI)

In addition, more and more TB programs are using directly observed treatment for latent TB infection (LTBI). DOT for LTBI is for persons who are at especially high risk of developing TB disease such as young children, and HIV-infected and other immunosuppressed persons.

DOT for LTBI is appropriate in institutions and facilities where pill ingestion can be observed by a staff member or for household contacts of a TB patient who is on DOT. Because persons taking treatment for LTBI have no symptoms of TB disease, it is very important that they understand the need for medication so that they are motivated to start and finish DOT for LTBI.

Recent data indicate low completion rates among patients on regimens for treatment for LTBI. The use of DOT for LTBI is one strategy that can improve patients' adherence to treatment for LTBI. However, if resources are limited, DOT for TB disease should be the priority over DOT for LTBI.

Tasks Involved in Delivering DOT

DOT for TB disease and DOT for LTBI are both more than watching the patient swallow each pill, although that is the crucial component of a DOT program. At each DOT encounter, the health care worker should perform the following tasks:

  • Check for side effects
  • Verify medication
  • Watch patient take pills
  • Document the visit

Table 9.2 details the tasks involved in a specific DOT encounter.
 

Table 9.2
Tasks Involved in Delivering DOT

Task Description
Check for side effects At each visit, before the drugs are given, the health care worker should ask if the patient is having any adverse side effects. Patients being treated for TB should be educated about symptoms indicating adverse reactions to the drugs they are taking, whether minor or serious. If the patient has symptoms of serious adverse reactions, a new drug supply should not be given; the patient should stop taking medication immediately (see Module 4, Treatment of Tuberculosis Infection and Disease, for more information on adverse reactions to TB medication). The supervisor should be told that the drugs were not given, and the prescribing clinician should be notified about the adverse reaction. The health care worker should arrange for the patient to see the clinician as soon as possible.
Verify the medication Each time DOT is delivered, the health care worker should verify that the right drugs are delivered to the right patient, and that he or she has the correct amount of medication. If this cannot be confirmed, the drugs should not be given to the patient. The supervisor should be asked for clarification.
Watch the patient take the pills Medication should not be left for the patient to take on his or her own unless self-administered therapy has been prescribed for non-DOT days, such as weekends. The health care worker or the patient should get a glass of water or other beverage before the patient is given the pills. The health care worker should watch the patient continuously from the time each pill is given to the time he or she swallows it.
Document the visit The health care worker should document each visit with the patient and indicate whether or not the medication was given. If not given, the reason and follow-up plans should be included. It is important to correct any interruption in treatment as soon as possible.

Often, DOT programs also include a number of other case management functions, such as

  • Helping patients keep appointments
  • Providing effective education to patients and key individuals in the patient's social environment
  • Offering incentives to encourage adherence
  • Providing social services to ensure patient's needs are being addressed so adherence to therapy can become a priority

For example, some DOT programs provide an array of services including DOT provision in locations convenient to patients, incentives and enablers to encourage patients to take medications, help in finding housing for homeless patients, a system to keep track of patients through hospital discharge planning, and a method of tracking inmates released from jail or prison. Other DOT programs include specially trained community service aides; transportation of patients to clinics; delivery of drugs to the patient's home, workplace, or other convenient site; and intermittent regimens after the patient completes an initial period of daily treatment.

Delivering DOT in the Clinic and the Field

DOT can be given anywhere the patient and health care worker agree upon, provided the time and location are convenient and safe. Clinic-based DOT is delivered in a TB clinic or comparable health care facility (Figure 9.3). For some patients, DOT must not interfere with the patient's work schedule, so DOT can be provided in a nonclinical setting or during nonbusiness hours. When a patient cannot easily get to the TB clinic, the health care worker must go to the patient. DOT delivered in a setting outside of the TB clinic or health care facility is called field-based DOT (Figure 9.4 and Figure 9.5). Field DOT can be given at almost any site:

  • The patient's home
  • The patient's workplace
  • A public park or other agreed-upon public location
  • A school
  • A restaurant

Figure 9.3  Clinic-based DOT.  This is a picture of health care worker administering treatment under direct observation in a clinic setting

Figure 9.4 Field-based DOT in the patient's home.  This is a picture of health care worker administering treatment under direct observation in the field at a patient's home.

Figure 9.5 Field-based DOT at an agreed-upon public location.  This is a picture of health care worker administering treatment under direct observation in the field at an agreed-upon public location.

DOT is usually given by TB clinic personnel such as a nurse or other health care worker. Sometimes staff at other health care settings, such as outpatient treatment centers, can be asked to give DOT to a patient who can get to the alternative health care setting more easily than to the TB clinic.

Likewise, staff may choose a person other than a health care worker to watch the patient take medicine. Family members should NOT be responsible for watching the patient take medicines. Because of strong emotional ties, the family may be unwilling to ensure the patient takes treatment if he or she refuses treatment. However, other persons -- such as school or employee health nurses, work supervisors, clergy, or other responsible persons who do not have strong emotional ties with the patient -- can provide DOT, if the patient agrees to this arrangement. These arrangements must be approved in advance by supervisory clinical and management staff and should be monitored closely to ensure there are no problems.

