A Promising HIP Intervention — Electronic Directly Observed Therapy for Active TB Disease
Prevention Case Study 2
TB is the leading cause of infectious disease death worldwide. The bacterium that causes TB, Mycobacterium tuberculosis, is spread when a person with TB disease of the lungs or throat coughs. In 2015, a total of 9,554 persons received a diagnosis for TB disease in the United States.1 The majority of persons with TB disease can be treated by taking certain medications for ≥6 months. Effective case management supports patients’ adherence to medication and treatment completion.
Directly observed therapy (DOT) is a key element of TB case management. Endorsed by the World Health Organization and CDC, DOT entails a trained observer watching as the patient swallows the anti-TB medications. As the percentage of the population that owns a mobile phone, computer, or tablet with video capability has increased, potential for having the trained observer use an electronic device to enable DOT also has increase.2,3 One form of electronic DOT, or eDOT, allows a member of the health care team to watch the patient swallow the anti-TB medications by using live or real-time video, or recorded video that is submitted for later review. Recently, multiple pilot studies have documented that eDOT is acceptable to patients and feasible to implement; the study also identified potential cost savings from reduced staff time and travel expenditures for either patients or medical staff.4-15 Adherence to attending scheduled sessions and treatment completion has been comparable with in-person DOT. For example, in a study based in New York City, 61 (16%) patients were on eDOT, and 329 (84%) were on in-person DOT. Adherence to scheduled eDOT sessions was 95%, compared with 91% for in-person DOT, and treatment completion was similar between the 2 groups (96% versus 97%, respectively). Among pilot studies that collected cost data, the amount of money saved by using eDOT ranged from $1,811 (2016 US$)/patient10,16 to $14,355 (2016US$)/patient.14,16 These studies selected participants for eDOT based on patients having demonstrated good adherence to initial doses of medication and that their TB cases were uncomplicated. Additional evaluations with large patient samples in different situations will add useful information about eDOT’s feasibility, effectiveness, and cost.
Selected Pilots and Small Case Studies with Cost Data Regarding eDOT
Suburban Illinois Pilot14
Summary: The DuPage County Health Department, Illinois, piloted an eDOT program from January 2013 to December 2014, enrolling 11 patients with active TB who did not have multidrug-resistant TB and who were considered likely to have high adherence (e.g., in stable housing). Using teleconferencing technology, staff connected with 9 patients using smartphones and 2 using their personal computers.
Results: Patients received 1,083 eDOT doses, with a 97% adherence rate (defined as the percentage of scheduled sessions the patient attended). Throughout the treatment course, eDOT patients saved an average of 9,499 travel miles. In total, the eDOT program saved 579 hours in staff time, representing $144,750 and $13,159 in travel expenses (or $147,288 and $13,390 in 2016US$, or $14,355/patient).16
Urban Washington State/Seattle-Tacoma Metropolitan Area Pilot15
Summary: During 2002–2006, two local health jurisdictions in Pierce and Snohomish Counties, Washington, conducted a retrospective chart review of 57 patients with TB disease who used videophones for medication monitoring.
Results: Medication adherence was documented 95.6% of the time. The average patient in the eDOT program saved $2,449 in travel expenses, compared with in-person DOT patients.5 The savings in staff salaries, benefits, and travel costs was $139,576 (or $169,441 and $2,973 in 2016US$). Staff saved 2,994 hours of travel time and 103,632 miles in travel.
Note: Monetary values were inflated from the year of publication to 2016US$ by using the Bureau of Economic Analysis, Personal Consumption Expenditure Index, Health Care component.16
Ongoing Studies of eDOT
Although the initial pilot and case studies of eDOT are promising, multiple studies are under way to evaluate it among a broader population of persons with TB disease. Two are being conducted in collaboration with CDC, with funding by CDC’s Antibiotic Resistance Solutions Initiative. The first is a randomized controlled trial to evaluate in-person DOT and eDOT for TB. This study will assess whether eDOT is an acceptable approach to monitoring TB treatment adherence, compared with traditional in-person DOT. This study will also compare patient perceptions of care, treatment outcomes, and the type, frequency, and time between initial symptoms of medication side effects and discussion with a medical provider across DOT methods [ClinicalTrials.gov Identifier: NCT03266003]. The second is an economic evaluation of eDOT that will assess both TB program costs from the health department and societal perspectives (e.g., potential savings to patients) in low-, medium-, and high-TB incidence settings in the United States. Results are expected in 2018.