Regardless of the arrangement, it is always important to protect the patient's confidentiality. For example, the patient may not want the health care worker to tell neighbors why he or she is visiting. If home visits create confidentiality problems, the health care worker should choose another location. Another critical consideration for conducting field DOT is the health care worker's own security. Health care workers should become familiar with policies and recommendations of local law enforcement agencies and health department administration regarding personal security. Current information on local high-risk areas for crime can be very valuable in planning and conducting safe field visits.

Health care workers should watch for tricks or techniques some patients may use to avoid swallowing medication, such as hiding pills in the mouth and spitting them out later, hiding medicine in clothing, or vomiting the pills after leaving the clinic. If it is necessary to make sure that the patient swallows the pills, the health care worker may have to check the patient's mouth, or ask the patient to wait for a half hour before leaving the clinic so the medication can dissolve in the patient's stomach.

Advantages and Disadvantages of DOT

DOT has many advantages and disadvantages (Table 9.3). When used as a collaborative effort with the patient, DOT has many advantages over self-administered therapy:

  • It ensures that the patient completes an adequate regimen
  • It lets the health care worker monitor the patient regularly for side effects and response to therapy
  • It helps the health care worker solve problems that might interrupt treatment
  • By ensuring the patient takes every dose of medicine, it helps the patient become noninfectious sooner

Often patients who have successfully completed DOT are willing to describe their experience or share it with new patients. If this can be arranged, former patients may help encourage new patients to participate in the DOT program. Before the patients are introduced, both parties should provide prior approval to avoid a breach in confidentiality (see Module 7, Confidentiality in Tuberculosis Control). DOT does have a few disadvantages because it

  • Is time consuming
  • Is labor intensive
  • Can be insulting to some patients
  • Can imply that the patient is incapable or irresponsible
  • Can be perceived as demeaning or punitive

It is important to explain the benefits of DOT to each patient and stress the fact that DOT is not punitive; rather, DOT is a highly effective way for the patient and health care worker to collaborate so that the patient will successfully complete an adequate regimen.  Table 9.3

Advantages and Disadvantages of DOT

Advantages Disadvantages
  • It ensures that the patient completes an adequate regimen
  • It lets the health care worker monitor the patient regularly for side effects and response to therapy
  • It helps the health care worker solve problems that might interrupt treatment
  • By ensuring the patient takes every dose of medicine, it helps the patient become noninfectious sooner
  • It is time consuming
  • It is labor intensive
  • It can be insulting to some patients
  • It can imply that the patient is incapable or irresponsible
  • It can be perceived as demeaning or punitive

 
Study Questions 9.16-9.20

9.16. What is DOT?

9.17. Who should be considered for DOT?

9.18. List and explain four tasks that are part of the DOT encounter.

9.19. Name at least five places where DOT can be given.

9.20. What are four advantages of DOT?

Answers 


 
Case Study 9.5
You are assigned to deliver DOT to Mrs. Wilson, a 76-year-old woman who lives alone in the house she and her husband bought many years ago. Mrs. Wilson was recently released from the hospital. Upon discharge from the hospital, she received education about TB and about the need to take medications until she completes treatment. She was told that she would be started on DOT and a health care worker would visit her at her home to help her take her medication. Mrs. Wilson is elated to have some company. She happily offers you cookies and wants to "talk awhile" before she takes her medication.
  • What are the tasks you complete when you deliver DOT to Mrs. Wilson?

Answers 


 
Case Study 9.6
Nick is a 27-year-old single unemployed male. He has been in and out of rehabilitation clinics for crack use. He picks up odd jobs in the warehouses and diners on the waterfront. He lives in a single room occupancy hotel.

Four weeks ago he was brought by the police to the emergency room of General Hospital for treatment of stab wounds to the right arm resulting from a drug deal gone bad. Upon admission he was intoxicated, appeared poorly nourished and underweight, and had a productive cough. His smears were positive for AFB and he was started on appropriate therapy. He remained in the hospital for 5 days. Against medical advice, Nick then insisted on leaving the hospital. On the day of discharge, the infection control nurse telephoned a report to the health department, and instructed Nick to go to the health department the next morning for evaluation and a supply of medicine. He failed to keep his appointment. The next week a health care worker was assigned to locate Nick and persuade him to come to the clinic. The health care worker found him lying on a park bench near the hotel where he lives. The health care worker convinced Nick to go to the clinic for follow-up tests. At the clinic, Nick reluctantly agrees to take his medication, although he does not want DOT. He says he is not a "baby" and can take the medication on his own.

  • How would the health care worker help Nick adhere to his treatment regimen?
  • What can the health care worker say about DOT to convince Nick of its importance?

Answers 


 
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