An eDOT Resource
As of 2015, 42% (47/113) of TB programs surveyed used eDOT in some form, and 36% were planning to implement an eDOT program in the next year.9 To support TB programs, CDC recently published a resource for programs that are considering initiating an eDOT program. The toolkit, “Implementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) Programs” is designed to help TB programs review the potential benefits and drawbacks of an eDOT program, gain insights related to management and regulation concerns, and use available resources.
- CDC. NCHHSTP AtlasPlus. Atlanta, GA: US Department of Health and Human Services, CDC; 2017.
- World Health Organization (WHO). Digital health in the TB response: scaling up the TB response through information and communication technologiespdf iconexternal icon. Geneva, Switzerland: WHO; 2014.
- World Health Organization (WHO). Digital health for the End TB Strategy—an agenda for actionexternal icon. Geneva, Switzerland: WHO; 2015.
- Chuck C, Robinson E, Macaraig M, Alexander M, Burzynski J. Enhancing management of tuberculosis treatment with video directly observed therapy in New York City. Int J Tuberc Lung Dis 2016;20:588–93.
- Garfein RS, Collins K, Muñoz F, et al. Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study. Int J Tuberc Lung Dis 2015;19:1057–64.
- Gassanov MA, Feldman LJ, Sebastian A, Kraguljac MJ, Rea E, Yaffe B. The use of videophone for directly observed therapy for the treatment of tuberculosis. Can J Public Health 2013;104:e272.
- Hoffman JA, Cunningham JR, Suleh AJ, et al. Mobile direct observation treatment for tuberculosis patients: a technical feasibility pilot using mobile phones in Nairobi, Kenya. Am J Prev Med 2010;39:78–80.
- Holzschuh EL, Province S, Johnson K, et al. Use of video directly observed therapy for treatment of latent tuberculosis infection—Johnson County, Kansas, 2015. MMWR Morb Mortal Wkly Rep 2017;66:387–9.
- Macaraig, M, Lobato MN, McGinnis Pilote K, Wegener D. A national survey on the use of electronic directly observed therapy for treatment of tuberculosis. J Public Health Manag Pract 2017. Epub ahead of print.
- DeMaio J, Sharma D. Tuberculosis therapy and telemedicine. Expert Opin Pharmacother 2002;3:1283–8.
- Molton JS, Pang Y, Wang Z, et al. Prospective single-arm interventional pilot study to assess a smartphone-based system for measuring and supporting adherence to medication. BMJ Open 2016;6:e014194.
- Story A, Garfein RS, Hayward A, et al. Monitoring therapy compliance of tuberculosis patients by using video-enabled electronic devices. Emerg Infect Dis 2016;22:538–40.
- Wade VA, Karnon J, Eliott JA, Hiller JE. Home videophones improve direct observation in tuberculosis treatment: a mixed methods evaluation. PLoS One 2012;7:e50155.
- Mirsaeidi M, Farshidpour M, Banks-Tripp D, Hashmi S, Kujoth C, Schraufnagel D. Video directly observed therapy for treatment of tuberculosis is patient-oriented and cost-effective. Eur Respir J 2015;46:871–4.
- Krueger K, Ruby D, Cooley P, et al. Videophone utilization as an alternative to directly observed therapy for tuberculosis. Int J Tuberc Lung Dis 2010;14:779–81.
- Bureau of Economic Analysis. Consumer spending. Table 2.3.4U. In: Price Indexes for Personal Consumption Expenditures by Major Type of Product and by Major Functionexternal icon. Washington, DC: US Department of Commerce; 2017.